The New Truth About Menopause

Straight Talk About Treatments and Choices from Two Leading Women Doctors

Carol Landau, Ph.D., and Michele G. Cyr, M.D.

St. Martin's Griffin

New Truth About Menopause, The
CHAPTER ONE
The New Truth About Menopause
"Don't panic! You will be okay. Let's rethink this." This is the beginning of many conversations we've had with our understandably anxious patients after they saw the alarming front-page headlines in 2002 about the dangers of hormone therapy. The Women's Health Initiative (WHI), a federally funded study, released a statement that it was stopping its trial of estrogen plus progestin because enough data had been collected to conclude that the long-term risks of the hormones outweighed the benefits. The increased risk of breast cancer, which had long been feared, was now well documented. There were increases in blood clots and strokes as well. But the real surprise, after years of reports that hormone treatment helped protect women against heart disease, was that there were no heart benefits to offset these negative consequences. So the millions of women in the United States who were taking hormone therapy woke up to quotes in the New York Times like, "This [estrogen/progestin] is a dangerous drug," from Dr. Deborah Grady, a well-respected leader in women's health. The second-largest selling drug in the United States was suddenly suspect, and the women taking it were overwhelmed by fear and distrust.
While discussing this bombshell we asked, "Could this situation get any more frightening?" Well, in fact it could and it did. The next week, the Journal of the American Medical Association published more upsetting news: a possible link between estrogen therapy and ovarian cancer. Breast cancer, as terrifying as it is, can often be detected early by breast exams and mammograms, but ovarian cancer is a notorious silent killer of women. Even though this was a single study, all hell broke loose. Midlife women, once promised estrogen as a magic bullet, were stunned.
In May 2003, after much of the menopause news had quieted down, additional analyses from the Women's Health Initiative were released. As one professor of gynecology told the Associated Press, there was "another nail in the coffin for the use of hormones during and after menopause." The lead article in the Journal of the American Medical Association revealed even more unexpected results from the WHI. Many experts had believed, again based on earlier uncontrolled studies, that estrogen might prevent Alzheimer's disease and improve cognitive functioning in older women. A subset of women participating in the WHI were evaluated specifically to determine whether the combination of estrogen and a progestin would prevent Alzheimer's disease and other types of dementia. Dementia is a larger category that includes Alzheimer's disease and other causes of impairment in memory, judgment, and reasoning. Once again, the surprise was that women taking hormone therapy (after age sixty-five--the age of the women in the study) were more, not less, likely to develop Alzheimer's disease or other forms of dementia.
Further analysis of the breast cancers that were diagnosed in the WHI participants revealed some troubling results. The breast cancers that were diagnosed in women taking estrogen plus progestin were slightly larger and more likely to have spread to lymph nodes and beyond. Previous studies had suggested that although hormone therapy might increase the risk of breast cancer, the breast cancers that developed on hormones had a better prognosis. This new information from the WHI contradicts that prior thinking. The study implies that there was a delay in the detection in spite of yearly mammograms and breast exams. An additional finding was that the women on combined hormone therapy were much more likely to have abnormal mammogramsafter only one year of treatment, and this increase continued throughout the five years of study.
After the Women's Health Initiative results were released, and so many women were upset and confused, some physicians said that they just stopped answering their phones. "Nice," we thought. After having a clear preference for using estrogen for decades, they retreated into silence now that the situation had become complicated.
We decided to take the opposite approach, to communicate with as many people as quickly as possible. We know that midlife women today need both an update on information as well as a plan for making new decisions. The New Truth About Menopause is the result of our many conversations with patients, family members, friends, and colleagues. We wrote this book to calm your fears if you are worried about the decisions you've made in the past and confused about decisions you need to make in the future. Drawing on our many years of experience in women's health and menopause education, the book establishes a process for making informed choices about menopause. It will empower you by reducing your anxiety and clarifying your options.
The outlook is brighter than you might think. Consider the following:
• There was never only one good option for treating the symptoms of menopause. Each woman has a specific history and medical risks that should be considered before making any choices.
• Menopause may lead to many health decisions or few. It all depends on your individual symptoms, medical problems, lifestyle, and needs.
• You have many more choices than you may realize. For every condition that estrogen was supposed to treat, there are other effective, safe, and well-tolerated medications and strategies, and new medications and herbal preparations are being developed at a rapid pace.
