Contents
What are the perimenopause
and menopause?
Natural menopause occurs when you have had no menstrual periods for
at least one year without being pregnant. Menopause occurring after
surgical removal of the ovaries, or damage to the ovaries by medical treatment
such as chemotherapy or radiation, is called induced menopause. The
perimenopause is the transitional period lasting up to ten years from having
normal menstrual periods to no periods at all. During this transition,
you may experience no symptoms at all or some combination of premenstrual
syndrome (PMS) and menopausal symptoms. Because most women experience
menopause between the ages of 45 and 55, at an average age of 51, perimenopausal
symptoms typically begin occurring throughout the 40’s. You can expect
to experience menopause at about the same time as your mother or older
sisters unless you have certain chronic conditions or health habits that
promote early menopause. These conditions include taking corticosteroid
medications, smoking, or having an autoimmune or motor neuron disease.
What are some common
perimenopausal changes?
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The most common changes occurring during the perimenopause are:
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Reduced fertility
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Hot flashes
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Urinary and genital changes
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Infections, particularly bladder, vaginal, and skin
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Changes in sexual function
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Changes in menstrual periods
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Mood swings
Reduced Fertility
Women’s fertility begins to decrease at about age 37, mainly due to aging
eggs. The risk of spontaneous miscarriage increases to about 50%
by age 45. The risk of chromosomal abnormality in the fetus increases
with each year to 1 in 40 by age 45. Women in their 40s tend to have
more pregnancy complications such as premature labor, stillbirth, and delivery
by caesarean section. The risk of such pregnancy complications is
already higher in many women with disabilities. If you do not wish
to get pregnant during the perimenopause, please be sure to continue using
contraception,
as pregnancy is still possible until complete menopause is reached.
Hot Flashes and Night Sweats
About two-thirds of all women have hot flashes, the most common symptom
during the perimenopause. A hot flash or flush consists of a sudden
hot feeling in the face, neck, and chest, blushing, faster pulse, and sometimes
perspiration, often followed by a chill, lasting from three to six minutes.
The most common duration of hot flashes is three to five years. Hot
flashes that occur with heavy perspiration during sleep are called night
sweats. Night sweats and hot flashes may interfere with sleep, as
can falling estrogen levels alone. Inadequate sleep in turn triggers
irritability and fatigue. Environmental conditions that may trigger
hot flashes include:
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Caffeine
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Alcohol
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Hot drinks
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Hot or spicy foods
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Stress
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Warm environment
Avoiding these conditions as much as possible will help reduce the number
and severity of hot flashes.
Hot flashes may be worse for women with neurological disabilities such
as SCI and MS due to preexisting vasomotor instability, also in women with
joint and connective tissue diseases who take corticosteroid medications.
However, all flushing is not necessarily menopausal in women with disabilities;
it may be neurological in origin. The presence of other perimenopausal
symptoms may help distinguish hot flashes from neurological flushing that
will not respond to estrogen replacement therapy.
Urinary and Genital Changes
As a result of natural decreases in estrogen, the tissues of the
vulva (outer genital area) and the lining of the vagina become thin, dry,
and more alkaline, making them more prone to injury. Atrophic vaginitis,
which is vaginal inflammation, not an infection, may result. You may notice
redness, itching, irritation, and discharge. These symptoms should
be examined by a physician to rule out other causes such as infection.
Regular sexual activity will help prevent vaginal atrophy. Without treatment,
this condition can cause painful vaginal ulcers that make sexual intercourse
impossible. Vaginal lubricants may help mild cases, but prescription
estrogen is the most effective for restoring the thickness and elasticity
of vaginal tissues. A daily diet rich in soy foods may help reduce
vaginal discomfort in a few weeks.
