Wednesday Bubble: the crystal menopause ball
Can you predict the age you will start menopause?
Most women and many experts say that there is a link between when their mothers started menopause and when they will likely start menopause. In fact, the ‘mother’ hypothesis has been explored in numerous studies, with explanations ranging from hormones to genetics to evolutionary selection. However, are there any other determinants or factors that also may come into play? Indeed, it appears that there are. And why is it important? Studies have shown both early (<age 45) and late (>age 56) menopause to be associated with increased health risks, such as heart disease.
Recent data from a study of over 1,000 women, almost of half of which were postmenopausal, show that weight gain and weight loss in the perimenopausal years may play an important role in determining the age that you start menopause.
After evaluating body mass index and height, and the women’s history of weight loss and gain in body mass index from age 25 to menopause, the researchers found that women with a history of losing 11 pounds or more between age 25 (excluding weight gain or losses due to pregnancy) and menopause or gaining roughly 1 pound or more per year during the same time period were more likely to start menopause later than the average age of 50 or 51. The greater the loss or gain, the later menopause began. Other factors that also appeared to influence a later menopause included the number of bleeding days between ages 20 and 30 (with “more” associated with “later”), use of an IUD, a later year of birth and how a woman perceived her economic status. On the other hand, women who smoked or had type 2 diabetes before transitioning to menopause and who had a mother who started menopause earlier than age 50, were more likely to start menopause earl
Wondering why this is important?
Clearly, the more information we have about when menopause might start, the greater our ability to start instituting effective strategies, such as exercise, relaxation, diet, etc, to stave off the numerous health issues that arise as our hormones decline. Some of these strategies might also serve a dual purpose of ameliorating vasomotor symptoms like flashes and night sweats.
Is the crystal ball accurate? Only time will tell. But knowledge is power. Always.
Read MoreWednesday Bubble: Nuts!
Last month my friend Mollie Katzen spoke to me about the importance of incorporating more good fats into your diet, including nuts. Well, it turns out that nuts are a lot better for you than many of us realize, especially those of you who are thinner and have higher LDL-cholesterol levels (the “bad” cholesterol that can build up in the arteries and form fatty deposits known as plaque). In fact, results of an extensive analysis of 25 studies shows that individuals who are thinner and have higher initial cholesterol levels and who eat about 2.4 ounces or (~2 servings) of nuts (e.g.almonds, cashews, peanuts, pecans, pine nuts, pistachio nuts, macademia nuts, hazelnuts or walnuts) daily can significantly lower their cholesterol over time.
In this analysis, which was published in the Archives of Internal Medicine this week, researchers examined data collecte4d from 583 men and women with either normal or high cholesterol levels and whose body-mass indices ranged from 17 to 49. The findings showed that compared to nutless diets, nut diets reduced total cholesterol by as much as 5% and LDL by as much as 7%. People with high triglyceride levels experienced declines by as much as 21%. Although different types of nuts had similar effects on blood fats, the most dramatic effects were seen among people who were thinner, ate more Western-type diets (i.e. higher in saturated fats) had higher LDL cholesterol levels.
What this implies is that nuts can help lower blood fat and cholesterol levels and in turn, help prevent heart disease. Although the studies included in the analysis did not last longer than 8 weeks, the researchers did note that the benefits of eating nuts can be expected at least in the short-term. For menopausal women in particular, this is fantastic news, not only because nuts are an excellent protein and energy source, but because the transition is associated with a dramatic increase in cholesterol and turn, heart disease.
The bottom line? Don’t go nuts….but start getting those nuts into your diet!
Read MoreWednesday Bubble: HRT – Ask the Hard Questions
Your doctor has just recommended that you try hormone replacement therapy, better known as HRT. You’ve heard the horror stories about increased risk for breast cancer, lung cancer, ovarian cancer, heart disease…yikes! And yet, you are flashing like nobody’s business, sweating like you’ve just run a marathon and moody as all hell. What should you do?
Ask the hard questions.
Anyone who reads this blogs knows that I am not a huge fan of hormone replacement therapy. There are numerous reason for my personal biases, ranging from the inherent health risks to the belief that menopause has been treated as a disease for far too long and that the paradigm needs to change. These reasons represent the initial driving force behind this blog, which is to explore viable and evidence-based alternatives to HRT and discover strategies for dealing with the emotional and physical aspects of midlife and the transition in more positive and empowering ways.
However, I also support any woman’s decision to use HRT. Your life is your life and only you can control the decisions that feel right for you.
Nevertheless, it’s critical to ask the hard questions.
So, what do I mean by that?
Medications are meant to heal, sometimes even cure what ails. But medications can be dangerous if they are misused, overused, or inappropriately prescribed. It can be confusing, because who can you trust to deliver the truth? And where should you turn when the media can’t agree on the story, when doctors are misinformed or too busy to take the time to thoroughly vet a patient or when one internet source states one thing and the other, another? What’s more, what’s at stake?
