Until a few years ago it looked like the “solution” to menopause, and the health problems of the years beyond, was to put almost all women on hormone therapy. Hormones not only relieved the symptoms of menopause, but also appeared to prevent heart disease, stroke, Alzheimer’s and a host of other terrible illnesses. If you look back at books on menopause from just a few years ago, it seemed like malpractice to deny women the benefits of estrogen replacement therapy. Then, in 2002, the Woman’s Health Initiative study showed that hormones not only had no net health benefit, but actually increased the risk of serious illness by a small amount.
That single study brought the era of putting every menopausal woman on estrogen to a sudden halt. Perhaps more significantly, it changed the scientific model of menopause from a disease requiring treatment to a natural transition managed only as needed for symptom relief. According to a recent National Institutes of Health consensus panel, most women move through menopause without major problems; there are effective treatment options for symptoms, but they carry risk; and, most noteworthy, menopause is a phase of life, not a disease.
Hormones, acupuncture and some alternative supplements work well as short-term solutions for specific symptoms when needed. But lifestyle—the platform of serious exercise, good nutrition and emotional integration—is the most important therapeutic option for moving through menopause. Above all, lifestyle choices are the foundation for embracing the thirty years that most American women will have after menopause.
Think about that for a moment. Most American women will live for thirty years after menopause. That means that menopause is nowhere near the finish line; it’s more like a starting line for a whole new phase of life . . . one that will last for three decades. And every morning of those thirty years, you will wake to that fundamental biological choice: do you want to decay or grow? That’s the good news. The bad news is that the question takes on more urgency now, because the tide sets against you with menopause. The stakes are higher. The pace of decay picks up speed. Your rate of bone loss doubles. Your risk of heart disease—a small fraction of men’s before menopause—catches up within a decade and then pulls ahead. You can still swim against the tide without too much trouble, but you can’t afford to drift anymore.
Back on the savannah, your hormonal cycles, from puberty until somewhere in your forties, were precisely controlled to maximize your chances of successful pregnancy. Stress, sedentary living and poor diets affect women’s menstrual cycles to different degrees, because in nature those were all signals of peril . . . of dangerous times to carry a child. So menstrual cycles may not always look like they’re precisely planned in modern times, but your body has a remarkably clear sense of what it’s doing . . . up until around age fifty-one, when menopause starts for most women.
And it has an equally clear sense of what it’s doing after menopause, usually by age fifty-five or so. Your body has moved into a new phase, no longer influenced by your estrogen cycles, but regulated by the daily balance between growth and decay that is built into all of us (women, men, antelope, dolphins, penguins, squid . . .).
Menopause is the hormonally tumultuous transition between these two highly ordered states, unpredictable, and different for each woman. It’s a period of temporary chaos. Somewhat like the turbulence of the Middle Ages between the long stability of the Roman Empire and the creative explosion of the Renaissance. The important point is that medicine and alternative treatments can only alleviate the symptoms of menopause, and they all carry small risks. To affect the underlying biology, it’s up to you to give your body guidance by managing your exercise, diet and emotions as you head into your own renaissance years.
It would be natural for you to ask how much is really known for sure about menopause, and what you should believe. After all, a few years ago the notion that most women should take estrogen after menopause, probably for life, approached religious dogma. How did the medical profession swing from that certainty to a diametrically opposed certainty so quickly? And where did the information come from, anyway?
These are important questions to ask, because you are going to be a critical consumer of medical information for the rest of your life and the media will bombard you with new recommendations and studies on a daily basis. Most of those stories will be inaccurate, and most of the recommendations will be wrong or, at best, partly right. The story of hormone replacement in menopause is a perfect illustration.
