Three years ago, Karen Fraser*, 54, was waiting in a queue, when she suddenly started shaking and battling to breathe. She felt as if she was on fire. Terrified that she was going to pass out, she asked for somewhere to sit down.
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With iced water and a cold cloth in hand, she loudly complained to the concerned staff in the store about the malfunctioning air conditioning despite their reassurances that it was working. When she felt better, she left the shop without making her purchase. It was only when it happened again, and became more frequent, that she recognised what was happening: hot flushes.
What was embarrassing, she admits, is that she had believed she was well read about menopause, yet failed to recognise one of its best-known symptoms when it happened to her.
Eighty-two. That's the current mean life expectancy for women worldwide, according to Cape Town obstetrician and gynaecologist Dr Veronique Eeckhout - except in countries struggling with HIV, where this figure has plummeted to 35 in the last decade. This means that in developed countries women are living almost half their lives postmenopausally.
Despite the fact that our generation is so well educated, many of us, like Karen, still remain pretty much in the dark about what happens to us at menopause; about the effect of fluctuating hormones on mind, body and soul and the vital importance of taking charge, right now, of our changing bodies and lives.
In 2002, the Women's Health Initiative (WHI) study on the impact of hormone replacement therapy (HRT) had every woman running scared with its headlines about higher risks of breast cancer, heart attacks and strokes - most of which, we now know, were not put into proper perspective.
But the study put paid to what Dr Carol Thomas, a specialist gynaecologist in Cape Town with an interest in menopause, refers to as the routine reflex scripting of hormone replacement therapy (HRT), a one-size-fits-all approach.
The spin-off was very much along the same lines as the Pill scare of the eighties, which resulted in most contraceptive pills today being low dose by definition. These days hormone therapy (HT) is the preferred name for hormones available during menopause. The word "replacement" was dropped post-WHI in order to distinguish HT from HRT, as the aim is not to replace the levels of pre-menopause, but to use for the shortest possible time the lowest effective dose of hormone that will control your symptoms and prevent osteoporosis. This has now been increased from five to seven years and, depending on individual risk assessments, may mean anything up to the age of 60.
Menopause is no longer regarded as the end of the road. It has come out of the closet, thanks to productions such as the hilarious Menopause the Musical and women like Coletta Canale, 49, a Capetonian who threw a menopause party to celebrate this rite of passage instead of feeling apprehensive or uncomfortable about getting older.
Right now menopause management focuses on making lifestyle changes to alleviate symptoms, cautiously giving alternative therapies a try, and only then making an informed decision about HT. Today's the start of the rest of your life: it's up to you to make wise health choices to ensure your emotional and physical wellbeing in the (many) years ahead.
THE BIG QUESTION Q Am I going to have the same menopause symptoms as everyone else? A Think back to the days when you first started having your period and discussed your experiences with your friends. Everyone was different: some cramped, others bled heavily and a few turned into such pains in the butt around that time of the month that you avoided them at all costs! That's exactly what happens during menopause, says Dr Eeckhout - the only thing you and your friends will have in common is that it will happen to you all.
Symptoms differ from woman to woman: some start with irregular cycles over two to three years; others have regular cycles and then an abrupt cessation of menstruation. Hot flushes come and go - for a lucky few, they never arrive. Night sweats, irritability, moodiness and even depression; an increase in abdominal girth or weight gain; increased or decreased libido and vaginal dryness; bladder symptoms or recurrent urinary-tract infections are all symptoms you may or may not experience at the average age of 51,8 years.
One percent of women experience early menopause or premature ovarian failure before the age of 40 and officially you only reach menopause one year after cessation of your last period.
HOT FLUSHES QWhat exactly is a hot flush? A While the Americans are the only people in the world to call this event a "flash", says Dr Thomas, your first hot flush may indeed be a "flash" - a newsflash of quality-of-life-altering significance. It's a sensation that starts from the neck up, lasting from 30 seconds to a few minutes, and because your heart and pulse rates increase, you may also experience palpitations.
