Ask The Expert

Ask The Expert

Are these symptoms of Menopause?
Are these symptoms of Menopause? page 2
Am I experiencing Perimenopause? page 3
Am I experiencing Perimenopause? page 4
Am I experiencing Perimenopause? page 5
What should I expect from HRT? page 6
What should I expect from HRT? page 7
What should I expect from HRT? page 8

Doctor, Are these symptoms of Menopause?   QuestionI hope you can help me.  I am 45 years old and have had frequent problems with perimenopausal symptoms.  I have been on organic and non organic hormone replacement therapies, gone off and have been fine for about six or so months.  My biggest issue is with the feeling like I am having an adrenal rush at about 4AM every morning.  This is the only symptom that I need help with.  I can live with the hot flashes, crabby moods, hair loss.  I also break out a lot on my chin.  Any advice?

Answer: I cannot give you any advice. Your story is not clear to me. I have no idea what kind of hormone replacement therapy is "organic and non organic'' and an adrenal rush is unknown to me.

Question:   I am 53 year old and up until December have had regular periods. My last period was the first week in December. Lately I do not sleep well.  For the past two nights  I have experienced severe leg pain that radiates from the back of my upper thigh down to my heels. The pain is severe enough to wake me and cause me to get up for several hours at night. I take over the counter sleeping pills every night and also get up 3 or 4 times at night to urinate. For the sleep problem, my physician first prescribed Sonata and the Ambien, but I get just as much sleep relief from over the counter medications at a much lesser cost. I also take medications for glaucoma. I perform moderate exercise and am not overweight (5'6 and 145 lbs). My concern is the frequent urination, sleepless nights and leg pain.  Are these common symptoms of menopause?

Answer: Not all symptoms originating during the menopausal transition are menopausal symptoms. Leg pain is not, sleeplessness is not unless caused by hot flashes and night sweats. Frequent urination can be caused by cystitis, or especially nightly frequency by cardiac failure. Frequent urination is also not a perimenopausal symptom.

Question:  How would you treat a 40 year old woman who has had surgical menopause a year ago who has lost libido and cannot take oral or patches as HRT? Gels will be the way, but how to figure precisely the amount I need? Blood test or saliva test? Who does the interpretation, the lab or the doctor? Please guide me.

Answer: Libido has to do with androgens. Both estrogens and androgens are available in some countries as implants. Patches with androgens are in pipeline. When implants are not available, and swallowing tablets or using patches is not possible, there is no way to supplement androgens. Estrogens are also available in gels or in nasal spray. In gels 1-2 mg estradiol is advised, with nasal spray 300 micrograms. No lab test available to check the amount. Usual, enough is administrated when hot flashes disappear, and to much is used when side effects such as mastopathy appear.

Question:  I have been menopausal for over 5 years.  I suddenly stopped having my period one day and never had another until just a few weeks ago. The doctor took a biopsy and nothing showed up.  Now she is recommending Provera for three months to see what it will do before going in and burning out the lining. I have never taken hormones of any kind.  Will this progesterone throw me out of balance?  I also have many of the problems that the side effects say you may acquire, i.e.. hair loss, overweight, fluid retention. Thank you for your attention to this problem.

Answer: Postmenopausal bleeding requires investigation. With a negative biopsy the risk of endometrial cancer is extremely low. Usually, an ultrasound investigation is done to measure endometrial thickness. With a thickness of less than 5 mm no action is required, because hardly never malignancy is seen with that measure. With endometrial thickness of 5 mm or more, also an endometrial polyp can be the cause of bleeding and further diagnostics can be done (saline infused sonography or hysteroscopy) to rule out endometrial disorders.

Question:  I am currently taking prometrium prescribed for eighth days to try and clear my uterine lining since my last period was 10/00.  My lab work states that I am post menopause.  I've had an ultra sound everything seemed to be normal.  I have had no spotting with the prometrium.  When can I just be in menopause and not worry about uterine cancer?

Answer: As long as your ovaries produce estrogens, a growth of the endometrium lining occurs. With progesterone, the lining is transformed and shed. A withdrawal bleeding will start after the end of the progesterone course. When no withdrawal occurs, there is no endometrial growth and the risk of endometrial cancer becomes extremely rare.

Question:  I have a problem with high FSH level, which later I was diagnosed with "POF." Is there a cure for this problem and is it hereditary problem?

Answer: POF is premature ovarian failure, defined as menopause before the age of 40. Sometimes a cause can be found (immunological disorder, genetic aberration). There is no cure for it, because the follicles in the ovaries are scarce and the high FSH can not stimulate them any more.

Please see the Premature Ovarian Failure Support Group they offer support and information for women with Premature Ovarian Failure (POF), often called Premature Menopause.

Question:  I am 37 years old and have been going through Premature Menopause for almost two years now (my sister and grandmother went through it at the same age). My FSH level was 120 when last tested. My hot flashes have subsided somewhat over the last year or so, although I still have mood swings and some trouble sleeping. I can live with that but my main concern is Osteoporosis and heart disease. My mother has Osteoporosis and my father heart disease.

I am 5'7" and only weigh 109 lbs. and have a small, delicate bone structure. I am also a former smoker, with very pale skin and am a vegetarian (but was vegan for a long time).  Because of all of this I know that I'm at a risk for Osteoporosis and because of a high fat diet, for heart disease as well.

But I am afraid of HRT, I really don't want to take it. The one time I tried Progestrone in pill form was for Endometriosis, but it made my Raynaud's Syndrome much worse and I had to stop. Any advice you can give me would be greatly appreciated.

Answer: Premature menopause  is menopause (last menstrual period) before the age of 40 years. It is not possible to go through menopause during several years. You are still menstruating or you are not. When you have had no menstruation during 12 months with high FSH, you are postmenopausal. With premature menopause the risk for osteoporosis and for cardiovascular diseases increases. With premature menopause, your rather low weight and a mother with osteoporosis, there is a strong reason to diagnose the amount of bone mass. With DEXA or CT-scan it is possible to measure bone mass accurate and to estimate your risk. With high or normal bone mass risk is low and preventive medication is not necessary. With low bone mass (osteopenia or osteoporosis) preventive therapy consists of either bisphosphonates, raloxifene or estrogens. Bisphosphonates have no other benefits than bone. Raloxifene (Evista) has probably also a beneficial effect on heart and blood vessels, but it can increase your hot flashes. Estrogens are beneficial for bone and cardiovascular system. Increase of Raynaud symptoms are sometimes seen with unopposed estrogens, but not with a combination of estrogens with progesterone. The best therapy to try with Raynaud symptoms is: transdermal estrogens (50 micrograms) with oral natural progesterone (Prometrium), either in continuous combination (daily 100 mg) or in a sequential regimen (200 mg during 10-14 days every month). With a history of endometriosis, I advice the continuous combined regimen. Lifestyle can influence both the risk of osteoporosis and cardiovascular disease. Regular exercise, healthy food (especially not to much unsaturated fat) and no smoking can reduce the risks considerable also without additional medication.

Question:  You say usually menopause does not effect the libido.  Why or how does it effect the libido sometimes? Why are you so sure, none of the women's libido has been effected that ask questions about this subject? If the answer is usually that means it is possible, right? Please explain?

Answer: Menopause per se does not effect the libido. Libido problems can be influenced by bad feelings because of night sweats, or by the experience of painful intercourse because of insufficient lubrication. So, indirect menopause can influence libido. And I am so certain because of the evidence in the medical literature.

Please check-out this great article called, "Decreased Libido," by D. Ashley Hill, MD

Question:  I'm a 33 year old female that had my uterus removed in 1996 and my ovaries removed in October 2000.  I kept getting reoccurring pain - when they finally opened me up to remove my ovaries they found cysts and hemorrhaging from same throughout both ovaries, also endometriosis.  When I first left the hospital they gave me an estrogen shot that was to last for up to four weeks - after the first two I started get hot flashes. Then I switched to "a red pill .625mg"  that didn't do anything for me as I was still flashing and depressed etc.  Then I tried the patch which seemed to work on the first day but not the second or third (and I hated the black circles it left).  Now I am taking 1mg of ESTRACE daily (since Jan 11,2001) and I still have hot flashes, am very moody, depressed and have headaches all the time, some migraines. What do I do next?

Answer: 1 mg Estrace is not always enough to combat hot flashes. Higher dosage is sometimes necessary: 2 mg Estrace, sometimes even more. Or premarin 1,25. When headache becomes a problem, transdermal estrogens with patches give more stable estrogen levels and are to be preferred. With recurrence of endometriosis, rare but possible, a continuous combination of estrogens with progesterone or progestagens is advisable also after hysterectomy.

Question: I have been going through menopause for about 5 years. I have not had a period since March 2000. I would like to know if it is normal to have a period after not having one for that long.

Answer: Yes, it can. You are perimenopausal. Menopause (the last menstrual period) is diagnosed retrospective after 12 months of amenorrhoe. So you have to start counting again.