Urinary problems may occur when the lining of the urethra also becomes
thin and the surrounding pelvic muscles weaken. More frequent urination,
urgency when the bladder is not full, frequent nighttime urination, incontinence,
and painful urination may result. If you already have some of these
problems due to having a neurogenic bladder, they may become more severe
with menopause. Smoking, drinking alcohol or caffeine, bladder infections,
weakening of the pelvic muscles and ligaments due to previous childbirth
or natural aging, and taking diuretics and some tranquilizers may also
increase incontinence. As many as 40% of women aged 45-64 have urinary
incontinence. Bladder studies by a urologist may be needed to determine
the exact cause. Estrogen pills, patches, and vaginal preparations
improve incontinence for 40-70% of women. Surgery may be needed to
correct anatomical defects.
Infections
Women with mobility impairments, particularly due to MS and SCI, already
have a high frequency of bladder infections. Taking antibiotics often
in turn causes more vaginal yeast infections. Menopause increases
the risk of infections by increasing the vaginal pH so that it is less
acidic.
Changes in Sexual Function
Most women surveyed report that they experienced no changes or improvements
in their sexual relationships with menopause. Many women remain sexually
active even when very old. However, low hormone levels in midlife
may lead to reduced sexual desire, or painful intercourse due to vaginal
thinning, dryness, narrowing, and shortening. These conditions are
often worse in women with disabilities. Women’s sexual activity and
interest during midlife may also be influenced by:
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Not enjoying sex while younger.
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Body image. Women with disabilities who accept changes in physical
appearance such as sagging breasts and abdomen, wrinkles, and grey hair
in addition to disability-related changes will feel more comfortable being
with a partner. After surgery to remove a breast or the uterus, women may
avoid sexual activity because they feel unattractive.
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Urinary incontinence
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Irritability due to sleep disturbance
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Medications for high blood pressure or depression that reduce sexual desire
Women with reduced sex drive may benefit from testosterone replacement,
which greatly diminishes at menopause. Before menopause, testosterone
is produced by the ovaries and adrenal glands; only adrenal production
continues after menopause. Androgens such as testosterone are important
for maintaining sex drive and bone density. If you have rheumatoid
arthritis, testosterone may decrease your disease activity. Testosterone
ESTRATEST may be prescribed, which combines estrogen and testosterone.
Taking too much testosterone without estrogen may deepen the voice, cause
baldness or facial hair, or increase muscle mass.
Changes in Menstrual Periods
During the perimenopause, the frequency of ovulation (egg release) decreases
and hormone secretion by the ovaries becomes erratic. As a result,
most women experience irregularities in their menstrual periods.
It’s a good idea to keep a record of the dates your periods start
and stop, the amount of flow, blood clots, and pain. This record
will help your health care provider distinguish what’s normal from what’s
abnormal for you. Remember that every woman’s cycle is different.
Changes may include:
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Heavier bleeding
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Lighter bleeding
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Bleeding lasting fewer days than usual
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Skipped periods
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Cycle shorter than 28 days
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Cycle longer than 28 days
When
should you be concerned that perimenopausal bleeding may not be normal?
Any trend toward increased bleeding should be checked by your health
care provider. In particular, any of the following changes may signify
abnormal bleeding:
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Very heavy bleeding that gushes, often with a lot of blood clots; needing
to change menstrual products every hour; needing 8-10 super napkins or
tampons daily
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Bleeding after intercourse
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Spotting between periods
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Continuous bleeding lasting more than two weeks
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Less than two weeks between periods of bleeding
Following are possible causes of these abnormal menstrual changes.
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Fibroids, noncancerous growths in or around the uterus, can produce
more bleeding or more frequent periods, as well as menstrual cramps, back
pain, difficulty with bowel movements or urination, or pain during intercourse.
Abnormal bleeding may be the only sign of possible fibroids for women with
impaired sensation.
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Hyerplasia (excess growth) of the uterine lining or noncancerous
polyps on the lining can increase bleeding.
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Cancer of the uterus, vagina, or cervix can cause abnormal vaginal
bleeding. These serious diseases can be screened out by regular pelvic
exams and Pap smears.
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Severe hormone imbalance between estrogen and progesterone secretion,
usually too much estrogen with little progesterone, can cause heavy bleeding
as often as daily.
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Hypothyroidism may produce very heavy menstrual bleeding.