It's the most common and often the earliest symptom of menopause other than a change in your menstrual cycle. Why it happens is not fully understood, but current theories suggest that a decrease in oestrogen levels affects the hypothalamus in your brain, your body's temperature regulator. During a hot flush, the hypothalamus senses that you're far too hot even when you're not, and tells your body to release excess heat. When this occurs at night it's often called night sweats and contributes to insomnia and subsequent daytime tiredness.
Hot flushes affect about 85 percent of women during the years immediately before and after menopause. The good news is that they do tend to run their course. It may seem so at times, but hot flushes don't last forever!
RESCUE REMEDY
Worried about having hot flushes in the workplace? Avoid these common triggers:
Caffeine
Spicy foods
Tight clothing
Heat
Cigarette smoke
MOOD Q I seem to be grumpy so often these days. Why? A Some women may be particularly sensitive to the fluctuating hormone levels that may be responsible for these emotional whirlwinds, explains Johannesburg gynaecologist Dr Trudy Smith, but this time in your life may also be associated with sleep deprivation due to hot flushes or changing sexual patterns due to untreated vaginal atrophy. Then there are emotional issues you need to deal with, such as children leaving home and fear of ageing.
There's no doubt that exercise and diet help to curb mood swings. If you have a history of mood disorders, be sure to tell your medical practitioner about this up front. While women are twice as likely to suffer from depression as men and this is usually diagnosed before 45, there are women who experience depression for the first time at menopause.
Some drugs used to treat depression, such as Venlafaxene and Paroxetine, have the added advantage of decreasing hot flushes.
IMPROVING MOOD AT MENOPAUSE
Decrease your caffeine and alcohol intake.
Increase your level of exercise.
Increase your intake of natural complex carbohydrates and dairy products.
Increase your exposure to natural light, i.e. moderate sunlight, instead of artifical light.
SEX Q Most women say they lose interest in sex during the menopause transition, while a few say they enjoy it. What can I do to be in the latter category? AResearch shows that the state of your relationship and your mindset at menopause has a much greater impact on your sexuality than what's happening to you hormonally, says clinical sexologist Dr Marlene Wasserman.
So if your marriage or relationship is unhappy, if you're battling with empty-nest syndrome or the thought of ageing, or if you're depressed and taking antidepressants, chances are you're not going to feel very sexual. Of course, hormone changes play a big role.
Lowered oestrogen levels result in vaginas that are dry, which, coupled with hot flushes, mood swings and erratic periods, don't exactly put you in a sexy frame of mind. HT does help with your libido and there are safe, localised HT creams or gels that can be inserted vaginally if you're not an HT candidate. It's normal to experience a loss of desire as you age but your sexuality still remains a case of "use it or lose it".
To enjoy sex at menopause, communicate honestly, be sexual as often as possible, pay attention to your relationship, focus on foreplay, use a good silicone lubricant and, most of all, have fun!
DIET Q I've never had a weight problem but I've recently found that despite eating the same amount of food and exercising as usual, I am putting on weight, especially around my middle. Is this menopause-related? A We're back to oestrogen again - a lower production of the hormone at menopause goes hand in hand with a reduction of cellular sensitivity to insulin, says Johannesburg dietician Anne Till. What this means is that your body's cells need more insulin to clear glucose than they previously required. High insulin levels in the blood are associated with increased fat storage and a reduced ability to burn fat for energy, resulting in abdominal fat deposition and a disappearing waistline.
This has serious consequences because, aside from not looking good, your tummy tyre is also associated with an increased risk for chronic diseases such as diabetes, coronary heart disease and high blood pressure. What all of this means is that as you get older you have to work just a little harder in order to remain healthy.
So increase the amount of exercise you do and adopt a low insulin-producing diet that is kilojoule-controlled. Choose loads of fresh vegetables and salad; wholegrain foods; controlled amounts of unsaturated plant fats such as avocado pears, olives and nuts, fatty fish such as salmon and mackerel, which are valuable sources of omega 3 fatty acids, and lean protein foods such as skinless chicken and fat-trimmed meat. Snack on fruit between meals.
