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Menopause: Embrace the Change

Online Health Chat with Holly Thacker, MD

November 19, 2010 | Reviewed on January 20, 2014 by Holly Thacker, MD

Introduction

Cleveland_Clinic_Host: Confused about hormone replacement therapy? Wondering if you really need a yearly mammogram? Do you want to check which foods affect PMS?

Many women have questions about their health care. Dr. Holly Thacker, the author of The Cleveland Clinic Guide to Menopause, has written a compassionate, practical guide that gently reminds women that midlife is not only a time of change but also a time of great freedom. Now is the time to ask questions about hot flashes and how to get a good night's sleep; the facts about vitamins, supplements, and antidepressants; using diet and exercise to boost energy; the basics of good bone health; preventing cancer and heart disease; and how to recharge your sex life.

Dr. Holly Thacker is the founder of the interdisciplinary Cleveland Clinic Center for Specialized Womens’ Health and is a trailblazer in women’s health. The executive director of Speaking of Women’s Health and author of several books on women’s health, Dr. Thacker is recognized as a national leader in women’s health issues.

To make an appointment with Dr. Holly Thacker or any of the other specialists in our Center for Specialized Women’s Health at Cleveland Clinic, please call 216.444.4HER or call toll-free at 800.223.2273, ext. 44437. You can also visit us online at www.clevelandclinic.org/womenshealth  Check out Speaking of Women’s Health at http://www.speakingofwomenshealth.com/

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Holly Thacker. We are thrilled to have her here today for this chat. Thank you Dr. Thacker for joining us today, let’s begin with the questions!


Menopause: What You Need to Know

michee: What would be the first signs or indicators that a women would notice that would indicate that they are going into menopause or perimenopause?

Speaker_-_Dr__Holly_L__Thacker: Change in menstrual cycle and/or hot flashes/night sweats.

gogetter: Is nausea a symptom of menopause?

Speaker_-_Dr__Holly_L__Thacker: No.

westwing: Can you get pregnant while in perimenopause?

Speaker_-_Dr__Holly_L__Thacker: YES! Until you have had 12 months of no menses over age 50, with signs and symptoms of menopause, there is still a chance of ovulation/pregnancy. The Guinness book of World Records for unassisted pregnancy is age 57!

lundy: HPV test (human papillomavirus) – is it only needed at age 20 if sexually active?

Speaker_-_Dr__Holly_L__Thacker: A woman needs a pap smear by age 21 or within 3 years of sexual debut/sexual activity. We do not test for HPV in the 20s UNLESS abnormal pap. Once a woman is 30 years of age both the pap smear and the HPV dna test should be done-IF both are normal then paps smears with HPV are done every 3 years. Women who smoke, who have HIV who have had abnormal paps or women exposed to DES in utero need more frequent paps.

taketwo: Pre-menopause, will this cause an increase in migraines?

Speaker_-_Dr__Holly_L__Thacker: Perimenopause with fluctuating hormone levels can worsen migraine. After menopause, migraine usually gets better in most women. I have a chapter in my book devoted to discussing migraines and how to prevent them.

canto: My sister had a hysterectomy about a year ago, without removing her ovaries. She was told that her ovaries died 6-8 eight weeks later. What does this mean?

Speaker_-_Dr__Holly_L__Thacker: It is generally a good idea to leave the ovaries in after hysterectomy-at least up to age 65-unless there is a family history of breast/ovarian cancer and/or abnormal ovaries, as even with hysterectomy, there is a survival advantage to keeping the ovaries. That said, usually within 2 years of hysterectomy, the ovaries don't function to the same degree. They do not 'die,' just may not be making eggs/estrogen as robustly as before.

rosalie: I’m 54, have never had children, and am having very heavy, disruptive periods. My doctor told me that via ultrasound I have a large uterine fibroid. What is the latest on UAE/UFE versus hysterectomy? Will an abdominal hysterectomy compromise my abdominal muscles long-term?

Speaker_-_Dr__Holly_L__Thacker: We have many non-hysterectomy alternatives, including UFE. However, if the fibroid is too large, then you might not be a candidate for UFE. Vaginal and laparoscopic hysterectomy is an option for women who don't want abdominal muscles cut as well as single port and robotic hysterectomy.

