Ronald Barentsen, MD, PhD

During a gynecologic consultation my patient, Mrs. Andersen age 48 years was distraught and asked me for advice. She was worried about her mother, but also about herself. She was very concerned and proceeded to explain in detail the current situation.

She believes her mother is probably suffering from osteoporosis

. Mother had experienced a forearm fracture more than 10 years ago, at the age of 63, and recently she suffered a hip fracture. She had been operated on for the fracture and was recovering very well. Her mother’s physician had told her that at her age (75), there is no way to prevent more fractures other than take measures to diminish the risk of falling. My patient, Mrs. Andersen has heard from her friends that osteoporosis has strong genetic influences and she is also worried that she will have fractures in the future too. Her question is, "What can I do to prevent what happened to Mother from happening to me?"

Questions like this are not uncommon in daily practice. With Ms. Andersen a generally accepted risk factor was involved (the genetic factor), but sometimes the same question arises just because a woman is concerned about her health. For a proper answer, you need more information about her fracture risk, so an inventory of risk factors is the first step.

Mrs. Andersen. is a Caucasian woman and her mother has had multiple fractures. She has a dietary intake of calcium with 2 portions of milk each day. She is non-smoking with average exercise. Her menarche was at 14 years, she has 3 children, and she was usually regular menstruating until recently. During the last year, her periods became more irregular and her last menstrual period

Weight 148 lbs. (67 kg). Height 5’5" (1.68 m). No disease, no drug therapy.

The history reveals no risk factors other than the genetic one and perhaps a smaller intake of calcium than advised.

What to advise her? Two important measures serve general health and can always be advised to women: to increase the daily intake of calcium to at least 4 portions of dairy products (eventually as calcium supplements) and somewhat more exercise. You can advise women who are at very high risk to start hormone replacement therapy or bisphosphonates, but when available, measurement of bone mass is the best next step.

Complaints/symptoms of possible osteoporosis

Impression of osteopenia at a X-ray investigation

Bone mass measurement was subsequently done on Mrs. Andersen both at the lumbar spine and at the proximal femur with DXA.

Result: Bone mass - L1-L4: 0,83 g/cm2: T: -1.7

As it turns out Mrs. Andersen has osteopenia. This is a clinical definition. But her personal concern is what can she expect in terms of fractures? There is a strong relationship between bone mass and fracture rate. It has been calculated that the fracture risk doubles with every standard deviation below the mean. So a woman with a bone mass of T=-1 has twice the risk of a woman with a bone mass T=0. And the lifetime risk of a woman at the age 50 for one or more fractures is nearly 40%. With a T-score of -1.7, her risk will be increased substantially.

Mrs. Andersen is still premenopausal, perhaps perimenopausal. After menopause one can expect that her bone mass will decrease within 3-5 years by about 15%. This amount is about 1 standard deviation. Her bone mass will decrease within a few years to a level of T –2.7 in the lumbar spine and a level of -2.4 in the proximal femur. After that first few years the decrease in bone mass will continue at the rate of 0.5% each year. Mrs. Andersen will certainly suffer from osteoporosis in about 5-10 years unless action is taken.

There are several options available nowadays.

Prevention of bone loss is achieved with adequate hormone supplementation from the moment that the ovaries cease their activity, so during perimenopause or shortly after menopause. With an adequate amount of estrogen, bone mass will remain unchanged and consequently fracture risk remains the same. For optimal results, one has to continue the hormone supplementation for at least 5-7 years. It is proven that with such therapy the number of fractures decreases significantly.

Recently bisphosphonates have been introduced in the prevention of osteoporosis. Before, these substances were used only in established osteoporosis after the occurrence of fractures. With the bisphosphonates, bone mass can be maintained for many years and we can expect that the number of fractures will decrease subsequently, but this outcome (less fractures) has yet to be proven.

In some countries the new "selective estrogen receptor modulator", raloxifene has been introduced recently for the prevention of osteoporosis. The experience is limited, but the expectation is that the effect on bone mass will be the same as that of estrogen.

First of all, we have to counsel Mrs. Andersen about the natural course of her bone mass and the risk of fractures. It is always difficult to speak in terms of risk. With severe osteoporosis, it is possible that no fracture will occur and with normal bone mass, a fracture is not impossible, but Mrs. Andersen has a substantial risk to suffer from one or more fractures in the future. She can diminish her risk. First of all, with some general measures: a change of her lifestyle with more physical exercise, preferably in the open air (vitamin D!) and increased intake of calcium to 4-5 portions of dairy products every day (or calcium supplements of about 1000 mg).

Secondly, medication has to be offered: estrogen/progestagen supplementation or bisphosphonates. For the definite choice, one has to consider the other benefits of hormone supplementation, such as the decrease of cardiovascular disease and the effect on dementia, but also the possible increase in risk of breast cancer, especially in long-term users. In addition, side effects such as withdrawal bleeding should be discussed. The most important point in this decision process has to be the proven effect of HRT on the number of fractures. On the other hand, with bisphosphonates, the side effects are rarely seen. But the ultimate proof of benefit after many years has yet to be found.

After counseling, Mrs. Andersen decided to start with HRT at least during the first few years. Her opinion was that she could always change to bisphosphonates if the treatment with HRT becomes problematic and she has no risk factors for breast cancer.