Question:  I am almost 46 years old and have been told by my doctor that I am perimenopausal.  I have been experiencing pain during sex irregular bleeding and loss of sexual desire. I have been with my husband for the last seven years and have had the most enjoyable sex life ever and now this is happening.  Will my sexual desire come back after a hysterectomy.

Answer: Sexual desire and hysterectomy has nothing to do with each other. Why to perform a hysterectomy? The cause of pain and bleeding pattern has to be investigated and diagnosed. Of course you have loss of sexual desire when intercourse is painful.

Please check-out this article called, "Painful Intercourse" by D. Ashley Hill, MD

Question:  Why do humans have a menopause?  Do any other animals have it and of so which?

Answer: A philosophical question. Maybe because a human child needs maternal coverage during at least 15 years. And a woman has to live at least that time after the last birth. Menopause is also present in several kinds of apes. 

Question:  Is there any information out there in reference to seizures and early menopause.  I recently had two grand mal seizures with no previous indication of having any before. any correlation?

Answer: Seizures can be provoked by estrogens, whereas progesterone has inhibitory effect. It is possible that a lack of progesterone (in annovulatory cycles) with persistent and high estradiol levels induce seizures. There is no proof of a relation like this but the hypothesis is accepted by many.

Doctor, Are these symptoms of Menopause? Question:  I had a hysterectomy at age 36 and I am now 41 and would like to know when I will go through menopause since I still have my ovaries? My uterus was removed and both ovaries remained. I had a lot of trouble with endometriosis.

Answer: After hysterectomy with both ovaries remained hormonal changes will occur exactly on the same moment as without hysterectomy. The function of the ovaries are not influenced by hysterectomy.

Question:  I am 36 years old and had a hysterectomy in December 2000.  What are the symptoms of surgical menopause?  How quickly is the onset of these symptoms after the operation?  I am on estratest and prometrium 200mg.  What type of HRT do you usually start these types of patients on?  The reason for the hysterectomy was endometriosis.  Are there any tests I should have done to make sure that the HRT is meeting my needs?  Your input would be greatly appreciated.

Answer: Symptoms of surgical are the same as symptoms of natural menopause. Because of the more sudden fall of estrogens in surgical menopause vasomotor symptoms are usually more intense. And the symptoms will start almost immediately after the bilateral ovariectomy.. After hysterectomy only estrogens are prescribed, sometimes with androgens as in estratest, but without progesterone. Progesterone is for the protection of the endometrial lining. However, in some situations like endometrial cancer or endometriosis, there is a reason to prescribe progesterone because of the possible existence of endometrial tissue outside the uterus. In such situations, continuous progestogens are advised. e.g. Prometrium every day. 100 mg usually is sufficient. When you have no hot flashes the dose is high enough and there is no need for tests.

Question:  My mother is 61 years old.  She had a partial hysterectomy at 40 years old and has been on HRT for many years.  She is still having a period, sometimes twice a month, and with it comes severe cramps and discomfort.  My mother is not one to complain, but she has called me about it several times in the past few months.  Her doctor for the past ten years just told her it was too bad, but nothing could be done about it.  I referred her to my ob/gyn who implied that the only reason my mother went to see her is to try for surgical solutions.  I'm very worried about her because her bleeding remains heavy and the pain is becoming unbearable.  What alternatives does she have in dealing with her condition, and is there any kind of specialist she should try to see?

Answer: Several questions arise by reading this report. First of all: for what reason your mother is using HRT? Does she have complaints without HRT or is it for prevention of chronic disease. For prevention, maybe other ways are better with such a bleeding pattern. For vasomotor complaints, maybe other regimens can be used. Does she use a continuous combined regimen, a sequential combined regimen, an interrupted combined regimen? What dose of estrogens, what kind and dose of progestagens? Without that kind of information, I cannot give any advice.

Question:  I am eight years past menopause. I have not taken hormone replacements. My last pelvic was painful. I have not had sex in 3.5 years. The last time I did have sex it was painful. I had a burning sensation in my vagina. Have I any hope of reversing this condition?

Answer: The problem is mainly no sex in many years. The best way to have no pain during intercourse is to have intercourse on a regular base. But local estrogens can make the situation much better.  For complete recovery of the vaginal epithelium and vaginal blood supply sometimes long-term HRT therapy is necessary. Without local estrogens, you can try lubricants.

Question:  Last year I had a complete hysterectomy. I tried taking estratest and then estradiol. I had a terrible time with both. I went to see my doctor and he told me not to take hormones in any form. I had stop taking them 2 weeks prior to the visit. On HRT I had lost my appetite, lost 15lbs., my thoughts became obsessive and very insecure. I felt like I was going crazy. I started to feel better within a week. It's been about 5 weeks now and I still have no appetite. I am still irritable. Hot flashes have kicked in as well as some insomnia. I am at a loss on what I can do. Any non HRT advice.

Answer:  After hysterectomy ovarian function remains intact. And no HRT is necessary. Only after bilateral ovariectomy, HRT becomes necessary. Loss of appetite and weight loss and irritability are possible signs of depression. Explore that with your doctor.

Question:  I hope you can help me.  I recently went for blood work for hormone levels. I am on the pill, I have been for years. I was wondering if you could help me understand it. My Free testosterone was <0.5 my testosterone was 21 my Estradiol was 32 Progesterone 0.3 and Prolactin was 18.8. I was wondering should I be concerned will my low numbers on the free testosterone and estrodiol? Is this a sign of early ovarian failure? I am 29 years old no children. Thank you for your advice.

Answer: During oral contraceptive pills one cannot measure ovarian function because ovarian function is zero by low FSH. So, no sign of ovarian failure. Only a sign of useless lab work.

Question:  I went through menopause several years ago.  I am taking estradiol and provera daily.  My ob-gyn says that I should not bleed at all now, but am having light monthly periods every month.  He is considering doing a D&C. What might be causing the bleeding, and would a change of HRT make any difference?

Answer Bleeding with continuous combined HRT is most times caused by atrophy and sometimes by polyps, but a small chance of endometrial cancer has to ruled out with endometrial biopsy (D&C).

Question:  I have an important question. My mother is 55 yrs old Indian and she has post menopause bleeding. She did "Pap smear" test but the test do not show anything unusual. She did "D&C" two times. She takes "Haemoci" tables or Homeopathy medicine (Trillium/Milluim 200) when she has bleeding and the bleeding stops. But the doctor said that there was a small thickening of the uterus (inner part) wall and its safe to remove the uterus because later in future it may cause problems. And the operation would require about Rs.20,000 in an Indian hospital (about $500). Now does my Mom really need to remove uterus? Is there any risk for cancer if not removed? In our family there is NO case of cancer. Except for my grand father's mother who died due to uterus cancer. Please let me know doctor. Thanks very much.

Answer Removal of the uterus is necessary when there is a strong suspicion of malignancy. Here is only the observation of focal thickening of unknown origin. There is certainly a need for further diagnostic procedures. Hysteroscopic evaluation of the endometrium with direct biopsy of a suspect lesion is the best way to come to a solution. However, when a blind biopsy reveals no abnormal cells the risk of malignancy is very low.

Question:  I'm 48 years old and have had fibroid tumors and an enlarged uterus for the past 5-6 years.  My doctor says my uterus is about the size it would be if I were 3 months pregnant.  At this time I have no discomfort or other problems and he suggest a "wait & see" treatment.  He says if the tumors & uterus do not reduce in size by the time I reach menopause then we will look at my options.  I was told if I need HRT that would increase the tumor size and HRT would be a determining factor for treatment.   Should I follow this advice or seek a second opinion?   How likely are the tumors to become cancerous?  I have a Pap test every year and a pelvic exam to keep track of the tumors every six months. I have noticed weight gain in my stomach & waist.  Is there anything else I should be doing or be aware of?

Answer: The chance of cancerous change in fibroids is very, very rare. There is no need for any intervention when there is no complaint, unless rapid growth is observed, because rapid growth can be a sign of cancerous change. After menopause usually a decrease in the size of fibroids is seen, but even unchanged fibroids without complaints do not need intervention after menopause. The use of HRT after menopause will prevent the decrease and sometimes there is a small increase of the size. But again, no need for any intervention unless complaints.

Please check-out the Hysterectomy and Alternatives Section Archive of Articles For Women and Patients for more articles concerning fibroids.

Question:  I am 45 and I believe I may just be beginning the perimenopausal stage having had two occasions of missing periods for 2 or more months, along with several occasions of feeling a very hot wave of heat crawl up my middle back to my neck. But of course, this brings the thought of, "Oh my, am I having a serious problem which may be a cancer hard to detect perhaps in the ovaries?"  How can the fear of having cancer be eliminated? Are there tests that can be taken so I can rest assured it isn't cancer, but just normal signs of starting the menopausal stages of a woman's life? Of course when this happens to you for the first time, many scary thoughts go through your mind and you think the worse. Just looking for advice and your comments on how to eliminate this as a possibility. Thank you!

