“Age cannot wither her, nor custom stale
Her infinite variety …”
William Shakespeare,
Antony and Cleopatra
The paradigm shift that is taking us into the next millennium can be described as an awakening of an inner goddess, a female perspective that has been suppressed or ignored since the days of the Roman Empire. Now the linear, logical, analytical, goal-oriented, win-lose orientation that has dominated modern Western consciousness, and that has been identified with male modes of thought and feeling, is undergoing a transformation. We are beginning to recognize that intuition, synergy, process, context, and relationship are essential if we are to be complete as human beings.
When we first recognized this psychological and cultural shift, it was described in terms of a left brain/right brain orientation. But we can also see this evolutionary change as a recognition and embracing of our feminine nature. According to psychoanalyst Carl Jung, each of us carries both primordial male and female archetypes within our psyche and that intimacy with our inner woman and inner man is the key to love, wisdom, and personal empowerment. It is also the basis of well being, for health is really wholeness, and it requires that we embrace every aspect of our nature.
Our expanding awareness of the feminine is transforming all aspects of life. As we collectively acknowledge the value of a more global, unifying, integrative vision, the goddess within our collective psyche is empowered to express herself in social, political, and economic spheres. The changing role of women is transforming relationships, families, organizations, and society.
Many of the changes we are seeing in health care derive from the new wisdom the goddess is bestowing upon us. As women regain their power in the many arenas of life, the model of a patient as a passive, unquestioning recipient of medical care becomes untenable. People who see themselves as important, powerful, and wise beings want to be active partners in creating their own health. Although it is natural to regress in the presence of a physician, we do not need to surrender all authority completely. Questioning and challenging are qualities of intelligent beings, and the empowerment of women in all decisions relevant to their lives and health is having effects throughout health-care. Research indicates that female patients consider good rapport and positive relationships with health-care providers to be extremely important. As women become more assertive in asking for what they want, the mechanical approach that has characterized health care must change to meet their needs.
What do masculine and feminine really mean? What distinguishes one from the other? Although poets, scientists, and philosophers have been exploring this question since the story of Adam and Eve in the Old Testament, I suggest that the fundamental and essential difference between our male and female nature can be described in one word: rhythm.
The male psyche is deeply imbued with the quest. The male principle in us sets a goal and pursues it unrelentingly, whether it’s the purchase of a new car, achieving a high position in an organization, reaching a certain financial status, or winning the heart of a lover.
The zero-sum, win-lose tools of male consciousness are designed for intense focus on achieving specific aims, and this approach has been phenomenally successful in our achieving the major material accomplishments of the past century. We have developed self-powered vehicles, global communication networks, spaceships capable of exploring other worlds, and major medical breakthroughs that have substantially changed the way we treat disease. But anxiety and alienation, disruption of family and community bonds, and the loss of connection to nature have accompanied our technological advances. None of us wants to relinquish our automobiles, cellular phones, and ATM machines, but we are also beginning to recognize that these things alone can never bring us lasting happiness.
The linear, male-consciousness approach has not been intrinsically wrong, but it is seriously incomplete. Conquest and achievement have been our reasons for being, and human history over the last two millennia has been the chronicle of this paradigm. When we’ve achieved a goal, we’ve set our sights on another. But the goals we’ve set have been in the external world rather than in our own hearts, and the path we’ve chosen has been a straight line pointed outward, rather than a circle leading back to ourselves.
Our feminine nature is intrinsically entwined with the cyclical rhythms of life. In fact, our concept of time is closely interwoven with a woman’s cycle. The word for womb in Greek, metra, is derived from the same word for measurement, meter, which is also the origin of the words mother and time. Feminine time, however, is not the same as linear time, since the former is self-referral. It can be observed in the passage of seasons, in the ebb and flow of the tides, and in the phases of the moon—each acts out a cyclical return. Until recently, our patriarchal society has substantially denied the power of nature’s goddesses, and the price for this repudiation has been great. As we embrace our holistic, intuitive nature, we naturally become more attuned to our connection to Mother Earth and our responsibility for her well being. Whether we are genetically male or female, embracing both aspects of our nature creates health.
One consequence of our predominantly male viewpoint has been the medicalization of women’s health issues. Pregnancy and menopause, and even menstruation to a degree, have become medical issues requiring pharmacological interventions to “keep them running smoothly” or to “fix them” despite the fact that women have been moving through these cycles of life without drugs for millions of years. Once again, we see a well-intentioned medical system dedicated to relieving suffering, but relying only upon a limited, expensive, and frequently invasive therapeutic repertoire. In contrast, it has been our experience that complementary mind body approaches to menopause and premenstrual syndrome can be very beneficial, in both relieving symptoms and as tools to enhance mind body integration in women. As women recapture balance, rhythm, and harmony within themselves, the world benefits.
