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Menacing Menopause?
By Maureen Connolly 
Published 4/24/2012 
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Cleveland Clinic docs demystify “the change” and offer their advice for making the most of menopause
Forty million U.S. women this year will begin “the change” or be just coming out of it. That’s why we’ve gone to some of the best Cleveland Clinic docs for their advice on the myriad ways you can effectively manage this life transition and, believe it or not, even become healthier during this time.
How do I know if I’m in menopause?
If you haven’t had a period for 12 months, and there are no other possible causes, such as disease, stress or a medication side effect, then you can consider yourself officially in menopause, or menopausal. The average age for menopause is 51. But the process really begins eight to 10 years before you officially hit menopause, as ovaries gradually produce less estrogen. Known as perimenopause, this is typically the beginning of hormonal imbalances that can last up until a year following menopause, or possibly longer in the phase known as postmenopause.
Why do hormonal imbalances wreak such havoc?
Hormones play a part in everything from the way our brain functions to our sex drive and cholesterol levels. So it’s not surprising to learn that when menopause throws off this delicate balance of estrogen and progesterone, our body reacts by going a little — or a lot — haywire. As a result, you might experience symptoms such as hot flashes, insomnia, night sweats or vaginal dryness. Some people also experience difficulty concentrating, weight gain, mood swings or depression around the same time. It’s hard to say if these are due to aging or menopause, but lifestyle changes can make a big difference.
What can I do right now to feel better?
Diet, exercise and stress reduction can be very effective for managing unpleasant menopausal-related symptoms. So starting right now, why not learn about all the ways to manage symptoms by making improvements in your diet, exercise habits and the way you deal with stress. Staying committed to these changes means you’ll also reap the rewards of lowered disease risk in the postmenopausal phase, when estrogen is lowered and your risk for certain diseases such as osteoporosis and heart disease go up as a result.
How much exercise do I have to do to improve my symptoms?
Walking just 30 minutes daily can make a big difference in reducing symptoms, such as anxiety and mood swings. “When you exercise, your body releases stimulating chemicals in the brain that promote relaxation and enhance your sense of well-being,” says Lori Gemma, DO, a family medicine physician affiliated with South Pointe Hospital, a Cleveland Clinic hospital. Don’t like walking? Any type of cardio exercise will do; just be sure to pick an activity you enjoy, that you can do for 30 minutes and will do at least four or five times per week. Regular physical activity will also help manage or prevent physical health issues that become more prevalent once estrogen levels drop, such as cardiovascular disease and osteoporosis.
Can attitude affect how you experience menopause?
“Embracing this time in your life rather than dreading it can make such a big difference in how you experience menopause,” says Judith Volkar, MD, staff physician at Cleveland Clinic’s Women’s Health Institute. Anthropological studies of various cultures suggest that how you go through this life stage is largely dependent on your attitude. Instead of living in fear of a hot flash, for instance, take steps to accommodate one: Dress in layers, wear breathable fabrics, keep alcohol and caffeine intake to moderate levels, and try engaging the mind in a meditative breathing technique to help you through.
Can yoga help?
When it comes to menopausal moodiness, yoga’s a hands-down winner. In a study published in the journal Menopause, researchers found that perimenopausal and menopausal women following an eight-week program of basic yoga poses, breathing exercises and meditation had decreases in both perceived stress and the tendency to experience negative emotions. (Other studies, by the way, have shown this mind-body exercise to have positive effects on hot flashes and sleep disturbances during menopause.) Multiple yoga-for-menopause routines are available on DVD; or see if your gym or community center offers a program.
Can diet make a difference during menopause?
There is no single magic cure-all food for menopause, but there is evidence that shows when you regularly nourish your body with foods that are rich in vitamins, minerals, antioxidants and healthy omega-3 fats, you may be able to lessen the severity of some of the symptoms associated with menopause. At the Cleveland Clinic, we are big advocates of the Mediterranean diet. Why? Because it’s filled with mood-boosting omega-3-rich foods such as salmon, which can help compensate for the loss of estrogen and other fluctuating hormones that trigger mood swings, irritability, anxiety and impaired concentration. As an added benefit, eating these foods regularly helps lower your risk for heart disease and osteoporosis.
Does acupuncture help with menopause symptoms?
