Menopause

This is the normal life phase starting a year after the last flow and lasting for the rest of our lives. It is sometimes called “postmenopause.” At the start of menopause we are in hopefully healthy midlife. Aging will occur differently for all of us but the adaptation process is an important task. Grandchildren are a special blessing for some. Retiring is both a challenge and an opportunity. 1. It is the job of menopause (which begins a year after the last flow and is sometimes called “postmenopause”) to continue (as long as we are able) to contribute to our communities using the wisdom we’ve learned through hard experience, to facilitate the independence of our children and the nurture of our grandchildren (if we have any), to support and care for our partner/friends through the changes life brings and to face aging with courage and good humour. 2. It is normal in menopause to see gradual changes in our body shape, our face, our hair and our sexual interest. It is normal for estrogen and progesterone levels to decrease to low in menopause. It is also normal to adjust our goals and dreams to the biosphere rather than the stratosphere. For 10% of us who are over age 45 at menopause and 20% who are younger than 45, it is normal to have another episode of menstrual bleeding. This usually occurs within the first three years of the last flow. If we feel premenstrual in any way before flow, we need no tests, but if the flow surprised us, we need investigation for endometrial cancer. It is normal for the diseases of aging to begin including high blood pressure, diabetes, cancers (breast, lung, bowel), heart disease, strokes and osteoporosis with fractures. It is also normal during later menopause to retire from our work or occupation, to take up a new challenge or invest in a new interest. 3. A menopausal woman continues to need to make a meaningful contribution to her family, her friends and her community. She needs to feel loved by partner, close friends and family and to feel she is still learning and growing and giving. 4. The things that can go wrong in menopause are often related to our health and habits when we were younger women. Evidence is increasing that silent but recurrent ovulatory disturbances (anovulation or short luteal phases) within regular cycles put us at risk for osteoporosis and heart disease later. Although we may be distressed with decreased sexual interest or increasing time/effort needed for orgasm, we usually continue to be responsive to the sexual interests of a partner with whom we continue to be simpatico. Vaginal dryness is common for two thirds of menopausal women even though they remain sexually active and is present in any woman who has been inactive for a time. It is easily treated /ask/vaginal-dryness. Hot flushes may continue to be waking us at night and problematic by day—they can be effectively treated with progesterone which also improves sleep /resources/progesterone-not-estrogen-hot-flushes-perimenopausal-and-menopausal-women. We can also continue to ensure sufficient activity, muscle weight, calcium, vitamin D and other measures to prevent osteoporosis here. Exercise, diet and treatment for abnormal blood pressure, lipids or blood sugary will help prevent heart disease. In summary, menopause is a normal life phase that has gotten a bad “rap” because it is equated with unhealthy aging. Rather it is the time when we finally integrate the experiences of our lives into something that is meaningful for ourselves, our families and our communities.

Breast cancer, although we think of it as one disease, it is really of many different types each with differing origins, response to treatment and risk factors. Women tend to be more worried about breast cancer than heart disease—most of us know some woman who has had breast cancer. Almost one woman of every nine white (western, privileged) women will get breast cancer in her lifetime—Asian women and those from less industrialized or more rural and poorer countries have lower breast cancer risks.

There are a number of breast cancer risk factors over which we have little control. A very few women inherit breast cancer risks because of a close relative with it (mother, sister, cousin, grandmother, aunt) or because of having the gene for BRCA1 or BRCA2. However, 80% of women who develop breast cancer have no known family history. We also cannot control our age at menarche—it is a risk to start menstruating at younger than 11-12 years. Women who have menopause at age 55 or later are also at slightly greater risk for breast cancer.

Although we talk of breast cancer prevention, screening mammograms, regularly doing breast self-examinations or having yearly health-care-provider breast examinations are finding a breast cancer that is already there. We also know many things that decrease our risks for breast cancer. These include maintaining a normal weight (BMI 18.5-24.9) throughout our lives, exercising moderately for 30 minutes a day, avoiding regular alcohol intake, using other barrier/vaginal spermicide contraception rather than COC, patch or ring and avoiding use of menopausal hormone therapy (OHT—combined estrogen and progestin/progesterone) especially in perimenopause or 5 years into menopause. However, if OHT is needed transdermal estradiol (patch, gel, or cream) with progesterone (rather than progestins like medroxyprogesterone) will not increase breast cancer risks (1).