• If you are currently taking hormone therapy, you can think through your decision. It may be that in your particular situation, the benefits are worth the risks. We will help you reevaluate your choices and discuss them with your health care professional.
• Lifestyle changes can result in enormous benefits to your health.
• There are millions of midlife women, so you are never alone with these concerns.
This last point raises an important issue: It's time to dispense with the negativism that pervades so many discussions of the whole topic. Almost every book or popular article on menopause has an undercurrent of pessimism and dread. Yes, menopause is a sign that we are growing older, and in our youth-oriented culture, this is dangerous territory. But guess what? We can grow older and try to do so with good health, good relationships, and wisdom. Or we can die young. If these are our choices, let's choose Door No. 1.
Midlife, then, is a target for our worst fears. Much of the hype about menopause has been a thinly veiled sales promotion for estrogen and other menopausal cures. In addition to aging, menopause represents a fear of death, of loss of control and femininity. Many of the major popular books have fueled these fears and overemphasized the positive effects of estrogen. Gail Sheehy's The Silent Passage, for example, paid enormous attention to physical appearance and extolled the power of estrogen. "I was staggered by the potency of the feminine hormone."
Television programs are even worse. Archie Bunker, in the ground-breaking All in the Family series in the 1970s, demanded that his wife, Edith, go through menopause quickly. Edith had been even more upset and tearful than usual. "If you're gonna have a change of life, you gotta do it right now. I'm gonna give you just thirty seconds." Many of the complaints about women's menopause are similarly male-oriented. In the 1960s, Dr. Robert Wilson wrote an extraordinarily influential book, Feminine Forever, that promised, "Estrogen makes women adaptable, even-tempered and generally easy to live with." Unbeknownst to his readers, Dr. Wilson was backed by a foundation supported in part by Wyeth-Ayerst Pharmaceuticals, the makers of one of the earliest estrogen medications, Premarin. His foundation published the book, which was effectively a marketing tool for estrogen.
Menopause also feeds into our competition with other women. From an early age, as women we learn to compare and compete with other women. Who is thinner? Prettier? Bigger-breasted? More popular? And of course, who looks younger? We've heard men and womenalike suggest that any woman over 35 is "menopausal." Two decades after All in the Family, the supposedly women-oriented television series Sisters included a younger woman played by actress Sela Ward, who got revenge on an older, competitive colleague by suggesting that she "has had such a difficult menopause."
Even one of the many post--Women's Health Initiative articles on menopause, written by a women's health physician, used the following words loaded with negative emotions: "vanishing eggs," "ovarian failure," "the aging ovary," "calcium pours out of bones," "the withering of reproductive organs," and the latest negative term for menopause, "reproductive senescence." Notice the intensity, the nonclinical nature of these descriptions. Men's problems don't get addressed with this same negativity. One never reads about, for example, the "withering penis" or "desperately plunging levels of testosterone" when men write about erectile or sexual dysfunction.
In the past, these negative terms were used to propel women toward using the magic bullet, hormone therapy. As it turns out, the bullet never was magic. It was a medication that, like all medications, had risks and benefits.
We believe that you can take charge of your health and your life and that not all changes or symptoms require treatment. A medical model--underwritten not only by a sincere belief in estrogen but also by hormone therapy marketing campaigns--has overdramatized the challenges of menopause. Midlife comes to us all, and there have always been older women who are healthy and happy. And now, as you'll see, there is an explosion of new treatments. Remember, too, that each of us is unique. No two women have exactly the same pattern of symptoms or long-term concerns at menopause. If you are like most women, you'll be able to deal with your lot. After all, it's not the end of the world; it's just the end of your periods.
So let's get started. We find it helpful to begin with a shared vocabulary. Here are some basic menopause definitions and facts:
• Menopause is the normal developmental stage that occurs after a woman's last menstrual period.
• Menopause is usually diagnosed when a woman hasn't had a period for twelve months or when a blood test indicates it.
• · A blood test measuring FSH (follicle-stimulating hormone) can also diagnose menopause. A high level of FSH (above 40) indicates menopause. Since FSH stimulates the ovaries to make estrogen, the pituitary is on overdrive when estrogen levels decline, producing more FSH. In other words, when estrogen is low, FSH is high.
• The average age of menopause is 51 years (51.4 years, to be exact).
