Answer from Dr. Prior: The answer to the question you asked about whether or not she needed hormone therapy depends on whether she was still menstruating when she had the surgery, whether it was performed for a non-malignant reason, and whether she now has disturbing hot flushes or osteoporosis.

I’ve tried to summarize the good reasons for menopausal hormone therapy on the Centre for Menstrual Cycle and Ovulation Research website www.cemcor.ubc.ca . Briefly they are: menopause too early (doesn’t apply to your sister); severe hot flushes not helped by other therapies and osteoporosis with hot flushes. There is also an article called “Stopping Estrogen Therapy.”

Since the Women’s Health Initiative study (the estrogen arm was recently stopped because of increased strokes and no benefit for heart) we know that otherwise healthy menopausal women do not need hormone treatment. In fact those studies are quite clear about risks, especially that of blood clots with pill forms of estrogen. I never, any more, prescribe estrogen except as a patch, gel or cream.

Women who have their ovaries removed almost always lose bone rapidly following the surgery. That would be ok if their initial bone health was good. If your sister has no risk factors I would still urge her to look at the ABCs of Bone Health for Menopausal Women on the website. If she has risk factors she needs a bone density and if it is low the ABCs of Osteoporosis Treatment would be more appropriate.

One of the treatments that has been shown to treat hot flushes is progesterone cream in a dose of 20 mg twice a day. That would be useful if she has mild hot flushes/night sweats.

Otherwise, she may need to take no treatment at all! After all, menopause is not a disease!

Question: I am 46 years of age and I knew there would come a day when the “hot flushes” would start and I find it is now that I am in perimenopause (premenopause?). I just refuse to believe that I must suffer through my body’s inability to control its heating system.

I have been doing as much research as a layman possibly can regarding premenopause and menopause and interestingly, the name of Dr. Prior came up in my doctor’s office today. With much excitement I asked for a referral to Dr. Prior but did not know if she accepts patients. This is why I am emailing now. I am keenly interested in Progesterone treatment or any cutting edge information and tools for relief of these symptoms I am experiencing. I just don’t believe I have to wait it out. Can you please help?

Answer from Dr. Prior: Although I’m still following women I’ve ever seen, I am not taking new patients. However I would be happy to speak with your doctor about your situation.

In the meantime, I’d suggest you look at the material we have on the Centre for Menstrual Cycle and Ovulation Research website www.cemcor.ubc.ca. There are articles, in particular “Perimenopause–the Ovary’s Frustrating Grand Finale” and the Daily Perimenopause Diary and instructions so that you can track what you are experiencing.

We know a lot about treatment of hot flushes in menopause. Currently no randomized trial has tested perimenopausal women and identified an effective treatment of hot flushes. However, our clinical experience suggests that cyclic natural progesterone (Prometrium) is both effective and a safe therapy in women with hot flushes and periods. There is a handout about Cyclic Progesterone Therapy also on the website.

Question: I would like advice on assembling a team for diagnosing and treating my perimenopausal symptoms and other conditions, as well as providing me with support and access to services.

At the moment I am feeling pretty well. Since I have not had a period for many months I may be approaching menopause, which may partly explain the reduction of my symptoms. Certainly I have used (extreme) lifestyle modifications to assist myself in coping. I have suffered symptoms which have been debilitating to me, which have caused me to live in a condition of disordered thought for several years and significant pain for the better part of one year. This has disrupted my life and nearly bankrupted me.

I have not been diagnosed as perimenopausal. I have been variously diagnosed as having Post Traumatic Stress Disorder (which is probably also true), having anxiety starting several years ago, and as having had anemia and gastrointestinal bleeding within the last year. I also believe I had symptoms of Mild Traumatic Brain Injury (from a motor vehicle accident several years ago ), and may have had health effects from removing around 12 mercury amalgams from my mouth about five years ago.

I would like to provide some information, but hope my letter doesn’t sound bleak. I am feeling better and therefore am writing this letter. I would like to be tested, to know what is going on with my body and mind as a basis for treatment. Some questions which I have follow: What pertinent tests (including endocrinological) are available in BC, in Canada, or elsewhere, to examine me? What practitioners or clinics could help me? What insurance plans could help or could have helped me to afford alternative medical treatments, counseling, and to provide money to support me during an extended (though temporary) illness?

Answer from Dr. Prior: First of all it sounds like you are very close to ‘graduation!’ That’s what I consider menopause–you will reach that when you have been a year without flow. Menopause is a normal part of every woman’s life and doesn’t need any treatment. However, if it came before the age of 40, or if you know you have osteoporosis (especially if you also have hot flushes) or if you have persistent, disturbing hot flushes then and only then does menopause need treatment. We have learned from the Women’s Health Initiative Estrogen plus Progestin trial results that hormone therapy is not healthy for menopausal women who don’t have one of those three situations mentioned above. We now know the same about estrogen therapy.

This is the time of perimenopause when you are more likely to experience hot flushes and night sweats. But often if they only start now they are mild and go away quickly. You may also notice some vaginal dryness. That usually only needs some water soluble (over the counter) lubricant.

I trust you have looked at the BCERF website (www.bcendocrineresearch.com) which has the article ‘Perimenopause The Ovary’s Frustrating Grand Finale’. That will help you understand perimenopause which it sounds like you have almost completed. There is also information on our Centre for Menstrual Cycle and Ovulation Research website (www.cemcor.ubc.ca).

Now’s a good time to think positive and look ahead to many healthy years. You don’t need a specialist. You can deal with your family doctor for any problems. If you live in BC and have a perimenopause problem you and your family doctor can’t solve, you can ask your family doctor to phone me.

Perimenopause can be quite rough, and it sounds like you’ve had a difficult time of it. You can rejoice when it is over!

Question: I need your help. I had a total hysterectomy five weeks ago. Since then, I am literally falling apart, and cannot get the doctors here to either listen to me, or else I cannot get an appointment at all. I guess they don’t consider endocrinology an emergency. I am basically treating myself because the doctors aren’t listening to me.

I switched from Premarin to Menest because I thought the Premarin made me feel mentally foggy. I discovered that Premarin does contain androgens (they don’t tell you that) because it was making my skin break out. I am now taking a .625 Menest and a .3 Menest every day because on the .625 alone I was still having night sweats. It seems, however, that I am still not getting as much estrogen as on the Premarin because my skin is still dry, and I don’t know if Menest has as much or any androgens in it as Premarin.

Now for the worst part, the part I need immediate help with. Since the hysterectomy, I have arthritis symptoms almost overnight. I can’t get an appointment with an endocrinologist here. I’ve been trying to get an appointment with an endocrinologist who can write prescriptions for compounds because I think my DHEA, which used to be high, and other hormones are all messed up.

The doctors, my OB/GYN group, pooh-poohs me when I try to talk to them about it. They won’t order blood work yet, but I am extremely chemically sensitive, and drugs affect me immediately.

I don’t know what to do. I am at my wit’s end about all of this. I need to get the right treatment so I can go on with my life.

Thank you very much.

Answer from Dr. Prior: It sounds like life is pretty rough right now. I will do my best to provide you with some ideas and support. However, I can’t really know what is going on without having seen you and taken a history as well as done a physical exam.

It is not uncommon to feel badly after having a sudden removal of your ovaries. The natural menopause or perimenopause transition is a more gradual process with spikes and dips over about 10 years.

The first and most important thing is that you get a prescription for oral micronized progesterone (Prometrium) 100 mg and take 3 capsules at bedtime (as long as you aren’t allergic to peanuts–the medicine is in peanut oil). This will help your sleep (improves deep sleep by 15%), help the estrogen to control night sweats and may also help your joint symptoms.

I strongly suggest that you use a kind of estrogen that is a patch or a gel rather than a pill. We now know that important risks for blood clots (increased by 211% over placebo) occur in menopausal women on estrogen pills. Estrogen delivered through the skin is less likely to cause clots.

Other things that will help with the hot flushes/night sweats are some regular exercise and some relaxation (such as yoga). I’d also recommend 400 IU of vitamin E, 1200 mg of calcium/day (with 500 mg at bedtime) and at least one multiple vitamin to provide 400 IU of vitamin D. Calcium has been shown to decrease PMS-like symptoms in a randomized double blind trial.

