That Certain Age


Armed with knowledge about natural alternatives to hormone replacement therapy, you can approach the second half of your life with strength and confidence

Menopause, like puberty, is a time of exquisite change--a time of fluctuating hormones, of shifting biological and emotional priorities. But unlike puberty, we don't celebrate menopause. We dread it. We ignore it. We treat it as an illness.

"Some people have this idea that menopause means that you're old; that we're somehow outliving what's natural for us," says Neal Barnard, M.D., author of Eat Right, Live Longer (Harmony Books, 1995) and Foods That Fight Pain (Harmony Books, 1998). "To which I say, 'That's a lot of hooey.' There's just as much life after menopause as there was before it."

That's likely to be good news to the 4,000 U.S. and Canadian women who reach menopause each day. According to the North American Menopause Society, women go through menopause at an average age of 51--and by the year 2030, 1.2 billion women worldwide will be 50 or older.

Menopause, technically, takes place on the first anniversary of the day you had your last menstrual period (assuming there are no other medical reasons to explain the absence of menses). The stuff we spend so much time obsessing over--mood swings, hot flashes and erratic periods, which on average last for three and a half years--actually occur during what's called perimenopause. Once the big anniversary has come and gone, you're postmenopausal and, according to health statistics, at increased risk for heart disease and bone fractures due to osteoporosis.

But there are many things you can do to make the passage from peri- to post-menopause a peaceful one and to make yourself comfortable once you've gotten there. Many of them can be done easily and naturally, without overmedicalizing a very normal and indeed exhilarating part of your life.

The decision whether to take hormone replacement therapy (HRT) is one that every perimenopausal woman faces. In addition to its recognized benefits in protecting against osteoporosis, HRT can also decrease hot flashes and vaginal dryness, keep skin supple and may ward off Alzheimer's disease.

Yet women are increasingly opting against HRT. An estimated 20 million prescriptions are handed out for HRT drugs each year, making Wyeth-Ayerst Laboratories' Premarin, the basic estrogen formulation, the most prescribed drug in this country for the past seven years. But 30 percent of women given HRT prescriptions never take them to their pharmacies, according to a 1997 report in the American Family Physician. Of the women who do choose HRT, 60 percent discontinue it within a year. And 80 percent of postmenopausal women in the United States do not use any form of HRT at all.

Why? Part of it is, of course, the serious inherent risks--with breast cancer topping the list. Then, too, the fact that Premarin is extracted from the urine of pregnant mares--not to mention the purportedly inhumane conditions under which these horses are kept and the slaughter of most of their foals for meat-makes it a non-option for many women.

The argument against HRT grew even stronger last year, when a major multi-center study of more than 2,700 postmenopausal women with heart disease found that taking HRT initially raises their risk of heart attack and over a four-year period gives them no heart-health advantage over women who don't take hormones. And yet, HRT's protection against coronary disease has been among the most touted and was the primary reason many women considered hormone therapy in the first place.

But even without that particular benefit, taking hormones of one sort or another may make sense for some women. There are HRT options that are less ethically questionable than Premarin. One is a prescription--only mixture of three estrogens (estrone, estradiol and estriol) derived from soybeans. This phytoestrogen mix, known as tri-est, is available from compounding pharmacies (specialty retail outlets such as the Women's International Pharmacy in Madison, Wis.) that blend their own pharmaceuticals.

In Japan, women so rarely experience hot flashes that their language doesn't even have a word for that symptom. On the other hand, eight out of 10 menopausal American women reportedly experience these "power surges." The explanation for the discrepancy, experts say, can be found in our diets.

"There's nothing like getting on a healthy diet way in advance," says Barnard. "If you go on a very low fat, plant-based diet in the years before menopause, the amount of estrogen in your blood decreases [because fat cells release estrogen] and so your body adapts to having less estrogen. In America, women are typically on high-fat diets. When you add menopause, when the ovaries stop making estrogen, it all comes crashing down. The symptoms you have are primarily [estrogen] withdrawal symptoms."

Barnard says that by cutting dietary fat to 20 percent of total caloric intake, premenopausal women can reduce their estrogen levels by a third, making menopause a much less dramatic transition. Barnard himself recommends an even more fat-restricted diet--10 percent of total calories and no dairy products. This eating plan will bring down estrogen levels by 50 percent, he says.

Other experts believe that the way to stave off menopause's "hormonal hang-over" is with a hair of the dog that bit you. That means eating foods that are rich in plant-based estrogens, or phytoestrogens, which affect the body in some of the same ways that the human version of estrogen does. But because they're a bit weaker than estrogen, phytoestrogens don't come with many of estrogen's downsides--including the risk of breast cancer. At least one type of phytoestrogen--genistein--has been reported to actually stop estrogen from getting to estrogen-dependent breast cancer cells by filling up the estrogen receptor sites on those cells itself, thus blocking the tumor's growth.