TRIM YOUR WAISTLINE
Match your calorie intake with expenditure: if you eat more, move more.
Eat regular meals.
Drink six to eight glasses of water a day.
SLEEP Q I find I'm not sleeping as well as I used to. Could this be linked to menopause? A Everyone experiences a reduction in the amount of sleep they get as they get older, says Dr Alison Bentley, head of the Wits Dial-a-Bed Sleep Laboratory at the University of the Witwatersrand, but the prevalence of organic sleep disorders increases after menopause - up to 53 percent of post-menopausal women suffer from either sleep apnoea, restless legs syndrome or both. Other sleep disorders that increase after menopause are those associated with depression and fibromyalgia.
This increase is a direct result of loss of sleep from both hot flushes and an increased frequency of urination. However, because insomnia may continue after your hot flushes have abated, it's important to deal with it now. Seek professional help for any organic causes - treat restless legs syndrome or depression symptomatically or try HT, which has a positive impact on sleep.
SLEEP BOOT CAMP
Cut out all caffeine after lunchtime.
Stay cool by wearing cotton pyjamas (or nothing at all), use lightweight bedding and invest in a fan or air conditioning.
Use your bedroom for sleep only.
When you go to bed, give yourself 15 minutes to fall asleep - if you don't, get out of bed, read or watch television until you feel sleepy, then return to the bedroom.
EYES QMy eyes seem to be dry and irritated - could menopause be the cause? A The most common ocular effect of menopause is dry eye syndrome (DES), explains Benoni ophthalmologist Dr Clive Novis. This can result in dry, scratchy, burny, itchy, red and tired eyes. Paradoxically, it can also result in watery eyes as reflex tear production tries to make up for the dryness. Unfortunately HT therapy does not always reduce DES - some studies show that it can actually worsen the condition.
The mainstay of treatment remains artificial tears; experiment with different types of drops and gels until you find what works best for you. Avoid air conditioning, use a humidifier, eat a well-balanced diet, take a good multivitamin and increase your intake of omega-3 oils. A mild moisturiser around the eyes and on the eyelids will help relieve any dryness of the delicate skin.
Never ignore DES. Aside from interfering with daily life, the risk for other eye disorders such as cataracts and glaucoma increases at this time too.
EYES RIGHT
See an eye specialist if:
artificial tears do not relieve DES.
you cannot read comfortably.
you have blurred vision and red eyes, or experience eye pain.
you have other diseases such as diabetes, arthritis or lupus.
BONES Q I've never exercised much and my diet is fairly poor. What can I do to protect my bones at this stage? A Natural ageing in both men and women leads to a loss of about 0,5 percent in bone mass per year after the age of 35. In women, however, lack of oestrogen around the time of menopause results in an acceleration of bone mass loss and the development of osteoporosis.
If you're a white, Asian or mixed-race woman over 50, you're unfortunately in the firing line with a 50 percent chance of suffering an osteoporotic fracture during your lifetime, explains Dr Tobias de Villiers, consultant gynaecologist and vice president of the National Osteoporosis Foundation of South Africa. "Black women have a lesser chance of an osteoporotic fracture. We don't know why this is the case, but they just do," says specialist physician Dr Stanley Lipschitz.
You can boost both your bone density and your overall health. Firstly, banish possible bone-toxic substances - stop smoking, reduce alcohol intake and ask your doctor to check if any chronic medication negatively affects your bones. Then get moving: make 30 minutes of weight-bearing exercise - which slows down normal bone loss associated with ageing - a routine part of your day.
Next reduce your risk of falling: check all household flooring surfaces as well as your choice of footwear.
Finally, check your eating habits. Concentrate on a diet rich in fruit and vegetables, with minimum fat and lean protein, and up your intake of calcium (1 000mg a day in healthy adults and 1 500mg in the elderly) and vitamin D (400 IUs).