I don’t know anything about you and what you do and what supports you have. But I would urge you to be with people you trust, to talk with close friends or family and to start thinking about what you are good at and that you want to do with the rest of your life. It is really easy, when life/hormones/health are disrupted as yours have been, to focus on illness and lose perspective.

Please also go to the Centre for Menstrual Cycle and Ovulation Research website at: www.cemcor.ubc.ca. You will also find the Daily Menopause Diary that you can use to track changes you are experiencing. Knowing changes helps you to better understand and deal with them.

I know that you will soon start to feel better.

Jerilynn Prior is a Professor of Endocrinology at the University of British Columbia and an internationally know expert on women’s health.

The post Question and Answer – with Dr. Jerilynn Prior appeared first on BC Diabetes Foundation.

First, we need to talk concepts and language. Women are obviously different from men ? our normal life cycle of hormones includes low estrogen and progesterone levels after menopause. However, for about six decades, medicine has taught us that having low menopausal estrogen was abnormal. Why? Because men’s high testosterone levels continue into old age (with a bit of a decline). Therefore, the idea that menopausal women were deprived of estrogen or ‘estrogen deficient’ became common. And ‘HRT’ was invented to fix women’s supposed problem.

But it wasn’t enough to say women were deficient’, this deficiency must cause disease. One early, important study, The Framingham Study, a decade-spanning observational study (meaning that the scientists observed what occurred over time) showed that when women reached menopause they started to have heart attacks. The authors noted that menopausal women have low estrogen levels. Therefore estrogen ‘deficiency’ must be the cause for heart disease! Of course, on average menopausal women were older, less active and heavier, too, but those facts were ignored.

The Framingham Study was followed by the huge Nurses’ Health Study that was another observational one. It showed that the women who took estrogen compared with the women who didn’t, had fewer heart attacks. However, women who took estrogen were slimmer, more active, less likely to smoke, less likely to have high blood pressure, abnormal blood cholesterol levels or diabetes. These characteristics, in addition to a family history, represent a woman’s main risks factors for heart attack. All of the observational studies, we now know, were biased’the women who took estrogen were healthier to start out with. Other similarly biased studies multiplied showing that women on estrogen had better sex, were less likely to get Alzheimer’s, grow wrinkles or fracture hips. ‘HRT’ became the wonder drug for women.

I don’t know quite why but I have never believed the estrogen deficiency idea of menopause. And I knew of the blood clots, strokes, high blood pressure and weight gain (for some) that estrogen therapy could cause. I also remembered a study of men who took estrogen or a placebo (sugar pill). The men taking estrogen had increased clots and heart attacks and the study was stopped early because of harm. This was in 1972. (Somehow the heart disease experts had forgotten that study). However, enough experts questioned the validity of the observational studies, that a very large multi-part, randomized, controlled trial called the Women’s Health Initiative was conducted. Results of the Women’s Health Initiative combined with several other controlled studies showed that one of every 250 women ages 50-59, and one of every 150 women over 60 taking estrogen treatment for five years will develop blood clots, stroke, heart attack or breast cancer.

But knowing this, what do we do now? First of all, accepting that low levels of estrogen after menopause are normal, means we don’t have to fear we’re missing out on some magic preventive. Instead we can concentrate on exercising, stopping smoking, getting to and keeping a normal weight, and (if needed) getting effective treatment for high blood sugar, blood pressure or cholesterol. There are now fracture-preventing non-hormonal treatments for osteoporosis such as etidronate (Didrocal), alendronate (Fosamax) and risedronate (Actonel). We can use very low dose vaginal estrogen or a compounded, safer kind of estrogen called estriol for vaginal dryness if over-the-counter lubricants don’t help.

And what about hot flushes? Relaxation, yoga, deep breathing and meditation decrease them significantly. Some of the newer anti-depressants and soy foods may also be effective. For severe hot flushes, relaxation combined with a synthetic progestin medroxyprogesterone (Provera) mean most women become virtually free of hot flushes. However, the pill form of natural progesterone that is the same as your ovaries made (bio-identical), Prometrium, is an effective option if you are worried that medroxyprogesterone might cause harm (because a low dose was used with full dose estrogen in one arm of the Women’s Health Initiative). The Centre for Menstrual Cycle and Ovulation Research (CeMCOR) at UBC and Vancouver Hospital is doing the first trial of Prometrium as treatment for hot flushes in a four-month placebo-controlled study in menopausal women. Because we are also studying blood vessel effects we are looking for women a year past their final period who have moderate or severe hot flushes and no risks for heart disease (for further information call 604 875-5917, email chris.hitchcock@ubc.ca or go to the website www.cemcor.ubc.ca).

What if you’ve re-started estrogen despite the bad news from the Women’s Health Initiative because you just couldn’t stand the hot flushes? As explained in ‘Stopping Estrogen Therapy’ on the CeMCOR website, the key is to take full dose progesterone to treat the symptoms while you very gradually taper and eventually stop your estrogen. Hot flushes are caused by the reaction of a brain that has become used to high estrogen levels. Therefore the process of effective withdrawal must be a slow one. Prometrium helps in the estrogen withdrawal process because it improves deep sleep (although this has only been proven in men!) and also treats hot flushes.

However, there are specific instances where menopausal women will need to take estrogen with progesterone therapy. These include women with early menopause (before age 40 for sure and probably before 45), women with both osteoporosis and hot flushes, and those with severe hot flushes not effectively treated by non-hormonal therapies. There are bio-identical choices for getting estrogen through the skin as a patch or gel (Estragel, Estradot and Climera, to name a few). These are less likely to cause clots than pill estrogen. Bio-identical progesterone is available as oral Prometrium (in peanut oil) or it can be compounded in oil by local pharmacies. Women with early menopause can safely continue estrogen and progesterone until they are 52 years old (the average age at menopause). Women with osteoporosis and hot flushes can count on combined hormones to treat hot flushes and prevent fractures. After five years estrogen should be replaced with a non-hormonal bone medicine (as described earlier). Women with severe hot flushes can use progesterone alone and (I believe) safely continue for as long as needed. Family doctors and women with questions will find more information on the CeMCOR website.

We are in a new and healthier world for women in 2004. We no longer need to rely on an old and wrong idea that menopausal women are estrogen deficient and need treatment. I think it is a good news story!

Jerilynn Prior is a Professor of Endocrinology at the University of British Columbia and an internationally know expert on women’s health.

The post Menopausal Women’s Hard Decisions appeared first on BC Diabetes Foundation.

Answer from Dr. Prior: Thank you for your question. I think it quite likely that your migraines are increased premenstrually because of the big hormone changes at that time of the cycle. Premenstrual migraines occur in teenaged and young women and are often increased by the higher and more chaotic estrogen levels of perimenopause.

You mentioned that they seemed to be getting better now. That would fit with your age and getting closer to menopause (what I call graduation!). Menstrual cramps seem to increase in perimenopause and there is some information that the prostaglandins causing them also can trigger migraine headaches.

In my experience migraines get a lot better after menopause. For many women they totally go away. However, one tricky thing is that the general brain activation with hot flushes can make migraines worse and prolong them if hot flushes persist after menopause.

If you have some more questions about perimenopause and what you are experiencing, you may find information on the website for the Centre for Menstrual Cycle and Ovulation Research www.cemcor.ubc.ca. My general advice to women having migraines is to avoid estrogen totally if possible. If you need to and decide to use either estrogen or progesterone, I strongly suggest that either should be taken continuously. The reason is that the brain of a woman with migraines seems to be sensitive to on/off changes especially going on and off of estrogen.

Question: I have polycystic ovarian syndrome, and was previously trying to treat it with diet and exercise only – however it has not been working well. I am now having increasing problems with my insulin (suspected – am going to the doctor next week). In addition to this problem I have slightly impaired kidney function and cannot take metformin/glucophage. I would like to know if you can tell me the name of a doctor at the centre who would be specializing in the field of PCOS that I could ask my GP to refer me to. Thank you for your help.