TM: Some have said soy should not be consumed by small children because of the Estrogen in it; what are your thoughts?

Speaker_-_Dr__Holly_L__Thacker: Soy foods are fine for all people of all ages and genders but not soy pills or powders.

onhealth8: What about an injection to put you right into menopause?

Speaker_-_Dr__Holly_L__Thacker: Lupron injections can temporarily shut down ovaries and put you into medical menopause-we do this sometimes for endometriosis and severe PMS.

starsnstripes: Can you break up 30 minutes of exercise into 2 15 minutes periods with the same benefit?

Speaker_-_Dr__Holly_L__Thacker: Yes. Try to get though a total of 60 minutes every day!


Hormone Therapy

clarice: What is your recommendation for Hormone Therapy studies with the reported link to Breast Cancer?

Speaker_-_Dr__Holly_L__Thacker: These are the results from one study and are not conclusive. Do NOT panic If you are a woman on hormone therapy (HT), you should continue treatment and return to your physician for regular follow-up care and undergo a HT evaluation every year. Most studies do NOT show an increased risk of breast cancer death on HT; in fact, overall LOWER all cause mortality rates have been reported in women using menopausal HT for 5 or more years who start prior to the age of 60, and/ or within 10 years of menopause. Most women find the benefits of hormones outweigh the risks.

crusher: What is CC's view on HRT now with the recent press release about its relationship to breast cancer? If I am currently taking synthetic HRT, should I switch to bio-identical hormones or should I stop therapy altogether? My doctor insists that the total body benefits outweigh the risks. Would you agree? What other nutritional supplements are available that can do all that HRT is supposed to be doing for me?

Speaker_-_Dr__Holly_L__Thacker: We provide a free monthly newsletter and addressed this in our last update. DO NOT get your medical care from the media. The media's job is to sell newspapers, ad spaces. They are NOT physicians. All hormones are 'synthesized' in lab even ‘bio-identical’ ones. It sounds like you have a good physician who is advocating for you! Please log in to http://www.speakingofwomenshealth.com/ .

kent1954: I had a hysterectomy at age 22 and they took my ovaries, I am now 56 and have been on estrogen patch since then. I have tried several times to go off the patch but get hot flashes and mood swings. Is it safe to stay on the patch? Also with all my female organs removed, do I have to have pap smears? Thank you.

Speaker_-_Dr__Holly_L__Thacker: There is no need for pap smear of cervix if no cervix and if no cancer. You still need pelvic exams. Why are you trying to go off estrogen? If your ovaries were removed then your body will never make any estrogen or ovarian hormones. Many women with complete hysterectomy need some dose of estrogen lifelong. The benefits of estrogen outweigh the risks for MOST women particularly women under age 65 and women who have had hysterectomy.

kent1954: After going through surgical menopause and being on estrogen for 30 yrs (56), shouldn't I be past menopause? After going off estrogen I still get the symptoms, will this be the case all my life?
Speaker_-_Dr__Holly_L__Thacker: You never get 'past menopause,' in that your body will never make estrogen again. Many women with surgical menopause need to take some estrogen lifelong.

prancer: I’ve been talking to a friend of mine who took Femhrt and said that she had really bad withdrawal symptoms and then the menopause symptoms returned. Are all menopause medications like this?

Speaker_-_Dr__Holly_L__Thacker: No such thing as 'withdrawal' off menopausal hormones. They are not addictive. 50% of women who stop menopausal hormone therapy will have recurrence of their symptoms and 50% won't. If one has recurrence of symptoms, then likely they need to go back on therapy.

jdcole: When taking medications for hot flashes, nights sweats, etc., how can you avoid the weight gain side effect?

Speaker_-_Dr__Holly_L__Thacker: Hormones in menopausal formulation do NOT cause weight gain. In fact, the studies show women menopausal HT (hormone therapy) is associated with LEANER body mass. With age, metabolism slows and most women gain weight, unless they step up exercise AND reduce caloric consumption.

changeisgood: Have you written prescriptions for patients to get the Intrinsa patch from Canadian pharmacies since it is not available in the USA?