This condition often accompanies fibromyalgia or other autoimmune disease.
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Contraceptive devices such as an IUD, the
Pill, the Norplant implant, or DepoProvera shots sometimes cause breakthrough
bleeding between periods. However, birth control pills are often
prescribed to stop irregular bleeding by reestablishing a regular, predictable,
menstrual cycle.
If your health care provider decides that your perimenopausal bleeding
is abnormal, there are several procedures that can determine the cause.
These include endometrial biopsy, D&C, hysteroscopy, or transvaginal
ultrasound. If your health care provider orders one of these procedures,
you can find out more about it in the Menopause Guidebook by the North
American Menopause Society on the following website: http://www.menopause.org/consedu/guidebook.html.
Other causes of abnormal menstrual bleeding may be related to your disability.
Women on long-term corticosteroid therapy for rheumatoid arthritis, lupus,
lung disorders, or other chronic conditions often have hormone imbalances
with irregular or heavy menstrual bleeding. After spinal cord injury,
menstruation may cease from a few months to more than a year, sometimes
permanently if the woman is near menopause.
What are
the treatment options for abnormal perimenopausal bleeding?
The perimenopausal period is the most vulnerable time for hysterectomy,
the surgical removal of the uterus. However, hysterectomy should
seldom be the first treatment choice for abnormal bleeding. Depending
on the cause of abnormal uterine bleeding, treatment options include:
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Nutritional supplements. If you have more bleeding than usual, take
an iron supplement to prevent anemia. If you are feeling more tired
than usual or having more frequent headaches, anemia may be the cause.
Although dietary sources of iron alone will not be sufficient, increasing
your intake of iron-rich foods such as beef, beans, and nuts will help.
Taking grape seed capsules, 1,000 – 2,000 mg daily, may help decrease the
amount of menstrual flow if capillary fragility is a cause.
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Hormonal medication. Your health care provider may prescribe a low-dose
birth control pill or progestin to regulate heavy, long menstrual periods.
Some perimenopausal women have benefitted from applying a natural progesterone
cream to their skin during the two weeks before menstruation but some gynecologists
disapprove of this option because the amount of progesterone actually absorbed
is unknown. Other prescription hormonal drugs may be used for short-term
treatment.
- Surgery. There are several different kinds of surgical procedures
that can be used to remove fibroids or to destroy the uterine lining.
The decision to remove fibroids surgically, and the surgical technique
selected, depends on their location, number, and size, as well as
whether the woman wishes to have more children. In the past,
a D&C was often done to diagnose and treat abnormal bleeding.
However, D&C was seldom effective. Today, this procedure
is considered obsolete. If your health care provider suggests
doing a D&C, or suggests hysterectomy before trying other options,
get a second opinion. If a hysterectomy is necessary, a woman
usually will not go through menopause unless the ovaries as well as
the uterus are removed. However, removing the uterus alone may
trigger menopause in older women. Young women may experience
hot flashes and night sweats temporarily until the ovaries resume
normal functioning. These women will still eventually go through the
perimenopause, but without irregular periods to warn them of its approach.
Menopause is immediate if the ovaries are also removed. To find
out more about surgical techniques, go to www.menopause.org/mgchanges.htm.
Mood Swings
The folklore surrounding menopause dictates that menopausal women are moody
and irritable. Many experts believe now that menopausal moodiness
may be due more to sleeplessness and poor sleep caused by hot flashes
and night sweats than to estrogen deficits per se. However, many
women have reported an increased feeling of well-being after replacing
estrogen. Estrogen can have an antidepressant effect due to its effect
on brain neurotransmitters. Midlife stress may coincide with menopause
and lead to depression and anxiety.
In addition, women with mobility impairments may have increased problems
during the perimenopause with:
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Skin breakdown
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Bladder spasms
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Spasticity
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Urinary dysfunction
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Autonomic nervous system dysfunction, including autonomic dysreflexia
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Intolerance to heat
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Poor circulation
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Fractures
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Decreased physical functioning
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Accelerated progress of chronic disease
What
major health problems increase in risk with menopause?