Answer from Dr. Prior: Thank you for your question. It certainly sounds like you may need some specialist help with what I call Anovulatory Androgen Excess. Your GP would need to be the one to refer you.

First let me suggest that you go to the Centre for Menstrual Cycle and Ovulation Research website www.cemcor.ubc.ca and look for information about ovulation (there’s a paper called “Ovulation Disturbances–they do matter”). I’d also start keeping the daily Menstrual Cycle Diary so that you would understand for yourself what’s going on with your cycles and experiences.

We don’t yet have the information on the website about treatment of Anovulatory Androgen Excess (AAE) but the heart of it is cyclic progesterone therapy. Progesterone is bio-identical, is usually too low in women with AAE, and acts to block the formation of dihydrotestosterone, the hormone that is active in the skin making unwanted hair and acne.

For insulin resistance the best “treatment” is exercise. There are now two randomized controlled trials showing that women and men at high risk for diabetes (type2) have a much decreased development to diabetes if they exercise. The goal would be 30 minutes of some activity a day, starting gradually and increasing. Walking is good exercise to start with. In one trial women were randomized to metformin (the insulin activity improving medication you mentioned) or exercise and the exercise group did better than metformin at preventing diabetes.

Question: My bride Patricia of some 30 years is turning 54 this May. Like many women her age she was on HRT until the studies came rolling out documenting all of the downsides. My recollection is that that occurred about 2 years ago which was the same time my wife threw away all the pills. (“Cold Turkey”). That was probably the last time she had a decent night’s sleep and even remotely felt like herself. She has tried chiropractic and massage and also returned to her family physician for additional guidance. From all the reading I have done she has every one of the symptoms of menopause including mood swings. At one point in time she was taking medication for that (courtesy of her family physician) but we were both very quickly convinced that the cure was worse than the disease. Those pills were thrown out as well. She presently is not taking any medication for anything!

I appreciate that we are both 54 and not 34 and even if we wanted to (and we do not) medical science cannot turn the clock back 20 years. Having said that however, I don’t think it unreasonable of my wife to want to go back to feeling like the person she was before this inevitable biological process started.

At my suggestion she is now seeing a naturopath but we are getting the impression that once again all that will be treated will be the underlying symptoms and not the basic fact that her hormone levels are all out of whack in comparison to what they once were.

I told my wife that having any healthcare professional prescribe a pill or any form of treatment modality unless and until they have a handle on what is wrong with you is kind of like taking your car to a mechanic and telling him/her that it is not running properly and the first thing they do is add a litre of oil before any of the fluid levels are checked or any diagnostic procedures are conducted. By analogy, it sure seems to me that the first thing that should be done in determining what would help my wife is to find out what the heck she is missing and by what amounts. I would think that would take the form of a saliva or blood test that would generate results related to hormone levels and the like which would then allow the healthcare practitioner to come up with some sort of reasonable strategy to try to take those levels “back to normal” ….. whatever that may be.

Are you aware of anyone who specializes in this field (medical doctor or not) who would have some sort of rational approach to fixing the problem as opposed to trying various things with the hope that something works?

I look forward to hearing from you.

Answer from Dr. Prior: Thank you for your question. If you don’t mind I’ll address my answer to your wife–you can print it out for her.

It sounds like you have been miserable since you suddenly stopped hormone therapy when the first Women’s Health Initiative results came out in July, 2002. What appears to happen is that the hypothalamus becomes accustomed to a high estrogen level. When those levels drop suddenly, it reacts with a rebound amount of severe hot flushes, night sweats associated with stress hormones, sometimes dehydration and fatigue. As that carries on you become sleep deprived, everything starts to hurt because of lack of a restful sleep, work is harder, there’s no time for you to do things for fun, you begin to get depressed and a vicious cycle has begun.

The normal estrogen levels for a menopausal woman are low. FSH (follicle stimulating hormone) levels aren’t helpful. In short, there is no need, as your husband suggests, to measure a lot of levels in saliva (at great cost and with dubious normal ranges and technical reliability).

My approach is to work hard to stop the hot flushes and night sweats. I guess I’ll ask your husband to go to the Centre for Menstrual Cycle and Ovulation Research website www.cemcor.ubc.ca to find the archived answer to a question “Natural therapy for hot flushes”. It is really important to learn about and practise relaxation/meditation/yoga breathing. I’d also suggest beginning 400 IU of vitamin E. The most effective non-estrogen therapies are medroxyprogesterone 10 or 20 mg a day and bio-identical oral micronized progesterone sold as Prometrium (in peanut oil). It also can be compounded in olive or safflower oils.

So I’d suggest also that you track your current experiences on the Daily Menopause Diary (you can download this from the CeMCOR website www.cemcor.ubc.ca). Knowing what’s going on helps hot flushes. Also I think you can begin the options suggested in the archived answer above. Then add Prometrium or other oral progesterone 300 mg at bedtime daily. This has the great side effect of increasing deep sleep by about 15%. In fact, if you are sleep deprived, as you sound like you are, don’t begin it until a Friday night when you can have a great sleep-in the next morning. When the body gets into rapid eye movement sleep after a long time without it wants to stay there!

I’ve written an article about bio-identical progesterone for menopause. I’m just about ready to post the attached on my website. You’re getting a preview!

If you are very stressed and have truly horrid hot flushes, you might need to add 10 or 20 mg of medroxyprogesterone in the morning to the Prometrium you are taking at bedtime. You’ll need to show this to your family doctor. I’m happy to take a call from your doctor about your situation.

Believe that the hot flushes will get better. And be sure to tell your friends not to suddenly stop estrogen treatment!

Jerilynn Prior is a Professor of Endocrinology at the University of British Columbia and an internationally know expert on women’s health.

The post Question and Answer – with Dr. Jerilynn Prior appeared first on BC Diabetes Foundation.

The US Food and Drug Administration (FDA) approved a drug called Seasonale® on September 5, 2003. Media coverage before approval was already significant, and is expected to increase over the next few months. Seasonale® is a repackaging of oral contraceptive pills in a new schedule: 84 days of active pills and a seven day pill-free interval. Women who take this extended schedule of oral contraceptives will have fewer pill-free intervals. In this case, four times per year, the intended effect being four periods per year. At this year’s meeting of the Society for Menstrual Cycle Research in Pittsburgh, PA, Dr. Jerilynn C. Prior and I participated in a symposium entitled “The menstrual suppression controversy: medical, psychological & sociocultural perspectives”. I presented a review of the published medical data on the use of extended oral contraceptive pills to suppress menstruation, and this article is a summary of what we learned in that review. The context of our analysis is that there has been considerable press coverage of menstrual suppression, and that it has been predominantly positive, with suggestions that menstrual suppression with an extended schedule of oral contraceptives (“Long OC”) is a safe, healthy, reversible choice that empowers women and gives them control over their bodies. We wanted to examine what data were available to support those claims of effectiveness, safety and reversibility.

Limitations of the studies

Our literature search found 10 published papers with data on Long OC use. To evaluate the effects of a treatment, researchers use a comparison group, and the best way to make a comparison is to assign the research participants to the groups by chance (to randomize them). Only 2 of the 10 studies used this randomized design. The most common research focus was on the effectiveness of Long OC at controlling bleeding.

None of the studies were blinded, that is, both investigators and the participating women in the studies knew who was taking Long OC and who was taking Standard OC. This introduces the possibility of bias (conscious, or unconscious) in the data. None of the studies included a group of women with normal, unmedicated menstrual cycles. Finally, most women in the studies were women who had already been using oral contraceptives. Because of this, women who do not tolerate oral contraceptives well are less likely to be in the studies. What this means is that the data on Long OC were mainly with a population of women who had already tried regular OC, and who knew what the researchers expected, and which study group they were in.