She will start therapy soon because we considered her already perimenopausal. A simple urine test that measures bone breakdown (resorption) can be done as soon as three months after the commencement of her treatment to make sure it is working. Then, after 2-3 years of treatment, bone mass measurement will be repeated to monitor the treatment.

Mrs. Anderson is satisfied with this course of action but still concerned for her mother’s prognosis. She comments on the fact that the type of information and treatment options offered to her were not available 30 years ago to her mother. "If they had been", she muses, "Perhaps Mother would be out enjoying herself instead of recovering from hip surgery." She is more than likely correct. 

Articles

Like Mother, Like Daughter

The relationship of sex hormones and breast cancer is a matter of concern of many women. Breast cancer is the most common form of cancer in women in industrialized countries. Approximately one in every 10-12 women develops this disease during her course of life, sometimes before menopause (25%), but mostly after menopause. Many studies with conflicting results have investigated the relation between hormone replacement therapy (HRT) and breast cancer. The overall opinion was very confusing and publications in lay press underlined more often the studies that published an increase in risk than studies with less spectacular results. During 1997 a excellent paper was published that combined all earlier studies, but the paper contains an enormous amount of data and is very difficult to read even for doctors. This contribution to 

 describes what really is known about the risk of breast cancer

 by the use of HRT based on the publication by: "The Collaborative Group on Hormonal Factors in Breast Cancer" in: Lancet 1997, volume 350, pages 1047-1059.

The authors have carefully searched the literature for all studies concerning the relation between risk of breast cancer and HRT. They included all studies with at least 100 women with breast cancer and clear information on the use of HRT and on other factors related to reproduction and the menopause. They were rather successful and they give details on 63 eligible studies. Thereafter, the authors have retrieved all original data of those 63 studies. Unfortunately, for ten studies original data were not available anymore and one group with 2 studies declined collaboration. Ultimately, detailed information was available from 51 studies of 52705 women with breast cancer and 108411 women without breast cancer.

This enormous amount of data is described in the paper in The Lancet, but only experts with a thorough knowledge of epidemiology and statistics can read it easily. So is the cumulative incidence of breast cancer increasing with age, but at the same time the relative risk decreases with time since menopause. Furthermore, many variables are interdependent.

To calculate the risk of HRT, the authors have constructed a model with all other factors constant. In this model age at menopause is set on 50 years and the cumulative incidence of breast cancer is calculated for women never using HRT and for women using 5 or 10 or 15 years of HRT.

The results are demonstrated in the figure.

On age 45 already 10 of 1000 women have acquired breast cancer and at the estimated age of menopause (=50 years) this number increased to 18. Without use of HRT 77 of every 1000 women will have diagnosed with breast cancer on age 75 and probably more of them when they become older. This number of breast cancers is represented in the figure with the blue line: the incidence without any exogenous hormonal influence.

With the use of HRT during 5 years, from 50 to 55 years, there is a very small increase in the calculated incidence of 2 extra breast cancers in 1000 women using HRT during this 5 years: 40 women with breast cancer on the age of 60 years instead of 38 (red line in the figure). But this difference is statistically not significant: this means that there is no real difference in the number of diagnosed breast cancers in 1000 women never using HRT and in 1000 women using HRT during 5 years. So, short term use has no breast cancer risk.

With longer duration of HRT also the number of breast cancers increases. Ten years of HRT (from 50-60 years) result in the extra diagnosis of breast cancer in 6 out of 1000 women in this group (green line in the figure). Without HRT 77 cases of breast cancer will be diagnosed in 1000 women, and with 10 years of HRT this number will be 83.

With 15 years duration of HRT the yellow line in the figure has to be followed. And this ends with an excess of 12 women more with breast cancer at age 75 than without HRT: 89 per 1000 women instead of 77 per 1000. 

Do these data prove that HRT causes breast cancer? No, because this kind of research can only demonstrate that a relation exists, but not if this relation is causal. The possibility of better surveillance, more frequent palpation of the breasts, more mammographies in HRT-users as consumers more concerned with their health than never-users still exists. An argument for this so called healthier user effect is the observation that breast cancer diagnosed in HRT users is often more localised and has a better prognosis. This problem will only be solved by randomised trials. Such research is on-going: the Women’s Health Initiative. But the first results are not available before the year 2006. In the meantime, it is prudent to consider the small increase in number of breast cancers in HRT-users as a unwanted side-effect. On this moment most medical professionals have the opinion that breast cancer is not caused by oestrogens. In fact, the lesion starts as early as the second or third decade of life. But oestrogens can definitely promote the growth of an existing small breast cancer.

There are several other conclusions to drawn from the paper in the Lancet.

The central hypothesis of the model described above is an age at menopause of 50 years. But the authors have also calculated the number of women with breast cancer with a menopause at age 55. These women have endogenous production of oestrogens during 5 years more than women with menopause at age 50. Comparing both models, one can conclude that one has to calculate not only the duration of use of HRT, but the total number of years with endogenous and exogenous oestrogens together. So, women with menopause at age 55 have the same number of breast cancer with 10 years of HRT use as women with menopause at age 50 and 15 years of use of HRT. This is good news for women with an early menopause. The length of use of HRT in terms of breast cancer has to be calculated from age 50 and not from their earlier start: only the total number of years of endogenous and exogenous oestrogens count.