CeMCOR believes that silent ovulatory disturbances having normal amounts of estrogen (during regular cycles) but not normal amounts of progesterone, pose the major unrecognized risk for breast cancer. Ovulatory disturbances are common and not recognized (2) and are associated with other health risks such as bone loss (3). A combination of socially and emotionally supportive environments and healthy life styles with maintained ovulation is likely to lead to true breast cancer prevention.

Reference List

(1) Fournier A, Berrino F, Clavel-Chapelon F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat 2008 Jan;107(1):103-11.

(2) Prior JC, Naess M, Langhammer A, Forsmo S. The point prevalence of ovulation in a large population-based sample of spontaneously, regularly menstruating women. The HUNT Study, Norway. Endocrine Society , OR 19-1 6573. 2013.

(3) Li D, Hitchcock CL, Barr SI, Yu T, Prior JC. Negative Spinal Bone Mineral Density Changes and Subclinical Ovulatory Disturbances--Prospective Data in Healthy Premenopausal Women With Regular Menstrual Cycles. Epidemiol Rev 2014;36(137):147.

"Estrogen Treatment" means that estrogen alone is used as a therapy. Estrogen treatment used to be called "Estrogen Replacement Therapy" but "replacement" is a term and a concept that are totally wrong—menopause is part of women's normal lifecycle and low estrogen levels then are perfectly normal. CeMCOR wants to change concepts and practice related to estrogen therapy in these two ways: 1) estrogen and progesterone work together with progesterone counterbalancing the effects of too much estrogen—estrogen should always be taken with progesterone because estrogen and progesterone are partners working together in all our tissues; and 2) estradiol or the bio-identical form of estrogen, should always be taken as a gel, patch or cream and never as a pill because estrogen by mouth increases blood clotting.

Investigators at CeMCOR are investigating whether estrogen-alone therapy is ever good or appropriate therapy. But, you may say, "I thought adding progesterone or progestin was only to prevent endometrial cancer." Yes, progesterone does prevent the estrogen-treatment related endometrial cancer, but that's only one of the many reasons to also take progesterone. Whenever estrogen treatment is taken, progesterone should also be taken since both hormones are part of the normal, ovulatory menstrual cycle. That means that a woman who has had a hysterectomy who is taking estrogen doesn't need progesterone's endometrial protection but she still needs progesterones effects for bones, breasts, heart and brain (as well as every tissue in her body). Take progesterone with estrogen.

For over 75 years we have known that taking estrogen as a pill increases the risk of potentially fatal blood clots. In the last 15 years we have had non-pill forms of estrogen treatment available that don't increase clot risks. Therefore, always ask for estradiol as a cream, patch or gel.

Hot flushes (flashes in the USA) and night sweats are a common and mysterious experience of midlife and menopausal women. They are episodic, start suddenly, last a few minutes and make us feel too hot with/without sweating. Night sweats are hot flushes occurring during sleep—they may or may not cause wakening. Although previously hot flushes were thought to be caused by low estrogen levels, in their brain actions, hormonal associations and experiences, they closely resemble an addict's drug withdrawal. CeMCOR attributes hot flushes to "estrogen withdrawal." The key trigger appears to be a dropping estrogen level (from high to normal or normal to low). Stopping estrogen hot flush treatment can make hot flushes worse than before estrogen was started.

How do dropping estrogen levels cause hot flushes? They trigger the release of norepinephrine, a brain stress hormone, as well as a "dog's breakfast" of other brain and stress hormones. Norepinephrine narrows the range of body temperatures in which we feel comfortable (thermoneutral zone); we both get too hot when it is only a little warm and too cold when it is only a little cool.

Hot flushes are worse when we are under stress (not just emotional stress but also being in pain or depressed), when we are overweight (especially in perimenopause), if we have irregular times for eating and sleeping and if we smoke. Hot flush strategies and treatments are effective when they decrease our responses to stressful situations. These successful strategies include regularly exercising, learning and practicing relaxation/meditation/slow, deep yoga-type breathing, eating and (as much as possible) sleeping regularly. Many herbal and alternative therapies improve hot flushes somewhat; the "placebo-response" to anything we believe will help us reduces hot flushes by 20 to 50 percent.

Although estrogen is the classical hot flush therapy, estrogen with progestin is more effective than estrogen alone; progestins alone are as effective as estrogen. Recently CeMCOR proved that natural progesterone is both effective and safe for menopausal hot flushes; there was no rebound increase in hot flushes when progesterone was stopped. CeMCOR is currently doing a Canada-wide study of progesterone for perimenopausal hot flushes (/studies/perimenopausal-hot-flush-study).