RISKY BONES
Ensure your bones are checked professionally if:
you suffer a fracture of any bone as a result of minimal trauma.
you enter menopause early.
you have or have had a significant eating disorder.
your mother or grandmother suffered from osteoporosis or had unexplained fractures.
you're losing height.
you take cortisone (by mouth) or receive Heparin injections on a long-term basis.
you drink alcohol excessively (more than two units daily).
HEART Q I've heard oestrogen protects the heart but your risk of heart disease increases after menopause. Is this so and what can I do? A Oestrogen does have a protective effect on your heart and your risk of heart disease does increase after menopause. In fact, states the Heart and Stroke Foundation of SA, your risk of heart disease and stroke increases threefold after menopause, so that after 60 men and women are at equal risk of developing cardiovascular disease. Before menopause, women naturally have higher HDL ("good") cholesterol levels than men, with oestrogen being the major contributor.
It's believed to increase HDL cholesterol, which is why premenopausal women are usually protected from developing heart disease. After menopause things change and you may well be at risk for heart disease and stroke. Although cardiovascular disease is the leading killer of women globally, there are lifestyle changes that you can implement to reduce your risk:
Maintain an ideal body weight and follow a healthy, balanced diet low in saturated fat. It may be necessary to consult a dietician.
Exercise regularly and stop smoking.
Have your blood pressure, blood cholesterol and blood glucose levels checked regularly and manage them if there's a problem.
Obtain a thorough risk assessment from a health professional.
HT AND YOUR HEART
There's still controversy regarding the use of hormones in women after menopause. While HT has reduced the risk of cardiovascular disease in post-menopausal patients who have been on it for years, HT should not be started over the age of 60 as it may have adverse effects, says Johannesburg cardiologist Dr Len Steingo.
CANCER Q Does my risk of developing cancer increase post-menopause? A The risk of getting cancer increases as we age. "Over time it becomes more likely that the genetic material in cells will become damaged by various factors," says gynaecologist Bronwyn Moore. "Many factors contribute to the development of cancer and it's seldom that one single cause can be identified. However, there are risk factors associated with certain cancers that are specific to post-menopausal women.
"The Women's Health Initiative study found that HT was associated with an increased risk of breast cancer, although this rise was small - an increase of only eight cases per 10 000 women per year. Also, this increase is usually seen in women who use HT for longer than five years."
Dr Theo Kopenhager, the secretary for the South African Menopause Society, says there is no argument with the findings of the WHI, only with the way sensationalised media reports skewed them in minds of the public: "The placebo group in the study had 30 cases of breast cancer per 10 000 women per year, and the group that was on HT had 38 cases per 10 000 women per year, after five years of therapy. This is how the researchers came up with the extra eight cases. But as Jacques Rossouw, the lead writer for the WHI study, himself said: 'The risk for breast cancer in women after five years of HT increased by less than one tenth of a percent.'"
To put the WHI findings into perspective, says Dr Carol Thomas, think of it this way: "If you don't use HT, your breast cancer risk is 3 in 1 000. If you use oestrogen alone, as in the case of women who have had hysterectomies, the risk remains the same. In the group of women where progestogen was added, in the case of women with a uterus, the risk increased to 3,8 in 1 000. A small risk indeed."
Remember too that there are some women (untreated by HT) who have breast cancer risks of one in nine, such as Ashkenazi Jewish women.
Using oestrogen only if your uterus is still present can lead to endometrial (uterine lining) cancer, so you should use oestrogen plus progestogen if you've not had a hysterectomy. Interestingly, HT reduces the risk of colon cancer. Lifestyle factors are so important when assessing risk profile, so how you live before menopause is crucial.
Reduce your cancer risk by not smoking, limiting alcohol and dietary fat intake and exercising regularly. Regular check-ups makes early diagnosis of many cancers possible, improving the outcome and often making a cure possible.