• For 95 percent of women, menopause occurs any time between 40 and the late 50s. When menopause occurs before age 40, it is called premature. This could be a result of a medical problem, so it definitely should be evaluated by your health care professional.
• Perimenopause is the time before menopause when menstruation becomes irregular. It lasts approximately four years, but each woman's experience is different.
• Hot flashes are by far the most common symptom of menopause.
• Night sweats are hot flashes that occur at night and involve profuse sweating. They can disrupt sleep.
• Another common change is the thinning and dryness of the vaginal wall. This sometimes leads to discomfort and irritation.
• Estrogen is an umbrella term for the female hormones used to treat the symptoms of menopause. It is available in different types and in many forms. At one time its use was referred to as ERT, or estrogen replacement therapy. Now the term estrogen therapy (ET) is used. The most common form of estrogen is conjugated equine estrogen, Premarin, first introduced in 1942 and so named because it is derived from pregnant mares' urine. Forty-five million prescriptions for Premarin were written in 2001.
• Progestin is the name used for a wide range of hormones that have the properties of progesterone, which is also produced during the menstrual cycle. A progestin is added to estrogen, unless a woman has had a hysterectomy. This is done because estrogen used alone leads to a buildup on the wall of the uterus, or endometrial hyperplasia, that can lead to uterine cancer. Estrogen plus a progestin was often called combined hormone replacement therapy, or HRT. Now the term hormone therapy (HT) or estrogen plus progestin (EPT) is used.
Let's use these terms and facts to answer some basic questions: What causes menopause? What are the main effects of menopause? What can I do about these effects? We'll also debunk some of the most common myths about menopause.
What Causes Menopause?
Menopause is the third natural major reproductive phase in a woman's life. Each baby girl is born with millions of immature eggs in her ovaries. The actual number of eggs is genetically determined. Recent studies, for example, have identified a gene that is associated with early menopause. That gene is associated with a woman having fewer eggs at birth. By the time a girl reaches menarche, the time when her menstrual cycles begin, the number of eggs is already reduced. The cause is unclear. Each month an egg is developed, but approximately 1,000 eggs will be shed. The follicles surrounding the eggs produce the ovaries' hormone, estrogen. If a sperm fertilizes an egg, pregnancy takes place. This causes another set of hormonal changes.
Usually, when a woman reaches her late 40s, her FSH level goes up and periods become shorter or unpredictable. The hallmark of the transition to menopause is the change in menstrual cycles. These changes involve the length of a period, the intensity of the flow, and the number of days in the menstrual cycle. Most women have four to eight years of menstrual changes before menopause actually occurs. Some women, on the other hand, just notice that their periods have stopped. These changes are the natural results of the declining levels of estrogen.
(A word of caution, however: Unusual or abnormal uterine bleeding is a different story. If your bleeding is much heavier than usual or lasts more than seven days or if you have blood clots or anemia, you should promptly consult your physician. In addition, bleeding or spotting after intercourse or between periods can also be cause for concern.)
So menstrual changes signify the beginning of perimenopause, the entree into the transition. Then hello, hot flashes! When menopause occurs, around age 51, estrogen production from the ovaries, or estradiol, is reduced by 90 percent. However, estrone, which is produced and stored in fat cells, replaces estradiol. Environmental and behavioralconditions can also hasten menopause. Smoking can bring on menopause years earlier than it would occur normally. Some chemical exposures can lead to an earlier menopause. Radiation therapy and chemotherapy can also cause menopause. And of course, when the ovaries are surgically removed, menopause occurs immediately.
Now we can go on, as psychoanalytic theorists did, to bemoan this loss of reproductive phase of a woman's life. Helene Deutsch, for example, wrote that a woman lost "her service to the species." Many psychoanalytic thinkers used this belief to explain what they saw as a natural, almost preordained midlife depression, termed involutional melancholia. Unfortunately, their belief system led to an overestimate of depression in midlife women and inattention to the much more prevalent depressions in younger women.
But there is another view, based more in reality. Many women struggle with birth control during their reproductive years. Some women experience mood swings associated with their menstrual cycles, the PMS for which we women are also often blamed or ridiculed. Other women are troubled by infertility in their 30s and 40s. The main infertility support group is called Resolve, suggesting that couples should do what they can and then come to peace with their situation, whatever it may be. And of course, many women give birth or adopt children. So perhaps by the time we reach our 50s we have not come to ovarian failure but to another type of resolution. Maybe, as Mary Mahowald, an ethicist, has suggested, we have reached ovarian fulfillment or ovarian completion syndrome. And remember, we women are not primarily reproductive organs, but rather complex individuals who happen to have female reproductive systems.