Night sweats (/resources/topics/night-sweats) mean hot flushes (or hot flashes) that occur during sleep. Night sweats appear to be many women's first experience of hot flushes. CeMCOR scientists found that night sweats that occurred only intermittently across the cycle were more likely to occur around menstruation for women in very early perimenopause. At the time, these early perimenopausal women had regular cycles and few daytime hot flushes.

Night sweats mean hot flushes (or hot flashes) that occur during sleep. Night sweats appear to be many women's first experience of hot flushes. CeMCOR scientists found that night sweats that occurred only intermittently across the cycle were more likely to occur around menstruation for women in very early perimenopause. At the time, these early perimenopausal women had regular cycles and few daytime hot flushes.

We know less about night sweats than we do about hot flushes since many studies do not track them separately from daytime ones. When night sweats become more intense and sweaty they are more likely to us wake up. Even if we aren't startled awake feeling too hot and sweating, night sweat occurrence during the night may make us feel we've had a less-than-restful sleep.

Like hot flushes, night sweats are more common when we are stressed, overweight or obese, physically inactive or smokers. Improving our responses to stress (relaxation/meditation/yoga breathing), losing weight so we have a normal weight, exercising regularly and stopping smoking will all improve night sweats. Anything we believe will help (like a placebo in a controlled trial) will improve night sweats about 20-50 percent. Night sweats are classically treated with estrogen and even more effectively with estrogen and a synthetic form of progesterone (progestin). CeMCOR scientists recent showed in a randomized controlled trial that natural progesterone was effective for treating night sweats and hot flushes in healthy women within 10 years of starting menopause. Although progesterone is effective in improving sleep, it similarly improved daytime hot flushes and night sweats.

Osteoporosis means weak bone at risk for breaking with a fall from a standing height or less force (called a fragility fracture). Normal bones should not break with that little force. Menstrual cycles that begin around age 12 or 13 and are regular about a month apart provide estrogen that women need to maintain bone health. Hopefully we also know that exercise and strong muscles are needed for bone health. Most of us know that calcium is necessary to build and maintain strong bones and some of us also know that vitamin D is needed, too for healthy bones. CeMCOR scientists have shown that progesterone and normal ovulation during our menstruating years are necessary to prevent bone loss. Further, CeMCOR scientists have shown that cyclic progestin (a synthetic cousin of progesterone ) causes bone gain in a randomized controlled trial in otherwise healthy young women without regular periods (amenorrhea or oligomenorrhea) or with regular cycles but don't ovulate normally (anovulation or short luteal phase cycles). Those who got the placebo treatment lost two percent of spinal bone in one year. Progestin or progesterone likely also causes more bone gain when given to menopausal with osteoporosis along with a bone-loss preventing medicine such as a bisphosphonate.

It is important to think of good general health, healthy nutrition and exercise as well as normal estrogen and progesterone when working to gain and keep healthy and strong bones.

Ovarian Hormone Therapy means the combination of an estrogen and progesterone (or a synthetic progestin) for the purpose of treating a health issue in menopausal women. Since we now know that estrogen-based treatment of menopausal without symptoms causes harms (blood clots, strokes, gall bladder surgery, incontinence) and does not prolong life or prevent heart disease (based on the Women's Health Initiative Randomized controlled trials), the concept of menopausal hormone "replacement" is now wrong. OHT is meant to replace this wrong "HRT" concept and to remind us that women have two reproductive hormones—estrogen and progesterone.

For years, CeMCOR has said that there are only three good reasons to use OHT: 1) Menopause too early (before age 40); 2) Severe hot flushes/flashes and night sweats; and 3) Prevention of bone loss in women with hot flushes needing therapy who are early in menopause and have osteoporosis by bone density or fragility fractures. Now, with the discovery that oral micronized progesterone (PrometriumÒ or compounded progesterone in olive oil) is effective treatment for hot flushes, that removes #2 from the list.