Speaker_-_Dr__Holly_L__Thacker: I have patients from Canada and Europe on Intrinsa. I do not have a license to practice in Canada or Europe so I usually have my American patients on compounded topical testosterone or oral combination estrogen/testosterone if they need it. 


Bio-Identical Hormones

Linda98: What is your opinion on taking bio-identical hormones?

Speaker_-_Dr__Holly_L__Thacker: Every woman is an individual. If a woman needs MENOPAUSAL hormones, they can be prescribed safely by prescription, regulated hormones including so called 'bio identical' estrogen and progesterone. There is not a reason to use compounded unregulated hormones for most women.

dl: I was wondering if you could address bio-identical hormones and when you use these for your patients.

Speaker_-_Dr__Holly_L__Thacker: I prescribe menopausal hormone therapy, including so called 'bio identical hormones.' Actually, that is a marketing term - not a scientific term - to women who have indication. There are lots of different choices, routes, doses and ways to give estrogen and progesterone. Most women (unless ovaries removed) do not need testosterone. If they do need testosterone, then it has to be compounded or used in 1/7 to 1/10 the dose of available male products because our FDA did not approve the testosterone patch for women (though wisely it is available in Europe and Canada).

friends: When going from oral HRT to bi-est progesterone cream, how do you determine dosage?

Speaker_-_Dr__Holly_L__Thacker: Progesterone cream does NOT protect the uterus.
Compounded progesterone is not protective for a woman on transdermal estrogen like bi-est. We have seen an increase in uterine cancer in women on unregulated compounded hormones.

daytime: One A Day Menopause formula – any thoughts?

Speaker_-_Dr__Holly_L__Thacker: I don't know. I would have to look at label. I would not use if has soy isoflavones or other non-vitamins in it.


Flashes, Mood Swings and other Symptoms

auntmoie: How long do I have to look forward to the hot flashes and fitful sleep?

Speaker_-_Dr__Holly_L__Thacker: You don't have to look forward to any uncomfortable symptoms, unless you want to. There are several options. There is NO way to predict what women will flash-some never do and some will flash their ENTIRE life if not treated.

1996: I went through menopause at an early age (42.) But lately I have been having symptoms like I was going through it again. I'm having hot flashes, mood swings, depression, euphoria...is it possible for someone to go through this twice or is something else going on in my body?

Speaker_-_Dr__Holly_L__Thacker: No such thing as 'going through menopause,' you are in it or not - meaning once ovaries stop making eggs/estrogen they don't start making it again UNLESS you were misdiagnosed with early menopause -perhaps you were just anovulatory. You should see a physician for evaluation and FSH and estradiol blood tests and examination.

JoyD: I am a 59 yo w f who went through menopause 8 years ago. I was on estrace since this time until one year ago at which time I stopped all hormone treatment. For the past year I have noticed that my scalp is becoming more and more noticeable because my hair is thinning, especially in front. I have been to a dermatologist and she indicates that it could be hormonal. She says I have mild shedding and no patches of baldness but I want to stop this immediately. Will starting back on estrace help?

Speaker_-_Dr__Holly_L__Thacker: Estrogen is good for hair and skin. Using estrogen to treat aging skin and thinning hair is not FDA approved; however there are clearly positive effects of estrogen on skin and hair. If you have a uterus, you cannot just take estrogen/estrace, you will need progesterone as well.

roseb: My doctors have never discussed menopause with me. How do I know what's normal and what's not? I have many medical issues and a need to talk often and seek reassurance. I very often feel like I'm bothering them. As far as depression goes, how do I differentiate between menopausal or other? Why should I stay on meds-my concerns are not unlike any other mother's and I still cry and feel low now and then?

Speaker_-_Dr__Holly_L__Thacker: Depression is not a sign of menopause. Menopausal symptoms are hot flashes, night sweats, vaginal dryness and thinning, and bone loss. If you are depressed, there are several effective therapies. If you are on anti-depressant medicines and menopausal-no periods, hot flashes, etc then hormone therapy may boost the antidepressants mood elevating effects.

changeisgood: Is it common for women to develop fibromyalgia during menopause?