In fact, many women do associate menopause with reproductive freedom. And there is a long history of differing perceptions of menopause. For example, in 1818, the U.S. attorney general, William Wirt, had an inquiry for the family physician. It seemed that Mr. Wirt's wife, Elizabeth, was not becoming pregnant.
In Anya Jobour's Marriage in The Early Republic we get a glimpse of Elizabeth's views on the subject. Earlier in their marriage, Elizabeth Wirt responded to a teasing question from her husband as to whether she was pregnant, to which she responded, "With me--as there is noprospect of escape--I only wish that when it must come I might have some choice in the affair." By the end of her letter, however, Elizabeth Wirt backs down by adding, "These things are overruled by Providence, and our part is cheerful submission" (see here). Later, although Mr. Wirt was unhappy his wife was not. Elizabeth Wirt wrote to her mother that she was overjoyed at the situation because by 1818 she had already given birth to her twelfth child.
What Are Menopausal Symptoms?
The primary symptoms of menopause are hot flashes and changes in the urinary and sexual organs and functioning. There are also less direct and less severe changes in mood and thinking (cognition), but these have been exaggerated as direct effects of estrogen loss. All the other symptoms--skin changes, memory loss, gray hair, and wrinkles--are part of the aging process and less directly related to menopause. In other words, midlife men get them, too, and there is much less fuss about it.
Hot Flashes
These are the calling card of menopause, or perimenopause to be exact. Somewhere between 75 and 85 percent of menopausal women in North America have them. Approximately 25 percent have hot flashes disturbing enough to seek treatment, and 15 percent find them to be severe. A part of the brain called the hypothalamus regulates body temperature. Some experts believe that changes in this temperature control mechanism cause hot flashes.
A hot flash seems to come out of nowhere. It begins with an overwhelming sensation of heat, followed by sweating, and is sometimes accompanied by heart palpitations. Then just as suddenly, body temperature drops, leaving a woman shivering and cold. Night sweats can significantly disrupt sleep, with these wide swings in temperature leading to multiple changes of nightclothes and bed linens. The severity of hot flashes varies from woman to woman. Similarly, some women may have them for several months, whereas others may have them for many years.
Here is how a hot flash happens. The capillaries in the skin suddenly open wider. This leads to blood rushing in, a flush, and pores opening. When the capillaries contract, the blood drains away, body temperature drops, and the skin pales. For some women, a hot flash is a not unpleasant sensation of warmth. For others, especially women after an oophorectomy (the surgical removal of one's ovaries) or chemotherapy, hot flashes can be disruptive and severe. In addition, some women experience a sense of dread just before a hot flash, with anxiety during and after. We'll explore treatments for hot flashes in detail in Chapter 3. Briefly, however, the main choices are estrogen, progestin, antidepressants, blood pressure medications, herbal remedies, soy, and self-management strategies. So you see, you have a lot of treatments to consider.
Sexual and Urinary Symptoms
Hot flashes and irregular periods are the first symptoms of perimenopause. Later, about five years after menopause, vaginal dryness may become noticeable. This can lead to an uncomfortable burning feeling, and sexual intercourse can be painful. Once again, however, we can thank the estrogen promoter Dr. Robert Wilson and others who referred to menopause as "a horror of living decay" for exaggerating this condition. Just to help out, Dr. David Reuben, of Everything You Always Wanted to Know About Sex fame, described menopause as a time of "decline of breasts and female genitalia." And it is true that the female sexual organs depend in part on estrogen to maintain their anatomy and function. But please! In reality, the decrease in estrogen levels at the time of menopause does not lead to irreparable, inevitable, or disastrous changes.
There are treatments for vaginal symptoms, too. In addition to low-dose vaginal estrogen, there are moisturizers. Sheryl Kingsberg, a psychologist at Case Western Reserve Medical School, was quoted in a news article about menopause: "We shy away from even discussing vaginal moisturizers. We feel comfortable using moisturizer for our face to prevent dry skin. This is the same thing." In addition, she and most experts agree that when it comes to sex, more is more. Practice makesperfect, or in this case, practice makes pleasure. "I like to think of it as going to the gym. Once I'm on the treadmill I think, This is great. I'm coming back again soon." Comparing sex to a workout on the treadmill may not be very arousing, but you get the basic idea.