So, I’d like to put forth some initial questions for your consideration.
For your doctor
- Why is your doctor recommending HRT? What does he/she believe it is going to help? What are your personal risks, based on your current health status, family history, genetics and disease profile? Are you a smoker, drinker? have heart disease, lung disease, diabetes, etc?
- Does your doctor have any personal investment in HRT, i.e., has he/she done research on HRT on behalf of companies who manufacture it?
- What is the risk/benefit ratio for you? Are the risks higher than the benefits or visa versa?
- How long does the doctor expect that you will need to take HRT? How does this affect your risk/benefit ratio?
- Has the doctor had any patients who have had bad experiences with HRT? Would he/she be willing to discuss those experiences generally?
About your information source
- What is the source of information about HRT? Is it/he/she reputable? Have you taken the time to follow the trail and looked into its/her/his personal interest in HRT?
- Is he/she/his/her company or association sponsored by manufacturers who have a financial interest in HRT?
- How accurate is the news report? Do you thoroughly understand the news report? Does the news report seem like it has a bias? Has it throughly explained the study that it is basing its information on? (Gary Schwitzer’s HealthNewsReview provides excellent guidance on reading health news and what you should be looking for.)
- Who sponsors the website you are getting my information from? Is it industry sponsored? What is the background of the people who are writing the information that is highlighted on that website?
I am sure I’ve missed some important considerations or questions but these represent great starting points.I’d love to hear your thought. Or if you feel that I’ve missed the boat entirely.
Always…if you want the truth, you’ve got to ask the hard questions.
Read MoreWednesday Bubble: HRT and the “Window Hypothesis:” Hope or Hype. Guest post c/o The Better Health Blog
HRT and the Window Hypothesis. Sounds a bit daunting, doesn’t it?
I was awed and inspired by this post on HRT, which was written by Dr. Peggy Polaneczky and appeared on the Better Health Blog on April 21. As the author states, Pfizer (formerly Wyeth), the maker of Premarin, is working furiously to frame the HRT argument around the Window Hypothesis, which refers to the time period in which a woman must start HRT in order to fully gain its benefits. Is the Window real? Or another mother of all inventions to convince women that HRT is as necessary as a daily vitamin?
So, dear readers, I’ll leave it to you to decide. Despite the length of the post, I am including it in its entirety because the issue is so important. I’d also like to state that I am grateful to Dr. Val Jones, the founder and CEO of Better Health, LLC, who has graciously granted me permission to repost the piece on Flashfree.
It’s only Wednesday, and so far three patients have come to their office visits carrying Cynthia Gorney’s article from Sunday’s New York Times entitled “The Estrogen Dilemma.”
The article explores the stories of three women who found relief from perimenopausal symptoms by using hormone replacement, framing the discussion in the larger context of what is being called the “window hypothesis” — the idea that starting estrogen replacement in the perimenopause and continuing it into later life may be neuroprotective and even cardioprotective, in contrast to beginning its use 10 or more years after menopause, where it can trigger heart disease, stroke and dementia.
The window hypothesis is one way of explaining away the findings of the Women’s Health Initiative, and goes something like this: “The WHI enrolled women who were too late into menopause to benefit from estrogen. If we had instead studied women starting estrogen at the right time, namely the perimenopause, we would have found that it protects against heart disease and Alzheimers.” Or as I explain it to my patients: “Think of it like exercise. If you work out vigorously and regularly from a young age, you can prevent heart disease. But take an overweight, out of shape 65 year old and have him/her run full out and you could trigger an MI.” (It’s a crude analogy, but it works.)
The Times article does a good job framing both the hope and the hype around the window hypothesis, and the dilemma it appears to pose for women entering menopause today, which is this: If you wait for data that proves the window hypothesis is right, by the time the results are in, you’re outside the window and it’s too late to start HRT. If you start HRT now and the hypothesis is proven wrong, then you’ve been taking medication with potential risks for years without any benefit. Or as author Cynthia Gorney so succinctly put it:
“If I make the wrong decision about this, I am so screwed.”
The pharmaceutical industry, particularly Wyeth, the maker of Premarin, is, not surprisingly, working hard to get the word out about the window hypothesis. Indeed, several of the researchers working on the hypothesis who are quoted in Gorney’s article have ties to Wyeth. At the risk of further hyping a hypothesis that may prove to be unfounded, I encourage you to read the Times article, and then take the time to peruse the intelligent discussion in the comments section. If anything it is testimony to just how well-informed the American public has become about HRT.
I myself have been hearing about the hypothesis for years now, but have yet to see definitive data to prove it. Fortunately, there are studies in progress that may settle the question within the next few years. But even if the window hypothesis proves to be correct, it will not mitigate the risks of breast cancer that accompany long term estrogen use in the menopause. That risk remains, in my opinion, the biggest concern for my patients when it comes to HRT, and it is surprisingly downplayed in the Times article.