Ovarian hormone therapy should not be continued for more than five years (breast cancer risk on estrogen alone or estrogen-progestin significantly increases after that time). The ideal estrogen for OHT is estradiol used as a gel, patch or cream since this form of estrogen doesn't increase the risk for blood clots. Doses vary by type but should be no more than 1 pump of the estradiol gel or the equivalent of 0.5 micrograms/d by patch or cream. Taking three to five days off estradiol each month is more physiological and allows the breasts a break from estrogen's stimulation. The ideal partner hormone with estradiol (for all menopausal women for whom OHT is indicated, whether or not they have had a hysterectomy) is progesterone taken at bedtime in a dose of 200-300 mg every day or 300 mg for at least 14 days a month (which will probably cause vaginal flow). The progesterone dose of 300 mg at bedtime is not a high dose but one that is required to keep the blood level within the normal luteal phase range for the full 24 hour day. Progesterone improves sleep (and thus may decrease risks for obesity and depression). Progesterone also makes possible the effective tapering and discontinuation of estrogen treatment for hot flushes in those wishing to, or for whom there are medical reasons, to stop.

Progesterone is women's second important and essential hormone and a partner of estrogen. Wherever estradiol is acting in women's bodies (bone, brain, breasts, uterus, skin and everywhere), progesterone is also acting. Women have two reproductive hormones—estrogen and progesterone. Men only have one (testosterone).

Progesterone therapy means taking natural progesterone (oral micronized progesterone) that is bio-identical. If, for cost reasons, a progestin must be substituted, medroxyprogesterone is the closest in action to progesterone (and, like progesterone, also improves hot flushes and increases bone density). Progesterone must be given at bedtime since its major "side effect" (smile) is to improve sleep; it is effective in a dose of 300 mg at bedtime daily which keeps the serum progesterone at or above the luteal phase level for a full 24-hour day.

Cyclic progesterone, for menstruating women of any age, means progesterone for the last two weeks of a menstrual cycle or of a month. Based on a randomized controlled trial, this treatment with cyclic progesterone increases spinal bone density and provides regular flow for women who have reversible (usually stress-related) reasons their periods have stopped or are far apart. Cyclic progesterone is also an essential therapy for premenopausal women with anovulatory androgen excess (AAE)(also called polycystic ovary syndrome [PCOS]) because it prevents endometrial cancer, slows the pulse frequency of luteinizing hormone (LH) thus decreasing testosterone production, provides regular menstrual-type flow and blocks the formation of the skin hormone that causes pimples and unwanted face hair. Cyclic progesterone is also a safe and effective treatment of perimenopausal cyclic night sweats (that occur around the time of flow for women whose cycles are still regular). In perimenopause, cyclic progesterone may also (especially if ibuprofen is also taken) help decrease heavy flow. Cyclic progesterone also helps with the sleep and premenstrual symptoms in perimenopause.

Early menopause (before age 40) can be treated with estradiol and cyclic or daily progesterone. This treatment is continued until a woman becomes age 50-52. With cyclic progesterone those women young enough to want regular flow will achieve it when estrogen is given in a long cycle (from the first to the 25th of the month) and progesterone from the 14 to the 27th. (Note—this is the only time ovarian hormone therapy is truly "replacement.")

Progesterone (taken daily) is effective treatment of menopausal hot flushes as shown by a CeMCOR randomized trial. Daily progesterone also significantly improves sleep in menopausal women (based on three controlled trials). In short, progesterone is effective therapy for women's menstrual cycle disturbances or perimenopause and menopause-related problems.

Restful sleep is essential for health and well-being. Sleep disturbances may arise from many situational stresses, feeling anxious or sad, from illness or pain, related to night sweats or due to the environment (a nursing baby, a snoring partner or unpredictable noises in the neighborhood). Sleep plays an essential role in our circadian rhythm—around-the-clock timing related to eating, temperature, reproduction and all fundamental processes necessary for the health of all of our tissues.

Natural progesterone helps sleep when given in therapy doses (300 mg at bedtime) by mouth as oral micronized progesterone (but not as progesterone cream or even vaginal progesterone). This sleep-inducing effect of progesterone has been proven in controlled trials in men as well as in menopausal women.

Progesterone shortens the time to fall asleep, lessens night time awakening and increases total sleep time while not being addicting or causing morning "hangover" effects. After three months of taking progesterone women's morning responses on a whole battery of memory and other brain tests were unchanged or improved compared to themselves when not on progesterone. In the first nights of taking progesterone, you can feel dizziness or "drunk" if you are awakened within an hour or two of taking it. And, if you are really behind on rapid-eye-movement sleep, you might feel like sleeping in to catch up when you first take progesterone. Finally, progesterone is safe from overdosing since it is the only sleep-promoting medicine that speeds rather than slowing or stopping breathing.