The small increase in the incidence of breast cancer in long-term users of HRT should be considered in the context of the benefits of HRT. Long-term use is indicated for the prevention of serious disorders as osteoporosis and cardiovascular disease (and perhaps also useful in the prevention of dementia). Only in women without any risk factor for these diseases and especially for cardiovascular disease, the excess of breast cancer is of real importance in terms of cost-benfit calculations. But for some women a small increase in the incidence of breast cancer is so terrifying, that they accept the probability of an earlier (premature) cardiovascular death.

The relationship of sex hormones and breast cancer is a matter of concern of many women. Breast cancer is the most common form of cancer in women in industrialized countries.

Breast Cancer and Hormone Replacement Therapy

 I am an Ob/Gyn and patients are asking me for "Natural Estrogens" and natural progesterones for HRT.  They understand the studies are not as complete as other HRT medications but desire to stay away from Premarin.  Could you please discuss these medications and their use in HRT?
 
    

The         request for "natural hormones" is nearly universal. But there         is a lot of misunderstanding regarding this idea. What is natural?         Compounds derived from nature? Or compounds from pharmaceutical         companies that are structurally similar to hormones produced by the         ovaries?

Premarin is a mixture of many compounds,         estrogens progestagens and even androgens. It is derived from the urine         of pregnant mares and contains mainly oestronsulphate but also equilines         that are natural for horses but not for women. The estrogen activity of         equilines is about the same as estradiol. So no difference in activity         but difference in source.

Natural estrogens (in women) are estradiol and         estron. Micronized estradiol is a very popular prescription in Europe.         With oral ingestion of estradiol, the estradiol is converted in the         intestine to estron and absorbed as such and during the passage through         intestine and liver most of it is converted to estronsulphate.         Estronsulphate is the pool for the active compound estradiol. So, no         difference in the end result with estronsulphate tablets and micronized         estradiol. Is estronsulphate now a natural estrogen or not?

In premenopausal women the estron:estradiol         ratio is about 1. With oral estrogen medication there are much higher         levels of estron than estradiol. Is this natural? With transdermal         estrogens, estradiol is absorbed through the skin and partly converted         to estron. The ratio estron:estradiol is about 1, just as before         menopause. This looks much more natural than all other ways of         administration. 

 The same is true with progesterone. The only natural compound is progesterone. But         this is absorbed very poorly both in the intestine and through the skin.         Nowadays we have special products with micronized progesterone with a         reasonable absorption pattern (Prometrium). This product is expensive         and high doses are needed, and can cause sedative or  hypnotic side effects. Because         of the rather bad properties of progesterone in the early days,         progestagens were developed with the same activity as progesterone, and         several other activities. These are not natural progestins. 

         Progesterone is also developed in a vaginal cream with good absorption         pattern (Crinone). The natural progesterone creams (very popular among         women) give no measurable progesterone levels in serum and are not         protective for the endometrium.

Herbal remedies for perimenopausal symptoms is         something for believers. The use of herbal remedies can be compared with         religion. No proof, but many know for certain that it works. As an obgyn         specialist in gynecology, I limit my comment to proven remedies. Only         with red clover (and only with one brand, Promensil) a proof of benefit         for hot flushes exists. When you wish an overview of non-western         medicine you have to consult an alternative practitioner.

Alternatives         to Menopause Management

reprinted with the kind permission from         Andrew         Dott, MD, MPH 

What         are the sources of widely used estrogen?

Menopause         & Perimenopause Ask the Expert Archives

The request for "natural hormones" is nearly universal. But there is a lot of misunderstanding regarding this idea. What is natural? Compounds derived from nature? Or compounds from pharmaceutical companies that are structurally similar to hormones produced by the ovaries?

A Discussion of Natural Hormones

An excerpt from the Menopause & Perimenopause

An excerpt from the Menopause & Perimenopause Ask the Expert column

Am           I experiencing Perimenopause?

How often do you find           cases of premature menopause?  I am 24 years old and have been           told that my ovaries have failed.  My doctor has recommended the           removal of my ovaries to prevent the possibility of cancer.  All           of this has been based on the testing of my LH and FSH levels...which           were elevated.  Is there something else that could be happening?             If so, what are the various possibilities?  I would like to           research different possibilities and treatments before I throw in the           towel.  When I was 19, I was diagnosed with polycystic ovarian           syndrome.  My current gynecologist has told me that this was           never possible without any explanation as to why.  Can you help?
 			
 			
           

 Premature ovarian failure (POF) is a much better           name than premature menopause in situations like this. First of all           the diagnosis has to be made           for certain. And a search for a possible cause has to be done. And not           only FSH and LH. You have to consult a reproductive endocrinologist.           And there is no reason for an ovariectomy in premature ovarian           failure. This is only the case in women with streak ovaries, and they           rarely have periods. POF has           no risk for malignancy.

Please be sure to check-out the           articles in the OBGYN.net 

             I am 67 years old and am having           severe and steady hair loss in the male pattern way.  I also have           had severe night sweats.  I have been taking Estratest for four           years and wonder if this is the problem.  (It was wonderful for           the libido and we were quite happy with it for some time.)           Gynecologist switched me to Prempro about two weeks ago at my request           (as I wondered about testosterone being the problem).  I read in           an ad for Prempro that hair loss is a side effect.  I am           wondering if I should just stop taking HRT completely.  My health           is good, weight just a little high.  I was also taking St. John's           Wort but stopped it months ago and hair loss still accelerates as well           as facial hair and acne.
  			