Let’s start with what it means biologically to say that we “know” something. In everyday life, we think of knowledge in terms of yes/no answers. We know or we don’t know. It’s like a light switch that’s on or off, making the room either light or dark. But in medical research, it is never that simple. We can’t put people in test tubes. We have to study them in real life, where there are hundreds of different influences on health, in addition to the drug we are giving them. Most of the time the drug effect is just a faint biological whisper that we try to hear above the roar of growth and decay. We try to factor out some of the major lifestyle issues, like the influence of smoking, cholesterol, and so forth. And we try to include enough people that all the other influences average out, but it’s an impossible task. We do our best, but the reality is that we never know for sure. Biology is like a huge jigsaw puzzle, and we only have bits and pieces. Sometimes we can connect enough of them to make a really great educated guess, and many times we have enough pieces to make a decent guess. But other times we know only enough to make dangerously bad guesses, cloaked in the guise of authority.
And while good researchers spend their lives thinking hard about these issues, the media, the pharmaceutical industry and many doctors simply ignore them. A study of twenty people means almost nothing scientifically, but the reporter on the ten o’clock news may think it’s just as newsworthy as a study of ten thousand people. And then there’s the issue of bias. Ninety percent of the studies published by drug manufacturers show that their drugs work as hoped, but independent studies show that only about half of them do. Are the industry’s studies outright lies? Generally not, but they are deceptive, because they present uncertainty as statistical probability, and then the willing media and many doctors present it as fact.
We should just say “we don’t know” when the studies and statistics are marginal, and many doctors do. But others don’t, because humans don’t like uncertainty. This goes back to our basic neural biology. No human likes uncertainty. We are wired to make rapid decisions, and we get very anxious if we can’t. When there is no hard information, we choose the fastest route to a decision—any decision—to end the panic of uncertainty. You can measure this in the lab, and experimental psychologists have shown over and over again that humans will reliably make blatantly bad decisions to end the feeling of uncertainty. So doctors, who after all are human, talk themselves out of uncertainty. And medical reporters, newspaper and magazine editors, and patients all do, too.
This was the case with menopause and hormone therapy. The science was equivocal, and no one really knew for sure what hormones did to women’s bodies. In that context, doctors, as a profession, forgot the critical distinction between the proven and the promising. Seduced by the possibility of offering women important health benefits, and with a strong push from an aggressive pharmaceutical industry, rafts of studies that provided partial answers were pulled together to provide what we assumed was the truth.
A host of “observational” studies over the years had looked at women who had already chosen, before the studies began, whether or not to take hormones. In those studies, the women who chose to take estrogen did better than those who didn’t—50 percent fewer heart attacks, fewer strokes, fewer cases of Alzheimer’s, less osteoporosis, albeit with a slight increase in the risk of breast cancer.
It seemed apparent that hormones were the answer. Luckily, just before the “answer” became completely locked in as established medical fact, the National Institutes of Health, under the leadership of its first woman head, Bernadine Healy, M.D., was charged with addressing (and redressing) decades of gender bias in medical research. And so began one of the largest, most ambitious and most successful public health studies in history: the Woman’s Health Initiative.
The WHI is a massive national research study looking at heart disease, breast cancer, colon cancer, hormone replacement therapy and osteoporosis in women from age fifty to seventy-nine. The hormone part of the study is over, but the rest of the study is continuing and will provide critical information on women’s health for decades to come. With an initial budget of 625 million dollars, the WHI is studying more than 160,000 women at forty research centers across the nation. The hormone part of the WHI involved thousands of women who—and this is critical—didn’t choose whether or not to take estrogen. They agreed to be randomized, to have the researchers flip a coin to assign them estrogen or placebo. The WHI is so accurate and powerful because all those women bravely agreed to leave their treatment up to a coin toss at a time when the benefits of estrogen seemed so clearly established that some thought putting women in the placebo group was unethical.
The WHI illustrates how ferociously difficult and expensive it is to do good science and how dangerous it is to confuse the proven with the promising. In the case of hormone therapy, the theory made all sorts of sense biologically. Women are far healthier than men until menopause, but then they catch up—especially in terms of heart disease. And all those observational trials showing that the women who took hormones did better were real studies. You can go back and read them today and think they are very convincing, until you realize that they are wrong.
What happened was that the researchers did not appreciate how central lifestyle is to our long-term health. The women who chose hormone therapy were not identical to the women who did not. They were, on average, more health-conscious. They exercised more. They ate better. And despite the fact that they lived in the same neighborhoods, went to the same doctors and quit smoking at the same rate, they got sick less often and lived longer. It was the lifestyle differences—not the estrogen—that accounted for the 50 percent reduction in heart attacks and the reductions in strokes and Alzheimer’s. The estrogen was just a marker for healthier lifestyles.