Many women complain of memory loss and mood swings. In general, mood swings are associated with perimenopause, especially in women who have hot flashes. As is true for women of all ages, high levels of stress and other medical problems can lead to depression. Women who have histories of depression may be vulnerable for a recurrence at the time of menopause. But most women should expect transient moodiness, not unlike milder cases of PMS.
As for memory changes, estrogen may well affect verbal memory. This could be true because estrogen may influence the brain chemicals known as neurotransmitters that assist in learning. Once again, for women going through natural menopause, memory changes are not severe. However, more significant changes are seen in women who have had their ovaries surgically removed (oophorectomies) or experienced sudden menopause due to chemotherapy or radiation therapy.
The Importance of Prevention
Those are, simply, the major symptoms associated with menopause. Midlife is also a time when women begin to focus on preventing conditions associated with menopause and aging. Some of the major conditions to consider are osteoporosis, heart disease, Alzheimer's disease, and most cancers. While most cancers are not specifically related to menopause, many do become more common with age. A few, such as breast cancer, are associated with some treatments that we'll discuss later.
Osteoporosis
The loss of estrogen at menopause interferes with the normal process of building and maintaining bones. Over time, bones can thin, leading to osteoporosis. Up to 20 percent of bone mass can be lost during the first five to ten years after menopause. Osteoporosis is a serious condition.After menopause, almost half of all women will suffer some type of fracture due to osteoporosis. Even more troubling is that 20 percent of women die within one year of suffering a hip fracture. Clearly, we want to prevent this condition.
The two basics of an osteoporosis prevention plan are adequate intake of calcium-1,200 to 1,500 milligrams a day, with 400 IU (International Units) of vitamin D--and maintaining good bone strength with weight-bearing exercise. Other treatments that we'll present in Chapter 4 include bisphosphonates (Fosamax, Actonel, or Didronel), raloxifene (Evista), or calcitonin (Miacalcin), estrogen, and many new medications in the pipeline.
Heart Disease
Heart disease is the number one killer of women. We can do a lot to prevent it. At one time, the medical community was optimistic that estrogen prevented heart disease. With the results of the Women's Heath Initiative, however, it appears that the opposite may be true. This still leaves us with the options of a heart-healthy diet, exercise, medications to lower cholesterol and blood pressure, low-dose aspirin (81 milligrams per day), and moderate (only) intake of alcohol. We will give you details later.
Alzheimer's Disease
Alzheimer's disease is a condition that affects memory and brain functioning. It is a progressive and tragic disease. Alzheimer's is not the normal memory slippage that occurs with aging. Although research is ongoing, currently there is no definitive effective treatment.
Preliminary research had suggested that estrogen, especially when started early and taken for more than 10 years, might reduce the risk of developing Alzheimer's by as much as 50 percent. However, the randomized controlled study from the Women's Health Initiative found that women who were over the age of 65 and taking the combination hormone therapy were twice as likely to develop Alzheimer's disease and other types of dementia than those taking a placebo. Given thecurrent risks of hormone therapy, estrogen plus progestin should not be prescribed to prevent dementia. This is definitely an area of active research to watch.
Menopause Myths
Now that you are armed with these basics, we also need to dispel some all-too-common myths:
Myth 1 Menopause is a disease and must be treated medically. Not true. On the other hand, there is no need to suffer unnecessarily because of a belief that menopause is totally natural. Although the decrease in estrogen can lead to troubling symptoms and to osteoporosis, it is a natural, gradual transition. Most women adjust to the declining estrogen levels within a few years.
Myth 2 Any remedy labeled "natural" is better or harmless. First of all, there is no regulation of the term natural. In addition, herbal products are not held to the same standards as medications approved for use by the Food and Drug Administration (FDA). In order for a medication to be approved by the FDA to treat a specific condition, studies must be conducted to demonstrate its effectiveness. The research also documents side effects and contraindications, which are made available to health care professionals and the public. In contrast, an herbal product is regulated only in a general way. So not only can companies make false claims for herbal products, they are not required to test side effects or interactions with medications. We say, be careful.