           

Testosterone           can induce hair loss in the male pattern way. And with stopping the           testosterone, this will stop also, but it is not reversible. You           cannot expect that hair will grow again on places where you have lost           it. Hair loss with Prempro is not an usual side effect, maybe it has           occurred sometimes but it is very rare.

Doctor, am           I experiencing Perimenopause?

 I           am 40 years old and have always had a regular, short (3 days) period.           I have now experienced a period that has been going on for 16 days.           Heavy the first few days, light in between and then heavy again.             I stopped in at a walk-in clinic, where they drew blood and did an           internal exam - the doctor said everything seemed fine and that I was           likely perimenopausal. What is your opinion and what, if anything,           should my next step be.

 One strange period is not conclusive for any           diagnosis. Wait for three months to see if your cycle is really           changed. At your age the start of perimenopause is quit possible and a           change of menstruation pattern is easily declared perimenopause.           Normal blood work does not allow definite conclusions, especially           hormonal values of FSH and estradiol can fluctuate. But a proper idea           can not be formed from one period. Wait and see what
           happens.

 I           am 42 years old.  My period has been flowing for the last 3 weeks           accompanied by lots of blood clots. I have had and endometrial biopsy           and fsh blood test.  The blood test was normal, however the           biopsy result was "proliferative endometrium".  I have           been given Provera, but have not taken it as yet because of the           horrible side effects that I've read about.  I have a strong           feeling that I have cancer of the uterus though my doctor has ruled           that out.  If I'm approaching menopause, why was my fsh level not           consistent with that?

 An endometrial biopsy rules out malignancy. The           diagnosis is proliferative endometrium and the history of 3 weeks           bleeding suggests strongly annovulatory bleeding. The treatment of the           condition is a monthly course of progestagens during 12 days. With           horrible side effects with Provera, an alternative can be Prometrium           200 mg every evening during 12 days a month or birth control pills.           FSH can fluctuate enormously and normal values are alternated by high           values. A normal FSH is not reliable to rule out perimenopause.  

I am 43 years old and am           having symptoms such as night sweats and during the day I have this           warmth that feels like I have just put on a pair of slacks that have           just been ironed. This warmth seems to affect my thighs and moves up           my body to my face, where I then seem to break out in a small sweat. I           seem to even have some sort of rash on my thighs prior to my period.           My periods have always been sort of heavy especially on the 2nd and           3rd day of my 5 day period. I normally have to wear a tampon and pad           that I have to change at least every 1 1/2 to 2 hours. I also have           breast tenderness 1 week before my period and as soon as my period           starts, the next day my breasts stop hurting. I also get leg cramps as           well as aching. Sometimes I feel like something is crawling on my           skin, especially my arms and legs. Lately I've even begun to           experience retaining water in my ankles during my period, which I had           never had a problem with and some anxiety. Do you think with these           symptoms this can be a sign of perimenopause?

 These           symptoms are very atypical and I can not categorize them as typical           perimenopausal. There are several possibility for heavier periods           especially at your age and an investigation for the increased blood           loss has to be done if it disturbs you or if it causes anemia.           Furthermore some premenstrual syndrome symptoms can be recognized.           With this complex set of symptoms you can better consult a           gynecologist.

I           am 45 years old.  My periods have gotten much lighter and           shorter. They're completely over in 3 days.  Six months ago           I had a vaginal sonogram and found nothing.  I have pap smears           every 6 months.  This month I'm experiencing bleeding again on my           18 day of my cycle.  My doctor said it could be because of           perimenopause.  Is that true?  Can stress cause this           condition also?  I also had one ovary removed in 1993 because of           an ovarian cyst.  I feel confused a lot lately and have become           extremely emotional and irritable mid-month and also before my period.             I am very forgetful around the house.  I sleep extremely well,           but dream am awful lot.  I wake up exhausted everyday, even after           8 or 9 hours of sleep.  Are any of these symptoms perimenopausal?            Do you have any other helpful suggestions?  At the moment, I            do not take any vitamins or supplements.  Can you suggest any?             Thank you for your help?

 You have           had a bleeding starting on day 18 of your cycle. This is the first           time that it happens. No one can tell you how the periods will be in           the next months. One strange period can occur also with stress           situations, but maybe this is the start of irregular perimenopausal           cycles. Wait and see.           Emotional disturbances can have many reasons. The climacteric           transition is only one of them. When you have serious ideas that           hormonal changes attribute to the emotional instability, then you can           try oral contraceptive birth control pills. This will regulate your           cycles and the hormonal balance is more constant. Discuss this with           your gynecologist.

I was wondering if there           is a certain time of the month to have the blood work done. Should it           be before, during or after the monthly cycle?

 It depends of the kind of blood work. Looking for           FSH as measure of ovarian reserve the best time is day 2-3 of the           cycle. Looking for progesterone has to be done in the second half of           the cycle. But most time there is no need for any blood work.

I have bouts of frequent           urination without pain, I went to a urologist and he told me it could           be a sign of perimenopause. I am 43 years old, there is never any           bacteria in my urine. Is this a sign of perimenopause? My blood sugars           are normal also.