Christine received very little direct talk about sex as an adolescent girl. Her young mother, divorced soon after the birth of her third child, was perpetually exhausted from single-handedly raising Christine and her two older brothers while working full time.
At age twelve, as her body began to show the changes of developing into a woman, Christine received predominantly negative messages from her mother about sex and reproduction. When she had her first real period, her mother described it as “the curse” and warned her not to get into the same mess that she was in. As a junior in high school, Christine began to have distressing cramping, migraine headaches, and mood swings as her menstrual time approached. As a result, she regularly missed several days of school each month. This pattern continued after she graduated and entered the workplace, limiting her ability to advance in her job.
At age thirty-three, following the death of her mother from ovarian cancer, Christine decided she was going to take charge of her life and began counseling sessions. This led to her visiting us at The Chopra Center, where she learned to meditate, eat healthier, follow a more balanced daily routine, begin regular exercise, and reduce her use of caffeine and alcohol. When I saw her after she’d followed this program for several months, she was a much more comfortable and confident woman, had lost ten pounds, and had only missed two days of work over the past three months.
The menstrual cycle links women to the rhythms of the natural world. According to Ayurveda, effortless menstruation is one of the four key fundamentals to good health, along with strong digestion, regular elimination, and restful sleep. When menstruation is smooth and natural, it is a sign that a woman’s mind and body are integrated in a healthy way. But distress and discomfort in a woman’s monthly cycle is evidence of an underlying imbalance in her mind body continuum. The fact that so many women in the Western world are troubled with PMS, therefore, should raise a red flag of concern about women’s experience in our society. It should cause us to question how women are regarded, and how they regard themselves.
PMS affects women of all ages, with several studies suggesting that almost a third of childbearing females have distressing-to-disabling symptoms prior to their menstrual periods.1 There are over 150 disturbing mental, physical, or behavioral symptoms associated with PMS, including anxiety, mood swings, irritability, headaches, breast tenderness, bloating, fatigue, increased appetite with food cravings, sleep changes, and memory and concentration problems. The hallmark of PMS is the repetitive presence of symptoms during the week prior to the menstrual period, which subside once menstrual flow begins. Well over half of all women have some of the symptoms associated with PMS, although they are usually not severe enough to interfere with normal activities. But even if her symptoms are not severe enough for a woman to stay in bed or miss work, the mind body interventions recommended in this chapter can still be very beneficial.
Before delving deeper into what is known about the cause and treatment of premenstrual syndrome, I’d like to review the extraordinary choreography that regulates a normal menstrual cycle. The brain, hypothalamus, pituitary gland, ovary, and uterus are harmoniously integrated to ripen an egg for fertilization and prepare the womb for implantation. Although I briefly discussed this process in Chapter 18, on reproduction, I’ll go a little deeper here. This detail is well justified, for the normal menstrual cycle is a beautiful expression of nature’s intelligence. A close consideration of the cycle can help us not only to understand it intellectually, but to minimize its potential for causing distress in women’s lives.
Cells in the hypothalamus, the nervous and hormonal center at the base of the brain, secrete pulses of a chemical messenger that stimulates the pituitary gland to release two hormones, luteinizing hormone (LH) and follicle-stimulating hormone (FSH). These two protein messengers enter into the bloodstream until they reach the ovary. Here, egg cells are stimulated to ripen and, in the process, produce estrogen, which stimulates the lining of the uterus to prepare for a fertilized egg. The process starts on the first day of menstruation so that by Day 14, the egg is ready for release and ovulation occurs.
After the egg is released, the cells that surrounded it in the ovary begin making another hormone, progesterone, which further prepares the womb’s lining. What follows next depends on whether a sperm reaches the ripe egg and fertilizes it. If fertilization occurs, the egg floats down the fallopian tube and eventually finds its way into the uterus, where it becomes embedded into the lining and begins to receive nourishment to support the development of a fetus. If a sperm does not reach the egg, the cells in the ovary stop making estrogen and progesterone, the lining of the uterus is released, and menstrual flow begins.
There are many other hormones and chemical messengers that also play roles in this elegant, though complicated, dance (Table 1). All of these codes of intelligence have widespread effects, not only on the ovary and uterus, but also on many aspects of the brain. Therefore, it is not surprising that subtle imbalances in this process can lead to distressing psychological and physical symptoms. Other factors that influence the normal cycling include emotional stress, level of physical activity, and nutritional status, all of which have important roles to play in premenstrual syndrome.