Myth 3 Most women become depressed at the time of menopause. This is a tricky one but is also false. Some women do become moody, but more often during perimenopause, not after menopause. Sleep deprivation may be the culprit some of the time. Most experts agree that untreated night sweats can lead to sleep deprivation, and this lack of sleep can trigger a depressive episode in a small group of women.
More often, such stressful life events as poor overall health, the death of a spouse or partner, or the need to care for elderly family members are associated with depression and anxiety. Studies of midlife women found that these stresses, not changes in hormones, predicteddepression in most women, though the story may be different for women who have histories of depression, especially postpartum depression or late luteal phase depression (depression associated with PMS).
Other women are unsettled by mood swings. Again, mood swings occur more often during perimenopause and are time-limited. Since antidepressant medication can treat both depressed mood and hot flashes, there is even more hope here.
Myth 4 Menopause can make you crazy. Well, on the one hand, if we took any individual, deprived her of sleep, and subjected her to dozens of hot flashes and night sweats every day for many months, we could understand that she could become irrational, irritable, and unproductive! However, if we take severe hot flashes out of the equation, menopause is merely a stage in life, and like other phases, has its ups and downs.
Why do we all hear so many stories about someone's Aunt Matilda who was up in the attic ranting and raving? Well, some psychiatric conditions, if untreated, get worse over time. Sometimes loss, illness, and the stresses of midlife and aging can cause severe psychological reactions in both men and women. But in addition, our society is particularly harsh on midlife and older women. Images and stereotypes of evil and crazy older women are pervasive, from the old witches in fairy tales to the Wicked Witch of the West in The Wizard of Oz and Cruella De Vil in the Disney film 101 Dalmatians.
As women involved in menopause education, we pay close attention to media portrayals of crazy or depressed menopausal woman. In short, we collect menopause stories. Ten years ago our favorite was the menopause legal defense in the offbeat television program Picket Fences. Yet another menopausal woman had killed a man in some blinding hormonal frenzy. Recently an even more dramatic example occurred in the HBO series The Sopranos, when Carmela Soprano finally asked her husband, mob boss Tony Soprano, to leave. In discussing Carmela's decision with their daughter, Meadow, Tony says that Carmela is having a "hard time because of the change." Tony and Meadow both know that Carmela has suffered through Tony's numerous affairs, as well as his brutal and criminal behavior, yet she's trapped by their lavish lifestyle. Her crush on a low-level mobster ended when he left her without saying good-bye; and Meadow, a college student, has recently humiliatedCarmela at dinner during a discussion of a novel. Knowing all this, father and daughter back away from the reality. Meadow agrees, "Yes, it must be menopause." (But this scene does represent a breakthrough as well, since both characters seem to have some sense that they're using menopause as an excuse to avoid acknowledging the real sources of stress in Carmela's life.)
Myth 5 Menopause signifies the end of a healthy sexual life. This myth is also related to a misconception that women become masculinized by menopause. In reality, it is true that with aging, sexual arousal takes longer for both men and women. One view of this is that women are slower to arouse with age. Another view, however, is that women do not get enough stimulation to become aroused. The net result is that it takes longer for women to become lubricated during foreplay. The explanation for these changes are numerous, including decreased blood flow to the vagina, which makes it less sensitive to stimulation, and decreased vaginal lubrication related to estrogen levels. In some women, there may be a change in the experience of orgasm and a decrease in the frequency of orgasms after menopause. But you do not have to be one of them! Although sexual changes do occur as we grow older, with good communication, these need not interfere with a fulfilling sex life.
Myth 6 Menopause is the beginning of the end. Much of the marketing of treatments for menopause plays on our fear of aging. As mentioned earlier, Dr. Robert Wilson started this trend with his book promoting Premarin (despite a conflict of interest). In Feminine Forever, he warned women that only with estrogen, "Breasts and genitals will not shrivel." Other advertisers have followed suit. We've seen many other claims of "curing" everything from wrinkles to gray hair!
In reality, most women adjust quite well to the changes associated with menopause. For most women, midlife brings a sense of freedom, and for other women, the struggles are really about life and getting older, not some "menopausal syndrome."
There are decisions to be made, and to make the best decisions, we need to be free of fear. You can do this. You've undoubtedly made many health decisions before. Maybe you had acne as a young woman and chose a treatment. You've probably made choices about birth control, and too many of us have made many decisions about dieting. Mostwomen have also either made health decisions for family members or helped them to do so. This is not all that different. We'll take it step by step to give you the skills to make health decisions now and in the future.