Extended use of oral contraceptives and bleeding

Dr. Ann-Christine Cachrimanidou provides the best data in a one year study performed at three clinics in Sweden (Cachrimanidou et al., 1993). She randomized 284 women to take either Long OC on a 63/7 schedule (n=198) or Standard OC (21/7) (n=96). Two-thirds of the women in each group were taking oral contraceptive pills immediately before they began the study, about 15% had never taken oral contraceptives, and the remaining women were past users. Cachrimanidou asked women to record their bleeding patterns on a monthly calendar, indicating days with spotting (requiring no more than one pad or tampon) and bleeding. She further categorized the data according to whether it was a pill-free day, or a day with an active pill. Menstrual bleeding on a pill-free day is called withdrawal bleeding, and is expected, or “scheduled” bleeding. Menstrual bleeding on a day with active pills is called “breakthrough bleeding” or “unscheduled” bleeding. Cachrimanidou found that the amount of scheduled withdrawal bleeding was less in the Long OC users than in the Standard OC users. Long OC users had slightly more days of bleeding per withdrawal bleed, but had only one pill-free interval during the same time that the Standard OC users had three pill-free intervals.

However, that was not the whole story. Women on Long OC reported significantly more days of unscheduled bleeding and spotting, particularly during the first 63 days of active pills. Women who were not already taking oral contraceptives and started Long OC had the most problems with unscheduled bleeding and spotting. On average, women reported unscheduled bleeding or spotting on 14.9 out of a possible 63 days, that is, almost a quarter of the time. Women who switched from a standard schedule of oral contraceptives (“Standard OC”) to the Long OC schedule had spotting on an average of 5.2 days, and 1.9 days of breakthrough bleeding. The amount of unscheduled bleeding for women switching from Standard OC to Long OC was similar to that for women who were newly starting a Standard OC schedule. Unscheduled bleeding is the most common reason that women left the studies early. The amount of unscheduled bleeding drops off over time. However, there were still more breakthrough bleeding days on Long OC than Standard OC at the end of the one-year study.

A second randomized comparison of Long OC (this time on a 42/7 schedule) with Standard OC (21/7) was conducted by Dr. Leslie Miller in Seattle, WA (Miller & Notter, 2001). This too was a one year trial, with 90 women randomized equally to the Long OC and Standard OC arms of the study. Unfortunately, Dr. Miller did not distinguish between scheduled and unscheduled bleeding in her analysis. The number of spotting days was not significantly different between the Long OC and Standard OC groups. However, there were fewer bleeding days in the Long OC group than in the Standard OC group. The Standard OC group had twice as many pill-free days as the Long OC group, but statistically had no fewer days of spotting, and only 60% (rather than the expected 100%) more days of bleeding during the year. Although they are lumped together in this analysis, women experience scheduled and unscheduled bleeding as different events.

These two studies show that Long OC regimens do reduce the number of days of bleeding and spotting relative to a Standard OC schedule. However, the decrease in days of withdrawal bleeding because of fewer pill-free days is accompanied by an increase in days of unscheduled bleeding and spotting. This effect is particularly strong for women who are not current Standard OC users, and during the first few cycles of Long OC. Poor control of bleeding is the major reason that women stopped using Long OC.

Side effects and symptoms

These studies asked women about side effects and symptoms, and, if women left the study early, they were asked their reasons for doing so. The common reasons for discontinuing studies of Long OC include headaches, breast tenderness, mood changes, “premenstrual syndrome”, and weight gain. These are also reasons that women on Standard OC discontinued the studies. Cachrimanidou found that women on Long OC were more likely to leave the study because of problems with bleeding (13.1% versus 2.1%), while more women on Standard OC left because of headaches (9.4% versus 1.5%). While most women reported no change in most symptoms, both Miller and Cachrimanidou found that women on Standard OC had more days with headaches than women on Long OC.

When talking about Long OC and symptoms, there are two additional studies that I should explain, because they are often quoted inappropriately. These studies come from the clinical practice of Dr. Patricia Sulak, an obstetrician-gynecologist who uses oral contraceptives as a therapy for women with difficult menstruation. For many years, she has encouraged women to extend the period of active pills beyond the standard 21 days. She recommends that women add three weeks at a time to their schedule of active pills, and systematically increases or decreases the number of active pills, depending on the reaction of the woman to the increased schedule. The first paper specifically included only women who found relief on oral contraceptives, and whose symptoms intensified during the pill-free window (Sulak, Cressman, Waldrop, Holleman, & Kuehl, 1997). Forty-eight percent of the women had menstrual migraines as their worst complaint, while 78% had painful periods, 76% had menstrual migraines, 36% had heavy flow and 32% are described as having “PMS-type” symptoms. Of these 50 symptomatic women, 37 chose to stay at a Long OC schedule for at least three cycles, and 13 chose to revert to a Standard OC schedule, eight for reasons of breakthrough bleeding or spotting, and six because of headaches. Some women (14/27 continuing on Long OC) report no side effects or problems, while some of her patients make an understandable choice to put up with some spotting and breakthrough bleeding in order to reduce other symptoms, such as menstrual migraines.

In a second paper (Sulak, Kuehl, Ortiz, & Shull, 2002), Sulak reports on 292 patients who were offered the opportunity to use a Long OC schedule. Again, these are patients from her clinical practice, many of whom are referred to her for menstrual problems. She found that 9% of women chose not to try Long OC, 19% tried Long OC and then stopped oral contraceptive use altogether, 13% tried Long OC but switched back to Standard OC, and 59% continued on a Long OC schedule. The average Long OC schedule of women in her practice is 12 weeks of active pills.

While these studies illustrate that some women find relief from symptoms with Long OC, they are often used to suggest that all women would benefit from Long OC. Sulak’s population is quite different from those of the other studies. First, they are women who have chosen to see her with menstrual problems. Second, many of them are using oral contraceptives as a medication and do not desire birth control. Almost all other studies are based in family planning clinics, and draw their participants from women who request oral contraceptives for birth control. Third, they are older women than the women in other studies. Fourth, and perhaps most importantly, they have a powerful motivation to put up with side effects in order to avoid significant symptoms that are more common for them during the pill-free interval.

Long OC and safety

In our review, we were also concerned about what research has been conducted on safety. Standard OCs are known to increase the risk of thrombosis (clotting), which can be very serious. In a large 25-year study of 46,000 women in the UK, Dr. Valerie Beral found that the use of oral contraceptives were associated with higher mortality from cerebrovascular events (such as stroke), and lower mortality from ovarian cancer and colorectal cancer. On balance, women who have used oral contraceptives had no higher mortality than non-users (Beral et al., 1999).

In addition to our interest in the standard risks of oral contraceptives, we also considered possible increased risks from Long OC. Long OC use results in a slightly higher total exposure to the high levels of estrogens in oral contraceptives. It also limits the amount of time that a woman’s body is free from external hormones. In a normal menstrual cycle, there is a cycle between high estrogen exposure and a time of low estrogen exposure. Long OC reduces the time that a woman’s breast tissue and endometrium are given a break from the high levels of estrogen.

Finally, oral contraceptives act by suppressing the complex and intricate hormonal feedback system between the hypothalamus, the pituitary and the ovary. They act at the level of the brain, preventing the signals that normally initiate follicular development and ovulation. Women who try to become pregnant after taking oral contraceptives take several extra months, on average, to become pregnant, when compared with women who stop using a barrier method (e.g., condoms or diaphragm) or an IUD (Bracken, Hellenbrand, & Holford, 1990). Higher dose oral contraceptives are associated with a longer delay to conception. Long OC has a slightly higher total dose of estrogen, but also has the potential to suppress the hypothalamic-pituitary-ovarian axis more strongly than Standard OC.

(Cachrimanidou et al., 1994) studied 13 women on Long OC (63/7) and 7 women on Standard OC to look at clotting factors and cholesterol. All of the women in her study were new users. There were no statistically significant differences in blood lipids (cholesterol, HDL, LDL) between the two groups. For the most part, blood lipids did not change across the year. Total cholesterol tended to rise across the year, and this increase was significant in the Long OC group. There was also an increase in the VLDL component of cholesterol after 3 months in the Standard OC group. There were increases in triglycerides under both OC regimens. Factors related to coagulation increased under both OC regimens, while coagulation inhibitors showed small decreases. This study demonstrates some of the physiological changes that may be associated with increased risk of clotting in OC users. Long OC users showed a non-significant tendency to be more affected than were Standard OC users.