 No, this is not a           sign of perimenopause. Micturition problems connected with menopause           are the results of a deficiency of estrogens and that is seen only           months after the last menstrual period.

Please           be sure to check-out the OBGYN.net 

I am 44 years old and for         the first time missed a period in November. My doctor did a blood test         that show LH 19.4, FSH 44, And estrodiol of 43.5. In August I had a         miscarriage at 9wks. Did I go straight to menopause? Does the use of         fertility drugs such as repronex and hcg shots hasten the menopause         process? Do I need to use birth control? Please explain what these         numbers mean.
                      
 			
           

 These         numbers indicate perimenopause. You can expect irregular periods and         maybe it will stop. But the possibility exists also that normal regular         periods return for a while. With FSH and estradiol you can not predict         the future, you can say something about the ovarian status at that very         moment. Fertility drugs do not hasten the menopause process. And birth         control pills are advised until 12 months after the last menstrual         period.

I am 44 and have            missed one period then bleeding heavy for 6 weeks. Had a gyn           office visit in which they did an ultrasound and many blood tests all           of which came back negative. Doctor prescribed  Loestrin birth           control pills to stop bleeding. Triple pills for 3 days, double pills           for three days, then 1 each day. Bleeding appeared to have stopped for           a week. I am on one pill a day now for  a week and bleeding is           very heavy again.  Doctor did say I was perimenopausal. Is there           something I can take that will work-anything natural-am I missing           something in my diet? I am in perfect health and did exercise until           this heavy bleeding occurred?

The           treatment that was given to you is a well known treatment for stopping           so called dysfunctional bleeding. Bleeding that starts after an           annovulatory cycle. Usually the high dose of 3-4 pills every day is           maintained for 5 days, and then stopped. During the course of           treatment, bleeding stops and after the course a withdrawal bleeding           starts. With lowering the dose as in your case, sometimes new bleeding           starts because of the decrease of the dose. The best thing to do is:           stop the pills now and start again with one pill a day for a week. At           the age of 44, every irregularity in the cycle has to do something           with perimenopause. That is a natural happening and has nothing to do           with disease or illness, so nothing in your diet or lifestyle. This           happens sometimes. That is all.

I am 38 years old, and           for the past 6 months have been having hot flashes at the beginning of           my menstrual cycle, i.e., day 3 until about day 16 ....they are worst           in the morning, and are accompanied by a rapid heartbeat, which wakes           me up too early and often prevents me from resuming sleep. I am also           very tired and have no appetite. Are these last 2 symptoms           inconsistent with perimenopause?
           



These           symptoms are very consistent with depression.

 In the last year, I have developed tinnitus.            I am 48 years old.  I know several women in the forties and early           fifties who have also developed tinnitus.  We are wondering if           there is any connection to perimenopause/menopause?  Has any           research been done on this.  If so, where can we read more about           it? 
            

           

Tinnitus           is not known as symptom of perimenopause or menopause. In fact, the           scarce literature on this connection describes more problems in           premenopausal women than postmenopause.

I am a 48 year-old female           who is trying to get pregnant.  I am remarried and my periods are           still regular although sometimes they last a few days longer--but are           no heavier.  My husband has only one child from a previous           marriage and would love another with me.  I don't really have any           signs of perimenopause except maybe now and again I get a little warm.           Is it still possible for me to become pregnant on my own?  Are           there any natural remedies to help the process along that are safe? We           are both very healthy and I have 4 children form a previous marriage.
 			

            

The           oldest woman with a spontaneous pregnancy and a healthy child is           recorded at the age of 56. So there is still a possibility for           pregnancy, but the change is low, very low. Also with artificial           procedures the chance is very limited.

           I am a 43 year old women and have been experiencing severe           night sweats, hot flashes and mood swings over the past 2 years.            My periods have become much heavier and further apart by as much as a           week, but I have not missed any.  Could I be in perimenopause           even though I still have periods?  My mother had her period until           she was 63 years old. Could I be in for the same?
  			

          

Yes,           you can be in perimenopause. It is not necessary to miss a period. The           change of the periods indicate that perimenopause is likely. No one           can           tell you how many years perimenopause will stay. The mean duration is           4 years, but also 10 years is possible. The age at menopause for your           mother is an indication for you but not as absolute as you might           think. For large numbers of women the relationship
           between mother and daughter is clear, but this is not true for the           individual. And 63 is one of the latest.

I had a hysterectomy,           with both ovaries left in place about 4 years ago. The surgery was           done to alleviate heavy bleeding, a retrograde and prolapsed uterus,           ovaries that were extremely low placed, and  endometriosis.            I am 38 years old.   I have periods of time when I           experience extreme hot flashes, I am so drenched at night that I can           wring out my clothing.  I have dizziness a lot along with severe           headaches.  For the first time in my life, I am experiencing high           blood pressure.  My ob/gyn's nurse called me with my test results           and told me that I am going through menopause.  I called the           doctor and she said that I  am not.  She feels that I will           go through it sooner than most people. She did blood work and a pelvic           ultrasound for pain and bloating.  These were the results:             right ovary was 38 x 26 x30mm with a simple cyst of 18 x 16 mm; left           ovary 34 x 20 x 31mm with multiple small cysts largest lcm; estradiol           42 and FSH 6.8 and TSH 0.49.  She has recommended calcium           supplements and estrogen replacement.  Could this be           perimenopause or could by the cysts be causing the symptoms?
 			