Answer: There are no test to detect ovarian cancer in an early stage. But the lifetime risk of acquiring ovarian cancer is very low, only 1.8% (a yearly risk of about 0.02%). Unless familial ovarian cancer is present, with a much higher risk, no need for any test.

Question:  What could cause traumatic uterine bleeding in a post menopausal patient taking tamoxifin?

Answer: Tamoxifen is an antiestrogen for the breast, but has estrogen-like properties for the endometrial lining. Bleeding with tamoxifen needs further diagnostic procedures. Frequently polyps are seen and some times (3 times more than controls) endometrial cancer.

Question:  I have a question regarding black cohash.  I am 32 years old and have no period.  I would like to know if using black cohosh will regulate me and help with achieving pregnancy.  I had a hormone test done and was told my estrogen level was low. Your response will be appreciated.

Answer: Black Cohosh has no use in fertility problems. With no periods, endocrinologic investigations are needed.

Question:  Now that I've had a hysterectomy, I find there's nothing out there.  People talk about menopause--and what can be done for women suffering through it.  I have had a hysterectomy, and I do not have any ovaries, and, pardon my frustration, there doesn't seem to be any answers out there for me! I am on the lowest dosage of estrogen (premarin).  I am a happy, well-adjusted woman, with lots of projects and passion to fill my life.  I only have two problems since the hysterectomy.  One is weight gain (with which I've never had to deal with before), and the other is that I've grown from a bra size of 36b to 36ddd.  I am still growing, and I don't know what to do.  I've thought about a breast reduction, maybe a tummy tuck along with it.  I am very discouraged, since I've found this costs a lot of money which I don't have.  I am a size 18 blouse, and a size 14 pant.  I have to make my own dresses, (I am in front of people a lot with my work), and I am very, very frustrated that I keep growing and growing.  Is there an answer to this?  I'm buying a new bra every month, or two. This weight gain, and growing chest size are really beginning to bother me. Thank you for your time

Answer:  With the decrease of ovarian function a small decrease of basal metabolism is observed. Therefore, the body has a smaller need for calories for its basal functioning (function with doing nothing). Furthermore, many women tend to restrict activities around the age of menopause. As a result one grows easily. Only food restriction and physical exercise will be helpful for weight reduction.

Doctor, am I experiencing Perimenopause?   Question: I would appreciate any information you can give me on this subject. I am a healthy 44 year old women. Every month usually one to two weeks before my menstrual cycle, I get these annoying headaches. After my cycle starts they go away. This has only been going on this last year. Is there something I could be doing for my body so that I don't have these headaches?

Answer: Headache is a complicated symptom. It can occur on every phase of the menstrual cycle. especially menstrual migraine is seen often. But in this case, headache occurs in the premenstrual phase. When it is only during this phase and not during the period and in the week after the bleeding, it is possible that it has to do with the premenstrual syndrome. Premenstrual syndrome symptoms are not easy to combat. Some women have benefits with oral contraceptive pills, others are cured by serotonine-reuptake inhibitors as Prozac. Recently, a herbal medicine (vitex agnus cactus) was proven to be better than placebo.

Question: I am 35 years old, with Hashimoto's disease diagnosed at age 23 and take Synthroid. Additionally, I take Depakote and Wellbutrin for psychiatric reasons. Recently, I have been experiencing menstrual periods that range from 32 to 41 days between each cycle, the strict norm I was accustomed to being a period that came on day 35. More troubling, I have begun to have extreme vertigo that I noticed happened right around the time of ovulation. Prior to this recent vertigo, I had a marked increase in PMS symptoms, enough for my psychiatrist to prescribe Prozac for a while. I do not take birth control pills, and cannot because of the risk of thrombosis. I have never had children, and am worried that if these symptoms are indeed perimenopause, I will have difficulty conceiving if I so choose. One month I can have very horrible PMS symptoms, (tearfulness, anger, feeling spacey and tired) and the very next month not have anything too terrible but the bloating and the strange vertigo. It is those months that my period arrives 'late' around day 37-41. Is this perimenopause, or annovulation, or none of these? Thank you for your response.

Answer: With this question, a difference is made between perimenopause and annovulation. And this is wrong. Annovulation is a symptom and can be caused by a lot of reasons. Annovulation is seen often during perimenopause. In fact, ovulatory disturbances are the cornerstone of perimenopause. Cycle disturbances are not unusually on the age of 35. Only the future will tell if this is the first sign of perimenopause or not. In a complicated case as this, a diagnosis on a distance is not possible. Let your psychiatrist be your guide.

Please check-out this article called, "Perimenopausal Bleeding - what's normal?" by Paul D. Indman, MD

Question:  I am 46, have missed 3-4 periods -- no irregularity, just stopped.  Also have been experiencing night sweats and hot flashes during the day.  I have been on Weight Watchers for six months and have lost 25 lbs.  I have had NO weight loss since my periods stopped.  I have started an exercise program also...any thoughts?  The lack of weight loss is frustrating.  Is this a compensation for the weight gain frequently associated with perimenopause?  Please advise.

Answer: Less exercise and a lower need of energy for basal metabolism (the energy for doing nothing) are the reasons for weight gain because of menopause. You have to work even harder during this phase of life (and also in the future) than in the past. I am sorry.

QuestionThe past few months I have been noticing that my periods have been much shorter. They used to last 4-7 days, and lately they've been lasting 1-2 days, and are much lighter. I have read that this is a symptom of menopause, but I am 22. I'm a little worried that it might be this or maybe something else. I am not, nor have I ever, taken birth control pills. Is it normal for menstruation to change like this?

Answer: Be happy with this change, and do not worry for very premature menopause. Less bleeding is not a reason for investigations.

Question:  I'm 31 years old and I have not had a period since Jan. 2000.  Could there be something wrong?  I would like to have another child.  What should I do?  I've already had a physical about 4 or 5 months ago. 

Answer: This amenorrhea needs further analysis. There are several possibilities to rule out. You have to consult an fertility specialist.

QuestionI am 48, and definitely perimenopausal. Lately, I have crashing bouts of sleepiness during the day- almost like I've taken an antihistamine- I can barely keep my eyes open. It is also reminiscent of early pregnancy. Is  this normal?  Is there anything I can do about it? So far I have avoided HRT, I'd rather not take hormones. I have been managing the past few years with hot flashes and all the rest- but this sudden sleepiness is awful and making my life hellish. It's pretty depressing, too. I should mention I am bipolar- have been on meds for several years for that, and have had no major changes in those meds or anything like that.  Any ideas? I am hoping this is normal.

Answer: Bouts of sleepiness is not known as perimenopausal symptom. Maybe your medicines are to strong for the moment. Ask your prescriber.

QuestionI'd like some input relative to itching, specifically skin itching for no apparent reason.  I've read that itching is a symptom of perimenopause and would like a little more information.

Answer: To control perimenopausal symptoms, and formication and insomnia can be perimenopausal symptoms, usually HRT is effective. Try a sequentially combined regimen or low dose birth control pills for 3 months. When this is helpful, continue. With no results in 3 months, other causes need to be sought.

QuestionIn the last year and half I have noticed that my periods have become so much lighter than they used to me.  When I was a teen, I used to have excess heavy bleeding.  Now at age 31, my periods are light for 2 days and spot for 3.  I've done 2 ivf cycles to get pregnant.  I've been diagnosed with mild endo.  I thought I was too young for perimenopause, but read that it can happen at my age.  What can be done?  I'm so scared. Thank you for any help.

Answer: It is hard to be scared about things that will not happen. Although no one can predict the future, and a change in menstrual flow can be the first sign of imminent perimenopause, it is very unusual at your age. When it begins, many years can follow with only a change in cycle pattern without further complaints and menopause at a normal age. The only thing to do is wait, there is no test that has any meaning. But be confident in yourself, so that not every change means trouble.

Question I am 44 yrs old and had a partial hysterectomy (have 1 ovary and cervix left) end of November last year. I am now having a few symptoms of menopause such as insomnia, night sweats, headaches and massive mood swings. Is it possible when I have still got 1 ovary that I may be starting Menopause?

AnswerThe ovaries get their blood supply from two sides. After hysterectomy only one feeding artery remains. This is usually sufficient for normal functioning. After hysterectomy with both ovaries left, hardly never (less than 1%) ovarian failure is seen. But with 1 ovary left, dysfunction is seen in about 15% of the women. This is because sometimes the main blood supply for the ovary comes from the uterine side. This is hardly ever at both sides. But with 1 ovary, the problem is seen in 15%. Of course, it is possible that you would also start with perimenopausal problems without the surgery. Because this can happen at the age of 44.

Question: Could there be a link between perimenopause and severe muscle weakness of the limbs?

Answer: No connection as far as I know.

Question: I am 53,have been going through menopause since I have been 42. I still have night sweats and a hard time sleeping, but the worse change is my bowels. Every time I eat or drink, I am running to the bathroom. I know every restroom from here to town. I do not eat fried foods, or junk food. I drink diet drinks. My stomach cramps and I feel nauseated and off I go!  Is this part of getting older?