We found no studies of breast or endometrial safety in these papers on Long OC. There are anecdotal reports of perhaps a dozen women among the various studies who discontinued Long OC and become pregnant. However, we did not find any systematic study of the return to fertility or normal ovulatory function following discontinuation of a Long OC schedule.

Long OC and menstrual taboos

Advocates of menstrual suppression with an extended schedule of oral contraceptives have several arguments. Some suggest that women might occasionally extend the number of active pills to delay menstruation on particular occasions. Some suggest that women taking oral contraceptives should have a choice about how frequently they menstruate. They often point out that the original schedule of oral contraceptive pills, 21 days of active pills followed by a seven day pill-free window (a 21/7 schedule, for short), was an arbitrary one, chosen in the vain hope that a normal menstrual pattern would render oral contraception acceptable to the Vatican.

Other advocates of menstrual suppression argue that fewer menstrual bleeds will result in less menstrual discomfort and premenstrual discomforts. Finally, some have suggested that unmedicated menstruation is itself unhealthy, and that extended use of oral contraceptives will improve women’s health.

Menstruation is a taboo in our culture, and women who are menstruating take efforts to conceal the fact. Women differ in how they feel towards menstruation, and those women who find menstruation most distasteful and embarrassing are the women who are most interested in the use of Long OC for menstrual suppression. Women also vary in the amount of discomfort they experience with menstruation. In a study presented at the recent Society for Menstrual Cycle Research meetings, distaste was more important than discomfort in predicting women’s attitudes to menstrual suppression with Long OC (Hoyt & Andrist, 2003).

Adolescents may be particularly vulnerable to Long OC. Having someone discover that you are menstruating is among the top mortifying moments that teenage girls share with magazine column writers (Houppert, 1999). Being able to avoid and control menstrual flow may become a status symbol as well as a convenience, adding peer pressure to the other reasons a young woman might use Long OC. A recent “how to” article for clinicians documents a variety of physical and social reasons to prescribe extended oral contraceptives to adolescents (Sucato & Gold, 2002). While the author states that there are no data on Long OC use by teenagers, she does not go so far as to urge caution, nor to comment that there are contraindications for oral contraceptive use on any schedule. The potential for harm from Long OC use is greater when taken by developing girls. It is common for there to be a vulnerable period during growth and development, and it is not known what effect extending the suppressive effects of oral contraceptives will have on a developing reproductive system. Risks must be weighted against benefits, and the prevention of pregnancy in a sexually active teenager is a greater benefit than the suppression of menstruation for convenience. Moreover, in general, Long OC for menstrual suppression is likely to be sought at a younger age than OC for contraception.

In the coming weeks and months, there will likely be much more media coverage of the idea of menstrual suppression with Long OC. There are research studies that have been conducted on Seasonale®, but the results of these studies have not yet been published. To date, the studies that have been published show that extending the number of active pills between pill free intervals decreases the amount of scheduled withdrawal bleeding, but increases the amount of unscheduled bleeding and spotting, compared with Standard OC schedules. New users have more problems than women switching from Standard OC to Long OC, and the amount of unscheduled bleeding becomes better with time. The primary reason for women to discontinue Long OC is dissatisfaction with the bleeding patterns.

In our review we found that, contrary to what has been commented on in the media, there are a number of important questions about the safety of using Long OC that have not yet been addressed. There are no published data on how an extended OC schedule affects the endometrium or breast tissue, and there are no systematic data on how long it takes women to return to normal ovulatory function or to become pregnant after stopping a Long OC regimen. Particularly for adolescents, it is important to confirm that the suppression of menstruation with Long OC is reversible and does not affect development. The fact that many women have been using Long OC for years suggests that there is no dramatic effect. However, we need systematic trials, not just testimonials and expert advice from clinicians who see a small number of women. Recent results from the Women’s Health Initiative trial of estrogen-plus-progestin hormonal therapy amply demonstrate that randomized placebo controlled trials are required to test even the most firmly held and widespread beliefs about the benefits of preventive hormone therapy.

References

1. Beral, V., Hermon, C., Kay, C., Hannaford, P., Darby, S., & Reeves, G. (1999). Mortality associated with oral contraceptive use: 25 year follow up of cohort of 46,000 women from Royal College of General Practitioners’ oral contraceptive study. British Medical Journal, 318, 96-100.
2. Bracken, M. B., Hellenbrand, K. G., & Holford, T. R. (1990). Conception delay after oral contraceptive use: the effect of estrogen dose. Fertility & Sterility., 53(1), 21-7.
3. Cachrimanidou, A.- C., Hellberg, D., Nilsson, S., von Schoulz, B., Crona, N., & Siegbahn, A. (1994). Hemostasis profile and lipid metabolism with long interval use of a desogestrel-containing oral contraceptive. Contraception, 50 (August), 153-165.
4. Cachrimanidou, A.- C., Hellberg, D., Nilsson, S., Waldenstrom, U., Olsson, S.- E., & Sikstrom, B. (1993). Long interval treatment regimen with a desogestrel-containing oral contraceptive. Contraception, 48 (September), 205-216.
5. Houppert, K. (1999). The Curse: confronting the last unmentionable taboo: menstruation. New York: Farrar, Strauss and Giroux.
6. Hoyt, A., & Aandrist, L. C. (2003). Women’s attitudes and beliefs about menstrual suppression. Society for Menstrual Cycle Research, Conference Presentation.
7. Miller, L., & Notter, K. M. (2001). Menstrual reduction with extended use of combination oral contraceptive pills: randomized controlled trial. Obstetrics & Gynecology., 98 (5 Pt 1), 771-8.
8. Sucato, G. S., & Gold, M. A. (2002). Extended cycling of oral contraceptive pills for adolescents. Journal of Pediatric & Adolescent Gynecology., 15 (5), 325-7.
9. Sulak, P. J., Cressman, B. E., Waldrop, E., Holleman, S., & Kuehl, T. J. (1997). Extending the duration of active oral contraceptive pills to manage hormone withdrawal symptoms. Obstetrics & Gynecology, 89 (2), 179-83.
10. Sulak, P. J., Kuehl, T. J., Ortiz, M., & Shull, B. L. (2002). Acceptance of altering the standard 21-day /7-day oral contraceptive regimen to delay menses and reduce hormone withdrawal symptoms. American Journal of Obstetrics & Gynecology, 186 (6), 1142-9.

The post What is Known: Extended Schedule Oral Contraceptives appeared first on BC Diabetes Foundation.

To participate, you must:

• Be past menopause (1-10 years since your last menstrual period)
• Currently experience hot flushes and/or night sweats
• Have no heart disease or history of heart disease
• Have no risk factors for heart disease (e.g. smoker, very overweight)
• Have taken no estrogen, progesterone or birth control pills within 6 months.

You will receive:

• Study medication or placebo
• Electrocardiogram (ECG)
• Cholesterol and diabetes test results.

Study by UBC Endocrinologist Dr. Jerilynn Prior. For more information, contact:

Christine Hitchcock, PhD
phone: (604) 875-5917
email: chitchco@ubc.ca

The post Wanted: Women Past Menopause to Evaluate Progresterone Therapy for Hot Flushes appeared first on BC Diabetes Foundation.