           

  The lab work-up does not           indicate perimenopause. I agree with your doctor on that. But I wonder           why estrogen replacement is necessary. You can try it because of your           hot flashes. When the symptoms are not cured within 2-3 months,           consider another cause for your symptoms than estrogen depletion.

            for more information about your question.

   I have been taking Prempro for seven months with no side effects except for  frequent spotting.  Recently I have developed discomfort in my legs,  particularly my calves and sometimes feel a bubble sensation.  I want to  continue with HRT because there is a history of osteoporosis in my family and  can tolerate the discomfort if it isn't a danger sign.  Could this feeling  be related to the HRT?           
           
 			
           

 One           of the side effects of HRT is an increased risk of thrombosis. The           risk is 2-3 times higher than without HRT, but still very small in           healthy women without own or family history of thrombosis. Maybe it is           prudent to consult your doctor to rule out the possibility of calf           vein thrombosis.

           I am 65, and have suffered 3 months with an ovarian cyst.              Ca125 benign, 2 ultras, simple cyst found which is golf ball size.             Two major surgeries: one hysterectomy, one hirshcsprungs. One specialist.           says laparoscopy with risk because of surgeries.  One specialist           says transvaginal aspiration.  95% sure not malignant.  I used           very sparingly over 3 yr. period Premarin vaginal cream.  Two           docs say this caused cyst.  One says no.  If not, what           would?  I need an opinion on type of procedure to aspirate it.           
            
 			
           

 I           am another specialist with my own opinion without seeing the patient.           So, my opinion will not be the most important of all these views.           Premarin           vaginal cream does not cause cysts. I agree with extra risk with           laparoscopy because of earlier major surgery. Aspiration will usually           be followed by new           filling of the cysts but you will have cytological test of the           aspiration fluid and diminish the change of malignancy further. My           advice is: do nothing at all. Wait for 3-4 months and have a vaginal           ultrasound again to see if there is any change (increase). Perform           aspiration when changes occur. Maybe the cysts have been there for           many years! We see them often after hysterectomy.

           I am menopausal, 52 years of age.            Hot flashes and all.  I was using HRT, and did not want to           continue, first, because of the side affects, and secondly, because I           still had periods.  I changed jobs and doctors and was given           samples of Tri-Est to take for a month.  It does help reduce my           hot flashes, although I still have a couple a day, but I can deal with           that. My question is whether or not there are any complications that           could arise from using this particular formula?
            
 			
           

 Tri-Est has the           same activity, benefits and side-effects as all oral estrogen tablets.           It is a combination of estradiol, estron and estriol. It has no proven           extras compared with other estrogens.

I           am 56 years old postmenopausal woman, I am  on the climara           patch 0.1 mg. I feel an imbalance. I would like to try the natural            progesterone cream.  Can I use them at the same time?
            
 			
           

 I suppose that           you have had a hysterectomy. Because Climara contains only estrogens.           With an intact uterus you need progestagens too. For a good choice it           is important to know the indication of the hormone use. Why did you           started the Climara patch, and why this dose? Progesterone cream has           no proven value, although many women use it. Progesterone cream can           NOT be used as the necessary addition of progesterone or progestagens,           because the absorption of the progesterone from the cream is too low           for endometrial protection.

Do you have any data on           micronized prometrium at the normal dose as it pertains to changes in           the lipid profile or bleeding incidences.  I'm particularly           interested in changes in HDL, LDL, total cholesterol and triglycerides. As           far as the bleeding profile, do you have any studies that speak to the           incidence of breakthrough bleeding or amenorrhoea.
 			

           

The normal           dose of Prometrium is 100 mg daily with continuous use and 200 mg with           sequential use. With this dose there are no changes in lipids. The           beneficial effect of estrogens are not counteracted by progesterone.           The bleeding profile and the number of women with amenorrhoea is not           different from other progestagens. This depends on the dose of           estrogens and the regimen chosen: sequential combined or continuous           combined. With sequential combined regimen 70-95% will have withdrawal           bleeding. And about 10% will have breakthrough bleeding. With a           continuous combined regimen 40-50% will have breakthrough bleeding           especially in the first 6 months.

             I had a total hysterectomy           three months ago and am not on any HRT at this point.  I had a           few hot flashes and night sweats but those seemed to have stopped. I           am taking calcium for my bones and have low cholesterol right now.            I take a multiple vitamin and vitamin C. My reason for not taking HRT           is that I have cystic breasts. What are your feelings about not taking           HRT?  I would really like to find a doctor that talks about           alternatives to HRT.  I am so frustrated.  I am wondering if           I should be on something but am afraid to go on HRT because of the           breasts and increase in breast cancer. Any light you can shed on this           would be appreciated.
 			

           

There is           no reason to take estrogens after hysterectomy. Your ovaries are still             producing hormones. And a short period of hot flash after           hysterectomy is seen very often. Reasons to take estrogens are:           climacteric complaints, or preventive           indications like low bone mass or high risk of cardiovascular disease.           As every woman you have to make up your own risk profile for           osteoporosis and myocardial infarction. With high risk you have to           consider the possible actions and among them estrogens have a role.           But because long term HRT is necessary in prevention you have to           calculate also your breast cancer risk and finally after considering           all these aspects, you can choose for yourself whether to take           estrogens or not.