Soy products offer one of the best ways to get phytoestrogens into your diet. Clinical studies have shown that in addition to cutting cancer risk, soy can lower cholesterol, and it may reduce the risk of heart attack and shore up weakening bones. However, cautions Sadja Greenwood, M.D., M.P.H., assistant clinical professor of obstetrics and gynecology at the University of California at San Francisco and author of Menopause, Naturally: Preparing for the Second Half of Life (Volcano Press, 1996), "We shouldn't rely on using the isolated soy protein in protein powders that are now sold for shakes and found in things like candy bars. You do better eating the whole food rather than taking an isolated part. It's not only the soy protein that's effective in working against heart disease and certain cancers."

Of course, tofu, tempeh and the like do not have a monopoly on the phytoestrogen market. Other foods bursting with plant-based estrogens include alfalfa, flaxseed, seaweed, wheat, corn, oats, almonds, cashews, peanuts, peas, lentils, corn, papaya and apples.

According to Woodstock, N.Y., herbalist Susun Weed, author of Menopausal Years: The Wise Woman Way (Ash Tree Publishing, 1992), what a menopausal woman needs to know can be summed up in a single word. "Minerals," she asserts. "Minerals from natural sources. No pills."

When Weed talks about minerals, she's talking about a lot more than calcium, the best-known supplement for menopausal women. "Focusing on any one mineral will not be very helpful," she says. "For instance, taking only calcium leads to brittle tissues. Chalk is made of calcium-taking calcium supplements will make your bones as strong as chalk. What you need is the entire spectrum of minerals--not just calcium but magnesium, manganese, potassium, sodium, selenium and zinc."

In fact, scientists looking into dietary requirements for the new government guidelines--the DRIs, or dietary reference intakes that replace the older recommended daily allowances (RDAs)--say that menopausal women don't need much more calcium than their premenopausal sisters (the DRI is 1,200 milligrams [mg.] for women over 50) and that HRT status doesn't play a role as previously believed. In addition, they say, vegetarians and people who are lactose-intolerant don't need to up their calcium intake beyond the recommended levels, either.

One of the best ways to get a variety of minerals in useful amounts is through eating seaweed and cooked greens like kale, spinach, collards and chard. And you want to eliminate certain foods from your meal plans, notes Barnard. "Keep the calcium in your bones by adjusting your diet. Sodium costs you calcium--it encourages the loss of calcium through the kidneys. Cutting sodium intake down to a gram or two a day is as good as taking a calcium supplement of hundreds of milligrams. Animal protein, too, encourages the loss of calcium through the urine."

Vitamins can play a role in keeping your body on a steady keel, even in the midst of "the Change." Vitamin E--found in relatively large amounts in almonds, sunflower seeds and wheat germ oil--can help throw cold water on menopause's hot flashes. The problem is recommended doses are quite high, plus they vary; your best bet is to start with 200 international units (IU) daily and step it up to what Barnard calls "fairly heroic doses" until you get relief. Don't take more than 1,000 IU a day, however, without consulting a physician or nutritionist.

Also on your vitamin hit parade should be the B vitamins, the benefits of which run the gamut from boosting liver function to fighting off insomnia--often a problem in perimenopause. Vitamin D is said to help lock calcium into bones. And, adds Greenwood, don't forget your vitamin K. "It's very good for the prevention of osteoporotic fractures," she says.

Finally, you might want to incorporate foods high in the essential fatty acids, or EFAs. These are key players in your body's own production of hormones--most of which continues even after menopause, despite the dip in estrogen. EFAs can be found in flaxseed, canola, corn and sunflower oils.

The amount of conflicting herbal advice available these days can be daunting; trying to distill a single remedy for menopausal symptoms is nearly impossible. Instead, you need to become your own modern-day medicine woman, collecting the wisdom of the masses and putting together your own personal potion.

A number of herbs have estrogenic effects. Chasteberry is frequently recommended as a hormone balancer. Sage, ginseng and red raspberry leaf are also flush with phytoestrogens. Then there's black cohosh. Depending on whom you speak to, it's either the most important or most over-hyped herb around. Some recommend it as an alternative to HRT while others--including Weed say they wouldn't touch the stuff. Whichever the case, it is one of the best-studied and most popular herbs for women grappling with menopausal discomfort. If you do take it, though, be alert for such side effects as low blood pressure and headaches and reduce the dosage immediately if they occur.

If decocting your own herbal infusion is beyond you, try one of the multitude of ready-made remedies on the market. Not only are they convenient, but the amount of active ingredient is standardized so you can be sure you're getting the dose of black cohosh you intended. Enzymatic Therapy's Remifemin is the best-known brand of the standardized extracts of the phytoestrogen-laden herb.