Osteoporosis (bones less dense)
In addition to being a woman with a mobility impairment, past menopause,
and getting older, other risk factors for osteoporosis are:
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Having an inadequate diet, particularly with too little calcium and vitamin D
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Getting little or no weight-bearing physical activity
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Cigarette smoking
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Heavy drinking of alcoholic beverages
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Having no menstrual periods while young for at least six months, as sometimes
occurs with spinal cord injury
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Taking bone robbing prescription medications such as steroids or anti-seizure
drugs
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Taking high doses of L-thyroxine for thyroid disease
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Premature menopause (before age 40) or menopause induced by surgery or
other medical treatment
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Being small-boned or thin
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Having a family member with osteoporosis
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Being Caucasian or Asian
Clues that you might have osteoporosis are prolonged, severe pain in the
middle of the back, change in the shape of the spine, loss of height, tooth
loss, and fractures.
Heart Disease
The risk of heart disease increases for women after age 55. This
risk may occur earlier for many women with disabilities. Your risk
for heart disease increases when estrogen levels drop at menopause.
Women who have heart attacks are twice as likely as men to die from them.
Many more women die from heart disease than from breast cancer. In
addition to menopause and getting older, other risk factors for heart disease
are:
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Being more than 30% overweight
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High blood pressure
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Diabetes
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Cigarette smoking
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Physical inactivity
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Abnormal cholesterol levels
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Having a close relative who had a heart attack or stroke before age 60
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Early menopause, before age 40
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Stress
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Drinking more than three alcoholic beverages daily
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Being African American
When
should you use estrogen replacement therapy (ERT) or hormone replacement
therapy (HRT)?
The North American Menopause Society recommends considering the following
when deciding whether a woman should use ERT/HRT or other treatments:
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Menopause-related symptoms
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Cardiovascular risk (heart disease)
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Osteoporosis risk (bone wasting)
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Breast cancer risk
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The woman’s lifestyle
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The woman’s view of each treatment option
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The woman’s general health status
If you elect to replace hormones and do not have a uterus, you only need
to replace estrogen (ERT). If you do have a uterus, progesterone
must be added to prevent excess buildup of the uterine lining and an increased
risk of uterine cancer (HRT). Estrogen with progestogen has proved
to be as effective as estrogen alone in treating menopause symptoms and
reducing risk of heart disease and osteoporosis. HRT can be taken
as a combination pill or patch. Both hormones can be taken every
day (continuous combined schedule), or estrogen can be taken alone most
days with progestogen added for part of the month (cyclic schedule).
Vaginal spotting and bleeding may occur during the first six months of
HRT, especially on the cyclic schedule. You may elect to use micronized
natural progesterone to avoid possible side effects from synthetic progestin
such as lowering HDL, fluid retention, headache, breast tenderness, and
alterations in mood. However, do not rely on over-the-counter
progesterone creams to oppose estrogen replacement, as not enough progesterone
is absorbed through the skin to protect the uterus against cancer.
If you have a history of breast cancer, blood clotting disorders, or liver
disease, you may not be a good candidate for HRT. Be sure to discuss
with your health care provider the pros and cons in relation to your risk
factors.
Menopause-Related Symptoms
ERT/HRT will relieve hot flashes, night sweats, sleep disturbances, vaginal
thinning and dryness, skin thinning and loss of elasticity, and urinary
symptoms that are not caused by neurological or mechanical impairment.
It can be taken orally or applied as a skin patch. An estrogen cream,
ring, or tablet can be applied vaginally to relieve vaginal symptoms alone.
Women tend to experience the fewest side effects with the estrogen tablet
and are less likely to discontinue using it than the cream form.
Cardiovascular Risk
Women who take ERT/HRT have a 35-50% reduced risk of getting cardiovascular
disease compared to women who do not use it. Estrogen reduces this
risk by raising HDL (good cholesterol), lowering LDL (bad cholesterol),
reducing the growth of fatty deposits in blood vessels, and dilating blood
vessels. Testosterone should not be added if you are at high risk
of heart disease or have low HDL levels (good cholesterol) because it reduces
HDL.