HT AND MENOPAUSE - WHAT YOU NEED TO KNOW
Hormone therapy is not for everyone. In line with other international menopause associations, the guidelines from the South African Menopause Society (SAMS) state that while HT does have great benefits for the treatment of conditions such as hot flushes, night sweats, osteoporosis, sleep disorders and vaginal dryness, concerns still remain around the incidence of breast cancer, blood-clot formation, stroke and, in the case of older women, coronary heart disease.
That's why, in general, HT should not be started after the age of 60. You need to take responsibility for your own wellbeing and make an informed decision with your medical practitioner about what's best for you while minimising the risks.
Here's what you need to discuss:
Q When should I take HT? A Generally speaking, says Dr Thomas, you should start taking HT if you experience moderate to severe symptoms. However, severity of symptoms is difficult to assess because it differs from woman to woman and is influenced by her own tolerance levels and world-view. But a good guide is your own perception of the change in your quality of life. It's always useful to write down your main symptoms at the beginning of any treatment (whether traditional or alternative) and to assess those symptoms two to three months after starting therapy.
Q How do I know whether my health profile makes me a suitable candidate for HT? A Every woman should be assessed to determine whether her individual risk profile will afford her greater benefit than risk or vice versa. This is also true for non-hormonal methods of managing menopause, for example dong quai should not be used by women with clotting disorders.
Specialised health checks to assist you in choosing appropriate therapy include:
A full gynaecological examination, including a cervical smear. An ultrasound examination generally does not form part of this examination, but may be necessary depending on the findings during the examination or the information you supply.
A mammogram to screen for breast cancer. An ultrasound of the breast may be added to detect benign disease.
A full fasting lipogram - a total cholesterol level alone will not tell you what your s-HDL-cholesterol (the goodies) and your s-LDL cholesterol (the baddies) levels are.
A fasting blood sugar test.
A thyroid function screen.
A bone mineral density test, depending on your risk profile.
If you do decide to go the HT route, these are the questions you need to ask your health professional:
Q What oestrogen dose should I take? A The lowest effective dose of HT (oestrogen and progestogen for women who have a uterus) or ET (oestrogen alone for women who do not have a uterus or who have a progestogen loop fitted) to help prevent osteoporosis and improve the quality of your life by making those hot flushes and night sweats far more tolerable.
It's advisable to start low and return to your health practitioner two to three months down the line to review your symptoms. If you're not happy, it's important to work together to find the correct dose.
Q What about progestogen? A This is necessary only if you still have a uterus because it counteracts the effects of oestrogen on the endometrium (the lining of the uterus) and thereby prevents uterine cancer. However, it's been linked to a higher risk of breast cancer than oestrogen on its own. So a good option is to have a progestogen IUD fitted, which minimises the risk of uterine cancer by decreasing the uterine lining growth (which is why you need it in the first place) without the presence of high levels of the hormone in your system.
Q Pills or patches? A Transdermal preparations (patches and gels) are preferred when cholesterol profiles are not optimal, because they bypass metabolism in the liver and therefore may offer a reduced risk of thromboembolism.
Q What happens when I stop taking HT - will I be back to square one? A Sixty percent of women can stop their HT without any adverse effects, especially if they've exceeded five years of use (i.e. the transition is usually complete). However, symptoms may rebound within six weeks of discontinuation if it's stopped abruptly. Avoid this by gradually weaning yourself off, with medical approval. If symptoms continue, the reasons for your first initiation of HT should be revisited.
Your risk-to-benefit ratio should be critically reassessed and, if it's still in your favour, you may continue with HT, provided that you have regular annual assessments by a health service provider with a special interest in the management of menopause.
Q Should I use bioidentical hormones? A Despite claims by supporters of bioidentical hormone replacement therapy (BHRT) that they are natural, non-synthetic, risk-free and more effective because they are individually customised and offer protection against breast and endometrial cancers through the use of oestriol (an oestrogen substance), the South African Menopause Society - together with other international menopause organisations - states that there is "no scientific evidence supporting the effectiveness or safety of compounded bioidentical hormone therapy".