TABLE 1: PRIMARY MENSTRUAL-CYCLE CHEMICAL MESSENGERS
| MESSENGER MOLECULE | PRODUCED IN THE … |
| Gondatrophin-releasing hormone (GnRH) |
Hypothalamus |
| Follicle-stimulating hormone (FSH) | Pituitary gland |
| Luteinizing hormone (LH) | Pituitary gland |
| Estrogen | Ovary |
| Progesterone | Ovary |
SECONDARY MENSTRUAL-CYCLE CHEMICAL MESSENGERS
| MESSENGER MOLECULE | PRODUCED IN THE … |
| Prolactin | Pituitary gland |
| Thyroid hormone | Pituitary gland |
| Melatonin | Pineal gland |
| Serotonin | Brain, platelets, digestive tract |
| Endorphins | Brain, hypothalamus |
| Prostaglandins | Diffusely |
| Insulin | Pancreas |
| Adrenal hormones | Adrenal gland |
It is safe to say that despite intensive efforts to understand PMS scientifically, there is no clear and widely accepted explanation. Several studies have suggested that women with PMS have different patterns of estrogen and progesterone secretion, but no consistent findings have emerged.2,3 Theories have proposed that there may be either a deficiency or an excess of certain prostaglandins involved in pain regulations. Evening primrose oil, which contains about 10 percent of an essential fatty acid, γ-linoleic acid, has been shown in some trials to reduce premenstrual breast pain, possibly because it leads to an increase in an important prostaglandin.4 Antiinflammatory medications such as naproxen block other prostaglandins and have been partially successful in treating headaches, abdominal cramps, and back pain.5
A low vitamin B6 level has also been suggested as a cause for PMS symptoms, and although several studies have shown B6 supplementation to be of benefit, others have failed to confirm its value.6,7,8,9 Vitamin B6 plays an important role in serotonin production and many researchers have sought to explain the mood and appetite changes in terms of altered serotonin metabolism.10,11 Although it is clear that several medications that affect serotonin in the brain can improve aspects of PMS, the precise role this important chemical messenger plays remains to be clarified.12,13
It is becoming obvious that looking at PMS from a localized perspective may yield interesting findings but is unlikely to give us a specific reason for a woman’s monthly discomfort. I am firmly convinced that the reason we have not been able to find the medical scientific explanation for premenstrual syndrome is simple: It is not a disease. The extremes of emotional and physical symptoms in women with PMS represent imbalances in a normal and natural hormonal tide, which, when ignored, lead to greater imbalances. Studies attempting to define the characteristics of women with PMS show that they have higher life-stress levels, lower self-esteem, and carry more anger and guilt.14,15 This understanding opens up the possibility for a more holistic approach to this common problem, one that integrates spirit, mind, body, and environment.
A vast array of medical interventions has been tried in women with premenstrual syndrome, generally directed to a specific physical or emotional symptom. To offset water retention, diuretics are prescribed. To reduce abdominal cramping, migraine headaches, and musculoskeletal pain, pain-relieving medicines, particularly anti-inflammatory drugs, are used. For the mood changes, irritability, and depression, almost every psychoactive medicine has been tried, including those used to treat depression, anxiety, epilepsy, and blood pressure. Oral birth-control pills, estrogen, and progesterone all have their proponents, although the enthusiasm for these remedies seems to outweigh the scientifically demonstrated benefits.16,17,18,19
Diet: A variety of nonpharmacological interventions can be helpful to lessen the symptoms of PMS. Dietary recommendations are widely suggested although most have not been fully evaluated scientifically. There is some support for reducing the intake of refined sugars and favoring a low-fat, high complex-carbohydrate diet.20,21 These simple dietary changes seem to stabilize mood swings and reduce breast tenderness. Eliminating caffeine-containing beverages (cola, coffee, and tea) can be helpful in reducing anxiety, tension, and insomnia.22 Although some women try to self-medicate with alcohol and other mood-altering drugs, there is often a substantial price to pay in terms of the severe agitation and irritability that follows.
Nutritional Supplements: Several nutritional supplements have been used in PMS for symptomatic benefit. As noted earlier, vitamin B6, or pyridoxine, has been helpful in reducing symptoms of PMS, but in fairly high dosages of two hundred to five hundred milligrams per day.23 The recommended daily B6 requirement is only two milligrams per day, and at the higher doses used, nerve damage is a real risk. Trying B6 in doses of fifty to one hundred milligrams a day during the second half of your menstrual cycle for several months is a reasonable approach, but discontinue using it if it is not clearly helping or you notice any tingling or numbness in your hands or feet.
Vitamin E, calcium, and magnesium all have their proponents. Vitamin E in doses of four hundred international units daily has been shown to produce modest benefits with minimal side effects.24 One gram per day of calcium can reduce both psychological and physical symptoms of PMS, including irritability, depression, bloating, and backaches.25 Magnesium supplementation can improve mood and reduce bloating but it takes several months before women notice any benefit.26
Although it is instructive to identify various specific nutritional elements that have been shown to produce some relief in PMS, I don’t believe that this type of approach alone reflects a real shift in perspective. Focusing on one or another vitamin or mineral perpetuates the “magic-bullet” mentality, which anticipates the entire problem disappearing if we only discover the one substance that is missing. Nutritional intervention under an integrated mind body approach focuses on the overall quality of food, the way it is prepared, and the environment in which it is eaten. It has been my experience that when we are prepared to look at our overall life patterns and make nourishing choices, the need for specific nutritional manipulations often evaporates.