That marker effect is, by the way, why I have reservations about studies touting the health benefits of moderate, daily alcohol. Moderate drinking may be just a marker for a more connected lifestyle, which is the actual benefit. Sitting down to dinner en famille is at least as likely an explanation of the French paradox as the bottle of Bordeaux on the table.
Most studies try to “control” for lifestyle, but whether you’re researching alcohol, estrogen, vitamins, antidepressants or cholesterol medications, lifestyle is too huge and varied an engine for health or sickness to ever truly control for it in an observational study. If you’re lucky, an observational study will generate the most important questions. Then you have to do a real study to answer them. The problem is that real studies are hugely expensive, like $625 million expensive, so we can answer only a small handful of the most important questions with certainty. Those are the studies that are supposed to generate headlines, congressional hearings and fundamental changes in the way we practice medicine. The rest of the studies—99 percent of the research published—are not supposed to be news. They are just scientists talking to one another, and should never see the evening news. So why do the media make it sound as if immortality lies just around the corner and every study is a major advance or retreat? Because they need headlines more than they need news, and no one would buy a newspaper with the headline TINY ADVANCE IN MEDICAL SCIENCE POSSIBLE. CONFIRMATION IN A DECADE. Luckily the NIH asked some important questions about women’s health and menopause ten years ago and dedicated $625 million to answer them. As a result, women today have more accurate information about menopause than we have arguably ever had about any major health issue.
With that as background, let’s look at what the hundreds of thousands of women who participated in the WHI and other studies have to say about menopause.
Natural menopause can start anywhere from your early forties to late fifties, but on average menopause in American women starts at age fifty-one and lasts about four years. The caveat is that no woman has an average menopause. Each experience is different, and the variations are enormous. Half of all women report only minimal symptoms, while others have significant symptoms throughout menopause and a few have problems for more than a decade on either side.
The studies showed that menopause itself has only a few true symptoms. More than 50 percent of women will have hot flashes, night sweats and mood swings, and about a third will have significant vaginal dryness. There is a small increase in urinary problems, and a small number of women have sleeping problems beyond those caused by the night sweats. Sexual satisfaction dips during menopause for some women and increases for others.
Hot flashes are caused by sudden dilation of the blood vessels in the skin, which brings warm blood from the core of your body to the surface. This is the normal mechanism your body uses to cool off in hot weather, but the control mechanism is somehow short-circuited by the changing estrogen levels of menopause. The temperature of your skin can rise as much as eight degrees in a matter of seconds during a hot flash. Each generally lasts around five minutes, though on occasion they can last as long as thirty minutes. The cooling mechanism is so effective that a long episode can leave you chilled and shivering.
Night sweats are hot flashes that happen at night. Your temperature drops a little when you sleep, so the proportional rise in temperature is greater; besides, you tend to be under the covers, so the heating leads to more sweating than during the day. Also, because your temperature regulation system works more slowly when you’re sleeping, the episodes tend to last longer, meaning they can significantly disrupt sleep. Apart from the sleep deficits caused by night sweats, the overall rate of insomnia in surveys remains about the same before, during and after menopause. That doesn’t mean some women don’t have worsening insomnia during menopause. Some do, while some sleep better, but the average stays the same. Most of the sleep trouble that women notice from age fifty onward is related to lack of exercise, stress, artificial light and noise, late-night TV and the natural shortening of the sleep cycle that comes with aging.
Symptomatic vaginal dryness affects about a third of women and makes sex less comfortable for about half of women. In the absence of estrogen, the lining tissue of the vagina atrophies, which can make urination painful and can limit the amount of lubricating fluid your vagina can secrete during sex. Surveys of sexual satisfaction in women without symptomatic dryness give mixed results, with some women reporting increased sexual desire and satisfaction, and slightly more reporting less desire and satisfaction; overall, women report about the same level of sexual satisfaction and frequency after menopause as they did before.