            I am 42 years old and perimenopausal.             After talking to my doctor, I asked for climara patch 0.05 mg.            He suggested that I also take progesterone also. I have regular           periods monthly, with heavy bleeding.   I also have fibroids           that I may have to have removed. How can I find more information on           progesterone?  Why do people/doctors say that a perimenopausal           women on estrogen should take progesterone too?  Isn't            progesterone taken only to make sure you shed (bleed) each month?             If you already do that naturally, why take hormones to do it?             I am exercising and dieting (eating sensibly) and am fearful that the           progesterone will make me gain weight.
 			
 			
           

Progesterone           or progestagens are necessary to inhibit mitosis in the endometrium           and to decrease the risk of cancer. During perimenopause the problem           is usually not a shortage of estrogens but a shortage of           progesterone. Most perimenopausal women, and especially in early           perimenopause, have more than enough estrogens. With regular cycles           and vasomotor complaints low dose estrogens without progesterone is           acceptable. But with higher dosage (and also Climara 50 belongs to the           higher dosage) additional progestagens are necessary for protection of           the endometrium. Your Climara gives extra estrogens to an already           proliferated endometrium and that is the reason probably of the heavy           bleeding. Are extra estrogens really necessary to you or will all your           symptoms disappear with only the addition of progesterone during days           15 to 26 of your cycle?

            When does a woman absolutely           HAVE to stop taking birth control pills? Can I just stay on Lo-Ovral           forever? I am a non-smoker, not overweight, do aerobics on a daily           basis.  I will be 50 next summer.
  			

           

There is           no absolute moment to stop birth control pills. The question is: are           they still necessary for contraception. The risk for thrombosis and           cardiovascular disease with contraceptive pills must be taken into           account. The risk of thrombosis is the same with birth control pills           and HRT. The risk           of developing cardiovascular disease is slightly higher with           contraceptive pills, but remains very low in non-smokers. This very           small cardiovascular risk is the reason to advice the change to HRT.           But other circumstances can be taken into consideration and when your           low-dose pill fits much better to           you, go further with it. After 56 no spontaneous pregnancy is seen.           And with age cardiovascular risk increases. And there is no data for           women using           pills in that age group.

           I am 47 years old & have been on the Climara           .025mg patch for 2 years. I recently moved and have a new doctor and           he has taken my off this patch, saying he thought I was too young.            My symptoms before the patch was prescribed were occasional "hot           flashes," lack of concentration, emotional uneasiness, and my           periods were & still are a little irregular but not extreme.            The patches seemed to help a lot with these symptoms before. Do your           estrogen levels decrease more than normal at certain times -- before           your menstruation-after menstruation? Are there any herbal or           over-the-counter products you would recommend I buy to help alleviate           some of these symptoms?
            
 			
           

I           do not understand that your new doctor can take you off your           medication. He or she can give you his/her opinion about that, explain           why this is prudent or not, and ultimately the woman herself decides           what she wants to do. That is the way we handle this kind of problem           in my country. Low dose estrogens can be helpful especially in the           early phase of           perimenopause. And as you can learn in many questions and answers in           our columns, age is not a criterion. Estrogen levels in a normal           menstrual cycle fluctuate. They rise in the early follicular phase.           There is a small decrease before ovulation, a new rise during the           luteal phase and a decrease at the end of the luteal phase to start           again the increase of the early follicular phase. Be aware that during           perimenopause this pattern can be changed when ovulation problems           occur. Some women experience good results with black cohosh for this           kind of problems. You can try that when you agree with your doctor not           to take the           low dose patch.

            I am 42 and am in the             stages of perimenopause. My periods became so irregular and heavy             that I opted to take Birth Control pills continually (not taking the             placebo). I am having extreme dryness, not only             during sex, but it is so bad I am uncomfortable all day.                       During sex, I am so dry             it is uncomfortable. We are using Astroglide which helps for             lubrication. But insertion is also painful - as if I have             "shrunk" and am too small? Also I always get fissures             (small tears) in the vagina area. And experience burning and rash             afterwards.
           
 			
            

  With birth control pills           vaginal dryness can occur but not as much as you describe. Maybe other           gynecologic problems are the cause. Lichen sclerosis can give this           problem too and that has to be cured with other medication. With this           complaint a gynecologic investigation and maybe a punch biopsy is           necessary to diagnose. Only when no other cause is identified and the           diagnosis is atrophy by birth control pills, you can try local vaginal           estrogens or a lubricants like Replens. But first of all a diagnosis.

Opinions expressed here are for educational purposes only and, as such, do not constitute and should not be interpreted as initiation of a physician-patient relationship. This information is not intended to supplant the need for you to consult with your physician prior to choosing therapeutic options and/or interventions. 

Are these symptoms of Menopause?Am I experiencing Perimenopause?What should I expect from HRT?

Ask The Expert

 Should a woman continue PAP tests after menopause?


 
 Menopause has nothing to do with cervical dysplasia or cervical cancer. The risk of cervical problems diminishes with age. Women with routinely normal pap smears and no risk of acquiring an STD (sexual transmitted disease), have no reason to continue pap smears lifelong. In the Netherlands, where I am based, we perform pap smears routinely for 5 years, and stop at the age of 60. In other countries, different advice is given.