Promensil, one of a number of new HRT alternatives being aggressively marketed, is manufactured by the Australian pharmaceutical company Novogen. It gets its estrogen from one of Weed's favorite menopause remedies: red clover. Because it's a dietary supplement, Promensil doesn't need Food and Drug Administration approval, so you can already buy it in Wal-Marts and K-Marts around the country. Of course, this also means (as is true of. all supplements sold in the United States) that there is no quality or safety oversight. When it comes to herbal medicine, the rule is user beware--and be educated.

The same caveat applies to natural forms of progesterone, either in oral (micronized) form or in a cream. Progesterone creams in particular are a controversial topic. John Lee, M.D., author of What Your Doctor May Not Tell You About Menopause (Warner Books, 1996) and perhaps the creams' biggest proponent, says that progesterone alone can stave off osteoporosis--and even potentially increase the density of the bone it saves. Other researchers, however, are dubious. They warn that the amount of progesterone in these creams varies so greatly that it's impossible to know what dose you're actually getting. Indeed, some formulations contain not progesterone but a precursor of it that the body is incapable of metabolizing.

Even if you could be sure you're getting the active ingredient you're paying for, critics argue, the therapeutic properties of progesterone creams have yet to be scientifically demonstrated. "Although Dr. Lee has claimed that progesterone rubbed into the skin can increase bone density by large amounts, there are no studies to verify this," says Greenwood. "Nor is there a mechanism to explain how this could happen." In fact, a study published last year in The Lancet that attempted to replicate Lee's results with the same progesterone cream found "little if any" systemic absorption of the hormone.

Nonetheless, Barnard supports Lee's hypothesis. "The skin cream concentrates the progesterone, which passes through the skin and into the bloodstream and stimulates bone growth," says Barnard. Plus, he jokes, progesterone has another effect: "When women have been using natural progesterone for a while, men start getting a little better looking," says Bamard, referring to the hormone's libido-enhancing powers.

Take a deep breath, all the way down to your diaphragm. Let the air fill you. Hold it for a moment or two. Then let it out, slowly, slowly, slowly. If you've ever taken a yoga class, you've learned how to get the most out of each breath. Now, it seems, slowing down your respirations--whether you call that paced breathing, belly breathing or just plain deep breathing--may also be a simple and effective way to control your hot flashes. In a study of 33 menopausal women, Robert Freedman, a behavioral neuroscientist at Wayne State University's School of Medicine in Detroit, found that by decreasing her number of inhale/exhale cycles by half, a menopausal woman can cut her number of hot flashes in half as well.

Paced breathing's benefits are most likely due to its relaxing effects on the body. Other forms of relaxation--such as meditation and yoga--have a similar impact. In the 1960s, Harvard University's Herbert Benson, M.D., gave a name to this sort of health-promoting stress reduction: the relaxation response. Women who regularly meditate, for instance, report fewer sleep problems. Practicing yoga for at least half an hour a day relieves feelings of stress and depression, which can be important during a dramatic life change like menopause.

Relaxation alone isn't enough, though. Women facing menopause also need to get up and go. Exercise can be as effective as any drug--if not more so--in preventing osteoporosis. And since half of all women over the age of 50 will fracture a bone during their lifetime because of osteoporosis, that's no small benefit. Miriam Nelson, associate chief of the Human Physiology Laboratory at the Jean Mayer U.S.D.A. Human Nutrition Research Center on Aging at Tufts University and author of Strong Women Stay Young (Bantam Books, 1997), found that postmenopausal women doing twice-weekly 40-minute sessions of weight-training showed actual improvement in bone density (as opposed to merely maintaining bone strength). At the same time, the control group, which did no weight training, experienced measurable bone loss. Nelson found that even modest exercise helped subjects improve their balance (making a bone-breaking fall less likely), gain flexibility and increase energy.

"You need to exercise," agrees Barnard. "Exercising muscles are attached to bones, and so it makes bones stronger. A right-handed tennis player, for instance, will have denser bones in her right arm than her left." In addition, studies have shown that an hour of exercise three times a week can reduce the number of hot flashes a woman experiences.

In the end, one of the best ways to "treat" menopause may be to stop thinking of it as a deficiency disease. "Menopause is not the end of life," says Barnard. "It's a completely normal thing and, for many people, a very welcome part of their Fife."

Weed believes that we need to start thinking of menopause as a positive, rather than a negative. Toward that end, we should seek out positive role models. "Start a 'butterfly collection'," she says. "Collect stories and images of older women who you want to grow up to be." After all, you probably have a full half of your adult life stretching in front of you. Make it be healthy and fulfilling.

PHOTO (COLOR): A healthy lifestyle paves the way for a smoother transition into menopause.

PHOTO (COLOR): The decission whether to take hormone replacement theraphy is one all perimenopausal women face.

PHOTO (COLOR): Apples are a good source of plant-based estrogens, which are important hormone regulations.

PHOTO (COLOR): A variety of herbs, with black cohosh being the best known, can help balance fluctuating hormones.


By Lori Oliwenstein

Lori Oliwenstein is a freelance health and medical writer who lives in Los Angeles.

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