Group-Therapy and Cognitive-Behavioral Approaches: Developing a deeper understanding of the nature of premenstrual syndrome, clearing emotional toxicity, and learning ways to enhance mind body integration can improve the quality of life in women dealing with this condition. Many women who received negative messages about their sexuality as children later develop PMS, and an agonizingly high number experienced sexual abuse.27 As adults, many of these women continue to have negative feelings about sex, menstruation, and reproduction along with anxiety, depression, and low self-esteem.28 Efforts to address the emotional pain and anger these women carry through group-therapy sessions have not received a lot of scientific scrutiny, but there is some evidence that women in support groups benefit from sharing their experiences with others facing similar issues.29
Biofeedback, relaxation techniques, stress-management programs, and meditation are sometimes collectively lumped together as cognitive-behavioral therapies. Several reports using one or more of these therapies have shown that both emotional and physical symptoms of PMS can be lessened, with less depression and a reduction in negative thoughts. Relaxation techniques have been useful in reducing premenstrual muscle tension and stabilizing mood variability, while programs designed to lessen anxiety and more effectively manage anger have proven valuable.30,31,32 In our experience, combining meditation techniques that offer the opportunity to quiet the mind with emotional processing programs that teach effective ways to cope with stress and address issues of repressed pain and anger provides the greatest benefit.
An important component of any effective behavioral program for women with PMS is exercise. Regular aerobic exercise has many benefits, including reduced fluid retention, less breast tenderness, and improved emotional states.33,34 The good news for those not used to being physically active is that even a low-intensity exercise program can provide substantial benefit in reducing PMS symptoms.35
The Ayurvedic framework provides valuable insights into the nature and treatment of PMS. With its emphasis on alignment with natural rhythm as the basis of health, Ayurveda views PMS as an imbalance, rather than as a disease. The goal then is to identify the source of imbalance, reduce any toxicity, and provide nourishment to the reproductive system.
Premenstrual syndrome may reflect imbalance in any of the three doshas, Vata, Pitta, or Kapha. Anxiety, depression, moodiness, and cramping pain reflect an imbalance in Vata dosha. Irritability, anger, hot flashes, and migraine headaches represent imbalances in Pitta dosha. Water retention, bloating, heaviness, weight gain, fatigue, and breast swelling are manifestations of imbalanced Kapha. When two or more doshas are prominently disturbed, it is a sign of ama accumulation, most likely due to accumulated emotional toxicity, poor diet, and a disrupted daily routine. Both general and specific Ayurvedic interventions can be helpful, depending upon which dosha is most predominantly aggravated. Learning to entrain with natural rhythms is key to healthy menstruation.
The most important component of our PMS program involves setting aside time each day for silence in meditation. The centering and stress-reduction benefits of meditation can immediately begin to reestablish balance. Focus on creating an ideal daily routine, getting to bed before eleven P.M., and awakening around sunrise. This helps to harmonize your internal rhythmic pacemakers with natural cycles.
Look carefully at your diet and eliminate anything that is not nutritive. This includes obvious substances such as alcohol, tobacco, and caffeine, and it is also important to increase prana-rich foods, particularly fresh fruits and vegetables along with whole grains. Favor those tastes that are pacifying to the most-aggravated dosha. If pain, mood swings, and insomnia are prominent, favor heavier, warm foods that pacify Vata. If irritability, agitation, and hot flashes are troublesome, reduce spicy, sour, and salty foods, which aggravate Pitta. If swelling and bloating are a problem, favor lighter, warm, Kapha-pacifying foods.
Pacifying aroma therapy, soothing music, and a daily oil massage can help to stimulate your internal pharmacy of pain relievers and mood stabilizers. Take extra rest during the second half of your menstrual cycle and minimize activities as much as possible on the first day or two of your period.
Several specific herbal nutritional substances have been traditionally used in Ayurveda to balance the female reproductive system. One-half ounce of aloe vera juice is a useful and inexpensive female tonic that can be taken throughout the month. Indian asparagus (Asparagus racemosus), known as shatavari in Sanskrit, is the primary Ayurvedic female rejuvenative. One to three grams taken with warm milk at bedtime is soothing and nourishing to the reproductive tract. Angelica root has been used in both Chinese and Ayurvedic pharmacopoeias for thousands of years. Known as dong quai in Chinese and choraka in Sanskrit, this herb promotes normal menstruation and combines well with shatavari. Another useful female tonic is musta, or nut grass (Cyperus rotundus). It has been used traditionally to relieve congestion and promote easy menstrual flow. One-half to one gram of both angelica and musta two to three times per day is the usual dose to balance and nourish the female organs.