I recently received a scholarship from The BC Endocrine Research Foundation (BCERF( to work as a student intern. I just graduated from Memorial University of Newfoundland and this was an excellent opportunity for me to get some research experience before I started medical school in September. I spent six weeks working with the Centre for Menstrual Cycle and Ovulation Research (CeMCOR) analyzing changes in fluid retention across the menstrual cycle. Fluid retention is a sub clinical sign that varies in intensity depending on what phase of the menstrual cycle an individual woman is in. This is largely reported anecdotally among women. Despite this common and well-known physiological interaction, published scientific literature is sparse on the topic. The issue of fluid retention associated with the menstrual cycle is a topic that may give a better understanding of women’s health. CeMCOR took the initiative to investigate this systematically. A review of the previous literature showed that virtually no published articles dealt with fluid retention as a natural process. Most research dealt with fluid retention as part of a disease such as studies of “premenstrual syndrome” or as a side effect of oral contraceptives. These articles do not investigate the fact that fluid retention occurs in healthy women and that there was a need for documentation of this sign in a normal population. Commonly women’s body weight fluctuates by as much as 2.5 kg during a menstrual cycle. Some of the fluctuation is hypothesized to be due to fluid retention. It is believed that the ovarian hormone, estrogen, promotes fluid retention through interactions with the renin-aldosterone-angiotension pathway. This pathway leads to fluid accumulation throughout the body. Another ovarian hormone, progesterone, is hypothesized to inhibit fluid retention.

The data for this analysis were collected by 61 healthy women over one year. The women recorded their basal body temperature (BBT) every day for one year. They also completed a daily menstrual cycle diary that included a score for their feeling of fluid retention (on a scale of 0 to 4). The women also belonged to one of three exercise groups. They were normally active women (non-exercising), women who were participating in regular exercise (constant runners), and women who were increasing exercise intensity in training for a marathon. Using a statistical algorithm (quantitative basal temperature analysis), the date of temperature rise was calculated from the BBT. From this, ovulation and length of cycle phases were determined. The documentation of ovulation in the cycles was a unique feature of this analysis because it is quite common to see published articles that fail to report ovulation occurrence. This actually is a major mistake in that it has been shown that ovulation does not occur every menstrual cycle and it seems likely that the physiological changes in ovulatory cycles may not occur. All days of the menstrual cycles were broken down into one of two categories. The perimenses period was 10 days long and centered on the first day of flow; the remaining days of the cycle were classified as midcycle.

What Were the Key Questions?

We had three questions: (1) Does fluid retention differ between midcycle and perimenstrual days? (2) Are there differences between ovulatory and non-ovulatory cycles? (3) Is there a difference in this pattern by exercise group?

This research adds to the understanding and expanding knowledge base that CeMCOR is working towards. The issue of fluid retention and normal cyclic patterns has possible implications on women with high blood pressure, those participating in fitness or exercise programs or those trying to understand more about their physiological patterns. A scientific manuscript is in preparation summarizing this study. The Centre aims to educate both the public and the scientific community about women’s health and natural body rhythms.

The post Fluid Retention During the Menstrual Cycle appeared first on BC Diabetes Foundation.

A: There are many stages in bone loss. Ostopenia is the lesser form, but when bone density gets really low its call osteoporosis. After menopause there is natural bone loss, and if you can prevent that bone loss you can prevent osteoporosis.

Q: When you talk about estrogen, what kind of estrogen are you talking about?

A: There are three types which the body makes. There’s estrodiol, estrone and estrogen. Estrodiol is the weakest of these three, but when I talk about estrogen in general, I am referring to all the three different types.

Q: Are there any long term benefits in taking progesterone?

A: Progesterone does increase bone formation. Taking etidronate or Fosamax helps (and the two work better together). Progesterone also helps with sore breasts as progesterone taken through the skin increases the cell turnover in the breasts.

Q: Can you use birth control pills instead of the standard treatment (of estrogen/progesterone)?

A: In menopause estrogen levels are already high and the birth control pill increases it even more.

Q: What can you do about a flagging libido?

A: That’s an extremely complicated problem to try to sort out. Most women in perimenopause simply aren’t very interested in sex, but many say that once they’ve reached menopause, they’re once again feeling more interested.

Q: What about using testosterone?

A: Testosterone gets turned into estrogen in the body, and that’s what you want to avoid. It’s known to increase hot flushes, and causes acne. We’re trying to see if progesterone can overcome testosterone induced hot flushes.

Q: Will these hot flushes ever end?

A: Hot flushes have a life of their own. Reducing stress is essential. Vitamin E is also helpful. Make sure you have maximum progesterone – prometrium at night, just before bedtime and medroxyprogesterone in the morning.

Q: You say you have three good reasons for Ovarian Hormone Therapy. What are they?

A: 1. Early or surgical menopause; 2. Osteoporosis or low bone density at menopause; 3. Persistent sleep-disturbing night sweats.

Q: Is there a safer way to take hormone therapy drugs?

A: Yes, the transdermal estrogen patch, a gel or a cream is better. Medications which must go through the liver before they get to the bloodstream increase other health risks. Because transdermal medications go directly to the blood stream, they do not impact the liver.

Q: Should I stop taking estrogen every month?

A: Yes. In a normal cycle, the body stops producing such high levels of estrogen for a few days every month, so stopping it is copying the normal cycle your body goes through.

Q: You say you don’t like the term “Hormone REPLACEMENT Therapy”? What do you call it then?

A: I want everyone to come away from the concept that we need to replace something. Menopause is a natural phase of getting older. I’d like to have it referred to as “Ovarian Hormone Therapy” – that’s the right way to talk about it. Let’s move away from the concept that we need to “medicate” menopause.

The post A Sample of Questions and Answers from Dr. J.C. Prior’s July 23, 2002 Presentation at Vancouver Hospital appeared first on BC Diabetes Foundation.

Dr. Diane Finegood with the Canadian Institute of Health Research spoke about having 58% prevention of diabetes with lifestyle intervention for people with high risk for type 2 diabetes. I can concur that my best HbA1c results were when I was called by a diabetes education nurse once a week as part of a research study conducted by the BC Endocrine Research Foundation. Dr. Finegood reported that even 30 minutes of exercise a day 5 days a week made an impact on the onset of diabetes and related complications. She also warned that obesity has been identified as the number 1 health problem in North America, is a major predictor of type 2 diabetes and the problem increases annually.

Dr. Jerilynn Prior, professor of endrocrinology at UBC spoke about what’s new in perimenopause. Contrary to common belief the levels of estrogen can actually be high and chaotic during perimenopause. Also, research is showing there is bone loss before menopause. Stress hormones were discussed as bad for bones and birth control pills have been shown not to build bone. Exercise, nutrition and some supplements can be helpful during perimenopause and after. Dr. Prior is involved with the Canadian Multicentre Osteoporosis Study (CAMOS).

Andrea Swan an RN from the Victoria James Bay Community Health Project spoke about what women want in midlife. Her involvement combines social, health services, community services and youth and womens education. She has identified that mid-life women have not had the opportunity to speak to their mothers about the changes during perimenopause and menopause because of cultural norms. In the year 2002 there is an overwhelming amount of information from media and professionals. In groups, such as the ones she facilitates at James Bay, she helps women find their way through the maze of information so they can make informed decisions about their health and life choices.

I found this an extremely enjoyable symposium with lots of valuable information. Many thanks to the panel and our very able host, Joyce Resin. Another success story for the BC Endocrine Research Foundation.

The post Women’s Health Symposium November 4th 2001 appeared first on BC Diabetes Foundation.

Having hot flushes? Past menopause? No risks for heart disease?

We are looking for women to participate in a 4 month research study on blood vessel function and hot flushes. The study is being run by:
Dr. Jerilynn Prior
Professor of Endocrinology,
University of British Columbia.

To participate, you must:

• Be menopausal (2 – 10 years since your last menstrual period)
• Currently experience hot flushes and/or night sweats
• Not be taking hormones (estrogen, progesterone, tamoxifen or birth control pills)
• Have no heart disease or history of heart disease
• Have no risk factors for heart disease

In this study we will be comparing the effects of raloxifene (Evista(r)) and progesterone (Prometrium(r)) on blood vessel function and hot flushes. Blood vessel function can indicate your risk for heart disease. The study will be conducted at the Echelon Centre, at W. 8th and Ash.

For more information, contact:
Christine Hitchcock, PhD
Phone: (604) 875-5917
Email: chitchco@vanhosp.bc.ca

This study is funded by Eli Lilly. Prometrium® and placebo have been donated by Schering Canada.

This study is investigator-initiated. The investigator retains the right to publish the findings of this study, regardless of the nature of the results.

The post Research Study on Blood Vessel Function and Hot Flushes appeared first on BC Diabetes Foundation.