Osteoporosis Risk
Menopause speeds up bone loss (osteoporosis), especially during the first
decade after menstruation stops. Having osteoporosis, in turn, increases
the likelihood of having fractures of the spinal vertebrae, hip, forearm,
pelvis, and ribs. All postmenopausal women should have their bone
mineral density (BMD) tested to detect osteoporosis. Calcium, 1200-1500
mg daily, will help slow down bone loss. Younger women should have
BMD testing if they have a fracture from any cause. Even if you delay
starting HRT until age 65, your protection against fractures will increase
more than 60% compared to women who have never used HRT. Taking testosterone
along with estrogen can promote new bone formation as well as preventing
future bone loss. Other drugs such as rezindronate, alendronate,
etidronate, calcitonin, or raloxifene may be taken instead for osteoporosis.
However, these drugs will not help any other symptoms associated with menopause.
You may also reduce your risk of osteoporosis by ingesting natural phytogestrogens,
which are plant-derived, estrogen-like agents, or ipriflavone, a
synthetic derivative. Phytoestrogens are plentiful in flaxseed, red
wine, and soy products such as tofu.
HRT may offer additional benefits to women with disabilities such
as multiple sclerosis and spinal cord injury. Estrogen substantially
increases skin thickness and collagen content, which can prevent, or improve
healing of, pressure sores. It may also improve urinary function
by reducing the risk of infection, bladder spasm, and incontinence.
Replacing estrogen may slow disease progress in MS and rheumatoid arthritis.
Breast Cancer Risk
When taken for long periods of time, more than 15 years, estrogen may increase
the risk of breast cancer. Most health care providers recommend that
women who have had breast cancer should not use ERT. Others believe
that short-term use of HRT is safe for women who have a history of breast
cancer. ERT does not increase the risk of breast cancer when this risk
is entirely genetic. For most women, the risk of getting breast cancer
is much smaller than their risk for heart disease and osteoporosis.
Other prescription drugs may be taken to relieve hot flashes,
such as clonidine, progestogen, and megestrol acetate. Certain medications
used to treat depression, such as Effexor, may be prescribed in low doses
to alleviate hot flashes, even if you are not depressed.
Complementary and Alternative Therapies
What alternatives
to HRT may relieve menopausal symptoms?
If you and your health care provider decide that HRT is not a good
choice for you, there are other remedies that may help reduce hot flashes
and other menopausal symptoms. Of course, beginning with a healthy
lifestyle is always the best insurance against severe symptoms. Following
are some remedies that have the best evidence for effectiveness.
Vitamin E, at 400-1200 IU a day, can help reduce hot flashes,
vaginal dryness, and the risk of fatal heart attacks. However, if
you are taking anticoagulant drugs or aspirin, check with your health care
provider first, as vitamin E can increase bleeding.
Calcium. Taking your calcium supplement at bedtime with
milk may help you sleep, as it has a calming effect.
Soy Products, such as tofu or soy isoflavone extract, and flaxseed
contain high levels of natural plant estrogens. Though this estrogen
effect is weaker than that obtained from ERT, eating 60-100 mg daily of
these products may reduce the number of hot flashes, lower cholesterol,
lower blood pressure, and reduce the risk of breast cancer. It may take
two to six weeks to note any benefits. Though proven to be highly
effective for hot flashes, they provide very little benefit to your bones.
Black Cohosh is an herb that is used to treat hot flashes, especially
in Germany, where it has been extensively studied.
Korean Ginseng is an herb that helps relieve fatigue and may
prevent vaginal thinning.
Acupuncture was proven to relieve hot flashes for at least three
months after each treatment.
Note that products labeled as natural are not necessarily safer or better
than other products. “Natural” is a marketing term, and even some
plants are poisonous. For example, do not confuse black cohosh with
blue cohosh; blue cohosh is toxic. Since herbs may be as chemically
potent as prescription drugs and interact with other drugs that you take,
be sure to notify a health care provider about which ones you wish to use
to determine their safety for you.
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