If irritability is a major problem, Ayurveda recommends taking a purgative at midcycle to reduce Pitta accumulation. Take a tablespoon of ghee herbalized with grated ginger root and licorice for a few days before using an herbal laxative such as senna or castor oil. Adjust the dose so that you have a few loose bowel movements and eat lightly for a few days before and after the cathartic is taken. If mood swings and anxiety are troublesome, be certain to perform a daily oil massage with special attention to your head and neck. Prepare warm milk before bed with saffron or cardamom to pacify aggravated Vata, and use soothing aroma therapy with rose, bergamot, patchouli, sandalwood, or ylang-ylang. If congestion is a major concern, reducing your intake of salty foods and adding wild celery seeds (ajwan), cinnamon, mint, and fennel to your diet will help to reduce excess fluid.
Regular physical activity is entirely consistent with an Ayurvedic approach. Daily yoga postures can be helpful in reducing back pain and abdominal congestion. Aerobic exercises three times per week for twenty to thirty minutes increase endorphins and help stabilize emotions.
A simple remedy for abdominal cramping and tension is massaging castor oil onto the belly, covering the abdomen with a thin cotton or linen towel and applying a hot-water bottle or heating pad. Soaking in a hot bath to which dried ginger, chamomile, comfrey, or lavender has been added, along with a teaspoon of almond oil and a few drops of essential aroma oil, can be very soothing. Use all five senses to balance mind and body, particularly in the week prior to your period.
As the new paradigm of health permeates all aspects of our life, we will see both men and women changing. Times of transformation are challenging, often requiring us to look at basic aspects of our life in a new light. Our reproductive rhythms remind us that our apparent ability to isolate ourselves technologically from nature is an illusion. We are dynamic living beings inextricably interwoven into the rhythms and cycles of nature. When we are healthy, our fundamental rhythms are harmonious, and when they are not, it is a signal from our innermost being that we need to look at what we are not paying attention to in our lives.
Modern women face unprecedented challenges. In addition to the traditional role of mother and homemaker, most women are now also in the workplace, seeking fulfillment through achievements in the world. But there is little recognition of a woman’s natural rhythms in the marketplace, and therefore there is conflict between a woman’s inner wisdom and the world’s outer demands. Even today, in remote parts of the world, when a woman’s monthly flow begins, she retires to a designated location, which may be a straw mat or a separate hut, and remains there for several days. One could certainly argue that this constitutes a form of exclusion, and perhaps even oppression. On the other hand, is it reasonable or fair simply to ignore the important physiological changes that take place in a woman’s body each month? Perhaps there is something to be said for withdrawing from the everyday routine while menstruation takes place. And perhaps the widespread incidence of PMS in Western society is an expression of physical and spiritual dissatisfaction, or even anger, at our current view of the monthly cycle and how it should best be dealt with.
Although nature flows in tides of rest and activity, we are just beginning again to consciously appreciate the cyclical dance of the universe. As women collectively embrace the many facets of their nature, healing on individual, community, and planetary levels will unfold.
Mrs. Roseman’s husband died of a heart attack a year ago. At age fifty-six, she was not ready to abandon her hope for a new life and new love, and despite the fact that she had gone through a very smooth menopause almost eight years earlier, she asked her gynecologist if she could begin hormone replacement. At first, she liked that her breasts were fuller and her vaginal dryness relieved, but after several months, she was troubled by breast tenderness and irregular bleeding. Despite reductions in her doses of estrogen and the addition of progesterone, she continued to feel uncomfortable with her choice and discontinued her hormone-replacement therapy.
Seeking a more natural approach, she began meditating regularly, increased her dietary intake of legumes, whole grains, and fresh vegetables, added a daily calcium supplement, and started exercising regularly with a personal fitness trainer. When she saw her physician nine months later, her cholesterol level was perfect, her bone-density test showed minimal signs of osteoporosis, and she felt genuinely healthier than she had in years.
A girl reaching puberty has between 200,000 and 300,000 potential eggs in her ovaries. Each month, many of these ovarian follicles are activated but only one ripens into a mature egg that is released for possible fertilization. Over a woman’s forty or so childbearing years, only about five hundred eggs fully develop. As her ovaries exhaust their supply of eggs, a woman transitions into menopause—a pause in her monthly cycling.
Menopause is rich in psychological, physical, and cultural symbolism. A woman can look at “the change” as an end to her productive years or as the beginning of a new freedom of expression. She can see the shifts in her body as a loss of her youthfulness or a blossoming of her feminine divinity. Her role in the community can be seen as a dependent liability or as a valuable wisdom resource. The uncertainty of menopause is an opportunity to tap into the field of infinite possibility and create something new and vital.