Answer: There is no reason to connect bowel problems with perimenopause. I suggest to consult a gastroenterologist.

Question: I'm concerned about the bleeding during intercourse, this has not happened in the past and has become an issue with my partner.  Should the estrogen to regulate my cycle also take care of the bleeding during intercourse?  (even when I have no spotting between my cycle, I bleed during intercourse) Am I looking at perimenopause? 

Answer: Bleeding during or after intercourse is not a perimenopausal problem. Always a reason for investigation and searching for local pathology. Maybe, the just regenerated new tissue after cone biopsy is still very vulnerable? Estrogens cannot regulate a menstrual cycle. One can regulate a cycle with progestagens or with estrogen/progestagen combinations.

Question: Is there any link to Phen Fen and perimenopause?  Is there any research being done in this area?

Answer: Phen-fen is not linked to perimenopause. It is used in the past for weight reduction. But in most countries it is withdrawn from the market because of serious cardiac side effects.

QuestionI am 46 and had a vaginal hysterectomy when I was 28, started experiencing pre-menopausal symptoms at around age 38 my symptoms were somewhat mild. Last year I had a BS&O for a torsion of my ovary around the sigmoid colon, I have been on cenestin 0.625mg daily since the BS&O in April 2000. From time to time I have needed to go in for estrogen injections to relieve hot flashes not controlled by the cenestin. Recently, in the last 3 days the hot flashes have been excruciating at approximately 20-30 per day. One symptom that is perplexing to me is that at night the hot flashes are almost constant at hour intervals then around 1:00 in the morning a headache from hell sets in and more hot flashes until around 6:00 or 7:00. I have some left over toradol from my surgery and took it, it did relieve the headache pain to where I could at least get out of bed.  My question is, have you ever heard of these hot flashes triggering the horrible headaches? I appreciate any advice you can offer.

Answer:  So much hot flashes with estrogens is sometimes seen. The problem is probably that only a small part is resorbed in the intestine or your metabolism is very high, or an abnormal metabolism as in smokers. There is a large variation in blood levels between women with the same dose of estrogens. And especially after BSO higher dosage is sometimes needed. When the problem is mainly at night, try to swallow the tablets in the evening or divide the dose in two portions. Headache can be the result of a decrease in blood levels. With transdermal estrogens the levels are more stable and the possibility of headache is smaller. Try this form of administration in adequate dose.

Doctor, am I experiencing Perimenopause?   Question: I was on oral contraceptives for about 15 years, stopping only when I wanted to get pregnant and life was great.  When I turned 35 I started getting migraines which worsened over the next year.  I was told may be worse due to the oral contraceptives, so I went off the pill.  Since then, my periods have been a nightmare for me.  Although the bleeding is never really heavy, I spot or bleed lightly for about a week and then have my period for about a week. Worse yet, I over the past 3 years, I have gotten back the migraines every time I am on my period.  So my cycle has basically been 2 weeks on, 2 weeks off for 6 years!  I have been through every test the gynecologists could put me through and thankfully, everything seems fine -- no fibroids, no tumors, no thick lining, etc.  My gynecologist feels it is just my age (peri-menopause) although my blood test shows I am not menopausal.  I am in great health and am not over weight.  We recently decided to try oral contraceptives again, and try to treat the migraines if they get worse again.  (I'm really tired of all this bleeding!)  The problem is I cannot seem to find the right pill. First he tried me on Mircette - I bled pretty much for 2 months straight.  I am now on desogestrel & I have just had major breakthrough bleeding basically the whole 2 weeks I have been on that.  Do you think I should stick with the desegel for more time?  Or do you think there is another pill on the market that would work better for me?  Do you think that this is perimenopause?  I think it is possible this happened because I was on BCPs for so long, but all the doctors say that is crazy!  I don't think I will ever find the right combination.  Help!!  

Answer:  Breakthrough bleeding with birth control pills are very frequent. The amount of estrogens is important. The lower the estrogen dose the more irregular bleeding. And pills without estrogen (POP= progestogen only pill) are famous for bleeding problems. Headache is more pronounced with higher estrogen dose. Here is a dilemma. If the headache problem is during the use of the pills, lower dose is better. But lower dose gives more bleeding problems. If the headache is during the week without pills another solution is possible. The cause of menstrual migraine is the sudden fall of estrogens. With a low dose of estrogens during the week off, the problem can be solved. Then the best issue is a normal dose BCP (30-35 micrograms of ethinylestradiol) with a second generation progestagen (norethisterone or levonorgestrel) and in the week without BCP a low estrogen dose: a patch with 50 microgr estradiol per day or conjugated estrogens oral 0.625 mg.

Question: I have a couple of different issues I would like to address.  First, I had a miscarriage at the age of 40. Since the miscarriage I started having very bad anxiety and some depression and my periods started to change.  Now my PMS is really bad, which it never was before and I have started to have night sweats from time to time.  Could the miscarriage have started the perimenopause?  Could my RH factor play into any of this?

Secondly, I am experiencing PMS and much anxiety. My anxiety goes way up during PMS also.  Can anxiety be connected to perimenopause? Can my hormone levels, if low, create anxiety?  I never had anxiety problems before.

Answer:  Miscarriage does not start perimenopause. The start of perimenopause is an ovarian problem. But in    perimenopause many pregnancies end in miscarriage. Mainly because of genetic anomalies in older eggs. Rh negative has also nothing to do with miscarriage. Anxiety problems can mimic perimenopausal symptoms but are not cured by  estrogens. Anxiety problems have to be treated as such, regardless of premenopause, perimenopause or postmenopause.

Question: I am a 46 year old woman who has never been pregnant and only used birth control for a short time. My maternal grandmother had ovarian cancer in her 70's and my cousin on my father's side of the family had ovarian cancer in her mid-thirties. I have a history of benign cysts and have an enlarged uterus. I also had one benign cyst in my 20's that had abnormal cells in the fluid surrounding the cyst but that was not considered dangerous. Three years ago I was found to have three complex cysts on one ovary but they disappeared prior to surgery. We have monitored this situation through ultrasounds and regular exams.

For the past 5 years I have had signs of perimenopause--off and on night sweats, irregular periods, spotting between periods, mood swings, etc. The doctor put me on hormones twice because I had prolonged spotting between periods. The hormones straightened out the problem. I also had a D&C and nothing irregular was found. I am beginning to experience spotting between periods again. My doctor
thinks I should have a hysterectomy (including removal of ovaries) even though he is sure that nothing is wrong. I am hesitant to undergo major surgery if it is not necessary, and due to a strong family history of early heart disease (my mother had a massive heart attack at 49 and died at 55) I am not ready to lose my ovaries even with estrogen replacement.

Am I being dangerous or foolish by avoiding surgery? Is spotting between periods normal for someone in perimenopause? How reliable are trans vaginal ultrasounds for finding ovarian cancer?

Answer:  In this history, I can not recognize a strong indication for hysterectomy. The family history of ovarian cancer in two family members, not related to each other, and 2nd or 3rd degree relationship does not legitimize ovariectomy. I wonder if it is enough evidence to ask genetic counseling for hereditary tumors. Also your own past history has nothing to do with ovarian cancer risk. Transvaginal ultrasound is only reliable in finding ovarian cancer in a population at high risk. Otherwise it is not useful. There is no test for ovarian cancer available for screening on this moment. Your only problem is spotting between periods. When spotting is mainly in the second half of the cycle, one can try cyclic courses of progesterone day 15-26 each cycle. When spotting during the whole period, another cause has to found: polyps? cervical inflammation?

Question: I am 49 and having irregular periods.  I don't have any obvious menopause symptoms (yet).  I find, especially in the early morning, my body feels damp like I am under too many covers - which I probably am.  We sleep with a down comforter.  My husband is guessing I have night sweats.  So, what actually is a night sweat?

Answer:  Night sweats is the nightly form of hot flashes. Some women experience strong nightly hot flashes. They awake and thereafter a heavy sweating starts.

Question:  I have just read an article that mentioned vaginal atrophy , what is that?

Answer:  Vaginal atrophy means a thin vaginal epithelium (no superficial cells, a few intermediate cells and mostly parabasal cells) as a result of estrogen deficiency. At the same time the surrounding connective tissue dimities and also the number of blood vessels. Sometimes this results in vaginal dryness. An atrophic vagina is more prone to infection.

Question:  I am almost 40.  I had a partial hysterectomy 4 years ago.  I have begun to have hot flushes, irritability, irrational thinking, serious crying jags, sleep problems, etc.  My doctor says my estrogen level is fine and I don't need HRT.  After reading all the side effects, I don't know if I want to try HRT.  My doctor placed me on Meridia because I have gained 30 pounds due to the depression.  I am beginning to take Estroven with black cohosh and soy.  If the mood swings don't stop, what other suggestions do you have?  I think my husband and 3 kids may leave me soon if I don't get it together!