A Straightforward Mode! for Making Health Decisions
All too often, a woman goes to her physician's office and comes out with a prescription in hand. Yet she may not know why she should take the specific medication. She may not know the common side effects or even the more serious risks of the medication. She may not even want to take a medication.
We want to change this. Our goal is to help you establish a logical process for making health decisions. If you become more involved in making these decisions, you will feel more in control of your health and of your life in general. You will also be more committed to whatever plans you make, whether they involve taking a medication, losing weight, or exercising more. Your commitment and motivation will lead you to be more successful, and thus a positive cycle will be created. Here's how we will proceed.
First, let's take inventory. What are you most concerned about now and for the future? Are you having troublesome hot flashes? Mood swings? Are you concerned about your risks for heart disease? Osteoporosis? You'll need to consider your current health profile, the current pressing issues, and your concerns about your health in the future.
The next step is to set specific goals. What do you want to happen? Most women want relief from the troublesome symptoms of menopause. So you might have a goal of stopping night sweats or treating vaginal dryness. Another possibility is that you want to prevent certain conditions like osteoporosis or colon cancer. Maybe you want to build up your muscle strength.
Next you'll want to gather information about your options. in the next chapter we will help you understand women's health research; then in Chapter 3, we'll present the latest knowledge about the treatment of symptoms and diseases associated with menopause. We'll alsolet you know the best resources--Web sites, books, and pamphlets available to help you stay fully informed.
Check with your doctor or health care professional, too, to see what she or he recommends. Schedule an appointment to do this. (The right time for important conversations is not when you are on your back having a Pap smear or when the doctor is going out the door at the end of the appointment or when you or your doctor is overly stressed.)
We will detail the best communication strategies in Chapter 6, but here are some initial tips. Listen to your doctor's responses to your concerns. Ask questions if you don't understand something. Be sure the treatments target your own specific goals, not general goals that are supposed to apply to all women. If your doctor interrupts you, calmly restate your point. If you feel as though you're not being taken seriously, express your opinion directly. State your goals. You might want to jot down a list of questions and concerns to take with you. If you tend to get nervous, your emotions will interfere with your ability to communicate and to process information. So you might ask someone close to you--your husband, your partner, or a friend, for example--to accompany you.
Once you've formulated your plan, it's time to act. This plan may involve taking a medication or herbal preparation, consuming more calcium and less fat in your diet, and/or increasing your exercise. Give yourself some time to implement all the steps in your plan. Continue to monitor your symptoms or goals.
Next, take a step back and evaluate your plan. Are your hot flashes occurring less often or less intensely? Are you having side effects from a medication or herbal preparation? Call your doctor. She or he can tell you whether the side effects will lessen with time or whether you need to adjust your dose. Have you been able to exercise? If not, tinker with your plan in order to improve it.
Take Heart
Our work in women's health has given us an opportunity to meet thousands of midlife women. One of the ways we've formalized the give-and-take is through our menopause town meetings, which we havebeen holding for over ten years in a variety of settings. Initially, we would deliver formal presentations, but we soon learned that the audiences--who impressed us time and again with their sophistication as health consumers--wanted something different. So now we make very brief introductory comments and open the floor to the audience. We not only answer questions but find that the women learn from each other and derive support from their shared experiences.
We continue to be inspired by the energy, resilience, and courage of these women. Their experiences have deepened our commitment to providing women with in-depth knowledge. For it is the combination of knowledge, self-confidence, and a good relationship with a primary health care professional that leads to informed health decisions.
Making smart health decisions can give us all an increased sense of competence and control. There are so many aspects of life that are out of our hands--disease, loss, and tragedy. But at the same time, we also need to recognize what we can control. The same is true with respect to our health. We cannot control our genetic makeup or family history, but we can control our exercise, stress management, nutrition, and problematic habits, and we can control the process of making health decisions. We will help you do this, with information on women's health research and treatment and preventive strategies, and with stories about how women make decisions. And we'll alert you to future trends and developments in sections called "Keep Your Eye On." By the time you reach the end of this book, you'll be better able to make decisions and enjoy this time of your life.
Copyright © 2003 by Carol Landau, Ph.D., and Michele G. Cyr, M.D.