The debate in the medical community continues as to whether menopause is more appropriately viewed as a normal physiological process or as a disease. Although the tendency in the Western world is to view menopause, like birth, as needing medical intervention, this is not universally true. In Japan, for example, over one-half of women experience menopause as relatively uneventful. A symptom such as hot flashes, which most American women anticipate as inevitable, is relatively uncommon in Japanese menopausal women.36 Known as konecki in Japanese, menopause is considered as a natural life-cycle transition that includes both men and women, with each sex experiencing it differently based upon their biological constitution.37 From the mind body perspective, the goal is to facilitate this time of change with as much awareness as possible, with a focus on enhancing balance and eliminating unnecessary obstacles to a smooth transition.
Hot flashes, emotional distress, bone weakness, and an increased risk of heart disease are the most common concerns of women facing menopause. Hot flashes and psychological imbalance create immediate distress, whereas osteoporosis (weak bones) and heart disease are longer-term problems. Vaginal dryness, a reduced sex drive, and skin changes are also frequent health issues in menopausal women.
Hot flashes are one expression of a generalized instability in the vascular system of many menopausal women. Flushing of the face, neck, and chest is most common with episodes lasting several minutes. Sudden sweating during the day or at night, nausea, heart palpitations, and headaches are other common manifestations of vasomotor instability. Hot flashes are more likely in women who have had surgical removal of their ovaries and in women who are thin. Without treatment, hot flashes may persist for a year but a small percentage of women will have symptoms that go on for several years. Alcoholic beverages and pungent, spicy foods often precipitate the symptoms.
Cells throughout the nervous system are affected by circulating estrogen, which may explain why some women undergoing menopause have changes in mood and memory. The steroid hormones, including estrogen, work by entering the nucleus of a cell and influencing the activation of certain genes. Receptors for estrogen are present in the pituitary gland, hypothalamus, and emotional part of the brain (the limbic system), so it is not surprising that women with less available estrogen report changes in their moods and memory.
Osteoporosis, or bone weakness, is a serious concern for post-menopausal women. Well over a million osteoporosis-related bone fractures occur each year in the United States at a considerable physical, emotional, and financial cost to society. Estrogen lack plays an important role in the development of bone loss, which occurs at about 2 percent per year for the first five years of menopause and then decreases to about 1 percent per year thereafter. One of the most useful ways to determine the strength of one’s bones is through a bone-densitometry test, most of which use special X-ray equipment to measure bone mass. In addition to estrogen loss, physical activity level, dietary calcium and vitamin D, daily caffeine intake, smoking, and alcohol consumption all affect the strength of our bones and the risk of fractures.
Estrogen has widespread effects on the cardiovascular system, influencing our heart, blood vessels, circulating blood cells, and serum lipids. The risk of cardiovascular diseases rises in menopausal women. Heart attacks are reduced in women who take estrogen-replacement therapy, but it does not seem to lessen the risk of stroke.
Modern women have definite choices about how to perceive menopause and what course to pursue. At The Chopra Center, I see women with a wide range of beliefs regarding medical management of menopause, and despite my own opinions, I am committed to honoring each woman’s choice. Some women strongly feel that any medical intervention is a sign of failure and are committed to a totally natural approach. Other women do not want their lives disrupted by disturbing symptoms and gratefully take medications that can alleviate their distress. Most fall somewhere in between, wishing to minimize or eliminate the need for drugs but not wanting to tolerate present or future health concerns. As a physician, I believe it is my role to provide education about available choices so that people can make responsible decisions. I don’t believe that there is one right approach for everyone.
Many of the distressing symptoms of menopause promptly respond to hormone-replacement therapy, but several studies have shown that less than 50 percent of women continue using estrogen two years after starting it due to uncomfortable side effects or psychological concerns.38,39,40 Despite this, it is clear that most, if not all, of the major health issues of menopause can be impacted by medications; however, as is true with every drug, there are benefits and risks that need to be weighed.
Hot flashes, experienced by more than two-thirds of American women, respond almost universally to estrogen-replacement therapy within a few weeks of treatment. The other symptoms of vasomotor instability, including nausea, vomiting, dizziness, and sweating, also improve on HRT. Progesterone therapy has also been used in women with a history of breast cancer with some benefit. Other medicines, such as clonidine, usually used in hypertension, have been used to stabilize the vascular system but have a wider range of potential side effects, limiting the usefulness.