Speaker_-_Dr__Holly_L__Thacker: No. However, fibromyalgia can get worse with menopause if you have menopausal symptoms preventing deep restorative sleep.

Gspice: Can you talk about normal behavioral changes during menopause? My mother is like a different person.

Speaker_-_Dr__Holly_L__Thacker: Behavior changes are not a part of menopause. Your mother should see a physician for evaluation for other causes of behavior change.

Nubianspirit: Can constant daily headaches be due to menopause. I stay in a fog day and night and feel off balance. I have been in menopause 3 years now.

Speaker_-_Dr__Holly_L__Thacker: No. You should see a headache specialist such as the doctors in our neurology/headache dept.

Nubianspirit: You mentioned crying and mood symptoms are related to neurotransmitters. So then menopause is not the culprit of sudden tears? So are antidepressants needed for the crying?

Speaker_-_Dr__Holly_L__Thacker: Maybe. Several factors - lifestyle, nutritional, exercise, sleep, stress reduction, etc. all have to be looked at.


Menopause and Sex

MS: Is there anything I can do to revive my low sex drive?

Speaker_-_Dr__Holly_L__Thacker: Decreased sex drive is normal throughout the seasons of our life. If your sex drive seems to be waning, the first thing you need to do is examine the quality of your relationship with your sexual partner. Conflicts (financial, in-laws, kids and stress) can and do affect sexual interest. Also, following traditional sexual habits can become routine and boring.

Speak with your partner about your concerns -- this conversation should not occur in the bedroom. Begin sexual activity outside of the bedroom as well, with fantasy, dates and planning for sex. As we age, it takes longer to achieve lubrication and orgasm. I often recommend erotic books, films and movies to get you in the mood.

If vaginal dryness is a problem, consider over-the-counter lubricants and increase foreplay with manual, oral or mechanical stimulators (vibrator). Let your partner know what is happening and what you would like to have happen. Exercise helps, as well as minimizing alcohol or drug use. Certain medications may also contribute to a decrease in libido, so don’t hesitate to discuss your concerns with your doctor.

changeisgood: I am currently on daily Divigel® .1% and Prometrium® 200mg days 1-12 each month since July 2010. I haven't had a libido for a very long time and thought once I started HT my libido would return. Needless to say no libido and that does nothing for a marriage. At this time, my husband and I haven't had sex since August and here we are in November already! Is there anything I can do at this point other than waiting for the Intrinsa patch to be approved for use in the USA? I tried compounded transdermal Testosterone some years ago, but it only made my voice deeper and my face hairier.

Speaker_-_Dr__Holly_L__Thacker: Sex drive is very complex. It can be normal after menopause to not have a spontaneous sex drive. The purpose of the sex drive is to reproduce and now you are in the post-reproductive phase of life. There are many things you can do to improve your sex life.


Menopause and Vaginal Dryness

91pls: What is vaginal atrophy?

Speaker_-_Dr__Holly_L__Thacker: Vaginal atrophy is thinning of the vagina. I did an educational video on-line for doctors and nurses and anyone interested on vaginal thinning/atrophy/sexual dysfunction on http://www.medscape.com/
Under the medscapeCME tab-type in vaginal atrophy and scroll to January 2009 to view.
 
Vanneh: I am having a significant problem with vaginal dryness. I am currently using 10 mcg Vagifem® (estradiol) tablets twice per week which does help. However, I seem to be extremely sensitive to Vagifem® as I immediately got breast tenderness when I began to use it. The tenderness does not go away between the biweekly doses. I am concerned about breast cancer risk due to this and am wondering if a compounded low-dose estriol cream would be safer. Thank you for your help.

Speaker_-_Dr__Holly_L__Thacker: Compounded estriol is very weak and expensive. There should be NO breast tenderness on local estrogen. You should look for other reasons for breast tenderness-too much fish oil, too much caffeine, too much progesterone. Estrogen in menopausal doses RARELY causes breast tenderness and breast tenderness is not a sign of breast cancer.