Mood swings are often the most disruptive symptom of menopause, and like the mood swings of adolescence—to which they are chemically related—they are unpredictable and different for everyone. They often begin years before menopause itself and can surge through the limbic and primal brains as great and powerful waves. Emotion is stronger than thought, preceding it both in evolution and in the wiring of our brain, so an emotion—frustration, rage, sadness, sexual desire, fatigue—can take on a reality independent of external circumstance. Because these mood swings can begin years before menopause, many women don’t see them as chemical events until long after they start. They seem to come out of the blue, which is generally the hardest part. Most women find that understanding the mood swings as the perimenopausal symptoms they are—as actual, physical surges of chemicals flooding through the brain in response to fluctuating estrogen levels—makes a big difference. It does not change the intensity of the emotion, but it does help keep it in perspective as a temporary, physical state and not a symptom of mental illness.
That’s a key point, and the research is crystal clear on this: Mood swings are not a mental problem, and they don’t trigger mental illness. For years, the link between menopause and a wide variety of mental illnesses was simply assumed. Well, it’s simply not true. Menopause has no association with depression, anxiety or any other psychological disorder. Women go through depressions and other problems during their menopausal years, but at the exact same rate as before and after menopause. As intense as the mood swings can be, they have no impact on your fundamental emotional health.
According to hundreds of thousands of women who have participated in careful research studies, those four symptoms—hot flashes, night sweats, vaginal dryness and mood swings—are the only major symptoms of menopause. So why is menopause linked with so many other problems? Because menopause happens during the years when the tide begins to set against you. Depression, weight gain, mental slowing, sleep troubles, joint problems, fatigue and anxiety affect women and men alike as our forties turn into our fifties. These problems are not caused by menopause; they are caused by C-6. They are caused by decay . . . which is good news, because your options for dealing with menopause are limited, but your options for dealing with decay are not. So here’s what we know:
There is no increase in the rate of depression or other mental illness during menopause. The mood swings of menopause, however bad they get, bear no relationship to mental illness. They do not trigger depression, and they are not permanent. Women (and men) get depressed in their forties and fifties at the same rate as before and after menopause.
There is no weight gain associated with menopause. Women (and men) gain weight steadily in this country, but there is no statistical spike upward during menopause. Just that slow, steady march toward obesity caused by being sedentary and eating too much. Of course, the tide changes more rapidly in some people than others, and there are plenty of women and men who gain fifteen pounds in a single year somewhere in their forties or fifties. No matter what the timing looks like, the studies show that it’s not menopause. Male and female alike, some people just hit a sudden riptide of decay in those years. Their metabolic rates plummet and the pounds pile on. It’s demoralizing, but avoidable. . . if you run to the gym and cut your portions down. If you need encouragement, consider this: studies show that there is no difference in body fat percentage between serious, post-menopausal women athletes and those in college. A few more wrinkles perhaps, but no difference in body fat, from twenty to old age, as long as you stay fit.
There is no decline in mental functioning associated with menopause. The benign trend toward forgetting where you put the car keys continues apace in both sexes, but there is no decline in cognitive abilities during menopause.
Women can experience waves of fatigue or aching as part of their mood swings, but there is no link between arthritis or chronic fatigue states and menopause. These symptoms are real, but they are symptoms of decay, not the absence of estrogen.
Exercise remains the foundation for reduced menopausal symptoms. The studies on this are largely observational, but both aerobic exercise and strength training reduce mood swings, hot flashes and night sweats. Morning exercise seems to be a little more effective than exercising later in the day, but both work well. The increase in lean muscle mass and baseline metabolic rate that come with serious exercise are your best weapon for fighting steady weight gain; in addition, exercise is by far the most effective preventive strategy for osteoporosis. (That doesn’t mean you can forget your calcium: 1,500 milligrams a day, with 400 IU of vitamin D. Take 500 milligrams when you brush your teeth in the morning and at night, and another 500 milligrams on your way to exercise every day.)