Estrogen-replacement therapy has been clearly shown to arrest bone loss and reduce the chances of fracturing a hip or wrist.41,42 Recent studies have suggested that the combination of continuous low-dose estrogen with progesterone can improve bone mineral density without causing the vaginal bleeding common when estrogen is used alone.43 Other agents, such as calcitonin, flouride, and the biophosphonates, are used to slow or reverse bone loss but most physicians consider estrogen to be the treatment of choice in menopausal women.
Many studies have shown that women who take estrogen replacement are at a lower risk for heart disease.44 Cardiovascular disease currently accounts for over a third of all deaths in women, and estrogen therapy has been shown to reduce it by about half. Estrogen replacement’s benefit on heart disease, as on every other symptom of menopause, rapidly diminishes as soon as hormone replacement is discontinued; therefore, lifelong usage must be anticipated if this route is taken.
Although today’s medical standard of care recommends HRT for women going through menopause, there are well-recognized complications of its usage. Vaginal bleeding is one of the more disturbing side effects of estrogen alone or in combination with progesterone and may be seen in over half of women receiving treatment. Low continuous doses of progesterone may substantially reduce this problem but this requires the long-term use of two drugs. Breast tenderness and swelling is a common concern of women taking estrogen and may occur at very low doses. Reducing estrogen intake to the point of eliminating this symptom may also eliminate HRT’s potential benefit to the bone and heart.
Of greater concern than the annoying symptoms of bleeding and breast tenderness is the potential risk of uterine and breast cancer. In studies of large groups of women, those taking estrogen alone do show a substantial increase in the risk of cancer of the uterus. Abnormal changes in the endometrium, the rich inner lining of the womb, are common in women on estrogen. Although the risk is reduced in women who take progesterone along with estrogen, it is still higher than in those who receive no hormone at all.45
Most reports have also found a relationship between HRT and breast cancer. The increased risk of breast cancer seems to be greater in women who have been on estrogen for at least five years. Those who get breast cancer while on estrogen seem to have less malignant disease and better survival. It has been suggested that estrogen doesn’t actually trigger cancer but simply accelerates the development so that it is discovered at an earlier stage. This is not an argument that is easily accepted.
With all the information that is becoming available on menopause, it is easy to become confused. The right choices are not crystal clear, so there is room for personal opinion in this area. If we accept that there are some benefits to estrogen replacement but are not certain if the risks outweigh them, an important question becomes, what are the alternatives?
There are alternatives, but they must be presented along with a number of caveats. If you are willing to commit time and effort to exercise at least three times a week, if you are able to ensure that you are getting adequate calcium intake, if you are certain that your diet is rich with natural sources of estrogen, and if regular monitoring of your bone density does not reveal any signs of ongoing osteoporosis, then natural approaches to hormone replacement are a reasonable alternative.
If you are going or have gone through menopause, there are several things you can do to improve your well being. Although there is good reason to believe that many of these natural approaches can reduce symptoms and potential complications of menopause, few of them have been systematically compared to HRT and no long-term studies are available. Whether or not you are planning to take estrogen, these approaches will benefit your health.
Diet: Calcium and Vitamin D are the building blocks of healthy bones. Ideally, young women should be building strong skeletons long before they complete their reproductive years. A woman usually attains her maximum bone mass by her mid-twenties, or by thirty at the latest. Calcium intake during childhood and early adulthood, therefore, is crucial for building a skeletal foundation that can withstand the changes that occur later in life.
Doses of one thousand milligrams of daily calcium have been shown to significantly decrease the rate of bone loss, and calcium supplementation can actually increase the bone mineral density in the lumbar spine.46 Eight ounces of milk, a cup of yogurt, or one to two cups of dark green leafy vegetables or broccoli all supply about three hundred milligrams of calcium per serving, so three to four servings per day should provide the necessary amount.
Studies from around the world suggest that hip fractures are more common in cultures where there is high animal-protein intake. It has been proposed that the high protein load increases the amount of acid the body needs to dispose of, resulting in a breakdown of the bone, which is used to buffer the acid.47 Although there have not been studies suggesting that reducing animal fat improves bone strength, this may be another good reason to favor a vegetarian diet in addition to its clear benefit for the heart.
Reducing consumption of caffeine, alcohol, and excessive salt can all play a role in improving bone strength and reducing the risk of fractures.48 Stopping smoking is also an important step toward cardiovascular and skeletal health.
Exercise: Exercise and fitness training are important components of a healthy lifestyle and have been clearly shown to reduce the complications of menopause. Strength-training exercises, performed twice a week for a year, can improve bone density and muscle mass, reducing the risk of falls and the likelihood of fractures.49 The benefits of regular exercise on cardiovascular health are widely known, yet more than 50 percent of Americans continue to follow very sedentary lifestyles.