Introduction

Women in midlife increasingly hear the words “estrogen deficiency” spoken as the ultimate in bad news. “Everyone knows” that low estrogen levels cause heart disease, osteoporosis, Alzheimer’s and frigidity. Right? But as Dr. Susan Love (renowned breast surgeon and author of Dr. Susan Love’s Hormone Book) states, “If estrogen deficiency’s a disease, all men have it!” [Love 1997]

Our purpose here first is to put women’s midlife experiences and concerns into a new and more accurate hormonal picture. Specifically, I’d like to present new information about high estrogen levels in the perimenopause. Not low, not even normal, but estrogen levels that are higher than those of the (sexiest) 20 year-old woman! Secondly, I’ll discuss how you can tell when your estrogen levels are high and out of balance with progesterone, the other important hormone for women. And finally, we’ll review the many ways a woman can help herself through perimenopause, “Estrogen’s storm season!”

What is perimenopause?

Women have often called “menopause” everything they experience during the changing times of midlife. However, now that we know about perimenopause, a hormonally distinct time in midlife, it is important to use the right names. Menopause means that a year has passed since a woman’s final period. Perimenopause refers to the long and changing time until a woman “graduates” into menopause. The newest name for perimenopause is “menopausal transition”.

The first perimenopausal change commonly masquerades as increased premenstrual symptoms (sometimes called PMS). A regularly menstruating woman may have her first migraine, start waking after two or three hours of sleep and toss and turn. Finally she may suddenly flood during what was a normal period or start having night sweats. On average the perimenopause lasts at least four and commonly eight to 10 years. The good news is that perimenopause ends! I am an expert on the perimenopause primarily because I have now graduated! I survived a rough 10-yr perimenopause and my own experiences told me that the experts had it all wrong about dropping or deficient estrogen levels!

High and swinging, not dropping estrogen levels in perimenopause!

Many studies in the last 20 years have measured estrogen levels in perimenopausal compared with premenopausal women. Each study, however reports by summarizing that estrogen levels are dropping.

Surprisingly, they don’t bother to mention the high levels they also found [Burger, Dudley, et al. 1995].

When all of the studies are put together (Figure 1, above), and the average perimenopausal estrogen levels are compared with average levels in young women, it is clear that estrogen levels are about 30% higher than normal during perimenopause [Prior 1998].

Let’s consider estrogen levels from a population-based study of over 300 Australian perimenopausal women (Burger, Dudley, et al. 1995). Each woman had a blood test 3-8 days after the start of flow-each woman’s level is a dot in Figure 2.

This shows lots of estrogen variation and high levels occurring not only in the regularly menstruating women (group 1) but also in women who were between 3 and 11 months since their last period.

Not only are most of the levels higher than the average end-of-flow estrogen levels for 20-35 year olds (dotted line) but many are even higher than the highest point at the middle of the cycle for 20-35 year olds (solid line). But what did these very good scientists say in summary? “Perimenopause is characterized by dropping estrogen . . .levels” [Burger, Dudley, et al. 1995].

The study we just discussed [Burger, Dudley, et al. 1995] also measured a strange new hormone called “inhibin”. I believe it is because inhibin, the ovary’s normal brake-type hormone, begins to slack off in its job of keeping the pituitary’s Follicle Stimulating Hormone (FSH) in line, that the perimenopausal ovary goes through its grand finale [Prior 1998]. Lower inhibin levels allow FSH to increase and to stimulate several rather than just one follicle (the nest of estrogen-producing cells surrounding an egg). As a consequence estrogen levels rise and become unpredictable [Prior 1998].

The other big hormonal change of perimenopause is that progesterone levels are too low [Prior 2001]. Progesterone, the important ovarian counterbalancing hormone to estrogen which is made after an egg is released, is produced in lower levels even when cycles are still regular [Santoro, Rosenberg, et al. 1996]. We know that normal progesterone levels are needed to prevent bone loss in young women [Prior, Vigna, et al. 1990]. We also know that too much estrogen with too little progesterone makes for heavy periods or frequent flow.

Clues that estrogen levels are high or out of balance with progesterone

There are many things you can observe that will tell you that you are experiencing the typical perimenopausal hormone imbalance-too-high estrogen and too-low progesterone levels. You’ll need to be a record-keeper and a sleuth to discover what is happening for you because such a wide array of experiences is possible. Early in the process of my perimenopause I had a disturbing dream-more like a nightmare. I woke suddenly, early one morning, from a most vivid dream that I was pregnant! I could feel my swollen and tender breasts, my moist and heavy-feeling vagina, the heat and expectation in my body. In my dream I felt like I had a belly full of a full term baby. I woke thinking that I had really lost it! At fifty, with my two children grown, the last thing in the world I wanted was to be pregnant. But after some thought, I began to understand that it was my subconscious self’s way of saying goodbye to my fertile years.

Many of the things I felt in that dream, however, are also high estrogen signs: swollen and tender (sometimes lumpy) breasts, increased vaginal mucous and a heavy pelvic feeling similar to cramps. High estrogen and progesterone levels in pregnancy are normal and necessary. In perimenopause however, estrogen levels are high but progesterone levels are not.

Heavy flow, bleeding less than 3 weeks apart, continual spotting or clotting and increased cramping are all signs that estrogen is too high. For the amount of estrogen, progesterone levels are also too low [Santoro, Rosenberg, et al. 1996]. Canadian researcher, Dr. Patricia Kaufert, who has done one of the best studies about what women experiences during perimenopause, found that women who have flooding menstruation are likely to start the time of skipped periods in perimenopause [Kaufert, Gilbert, et al. 1987].

Heavy and unpredictable flow is not only horrible to live with but they can cause iron deficiency, low blood counts (anemia) and deep fatigue. Although some women will soak a half a box of tampons a day, soaking 16 or more pads or tampons in any (entire) period is abnormal. The culprits are too much estrogen and too little progesterone or whether or not your uterine muscle has a fibroid. Fibroids disturb the endometrium (uterus lining) less than 10% of the time and are therefore, rarely the cause for abnormal flow.

What about breast swelling and tenderness in perimenopause? It is normal for the breasts to swell a bit during the week before flow. It is sometimes normal to feel tenderness in the front or nipple area of the breast at the middle of the cycle when estrogen hits its high peak. But continuously swollen breasts, front-of-the45breast soreness before flow or for more than three days each month means high estrogen levels. During perimenopause women may become forgetful. We now know that stress makes for memory problems. And the high estrogen levels of the perimenopause (added to the stress of this major life change) make cortisol and other stress levels higher (Kirschbaum, Schommer, et al. 1996). No wonder it feels like PMS-city! One nurse said it very well, “At (peri)menopause life can turn into one long pre-menstrual experience. Hormones slap you up against the doors of your unfinished business” (Kelsea 1991).

Are hot flushes (or flashes) from low estrogen?

Periods once a month tell us our estrogen levels are normal. Many doctors still believe that night sweats and hot flushes are caused by low estrogen levels. If that were true, how come so many perimenopausal women start having night sweats when their periods are perfectly regular? The answer is that hot flushes/night sweats are caused by decreases or swings in estrogen levels even if they are still high. The brain becomes used to the young normal estrogen levels and, when it has been exposed to the high levels during the perimenopause, it rebels as those levels drop, even to normal. What happens with a hot flush is similar to what a drug addict goes through during withdrawal-a major brain discharge of stress and other hormones. It is this hormonal discharge (along with the flush) that causes the anxious feelings, nausea and chest pain as well as the feeling of heat and the sweating that go with them. So if someone tells a you your flushes are in your head just tell them that “darn tootin” they are!

I first twigged that I was perimenopausal when I woke abruptly one dark November morning in 1990 feeling MAD! I looked for a cause-my dog and my partner were sleeping soundly, all was quiet in the house and in the neighborhood. But my heart was pounding, my legs wouldn’t lie still and I was ready to do battle.

Then I felt a weak and woozy wave of heat and began to sweat. A day later my period started. I had no more night sweats until the day before my next period.