The biggest problem I have with the article is that Gorney’s experience with both menopause and HRT is anything but typical. Most women get through the transition without major mood issues, although crankiness and irritability are common, especially in women who are not sleeping because of night sweats. When true depression hits, as it did for Gorney, antidepressants are needed, with or without HRT (Gorney takes both). I have seen the occasional woman who declares “I am back!” after starting HRT, and one particularly memorable patient whose depression was cured, but this is the exception, not the rule. Most perimenopausal women who take HRT are just relieved to be able to sleep through the night or get through a meeting without hot flashes.
But most importantly, what does Gorney’s individual experience with HRT and mood have to do with the window hypothesis? She is not taking HRT to prevent Alzheimer’s or heart disease, she is using it to augment the effects of her antidepressants. The whole window discussion thing is distracting from the real question at hand for her, which is sinply this: How long should she take HRT? That depends, not on whether the window hypothesis is true, but on how she feels when she tries to stop taking HRT.
If I were Gorney’s doctor, I’d be focusing her off the window hypothesis and onto why she is taking HRT in the first place — for emotional well-being. Now that it’s been a few years on the stuff, I’d say, let’s lower your dose and see how you do. If you do well, then stay on that dose for 6 months to a year, then go off and see if you still need it. Based on Gorney’s experience with occasional missed patches, I’ll predict she’ll still need HRT, but will be able to get away with a lower dose. But if she feels just as well off HRT, then I would advise her to stay off. Do everything else she can do to prevent heart disease – diet, exercise, low salt, get enough sleep (you know the drill.)
As for using estrogen to prevent Alzheimers, well, that’s a big leap of faith that I for one am not yet ready to take. Which does not mean that I don’t have an occasional patient (usually a scientist) taking HRT because she hopes it will prevent Alzheimers. Such women, in my experience, are much less worried about breast cancer than about cognitive decline, in an attitude similar to that of Julia Berry, one of the women profiled in the Times article, who had this to say:
“I could have my breasts removed. I like them. But they’re not my life.”
Recent data suggests that Berry may not need to make this Sophie’s choice between her brain and her breasts. The mental confusion so many women experience in perimenopause may in fact resolve itself once we come out the other side, irrespective of hormone use. This suggests that it is the widely swinging hormones of perimenopause that pose the most trouble for women, but that once things settle down, so do we.
Now that’s a window hypothesis you won’t hear Big Pharma talking about.
Read MoreWednesday Bubble: herbs and breast cancer
Can herbal medicines used for hot flashes, namely black cohosh and phytoestrogens, be safely used in women who’ve had breast cancer?
If you’ve had breast cancer, you’ve probably been told to stay away from herbal medications, right? Yet, women who’ve had breast cancer know that hot flashes are a common side effect of many cancer therapies. Research also suggests that the older a woman is at the time she receives chemotherapy, the more likely she is to develop menopause as soon as treatment stops. Moreover, roughly 80% of women taking Tamoxifen have hot flashes and about a third of those women rate them as severe. Hormones are not even an option due to the increased breast cancer risk.
The good news is that an extensive analysis of scientific studies shows that black cohosh might be safe for women who have had breast cancer. Although the researchers note that the evidence for the effectiveness of black cohosh for alleviating hot flashes is mixed, they cite research from the National Institutes of Health and other reviews that suggest that use of black cohosh in former breast cancer patients requires only standard screening. They also report that there is “little reason for excluding patients with estrogen-responsive tumors from using black cohosh.” In fact, recent laboratory studies, although not yet carried out in humans, suggest that black cohosh may actually protect the breast from developing tumors.
The case for or against the use of phytoestrogens (e.g. soy, red clover, chaste tree berry and flaxseed) in women with breast cancer is not quite as clear as it appears to be for black cohosh. In one of the largest reviews examining soy or red clover for menopausal symptoms, the outcomes were equivalent to placebo. Other studies have shown that they might be beneficial for women with mild to moderate symptoms who start menopause early. Moreover, while red clover in particular does not appear to affect certain breast cancer risk markers, reports about phytoestrogens in general, especially in estrogen positive cancers is conflicting. Still, the American Cancer Society does not advise against eating soy-rich foods by women who’ve had breast cancer. Some studies have also showed improved prognosis.
If you are wondering if there are any drawbacks, one of the largest challenges is that there are not that many studies looking at herbal medications in women with breast cancer and the ones that do exist are mostly short in duration. The researchers point out that because herbs can take awhile to work, a three month study might be too short to form a conclusion.
Clearly, more study is needed. In the interim, it appears both black cohosh and soy might be safe to try if you’ve had breast cancer. As always, the most important consideration is to speak to a certified practitioner who is well versed in herbal medicine and make sure that she or he works with your oncologist.
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