Answer:  It is not only the level of estrogens, but also the variability and especially a fall in estrogens that can provoke hot flushes. But most times estrogen levels are high enough at the age of 40.  It is not certain that the problem has a hormonal cause. Anxiety and depression can induce the same kind of symptoms. Antidepressants or anxiety treatment is advised in case of non-hormonal cause. When you and your doctor agree it must be hormonal: try additional progesterone (prometrium daily 200 mg, daily in the evening) during two weeks every month. With no good result in 3 months, stop with this treatment. With good results, you can go forward with it. Progesterone will also help for sleeping problems.

Question: I am 37, with serum of estriol level at 27! Hot flashes, palpitations, nervousness, tension and irritability levels are HIGH and constant. I can not take HRT due to a mild stroke from smoking and taking the pill years ago. Black cohosh makes palpitations worse and pro-gest crme only helps a little. When a hot flash hits, the palpitations increase, dizziness is present at times, and get very weak. Everything else has been checked, and am otherwise healthy. This is on the increase and for two weeks out of every month, I am not available for anything! Why is this so bad? What can I do?

Answer:  I have serious doubts on the diagnosis perimenopause, just from one lab observation of one hormone (I suppose, you mean estradiol and not estriol). Nothing is mentioned about the menstrual cycle. With a cyclic pattern of complaints I suppose that there are still menstruations. And with menstruations there is always an adequate level of estrogens despite the lab observation. Consider also Premenstrual Syndrome as diagnosis. With Prozac as possible treatment or Vitex Agnus Castus for herbal treatment.

Question: I took a saliva test for my hormones. My DHEA was 814 (high) pg/ml their normal ranges are 80-350. I am 33 years old, am I going through early stages of menopause? My husband and I are now trying to conceive and this has me concerned. What could be other causes? Diet? Any info would be appreciated.

Answer:  You have to discuss the results of the saliva test with the manufacturer, or with the person who advised you to take the tests. The meaning of those test are completely unknown to me.

Question: What causes menstrual cramps?  What is the best way to treat them? I am 48 years old and never really understood why exactly we get cramps.  Now that I am perimenopause I get the cramps but sometimes no period.  Is that normal?  What can I take for the pain?

Answer:  Menstrual cramps are caused by prostaglandins. The best treatment is the use of prostaglandin synthetase inhibitors.

Question:  I am a 39 year old female who was exposed to DES in utro. I have never had any children and am now experiencing strange symptoms such as night sweats, 2 day periods, extremely light in nature. However, they are on a "normal" cycle as opposed to irregular cycles I was experiencing approximately 1 1/2 to 2 years ago. My PMS symptoms are getting extremely difficult to handle. I have breast tenderness all the time, which gets really painful during my cycle. I have lost my sex drive. I do experience heart palpitations on occasion. Am I perimenopausal and can some of these symptoms be attributed to the DES exposure?

Answer:  PMS is frequently worsened around 40. I have found no relationship with DES nor with menopause.

Question: I am 45 and last year quit smoking after 29 years. 2 weeks later I started feeling very irritable, angry and mouthy, very forgetful and confused. My Dr. said I was starting perimenopause. My cycle had changed a little in the last 2 or 3 years (lasting longer & a little closer together). She started me on 1 mg estradiol & 5 mg provera. The symptoms got a little better but not much. She added Paxil 20 mg per day. It helped a lot. My cycle took 3 or 4 months to even out. 8 months later I started with SEVERE night sweats and hot flashes. The Dr. upped my estridoial to 1.5 mg per day. I had been having the same type of cycle for a few months, fairly regular. An ultrasound revealed 2 fibroids, doctors recommended a hysterectomy. Then I had my first mammogram, they found small calcium deposits they think? I was sent for a sterotactic breast core tissue biopsy. The path said I have atypical hyperplasia? Now they want to take a biopsy the size of a golf ball. I am very confused. What do you think? HELP.

Answer:  These are several questions in this report. The most important one is the suspicion of breast cancer. Calcium deposits are a sign for further investigations by biopsy. This is independent of bleeding problems, hormone therapy or fibroids.

Please be sure to visit the Breast Care Section for more articles related to Breast Health.

Question: I am 41 and for about a year now I have been experiencing very irregular periods( sometimes 2 weeks apart sometimes 6). I feel hot but cold at the same time. I am assuming that this is perimenopause. Lately (the last couple of months) I have become very emotional. I feel like I am losing my mind sometimes. I cry over things I maybe should have done in the past. I never had children and sometimes that really bothers me. I also cry because I feel like my life is over now that menopause is here. Are these feelings normal? Am I nuts?  Please tell me what I can do. Thanks.

Answer:  Maybe it is perimenopause. At the age of 41, this is the most likely diagnosis. What to do? Try to regulate the cycle with low-dose birth control pills and perhaps all other symptoms will disappear too.

Question:  I am a forty-five year old woman.  My periods have always been fairly regular and predictable, although the cycle became somewhat shorter and the bleeding heavier once I turned forty.  Lately I have been experiencing increasing heart palpitations and during my last ovulation, I experienced some very light bleeding--but it only occurred for a period of a couple of hours.  Is this truly normal for a woman of my age and can it be related to perimenopause?  I have also been under a fair amount of stress in the last year so I am wondering how that plays into these symptoms. I have had no blood tests, but I did have a pelvic exam and pap smear which was normal.  I have a fibroid and a slightly enlarged uterus but the doctors don't seem to be very concerned about any of this.  Any information you can provide would be much appreciated.

Answer:  Changes in the menstrual cycle are normal. Ovulatory bleeding is caused by a decrease of estrogen levels just before ovulation, in fact the decrease triggers the ovulation. So far, no problem. Palpitations are caused in nearly all situations by stress and almost never by cardiac disease and without hot flushes also not by perimenopause.

Doctor, am I experiencing Perimenopause?   Question:  I am a healthy, 35 y/o mother of 2.  I have been experiencing hot flashes, night waking, moodiness, lack of focus, anxiety and palpitations, however the only period abnormalities have been longer, heavier periods with slight spotting about 2 days prior (making the entire period, spotting and all last no more than 7 days.)  My doctor has tested my LH, FSH and testosterone.  The first two were abnormally high, testosterone abnormally low.  He diagnosed perimenopause and started me on BCPs and EstraTest HS.  I have been on this regimen for 7 weeks, with no noticeable improvement. Could this really be perimenopause?  Are there any other explanations for this that should be explored?  Is this appropriate treatment?  Do I just need to be more patient?  Thanks for your help!

Answer:  By definition, perimenopause starts with menstrual irregularity, but we know that most women experience other changes in their periods before irregularity starts. Your menstrual cycle does not make the diagnosis of starting perimenopause impossible. It is curious to see that FSH and LH are abnormally high. I wonder how high is abnormally high and on which day of the cycle. A small increase (e.g. FSH = 10 U/L) is high for your age but not very high and possible in very early perimenopause. Your complaints are compatible with anxiety disorders and not necessary with perimenopause. With BCP the cycle will be regulated and ovarian function is during the use of the pills zero. I do not know why estratest is given extra. It is a quit unusual combination but your doctor will have an excellent explanation for his/her reasons without doubt. Ask it.

Question:  I have been hearing lately about PMDD and am rather confused about its relationship if any to menopause. I seem to have quite a sensitivity to progesterone and most HRT medications require that you take both estrogen and progesterone together,
rather than unopposed. I had done a bit of reading on the subject and found that you could take the estrogen unopposed but recent research has suggested that this may not be the case. My responses do not appear to be the norm. Is there any help for people like myself? My Doctor recently started me on Ortho-Prefest and the days that the pills contain some type of progesterone. I have a terrible time with anxiety, feeling of being overwhelmed, inability to make decisions, and depression. I have only been taking this medication for approximately a month. To your knowledge are there any testing procedures for hormone levels today? Any information would be much appreciated.

Answer:  PMDD (or PMS) is usually less pronounced when using birth control pills, although they also contain a progestogen. Change in estrogens or progesterone is never proven as an adequate treatment. The only treatment better than placebo is the use of ssri's (selective serotonine re-uptake inhibitors). Also some cure is seen by the herbal drug Vitex Agnus Castus. Tibolone seems to be a good alternative as HRT. But when used in the perimenopause, it will induce bleeding problems.

Question:  I am 45 with a history of endometriosis.  I have been experiencing symptoms of perimenopause, 20 day cycles, increased pain and GI symptoms of nausea combined with upset bowels.  I had a colonoscopy which was negative.  I recently started taking Activella to try to eliminate my cycles for a few months.  I felt good for the first few weeks but as I approached when my period should start I began to feel cramps and my GI symptoms worsened.  Could this be due to the Activella and should I discontinue taking or should I continue with the hormones and see if my body adjusts?  Also, are there risks that the Activella will increase my endometriosis?