“My absolute favorite treatment for menopausal symptoms — as in don’t pass go, do not collect $200 — is acupuncture,” says Tanya Edwards, MD, MEd, a family physician at the Cleveland Clinic Center for Integrative Medicine. While it’s not scientifically clear as to why this alternative treatment helps, Eastern medicine would explain that acupuncture helps lessen the intensity and frequency of hot flashes by realigning your chi energy, says Dr. Edwards. She recommends weekly acupuncture treatments, for two to six weeks, and then seeing how your hot flashes are responding. If you’re doing really well, you can wean visits to every two weeks until you find the maintenance schedule that works for you.
Why do women get hot flashes?
Believe it or not, we don’t exactly know. One possible cause for hot flashes is increasing follicle stimulating hormone [FSH] levels, which occurs as estrogen levels drop during menopause. High FSH levels may affect vascular irritability and central temperature. Rising FSH levels may result in less regulated/efficient temperature control. What we do know is that the hot flash is the second most frequently reported perimenopausal symptom after irregular periods, and that 25 percent of U.S. women never have a hot flash or night sweats. Most women experience hot flashes for six months to two years, but some may experience them for as long as three to five years, and the occasional woman can experience a recurrence of hot flashes more than 10 years past menopause. Also, so women don’t get any symptoms in the premenopausal phase but can be more symptomatic postmenopausally.
Should I consider hormone therapy?
There are some women who should definitely NOT use hormone therapy (HT), because of their particular health situation, such as a personal history of breast cancer or blood clots. But for most, “The risks for using hormone replacement therapy are not nearly as extreme as women think they are,” says Dr. Volkar. And the short-term benefits for hot flash relief are proven. That’s why your doctor will work with you to individualize your treatment, using the lowest dose possible for the shortest time possible to get you your desired result. Short-term use (two to five years) of HT is associated with very few risks.
Do you take estrogen in a pill form?
Most women who chose estrogen therapy (ET) for hot flash relief use a daily pill or a biweekly or weekly skin patch. Estrogen also comes in gel form as well, and sprays and creams. Your doctor can recommend the form that’s best for you. There is some thought that the non-oral route reduces the already small risk of blood clots. Many women will also need to take some progesterone along with the estrogen. This is to protect the uterus from cancer. The progesterone currently comes only in oral form.
What are bio-identical hormones and do you recommend them?
“Bio-identical hormones look chemically similar to the hormones your own body makes and are usually derived from plant sources. This is in contrast to another popular estrogen preparation, which is derived from animal sources. Both forms are equally effective and safe as long as there is FDA oversight of the manufacturing process,” says Elisa Ross, MD, FACOG, Department of Gynecology and Obstetric at Cleveland Clinic. The “bio-identical” idea appeals to some women. “However, the term bio-identical has also come to mean estrogen individually formulated at a pharmacy,” Dr. Ross explains. “This is a problem for two reasons. The main one is lack of regulation in the compounding process. Studies have shown that 30 percent of compounded medicines did not contain what they were supposed to, or were contaminated with other substances. The other concern about using these individually prepared medications is that usually the dose is decided on through the use of a saliva estrogen sample. Saliva tests have been shown to be inaccurate for estrogen levels. Also, doctors today choose a dose based on symptom relief, not estrogen levels.” Make sure you speak to your doctor about what’s right for you.
What about all-natural supplements and creams?
“A rule of thumb for any medication or supplement use is that it should be safe and it should be effective. Most over-the-counter “natural” supplements and preparations haven’t been studied enough to make this claim,” says Dr. Ross. The Cleveland Clinic Wellness website can help you make sense of the options that are out there. Don’t waste your money and don’t risk your health!
Why is calcium so critical now that I’m in menopause?
As your body gradually produces less estrogen, it can be harder to absorb calcium. PMS symptoms, which can get worse in perimenopause, are exacerbated by low calcium levels. The added calcium will also help protect your bones from osteoporosis. Premenopausal women need a total of 1,200 mg of calcium per day; postmenopausal women should get 1,500 mg daily. When looking at your supplement dose, take into account other forms of calcium, particularly dairy, that are routinely already in your diet. For optimal absorption, take calcium in equally divided doses twice a day. Calcium carbonate should be taken with meals for best absorption and calcium citrate can be taken either with or without meals.