I Along with my night sweats and hot flashs, I get adrenalin surges. A friend that had experienced the same thing explained her's a panic attacks. I have never read anything about this and my doctor didn't seem to know about this. I have tried HRT but was taken off of them because of possible blood clots problems. I had experienced leg pains. Have you any information of this or suggestions for possible treatment. I still am getting my period but it's very irregular, have high blood pressure prior to period for about two weeks, and am on Depokote for seizure treatment.
 
 

 
 
 Panic attacks can certainly mimic climacteric hot flushes. With a panic disorder many symptoms are seen that usually are connected with menopause: flushes, dizziness, anxiety, sleeping troubles, nervousness, lack of libido. Panic is one of the main diseases to consider when climacteric complaints are present in a young women with regular periods.

I am 35 years old and recently have been experiencing symptoms that are very much like those described as "pre menopausal". Some of them have become more severe in the last few months. I had my thyroid checked not long ago and it was fine, so I'm able to rule that out (my mother has a thyroid condition). I have been taking Minovral since last summer due to irregular periods (something I never had to deal with before I had my 4th child). My Doctor has told me that I can stay on the birth control pill indefinitely (even though I smoke). He said that birth control pills are now being used to help with perimenopause. I have 2 questions regarding this.
 
 1) Would my Doctor be able to tell if I am actually experiencing perimenopause while I am taking the pills?
 
 2) Just how does the birth control help? My symptoms are not any less than they were (except that my periods now come on a regular basis).
 
 
 

1) No, he cannot test for perimenopause while you are on birth control pills. But is this important? With the BCP there is an adequate hormone level, and the periods are regular. Perimenopause can stay for many, many years. The mean duration is 4 years, but more than 10 years is also possible. So, the mere knowledge of the existence of perimenopause (starting with irregular periods) has no meaning to the near future. 
 
 2) I do not know what your symptoms were. It is not known if those symptoms were really adequate enough to diagnose as perimenopausal. When symptoms stay during the BCP, one can doubt the connection of these symptoms with perimenopause.

HRT helps prevent heart disease in menopausal women. Does it also prevent stroke? I have a strong family history of both heart disease and stroke.
 
 


 There is at the moment a controversy over this topic. Theoretically, there is a base to believe that HRT prevents stroke, but there is no proof of that. Large epidemiologic studies have failed to demonstrate any beneficial effect of estrogen for stroke.

I am 50 yrs old and had a hysterectomy 2 years ago. 1 ovary was removed. After 2-3 months I was placed on HRT. (premarin). I had a constant problem with bladder spasm, sometimes so badly, that I could not control my urine. That was one problem. After about a year, I also started to develop redness and burning, swollen labia. Thinking that I was not getting enough estrogen the dose was increased from .625 to .9. This only exacerbated the problem. The premarin was discontinued, on the basis that it might be an allergic reaction, and I was put on Estrace 1mg. I still have the same problem. We then tried Estrace creme, which definitely worsens the problem. I have been so sore, that at times it was all I could do to get through work to come home and sit in a tub of cold water and just cry. I am almost in constant pain. I have tried oral HRT and patches in varying doses. There are times when I get relief and my doctor and I feel we have arrived at the correct dose, but then after a few days, or sometimes a week or 2 the problem is back (and NO I am not allergic to my soap! or my panties!, the times when I do experience relief, I am using the same products). Do you have any suggestions for me? I am so depressed, this is ruining my life, every aspect of it. My doctor has now referred to this as "burning labia syndrome", but it is not merely a "syndrome" - I have very obvious physical changes in my labia.
 
 Do you think it could be the estrogen? Have you ever known of maybe an excess of estrogen such as a "build-up" to cause this? I had been taking birth control pills (Ortho-Novum 1/35) for about 25 years prior to my hysterectomy,and I had no such reaction to them and no problems such as this prior to my surgery.

This is not a problem related to estrogens in my opinion. A diagnosis has to be made for further advice. I suggest an investigation by a dermatologist when the problem is on the skin or by a gynecologist with vulvo/kolposcopy when the problem is on the vulval or vaginal epithelium. With a biopsy and the help of a pathologist, a diagnosis can be made and adequate advice can be given.


 How do I handle vaginal shrinkage with painful intercourse even with liberal lubrication?

Painful intercourse is possible because of bad lubrication, but also because
 of contraction of the pelvic floor or by shrinkage by lichen sclerosis. In
 this question shrinkage seems to be the problem. A gynecological investigation is necessary to make a diagnosis so advice is not possible.

Should DES daughters avoid hormone replacement therapy?

Nothing is known about HRT and DES-daughters. We know that DES-mothers have a slightly increased risk of breast cancer (1.4x). But for DES-daughters this is not known. There is at this moment no reason to withold HRT for these women, but the prescriber must realize that this group of women has a profound mistrust of hormone therapy. As always, it is wise to ask about a strong indication for the use of HRT, and to discuss with the woman our lack of knowledge.

I would like to know what kind of a vaginal cream is good for dryness?

There are hormonal creams especially for postmenopausal women (e.g. premarin cream) but also nonhormonal such as Replens.

Should a woman continue PAP tests after menopause?