According to Dr Theo Kopenhager, gynaecologist and North American Menopause Society-accredited menopause practitioner, all oestrogens, whether used in BHRT or HT, are synthesised from yams or soya to be identical to human hormones.
Furthermore, there are no clinical studies to show that BHRT is safer than HT. In fact, the American FDA issued a warning in January this year that "the safety and efficacy of oestriol is unknown". Customisation, he adds, is reputedly achieved with blood or saliva hormone tests, the levels of which vary considerably according to the time of day.
Most importantly, BHRT is not registered with any medicine control council anywhere in the world and is often prescribed by non-medical practitioners or non-gynaecological practitioners. No woman should receive any hormone product without undergoing the abovementioned health checks carried out by a medical practitioner who is well-versed in menopause.
Q What else can I do if I don't take HT? A Lifestyle changes can help alleviate the symptoms of menopause. Wear layers of loose, comfortable clothing, stabilise your blood-sugar levels by reducing your intake of refined foods, eat correctly and avoid food and drink that has a stimulating effect (caffeine, alcohol and spicy dishes), says Professor Celene Bernstein, author of the book Health Seekers: A Formula for Living a Healthier Life (Vivlia, R135 ).
Increase your intake of essential fatty acids and fibre, reduce sodium and add phyto-oestrogens such as tofu, chickpeas, soya milk and beans to your daily diet. Regular exercise - weight-bearing and resistance training - and deep breathing will also alleviate symptoms.
NATURAL MENOPAUSE ALTERNATIVES
To date alternative products have not been scientifically proven for efficacy. However, many women do find them beneficial for menopause symptoms, which is why you should consider trying them out before HT. A word of caution, though: just because they're natural doesn't automatically mean they're safe - always consult a medical practitioner.
Some options include:
Natural progesterone. In his book Food is Better Medicine than Drugs (Piatkus, R345), Patrick Holford quotes a double-blind trial done in 1999 in which some 83 percent of women on progesterone found that it significantly relieved or completely arrested menopausal symptoms, compared with 19 percent on the placebo.
Professor Bernstein says: "Sixty years ago women would go through menopause with relative ease. Because we have been playing around with chemicals since WWII, the delicate balance between oestrogen and progesterone in our bodies has been upset. Today, many women are oestrogen dominant, and by balancing hormones with natural progesterone most symptoms could be relieved."
Isoflavones. In the same book, Holford mentions four trials published in 2003 that showed that oestrogen-like, plant-derived substances known as isoflavones, found in high concentrations in soy and red clover, approximately halved the incidence and severity of hot flushes.
Black cohosh. This herb can help reduce hot flushes, sweating, insomnia and anxiety but avoid it if you're on liver-toxic drugs or have a damaged liver.
Yarrow is a herb that can reduce hot flushes.
Motherwort can reduce hot flushes and vaginal dryness.
Dong quai helps with hot flushes, night sweats and vaginal dryness. However, it can thin the blood and is therefore contraindicated for women on the drug Warfarin.
St John's Wort, a herb well known for its anti-depressant effects, has also been known to alleviate other menopausal symptoms such as headaches, palpitations, lack of concentration and decreased libido. Do not use if you are already taking an anti-depressant.
Agnus castus stimulates and normalises the function of the pituitary gland, which controls and balances hormones.
Essential reads
The Wisdom of the Menopause by Christine Northrup (Penguin, R244);
The New Natural Alternatives to HRT by Marilyn Glenville (Kyle Cathie, R195).
[The South African Menopause Society (SAMS) is a non-profit organisation dedicated to promoting women's health during midlife and beyond through the understanding of menopause. It has a membership of more than 190 leaders in the field, including clinical and basic science experts from medicine, nursing, sociology, psychology and nutrition. This allows SAMS to be the dominant resource on all aspects of menopause to both healthcare providers and the public. Visit www.samenopausesociety.co.za for more information.]
(This is an edited version of an article by Lynne Gidish which originally appeared in FEMINA magazine, May 2008. The current edition is on sale now.)
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