Is menopause linked with depression?
“The good news: Menopause does not cause depression,” says Holly Thacker, MD, FACP, CCD, director of the Cleveland Clinic’s Center for Specialized Women’s Health. “However, women with prolonged perimenopause are more likely to report having depression,” she says. In people who are prone to it, the hormone imbalance can set things off. And having a history of depression may bring on earlier menopause, according to a report issued by the Harvard Study of Moods and Cycles. If you are experiencing a prolonged low mood or deep anxiety, you should speak with your physician and seek treatment specifically for this condition. “There are multiple ways to address mental changes during menopause,” says Elizabeth Ricanati, MD, founding medical director for the Cleveland Clinic’s Lifestyle 180 program. “Exercise and stress management are key, and certain antidepressant medications can be really helpful.”
Can menopause affect my memory?
Feeling fuzzy headed or forgetful? It may just be in your head — literally. Your brain has estrogen receptors in the hippocampus, the area of the brain responsible for memory formation. Leading scientists believe the hormone has a direct impact on our mental acuteness. While the hormonal fluctuations of menopause are not the only cause of declining cognition, says Michael Parsons, PhD, a neuropsychologist at the Cleveland Clinic’s Center for Brain Health, “it can be one variable.” But even if your midlife transition is affecting your memory, it’s likely only temporary and will rebound to former levels after menopause. (Thank goodness for that!)
I’m not even interested in sex. Is that abnormal?
“Not necessarily,” says Dr. Ricanati. “We all define for ourselves what happens within our relationships and what we consider ‘healthy’ and ‘normal’ sexual relationships. As we go through menopause, our minds and our bodies do change. These changes may affect our sexual health as well. It’s important to understand what happens to your body during menopause so that you can identify problems with your health — including your sex drive — and take steps to minimize unpleasant effects.”
Why has sex become so uncomfortable?
As menopause kicks in, estrogen levels decline, according to Dr. Ross. This can cause a thinning of the walls of the vagina, which can affect lubrication, making the vagina too dry for comfortable intercourse. The loss of estrogen can also make it harder for you to become aroused and may make you less sensitive to touching and stroking — all of which can make you less interested in sex. But the best way to combat becoming uncomfortable with sex is to, yes, have regular sex! Studies show that the health of the vaginal tissue is maintained by regular contact, she says.
What can I do about vaginal dryness?
For intercourse, over-the-counter water-based personal lubricants can help. For daily vaginal dryness, a daily vaginal moisturizer can be used. If these aren’t sufficient, and “vaginal dryness is the only problem you have, then you can use a very low dose estrogen containing vaginal cream that does not cause any systemic effects, but helps the vaginal tissue,” says Dr. Volkar. Even if you are on systemic estrogen, it sometimes doesn’t reach the vaginal tissues and a little local estrogen cream can be added.
How can I put some sizzle back in my sex life?
Change the way you think, really! A major research study conducted at the New England Research Institute and the University of Massachusetts Medical School suggests that a woman’s loss of sexual desire during midlife may be more driven by negative attitudes toward sexuality, overall health and marital status than by a decrease in estrogen production during menopause. In fact, the study revealed that the only women who experienced diminished sexual desire were the ones with the preconception that aging meant loss of libido. Women who embrace a positive mind-set may find that menopause signals the beginning of a sex life that is more satisfying and active than ever before.
Is it true that exercise makes for better sex?
Yes! In addition to making you feel better about your body (which, let’s face it, goes a long way to how you feel about yourself in the bedroom), regular physical exercise (sex counts!) actually makes you enjoy sex more. Improved circulation gets the blood moving everywhere, including to those nether regions, which improves arousal. Plus, you’ll be more flexible, which will increase your ability to partake in and enjoy sex.
Is there anything to look forward to about menopause?
The words menacing and mysterious might come to mind when you think of menopause, but thanks to everything we’re learning about the positive impact diet, exercise and stress reduction can have during this phase, docs are now teaching women to rethink how they approach menopause. “When patients complain about not feeling well during menopause, I stress that this is a phase and that they’ll come out of it feeling better and ready to really enjoy the next stage of their life,” says Dr. Ricanati.


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