Menopause and Thinning Hair

springfever: My hair is beginning to thin. What over-the-counter products might help prevent further thinning and/or loss. I’m not interesting in taking Rogaine or any other prescription drugs. I understand that the vitamin Biotin is helpful and shampoos and hair products containing Nioxin® might be helpful too. What do you think about these products and are there any other products that might be helpful?

Speaker_-_Dr__Holly_L__Thacker: There is a study that our dermatologists are doing on women with thinning hair using the laser comb (for women not on hormones with thinning hair). The products you note are helpful, including HP Rogaine which has to be used 6 months prior to making a decision on benefit. There are several cosmetic options like TOPPIK hair spray that can be helpful.


Menopause and Cancer

fairies: Can Premarin® cause uterine cancer?

Speaker_-_Dr__Holly_L__Thacker: Any unopposed systemic estrogen in women with a uterus, not taking adequate amounts of progesterone, can be at increased risk for uterine endometrial hyperplasia and cancer. Even obese women not on hormones can be at increased risk for uterine cancer as adipose cells can convert androgens to estrogens and women with too much adipose tissue can have unopposed stimulation to lining of uterus, resulting in cancer. Being slender, exercising, not having diabetes, having had children and/or having been on birth control pill and/or being on ADEQUATE progesterone with estrogen postmenopausally is all protective.


Osteoporosis: Menopause and Bone Health

sappy: When should I get tested for osteoporosis?

Speaker_-_Dr__Holly_L__Thacker: I recommend BMD (bone mineral density) testing within two years of menopause – earlier for patients with a family history of osteoporosis, low vitamin D levels or long-term steroid medication use. Women who have unexplained bone fractures, skipped menses or who have taken treatments that lower hormone levels also should be tested. Your physician will determine whether you need a BMD test based on your clinical history and risk factors. A BMD is a quick and painless x-ray test that enables the physician to get a snapshot of bone health by measuring the mineral density in your bones.

enough: Does the use of caffeine affect your bone density?

Speaker_-_Dr__Holly_L__Thacker: More than 2-3 cups of caffeine per day increases calcium loss in the urine which in turn can negatively affect calcium balance.

canteen: Can you over take meds for building bones? (i.e. Fosamax®)

Speaker_-_Dr__Holly_L__Thacker: Fosamax® is a prescription medicine used to treat or prevent osteoporosis. Any medicine can be over taken, over used or not indicated in certain circumstances. You need to see a physician yearly to determine what type of bone regimen is best for you.


Vitamin D

homefires: What is your recommended amount of daily Vitamin D?

Speaker_-_Dr__Holly_L__Thacker: Adults need at least 1,000 to 2,000 international units (IU) of vitamin D daily in order to absorb calcium. Vitamin D deficiency is very common, particularly in northern latitudes such as Northeast Ohio.

jojo: Should vitamin deficiency testing (such as D) be done during an annual physical exam?

Speaker_-_Dr__Holly_L__Thacker: If there is any concern about deficiency, a 25 OH vitamin D level can be obtained. Most adults will maintain a normal vitamin D level with a daily 2,000iu daily ingestion of separate(not connected to calcium or other multivitamins) vitamin D3 daily.

jojo: Can you hurt yourself if you take too much Vitamin D?

Speaker_-_Dr__Holly_L__Thacker: Doses up to 10,000 iu daily of vitamin D3 appear safe. It is hard to get too much vitamin D unless you are on megadoses, or have sarcoidosis.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Holly Thacker is now over. Thank you again Dr. Thacker for taking the time to answer our questions.

Speaker_-_Dr__Holly_L__Thacker: People often ask am I 'for or against hormones' which seems like a ridiculous proposition-almost like asking if you are 'for or against' a political party.  I am for women feeling healthy, being in the correct hormonal balance.

Too much or too little of ANY hormone is not good. For the folks who think 'estrogen is bad' or conversely that 'hormones are the solution to everything/and/or a fountain of youth' are sadly misguided.

There is so much MISinformation about menopause, hormone therapy and women's health in general. Women owe it to themselves to get educated, get unbiased truthful information and be given options and tools to improve their health and vitality.


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