Answer:  With Activelle in postmenopause the endometrium is usually very thin and also endometriosis are not activated. But it is less certain what the effect is before menopause. Is it suppressing ovarian activity? Sometimes yes, sometimes no. Birth control pills are much more efficient in suppressing ovarian function completely. And will give the same results as activelle
when used without pause continuously.

Question:  I am 39 years old and have been on oral contraceptives for 20 years.  I will be going off them next week due to a slight rise in blood pressure.  The last 2 years, I've experienced longer periods (7-9 days) with a heavier flow on two of those days, but this month I had blood flow (more than just spotting) from about 3pm-9pm every day since my period ended 3 weeks ago.  I am due to start my actual period in three days, and have just taken my last pill.  Can this be due to perimenopause, or an estrogen dominance?

Answer:  Bleeding pattern with oral contraceptives has nothing to do with (peri)menopause. Nor with estrogen dominance. With oral contraceptives all ovarian activity is zero. When persisting in the next cycle, consult your

Question:  I am a 43 year old woman. My menstrual cycles have been 28 to 30 day cycles with no spotting. Within the last year my cycles have changed to 25 to 28 days. I usually have cramps the first day but now they are starting to decrease in severity. I have now started to have muscle thigh pain which sometimes radiates to my groin area. My last period lasted about a week but  several days before and after I had a pink discharge. Now 13 days from the beginning of my last period I am starting to have spotting and mild cramping. My skin has become drier and I will sometimes get a burning sensation in the area around my underarms. Oh yes, the thigh pain that I am experiencing is sometime so severe I am unable to sleep and it is not alleviated with the 600-800mg of Ibuprofen 8 hours that I have taken when it occurs. Is this the onset of perimenopause? If so how long will it last?  I started menstruating at 13. I have never been pregnant (if this has any bearing).

Answer:  Changes in the aspects of the menstrual cycle are often seen preceding the irregularity that starts with perimenopause by definition. But intermenstrual bleeding, spotting and cramping is not a perimenopausal sign and needs further investigation. I have no idea of the kind of your skin sensations.

Doctor, What should I expect from HRT?   Question: I am 39 years old. Two years ago, I had a total hysterectomy as a result of severe endometriosis. My Doctor prescribed Prempro to reduce the risk of endometriosis returning. Prempro has worked great for me. I recently moved and have a new doctor who is taking me off of Prempro to be replaced by Premerin. She tells me I do not need the Progesterone because I have no uterus. I am confused on what to do. I don't feel comfortable with the change since Prempro has worked great for me. In your opinion, Is there any reason I should not continue taking Prempro? Thanks.

Answer: Both doctors are right. Without an uterus there is usually no need to take progestagens, because the only reason to take progestagens is the protection of the uterine lining: the endometrium. But in endometriosis the same tissue is active. Endometriosis is ectopic endometrium. In most cases endometriosis is not reacting with the low dose of oestrogens as in Premarin, but sometimes it happens and can cause serious problems. You can protect yourself for recurrence of endometriosis by taking the progestagens. So take Prempro instead of Premarin.

Question: What is the best soy vitamin to take as a daily supplement during menopause?

Answer: The benefit of soy during menopause is questionable. And I have seen no studies comparing brands.

Question: I am a 51 year old female and started exhibiting classic symptoms of perimenopause about 2 years ago.  I have suffered from mild partial seizures since I was in my late twenties and had my first full seizure two years ago. The neurologist has me on Neurontin and my gynecologist put me on Combipatch.  My research seems to indicate that estrogen spiking can cause these full seizures and progesterone may prevent them.  I even noticed that on two occasions when my patch fell off in the middle of the night, I had a very severe partial seizure 1.5 days later.  I gradually reduced my daily Neurontin intake, under the supervision of my neurologist, and just suffered my first full seizure in over a year.  I'm terrified that this may happen again. The ER doctor doubled my Neurontin dose and I'll stay on it forever rather than face another seizure. Do you think there is some correlation between perimenopause and these full seizures?  This last one really scared me because I had absolutely no warning that it was coming on, whereas the previous two were preceded by severe lightheadedness.

Answer: As you have found already by yourself, estrogens can provoke seizures and progesterone will prevent them. During perimenopause from time to time very high estradiol levels exist because of persistent follicles. After menopause you will not see this again. When HRT is necessary, the continuous combined regimen (as in Combipatch) is the best. The effects of progestagens on seizures are less well studied than that of progesterone. Maybe (but there is no proof of it) oral progesterone (Prometrium 100 mg per day) is better than transdermal progestagens. You can combine an estrogen patch with the daily intake of 100 or 200 mg Prometrium.

QuestionWhat is known about estrogen replacement (patch, oral, soy-based) intolerant women?  My MD has no experience with this issue.  Symptoms include vulvar swelling, redness, irritation and thick yellow discharge - all of which disappears within about 2 months of discontinuation of estrogen.  Prempro, Premarin, Estrodial patch, and OTC soy products have all been tried with the same result.  Currently using no replacement.  Cannot find any info about this on Internet.

Answer I do not recognize this description as estrogen intolerance. Has it to do with candida infection? Candida species can react with estrogens.

Question I am 48 and have been in menopause for 2 years (per testing at OB GYN). Last year my OB GYN gave me Prempro, but after reading about it and experiencing chest pain, I discontinued taking it after 2 months.  I have a female family history of early heart attach (early 50's) and osteoporosis.  I eat fairly well, have just begun exercising, and take a multivitamin. 

At my daughters insistence, I began taking Estroven this month, which is suppose to naturally help hormonal balance, according to the box.  I am not confident because it was purchased in a health food store. I would like to know what is the "safest" thing to take or do for menopause, especially because I am so young, and will need to do so for a long time.  The biggest problem I have with menopause is that I cry easily (being a professional this is not good) and am a little forgetful (but I also have a stressful job).  I am concerned about my female family history of early heart attack and osteoporosis.  These are the reasons I feel I should be taking something. Can you make any suggestions? Thank you very much for your time and any suggestions you may have.

AnswerChest pain with HRT is reported in case histories because of the progestagen medroxyprogesteroneacetate. Maybe another combination like the Combipatch with another progestagen will not give you this symptom. Also the combination of estrogens (as Premarin) and progesterone (as Prometrium) can be tried. It is less convenient because you have to take daily two tablets instead of one, but narrowing blood vessels causing chest pain is not to be expected by progesterone. The risk for heart disease can be diminished largely with a healthy lifestyle: do not smoke, exercise and eat fish and fruit instead of fatty meat. Taking "natural estrogens" in herbal drugs has not proven any benefit on the incidence of myocardial infarction. You have to see this habit in a healthy life style.

Question:   I am 43 and experienced ovarian decline/failure after hysterectomy a little over 12 months ago. I was finally successful finding an estrogen regime for me (Sandrina 1mg gel) and have been on that for 3 months. I have not ovulated since I have been on it. The first two months were fine and I felt good, however now I feel like my body is attacking itself - rare hot flushes but heat intolerance, aching bones, inflammation of gums, a flu-like feeling and occasional raised lump in my neck above and to the left of my thyroid gland. Tests reveal low but normal TSH and free T4. I have a family history of thyroid problems on my mother's side. I also have a family history of osteoporosis on that side, although the ones affected did not take ERT. Should I try lowering the dose to 0.05 - does it reactivate the receptors after 3 months? If I do this and am successful I may find that my bladder worsens though. I had detrusor instability and slight incontinence after voiding when on my previous regimes of estrogen. Sandrena has improved that.

Answer: For the application of Sandrena it is important to apply on a rather small area. The concentration in blood is determined by the application area. Spreading it on a large area will give low levels. Sandrena is studied mainly with application on about 20 cm2. With your symptoms, I will suggest to increase the dose to 2 mg and not to diminish it to a half dose. Maybe the right amount is in between. Only trial and error can give the solution.

Question:  I've been experiencing problems which sound similar to the ones I'm reading about.  I am currently 30 years old.  My mother went through menopause in her early to mid-forties.  About 3 years ago, while taking a tri-phasic birth control pill, I began experiencing hot flashes.  My ob/gyn switched me to a mono-phasic pill which helped but did not alleviate the problem entirely.  I tried the Depo-Provera shot for 9 months, but experienced continual bleeding.  I then switched back to BCP (Loestrin Fe 1.5/30) which I have been taking for more than 6 months now.  I have begun experiencing migraine headaches (it is unusual for me to have headaches) during the week I don't take a pill which continues into the first 5 to 7 days of my new pack.  I am also unusually moody and irritable during this time and have now begun spotting in the middle of the month.  While reading the questions posted, I realized that I also have trouble sleeping (both in getting to
sleep and staying asleep).  I have not been experiencing more hot flashes.  Could this be symptoms of perimenopause or is it more likely that these are side effects of the BCP?  What do you suggest that I do?

Answer: Your problems are side effects of birth control pills and have nothing to do with perimenopause. Headaches in the week without pills and the first days of the new pack is caused by the drop of estrogens. You can treat that symptom most times by taking a little bit of estrogens during the week without BCP. This is possible by wearing an estrogen patch during that week.