Natural Estrogens: Many commonly available fruits and vegetables contain natural estrogens, known as phytoestrogens. Soybean-derived foods such as tofu and miso are the richest source of plant-derived estrogens, which are also found in smaller quantities in almonds, apples, beets, cabbage, carrots, cashews, cherries, corn, cucumbers, rice, squash, and yams. Studies of the dietary habits of women in different countries have shown that there is often a good correlation between reduced symptoms of menopause and increased amounts of dietary estrogens. One study reported a better than hundredfold superiority of phytoestrogens in the diet of Japanese women compared to women in the United States and Finland, mostly due to the Japanese women’s greater consumption of soy foods.50
For thousands of years, beans and legumes were our principal source of protein, and it appears that over the centuries the human body evolved an ability to convert the estrogen chemicals of plants into useful biological agents. In addition to providing a natural source of hormones, the phytoestrogens seem to provide protection against a wide range of cancers.51 The full physiological effect of these natural estrogens is still being clarified, but there is reason to hope that increasing our consumption of flaxseed flour, lentils, chickpeas, soybeans, kidney beans, oat bran, and kelp can diminish the need for hormonal drugs and reduce the risk of a variety of cancers.
Ayurveda teaches that blood (Rakta dhatu) is a major site of Pitta in the physiology. Throughout a woman’s menstruating years, she has the ability to eliminate this accumulated Pitta through her monthly blood flow. Because men do not have this capability, they more frequently develop Pitta-aggravated health concerns such as stomach ulcers and heart disease, as well as Pitta emotional imbalances such as chronic anger and aggressiveness. As women go through menopause and are no longer able to eliminate Pitta, they too begin to develop manifestations of Pitta imbalance. In menopausal women, hot flashes are the most acute expression of this tendency. The increased risk of heart disease in postmenopausal women is also a manifestation of greater susceptibility to Pitta imbalance.
The loss of the menstrual elimination mode also leads to increased Vata imbalance in women undergoing menopause. The consequences of rising Vata include bone weakness (too much air, not enough earth), dry vaginal tissues, and mood instability.
Interventions designed to pacify Pitta and Vata can improve emotional balance and physical well being in menopausal women. If she finds that hot flashes and irritability are problematic, a woman should follow a Pitta-pacifying diet that includes reduced pungent, sour, and salty foods. The diet should include cooling spices such as fennel and coriander, as well as Pitta-pacifying herbs such as sandalwood, saffron, musta, shatavari, and manjishta. Aloe vera juice, one-half ounce twice daily, is cooling and balancing to the female reproductive tract. When the symptoms of Vata imbalance are a concern, warmer, heavier Vata-pacifying foods including heated milk, herbalized with saffron or cardamom, can be beneficial. In general, maintaining a regular daily routine and eliminating all potential sources of toxicity are vitally important.
Aroma therapy, using balancing essential oils and daily massage, can also contribute to a smooth transition through menopause. To pacify Vata, ginger, rose, sandalwood, and vetiver are useful. For Pitta pacification, include clary sage, mint, sandalwood, and rose. For the bloating and heaviness of Kapha, use juniper, sage, and geranium.
Change is almost always challenging, but it also creates opportunities for evolution. A charming lady in her sixties recently told me she had learned that we don’t really solve our personal problems—we simply outgrow them. Menopause is a time of change and challenge, but it is not a disease. It is an opportunity to transition into a new phase of balance, purpose, and knowledge. The wisdom of a woman passing beyond her reproductive years may be the most valuable asset she has ever had. By deepening her understanding of her femininity and its connection to the earth and nature, a woman can teach her family and community members to honor their deeper selves.
Fortunately, today’s women have many options in how to approach menopause, and each option has its benefits. Listen to the inner wisdom of your body for guidance in navigating this transitional time. Know that the key to a successful menopause is not found in the presence or absence of hormone-replacement therapy, or in any other medical procedure. Rather, it derives from learning more about yourself as you tap into the primordial wisdom that permeates every cell and atom of your being.
1. Honor your natural rhythms and pay attention to the signals your body is sending you. Take rest when you need it, particularly on the first day of your period.
2. Take time in silence every day and consciously connect with the beauty and wisdom of nature.
3. Focus attention on getting to bed before eleven P.M. and awakening around sunrise.
4. Eat foods rich in phytoestrogens, including legumes, fresh fruits, vegetables, and soy-derived protein sources such as tofu.
5. Ensure that you receive adequate calcium intake (at least one thousand milligrams) each day.
6. Perform a daily oil massage. As your menstrual time approaches, spend extra time gently massaging your breasts and your lower abdomen.
7. Perform regular exercise to improve strength, flexibility, and aerobic capacity.
8. Try drinking aloe vera juice, one-half ounce twice daily.
9. If you are having difficulties with your periods or are going through menopause, try shatavari, one gram twice daily in warm milk.
10. Avoid the intake of any substance that does not provide nourishment to your body, mind, or soul.
11. Culture loving relationships that treat you with honor and respect.