I had learned an important thing-in the early years of perimenopause; night sweats are a clue that your period is coming (Figure 3) [personal communication, G. Hale, 2001].

Another new observation is that women who have increased premenstrual symptoms early in the perimenopause are more likely to have a difficult time with hot flushes at the end of perimenopause and in early menopause. That information came from the same Australian study I told you about earlier {Guthrie, Dennerstein, et al. 1996}. High estrogen levels cause premenstrual symptoms. It makes sense that the brain would react when these high levels do their chaotic dance in perimenopause or eventually settle out to the normally low levels of menopause.

What can I do to help myself through the rough times in the perimenopause?

The first and most important thing to realize about perimenopause is that, ready or not, we must go through a major life change-change in body, change in fertility, even change in concepts about ourselves [Page 1994]. A number of years ago I was captured on a National Film Board video “Is it hot in here?” saying I was only 22 times 2 and was looking forward to menopause as a normal phase of life! But, when perimenopause hit me, though my mind said I was okay with it, although I have all the children I ever wanted, and despite my fulfilling job and lots to look forward to, I went through times of real sadness. Losing youth, fertility and even predictable periods are justifiable reasons for feeling blue. It helped me and will help you to deal with this natural sadness if you talk with friends, family and perhaps even a counselor about these important and often hidden feelings. I also suggest reading a book by Vancouver counselor, Lafern Page, Menopause and Emotions: making sense of feelings when feelings make no sense [Page 1994].

The next most important thing we can do to help ourselves in perimenopause is to take time to care for ourselves. A friend and important pioneer in the work of bringing perimenopause information to BC women, retired public health nurse, Pat Chadwick, said, “The first two letters of the word menopause are ME!” That means we need to take time out for exercise, meditation and having a latte with a friend. We also may need to say “no!” to more overtime or to continuing to make our 12 year old’s lunch. Get your priorities straight-take care of yourself!

I was significantly helped in my perimenopause by keeping the Daily Perimenopause Diary ((c)1991). To allow many women access to this self-record tool we have made a video that both describes the hormonal changes of perimenopause and explains what you can learn from using the diary [Prior 1999]. A completed diary showing 8 days of flow in which you soaked 6-10 tampons a day is more likely than your complaints about it to convince your family doctor that you need a blood count and some progesterone therapy!

Our bones face at least three challenges during later perimenopause: swinging estrogen levels (causing increased bone loss), too low progesterone levels (causing less new bone to be formed) and higher stress hormone levels (causing both bone loss and less new bone) [Prior 1998]. It is therefore a good idea to increase your daily calcium intake (from food and supplements) to 1500 to 2000 mg/d (spread across the day with food and 400-600 mg at bedtime). Calcium supplementation also decreases premenstrual symptoms [Thys-Jacobs S, Starkey, et al. 1998] and will help with sleep and with restless legs that can start in perimenopause. In addition to calcium, you should also take at least one multiple vitamin to provide 400 IU of Vitamin D each day. Our skin can’t make vitamin D during October through March from the slanty northern sunshine we get in most of Canada and the northern U.S.. If you have a family member with osteoporosis (by bone density measure or a broken bone with low trauma) you probably should take 800 IU/d of Vitamin D.

Night sweats are troubling and sleep-disturbing. Vitamin E in a dose of 400 to 800 IU each day may help in addition to regular exercise (both walking and heart-rate raising aerobic exercise), decreasing stress [Swartzman, Edelberg, et al. 1990} relaxation and slow deep breathing. It may also be that eating foods made from soy such as tofu or drinking soy beverages on a regular basis will decrease hot flushes [Murkies et al., 1995].

Heavy and too frequent periods are the most urgent problem for us in perimenopause. What can we do about periods, flooding, cramps and the risk for anaemia? If you are regularly soaking over 12 pads or tampons during a whole period, I suggest you start taking iron because you are likely to have low iron stores if not anemia. Take one (inexpensive) tablet of ferrous gluconate a day (34 mg of iron, an inexpensive, green pill). This can be purchased from the drugstore without a prescription (but be sure to tell your doctor). For menstrual cramps, as well as to decrease heavy flow, ibuprofen (Advila, Motrina or generic) 200 mg, can be used at the first hint of cramps and repeated four or more times a day. Ibuprofen use has been shown to decrease the amount of blood loss. If the cramps are really bad, take two tablets at the first hint of cramps and take one more each time you start to get the heavy pelvic feeling that cramps are returning.

If taking ibuprofen and iron doesn’t resolve the perimenopausal flow problems and anemia and if bleeding lasts longer than a week or occurs at shorter than 3-week intervals, you need to see your family doctor. Ask for a prescription for progesterone (Prometrium(r) or medroxyprogesterone) which works to prevent estrogen’s over-stimulation of the endometrium.

Progesterone also controls or even stops flow depending on the dose and your estrogen levels. It is ideal to take it cycle days 14 to 27 after the first day of flow (Figure 4). If your cycles are shorter (flows less than 25 days apart), start the progesterone on day 12 and continue through day 25.

Each time you start it finish the full 14 days of progesterone. Full doses (3 capsules of progesterone =300 mg/d or 1 10-mg tablet of medroxyprogesterone) are absolutely necessary because we are trying to balance very high estrogen levels. It may be necessary to take high doses for a number of months. If you have migraine headaches, ask your doctor to prescribe it every daily because often hormone changes can trigger migraines.

In most cases of heavy/frequent flow there is no need for a referral to a gynecologist, an endometrial biopsy, a D & C or a pelvic ultrasound. Keep in close contact with your family doctor. Unless both you and your doctor decide that at least six months of full or high dose cyclic progesterone hasn’t helped don’t see a surgeon whose common “choices” are oral contraceptives, uterine lining ablation (killing the endometrium) or hysterectomy. I suggest you decline the oral contraceptives your doctor may offer because even “low dose” pills contain high estrogen that won’t suppress the estrogen your ovaries are already making in abundance! If at all possible, refuse the hysterectomy or endometrial ablation (killing the uterine lining) surgery that gynecologists often offer. Either surgery takes away flow that provides one of the few clues we have to the ovary’s mysterious antics during perimenopause and helps us to know when we are menopausal. Like the rest of perimenopause-this heavy flow will get better!

Summary

So, let’s review. We have talked about the perimenopausal puzzle of high rather than low estrogen levels and the paradox that many doctors believe estrogen treatment will help. Now you will be able to recognize when your estrogen levels are too high and will know that, although life may be miserable right now, this is likely quite normal and will pass. You can now figure out that you are perimenopausal, even though flow is regular, when you start getting night sweats and or premenstrual symptoms increase. Most importantly, when flow is abnormal and persists in being so, you can ask for cyclic full-dose progesterone treatment to help balance your high estrogen effect in the brain and bone and uterus. And, if you are taking good care of yourself and find you still can’t cope with premenstrual symptoms, waking in the wee hours of the morning and night sweats, you could ask your doctor for cyclic progesterone therapy for those reasons also.

Most important-understand that you, like me, can survive perimenopause!

As Ursula LeGuin, the science fiction writer says “The woman who is willing to make that change must become pregnant with herself, at last” [LeGuin 1991].

Jerilynn Prior is an internationally known expert on progesterone and an active researcher and educator.

References

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13. Thys-Jacobs S, Starkey P, Bernstein D, Tian J, The Premenstrual Synrome Study Group: Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Am.J.Obstet.Gynecol. 1998; 179: 444-452.
14. Swartzman LC, Edelberg R, Kemmann E: Impact of stress on objectively recorded menopausal hot flushes and on flush report bias. Health Psychology 1990; 9: 529-545.
15. Murkies AL, Lombard C, Strauss BJG, Wilcox G, Burger HG, Morton MS: Dietary flour supplementation decreases post-menopausal hot flushes: effect of soy and wheat. Maturitas 1995; 21: 189-195.
16. LeGuin UK: The Space Crone. In: Women of the 14th Moon: writings on menopause. Sumrall AC, Taylor D, eds. Freedom, California: The Crossing Press, 1991; 3-6. Copyright Jerilynn C. Prior October, 2002

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