Question:  I am 55 and have been menopausal for three years.  Two years ago I started HRT because of severe hot flashes and vaginal dryness, and have had persistent problems with breakthrough bleeding.  I don't want periods anymore, but every combination tried has the same result.  Have tried Prempro, FemHRT, Climara and Prometrium, OrthoPrevest.  As long as I'm on just Vivelle 0.05 no problem, but as soon as progesterone is added the bleeding resumes, even with continuous therapy.  Have had two D & C's, and Thermal Endometrial Ablation last October, two pelvic ultrasounds that were negative and show 4mm endometrial thickness.  I understand many people have a progesterone intolerance and suspect I fall in that category.  Do I have any options?

Answer: Sometimes, the bleeding problem is only to solve with hysterectomy. But, you have not tried all possibilities yet. Oral or transdermal estrogens and local intrauterine progestagens is a possibility. The Mirena IUD will bring a high level of progestagens into the uterus and most times an amenorrhea is derived. Also progesterone application with the vaginal cream Crinone is possible. A low dose of estrogens can also be helpful, but the question rises if this is also enough to combat the hot flashes. The lower the dose of estrogens, the less bleeding. Some women are treated with estrogens alone because of intolerance for progestagens. But because of endometrial cancer risk periodic endometrial biopsy is necessary, and it is not safe especially with higher dosage of estrogens, but with low dose estrogens this regimen is acceptable in selected cases.

Question I am currently using Cenestin every 2-3 days and using Progest cream when I use the Cenestin. This seems to work the best for me. Is the progesterone in the Progest Cream enough? I use about 1/4 teaspoon.  I don't like Prometrium at all and I won't take synthetic progestin.  I just read about a progesterone vaginal gel called Crinone and liked the idea that you use it only twice a week.  What do you think about that along with the Cenestin instead of Progest Cream? Thank you in advance.

Answer: Progesterone cream has no benefit for the uterine lining. There is not enough progesterone resorbed for any benefit. When using estrogens, other formulations of progesterone are necessary. Vaginal Crinone is an excellent possibility.

Question:  Doctor, I've been using ortho-prefast for two and a half months.  No bleeding, no hot flashes and somewhat increased energy.  I do have more frequent headaches, swollen glands in my neck (often feel like "coming down" with something) and I have gained ten pounds.  This weight gain despite increasing my exercise from one hour a day 3 to 4 days per week before O-P to one and one half to two hours per day 5 to 6 days per week for the last month.  I have gained 2 pounds in the last month!  Have cut out most sweets in the last month!  Is weight gain a side effect?

Answer: Weight gain is not a side effect of hormone suppletion. Water retention during the first weeks of therapy can be caused by estrogens. And water is also weight. This is a problem only of the start of therapy and seldom more than 2 pounds. In randomized trials users of hormone suppletion had less weight gain than placebo users. So hormone therapy protects against weight gain.

Question:  I am 50 and have been on Depo Provera injections for 7 years.  I have not had a period in this time.  I recently had an FSH test and it was 51.8.  I do not want to stop taking the shot too soon.  Do you think it would be OK to stop taking it now or should I take it a while longer just to be sure?

Answer: Yes, you can stop. Maybe you are not yet completely postmenopausal, but with such a high FSH and the age of 50 whilst under the influence of DepoProvera the risk for pregnancy is almost zero.

Question:  I have endometrial cancer, hopefully stage 1A or 1B.  To treat the cancer, I'll have a total hysterectomy (ovaries, tubes, uterus, cervix).  I'm 43 years old and I understand that I'll "nosedive" into menopause within days after the operation.  My doctor will not prescribe estrogen replacement therapy because of my history.  What kinds of symptoms can I expect to have?  How intense might the symptoms be, and for how long?  Are there any herbal medicines that might help me tolerate the symptoms?

Answer: Removal of ovaries will induce hot flashes and night sweats. No herbal medicines will combat that. When the symptoms are serious, progestagens can be used safely. Provera daily 10 mg will diminish the problems in most cases. Not as good as estrogens, but usually sufficient. When quality of life is seriously threatened by hot flashes, even the use of estrogens is possible in stage I endometrial cancer.

Please check-out this article called, "Managing Menopause, Without the Use of Drugs," by Judith A. Norris, Ob-Gyn, RNP

QuestionIf a person has perimenopause and is having hot flashes, difficulty sleeping, and mood swings, but can't take estrogen due to problems with deep vein thrombosis, what other options are there for drug therapy to help relieve these symptoms? Have any studies been done with other drug therapy not related to HRT? Thank you.

Answer: Clonidine, a noradrenaline antagonist is sometimes helpful. Also serotonin reuptake inhibitors like Prozac can help sometimes. Some women are helped by soy or red clover. But first of all: what was the cause of deep vein thrombosis. Some causes are not related to estrogens, others are definitely.

Doctor, What should I expect from HRT? Question:   I am a woman eight months away from my fiftieth birthday. I had a hysterectomy in 1991,with ovaries left intact. I am recently experiencing a great decrease in libido, to put it bluntly, I have absolutely no desire whatsoever, and always before have enjoyed a good, healthy sexual relationship with my husband. This is very hard on us both. I was told by a friend about Estratest HS. and would like to know how common the side effects of male pattern baldness are, and also if there are studies that show it does enhance sexual desire? There is no breast cancer in either side of my family at all known for at least three generations. I have no known liver problems. I am however on Diovan 80mg for blood pressure which has been perfect since starting it. What are the dangers and what are the benefits of this hormone?

Answer: Decrease in libido has many possible causes. First of all the relation with your partner can be changed. Tiredness, depression and so on. There are no studies that prove that androgens improve libido in women with intact ovaries. There are a few studies after bilateral oophorectomy that claim benefit of androgens. But usually enough androgens are produced by your ovaries until old age. Problems with androgens are hirsutism and voice deepening. These side effects are rare, but voice changes are irreversible. On the other hand Estratest is used by many women in Canada and the USA. Estratest contains estrogens and with estrogens the usual benefits and dangers are expected, as with all kinds of estrogens.

Question:  Is Implantable hormone pellets considered acceptable standard medical therapy for menopausal symptoms?

Answer: It is, after hysterectomy. Implants can give estrogens during many years after the last implant. So, for women with an intact uterus endometrium dangers exist during many years. Progestagens are needed also after stopping the implants. That is the reason not to insert implants in women with an intact uterus. Another potential problem is accumulation: inserting a new implant long before estrogen levels are low again. I do not prefer implants because of that. But, implants belong to the standard armentarium.

Question:   I am a 45 year old woman who was diagnosed with hypothyroid condition in early December.  I had extreme fatigue and had been having periods every 21/2 weeks for about two months.  I began taking synthroid (.025) in mid-December and have recently been increased to .075, since  my last blood work indicated that the thyroid is still needing help. My last period began the day after Christmas and lasted about five days.  I have not had another period and three weeks ago I began having hot flashes and night sweats.  Blood work indicated that my estrogen level is very low and my Dr. says that I am going through menopause.  She prescribed Prempro, since I have not had a hysterectomy.  How can I be certain that this is indeed the big "M"?  Can an under active thyroid affect estrogen levels?  Is there any chance that I could return to normal cycles and stop the sweats once my thyroid is OK?

Answer:  Thyroid problems can interfere with ovarian function. I suppose that within a few months the thyroid problems are solved by medication. Then a new situation is created that allows appropriate judgment about (peri)menopause. At the age of 45 it is quite well possible that your ovaries are not functioning as in the past. But hormone levels (FSH and estradiol) can fluctuate enormously during this period. Prempro is designed for postmenopause: for women with the last menstrual perliod more than 12 months ago. Before that time breakthrough bleedings are very frequent. My advice is: To combat the hot flashes and night sweats in the next months take birth control pills or a sequential HRT regimen like Premphase. When your thyroid problems are solved stop with HRT and wait for 2-3 months. Maybe your menstrual cycle returns. When not or irregular, perimenopause is a fact and HRT is indicated if complaints like hot flash is a problem.

Question:  What other forms of replacement therapy apart from HRT are available and safe to relieve flushes, tiredness, and fogginess?  I am 51 and need to feel good to work effectively.

Answer: HRT is the most effective treatment. More than 90% of all hot flashes disappear. Soy products and red clover claims to diminish flushes and there are reports with 60% decrease, and that is somewhat better than placebo. Also clonidine is effective in some women, just as antidepressants like Prozac. But when vasomotor complaints are really serious, only HRT is really effective.