Diets high in soy may help with all the symptoms of menopause (including vaginal dryness), probably because soy is a distant chemical cousin of estrogen. Japanese women, whose diet is naturally high in soy, almost never have hot flashes; in fact, there is no word for them in Japanese. But if you’re not into soy, try a lighter diet high in fruits, vegetables, whole grains and unsaturated fats. Sugar, caffeine, alcohol, chocolate, hot or spicy foods, overeating, stress and sedentary living all trigger hot flashes and night sweats. Since the triggers are so individual for each woman, there may be other triggers for you. It often helps to keep a detailed diary of symptoms, diet and exercise for a month to see what the correlations are for you.
Attitude counts! Studies show that a positive attitude reduces the frequency of symptoms. Women who report positive attitudes going into these years do best in terms of reported scores of life satisfaction and seem to have an easier time managing symptoms. Formally structured behavioral techniques like meditation and relaxation exercises have also been effective in a number of studies, and some women find it helpful to have the support of meditation classes and other groups.
Vaginal dryness does not respond to most lifestyle changes (other than possibly soy). It helps to start using a lubricant immediately if you notice discomfort during sex. This works well for most women, though for some it’s not enough. In that case, talk to your doctor about whether hormone replacement is right for you. It’s important to address this early on, because the less often you have sex, the more fragile the lining of your vagina can become, and this can set up a cycle of painful sex, less sex and even more painful sex.
If lifestyle alone is not enough for you, the medical treatment options are simple and effective. Acupuncture helps a number of women, and the risks are minimal, or you can replace the estrogen your body used to make with either hormones prescribed by your doctor or herbal supplements. It’s important to understand that herbal supplements are still hormone treatments. They seem to work because they have plant-derived estrogens rather than the animal-derived estrogens of the pharmaceuticals. Which is safer is anyone’s guess, since no good studies have been done. The likelihood is that it makes little difference where the estrogen comes from; however you look at it, you’re accepting risk in exchange for relief.
The risk you accept with hormone treatment, according to WHI data, is a small increase in the possibility of invasive breast cancer, heart attack, stroke and blood clots in the lung. Putting them all together, there is a 0.3 percent increase in the risk of serious illness for each year you take hormone therapy. Balancing it out, your risks of hip fracture and colon cancer go down by about 0.1 percent with hormone therapy. Assuming that each of these events, good or bad, is equally important, then on balance there is a 0.2 percent net increase in the risk of serious illness for each additional year you take hormones. Another way of saying this is that for every thousand women taking hormones, two will face serious illness each year as a result and 998 women will be fine.
The WHI also found that low-dose hormone therapy is very effective for the symptoms of menopause. For women with severe hot flashes, vaginal dryness, mood swings and night sweats, the benefits may be worth the small risk. For most women, they are not. The WHI study was stopped early because the risks became apparent, and all the women who were on hormone therapy stopped it at that point. Most of them (75 percent) stayed off hormones. But 25 percent resumed hormones because, for them, the symptom relief was worth the risk. Most women use hormones for a relatively short time, stopping within five years, and move into the postmenopausal biology without further trouble, but there are a small number of women who find that estrogen improves their long-term quality of life enough that they choose to use it indefinitely.
It would be nice if our news was that the right exercise, nutrition and attitude revolutionize menopause, and that you will skate right through with no symptoms if you adopt the healthy lifestyle, but it’s not. Women report over and over again that being strong and fit, eating right and taking charge emotionally make a major difference to their menopausal experience. It helps every woman; for some, it makes all the difference in the world. That should be reason enough to give it a whirl. But the real reason to change your lifestyle is that menopause kicks off the tide of decay like a hurricane. For whatever biological reason, decay is slower in women than in men up until menopause. After that, the increase in bone loss, and the dramatic acceleration in heart disease, cancer, arthritis, fatigue, obesity and depression is like being on a bobsled run. But it’s all just decay, and decay is optional.
The bottom line is that whether your menopause is easy or hard, it’s only a stage of life. Like adolescence, graduate school or raising toddlers, it has its own finite time frame. No matter what you do, it will last a number of years, and then it will end. The thirty years of the renaissance that then lie ahead of you are the real reason to exercise, to eat right and to connect . . . because the end of your menopause is the starting line for the rest of your life.