Question:   I am 47, have had monthly periods, and have been on Provera for spotting for the past two years. I have occasional "hot flashes" at night that wake me up at night. I am awakening almost nightly at about 2am, often not being able to return to sleep for 30 minutes to an hour or more. I am also feeling very moody, sometimes to the point of crying on a daily basis, and have other symptoms of perimenopause. I exercise daily, both aerobically by walking and using free weights for bone/muscle strength. I have tried herbal teas for relaxation, hot baths, reading to relax, and meditation, but still have these bothersome symptoms. Would going on a low-dose pill, such as Mircette or Lo-Estrin 20/1 be more beneficial to me until I reach menopause? I am feeling like a ball of stress and need some answers soon. My doctor does not want to put me back on pills due to "menstrual migraines" I developed right around the time my father passed away three years ago. Wouldn't a trial period or a month-to-month trial of pills be ok? I am an NP and know there are such possibilities, but would very much like another professional opinion. Thank-you for your input.

Answer: Low dose birth control pills will regulate the menstrual cycle and usually all cyclic problems disappear. However, also with BCP premenstrual tension syndrome exists. Menstrual migraine with BCP is caused by the sudden decrease of estrogen levels and can be prevented by taking an estrogen during the week without BCP. With a normal dose patch, or estrogen tablet the estrogen levels decrease less and menstrual migraine is not longer a serious problem.

Question:  I heard recently that Black Cohosh can cause Breast Cancer. Is there any truth to this?  I've been taking it for over a year now, and it has helped my hot flashes.  Now I am scared to continue taking it.  Can you shed some light on this for me?

Answer: Nothing I'd known about that. The main compound in black cohosh is cicicifuga and that has no estrogenic activity and looks safe. Some brands contain also a small amount of phytoestrogens. And maybe they can harm, but that is not likely. We regard black cohosh as safe, but just as other herbal drugs, no proper scientific research is done with the product.

Question:  I am 44 years old and have experienced irregular menses.  Last year my doctor prescribed 200 of prometrium.  I had a follow-up last May 2000 and she told me to stop the prometrium in January 2001.  I have not had a menses since Dec. 2000.  I am concerned since I had a mammogram in Jan. 2001 and then an ultrasound: Density/ 5mm cyst.  I read that this medication could cause cysts etc.  I have another ultrasound scheduled.  I am very concerned about this cyst.  What does it mean if a reading finds some activity in the cyst? My doctor had another surgeon read the ultrasound after the first Radiologist concluded that the cyst was not solid.  Could this be the beginning of cancer?  I don't know if I should go back on the medication when I have my follow-up in May for a pap.  But how else could my menses be regulated? I feel fine but do experience cold chills and some hot flashes (but not severe) at night.  Could this be a thyroid problem? Any information you can provide would be greatly appreciated. Thank you.

Answer: This situation is not clear to me. Prometrium can regulate the menstrual cycle effectively by taking courses of 10-14 days a month from day 15 of the cycle (the first day of the period is day 1 of the cycle). And not with continuous prometrium. Prometrium will not induce ovarian cancer. Ovarian cyst more than 3 cm needs further evaluation. Smaller cysts are seen very frequent and are usually without consequences. They disappear spontaneously. Persisiting cysts of more than 5 cm, or cysts with papillous structures within must be removed. Another way to regulate your menstrual cycle is the use of birth control pills. The easiest way. Also for prevention of ovarian cysts.

Question:   Some physicians still recommend ERT 21-day out of month for hysterectomized postmenopausal women. Is that regimen more or less beneficial than the continuous one, and why?

Answer: There is no reason for interruption of estrogen therapy. No benefits are described ever. And the possibility of hot flashes during the week off are substantial. Also bone mass is better influenced by continuous estrogens than by a cyclic regimen. Sometimes women have side effects as painful breasts. In such a situation one can advice a week without ERT

Question:  I am a 41 year old woman who has no children.  My doctor's have tried about 5 different types of birth control pills in the past year in an attempt to diminish night sweats and painful menstrual cramps.  I have had an initial hormone test (just a blood test, use of birth control pills wasn't stopped), that said I was not going thought menopause. I'm currently taking Ortho TriCyclen, which is fine for the first two weeks of pills.  However, when the third week of pills arrives, I have breakthrough bleeding and painful cramps.  I'm in my second month of pills. Any suggestions?

Answer: A blood test during the use of birth control pills will always shoe that menopause has not yet arrived. The BCP causes very low levels of FSH and of estradiol. Breakthrough bleeding with BCP is not unusual, most times harmless, but endometrial polyps has to be ruled out.

Question:  I am a 43 year old and am very frustrated with my care for HRT and thyroid replacement.  I had a hysterectomy 5 years ago because of severe endometriosis.  They also took out the ovaries.  I was put on estratest and then premarin when the endometriosis symptoms came back.  The premarin took care of the endometriosis symptoms.  I was taken off of the premarin in Dec 2000.  Now my thyroid levels are going haywire.  I was on synthroid .15 when on the premarin and showed normal.  After I quit taking the premarin it was high.  They lowered me to .10 and it is showing even higher.  Now I am being lowered to .075. I have no thyroid so I am not producing any on my own.  Is there a estrogen replacement that will not interfere with thyroid replacement?  What are my options?  I also have brown blotchy patches on the sides of my face that I never had before HRT, feel tired almost all the time, have poor concentration, depressed.  Could the estratest be causing that?  My doctor just won't listen or explain and if you could give me some information that I could research further, I would be more prepared to demand some answers on my next visit.  Thank you.

Answer: Estrogen therapy does not interfere with thyroid function and thyroid therapy. Tiredness, poor concentration and depression during adequate HRT have other causes. Discuss this with your doctor.

Question:   I am 49, in good health physically. I have stopped my periods completely about 3 years ago. My periods were just like clockwork, right down to the minute.  5 years ago I started experiencing depression, no libido then came the hot flashes. But the depression was the worst and difficulty sleeping. My daily routine have not changed and I don't feel like I have a stressful live, But when the depression hits, I have thoughts of suicide which really scares me. My doctor put me paxil which helped better than Celexa. I started seeing a councilor about 2 months ago which is helping with the mental end of things, there is a history of mental illness in my family, my dad (depression), brother (schizophrenic), sister (manic depression), I thought maybe I had some form of it, too. I just wanted to check out all avenues as to way I felt like this. I also went to my obgyn and had my hormone level checked which was very low, he prescribed me Provera 2.5MG and Estratest HS. I read where Paxil decreases sex drive and Estratest HS is to help increase sex drive. Is this true?  I am feeling better since I have started the hormone pills two weeks ago. Should I continue to take Paxil? Or there a better antidepressant that would work better with the HRT prescribed? I see my obgyn in 3 months for a check up to see how I'm doing on the pills. I know this is a rather long e-mail, but wanted you to understand my history. Any suggestions, I'm I on the right track?

Answer: You are on the right track. Do not stop the antidepressants. Hormone therapy can induce better feeling, but it is not a therapy for depression. Paxil and Estratest both influence the libido, just as you describe. Continue both medications.

Question: I had a hysterectomy (have ovaries) at 43 because numerous fibroids. I incurred severe hemorrhaging 10 days after surgery which lasted for 8 weeks. Finally made a full recovery. Now at 46 I am experiencing hot flashes, sleepless nights, no sexual desire at all, it seemed to diminish somewhat after the surgery, but has now hit rock bottom. My husband is ready for twin beds and would really like the old me back. My gyn. has really given me no answers. Is this the beginning of menopause or a side effect of the surgery?  My Dr. has not mentioned any medication or remedies. Would HRT help?  This is really stressing me and my marriage. Thanks so much.

Answer: Not a side effect of surgery but menopause. At the age of 46, vasomotor symptoms are not a strange symptom. Try estrogens to combat the complaints.

Question:  I had my normal period, it stopped, then I started another period the next day.  I am concerned about the additional bleeding.  I'm 49 and have been going through perimenopause for a number of years.  I have hot flashes, wake up at night, migraines, breast tenderness, heart palpitations, etc.  I was on HRT a few years ago but that's when I developed migraines so I haven't been on anything since.  I take Calcium, magnesium and vitamin E.  I had cervical dysplasia a few years ago but have been back to normal PAP's.  The doctor did an endometrial biopsy, which he said showed no dysplasia or malignancy but showed "irregular hormonal affect."  He wants me to go on progesterin.  I have never heard of taking just progesterin.  Is this normal?  I'm sure my hormones are irregular since I'm going through perimenopause, but is it necessary to take the progesterin?  What will it do for me?  Any side effects?  Thanks -- I appreciate any input during this crazy time in my life!

Answer: The main hormonal problem during perimenopause is a shortage of progesterone. Women have enough estrogens as long as the periods are not to much separated (2-3 months). The best measure to take for regularity is: cyclic progestagens day 15-24 or 26 of each cycle.

What Should I Expect from HRT? Question:  I am a 43 year old woman.  I had a partial hysterectomy 10 years ago.  I still have my ovaries.  Am I too young to be going through menopause?  I have been experiencing mood changes, vaginal dryness, pain during intercourse, anxiety, fatigue, hot flashes, night sweats, etc.  I had my FSH level tested and it came back normal.  I have been tested for low thyroid and the blood tests came back as normal.  I am currently on Premarin 1.25 one time a day, for two years.  I no longer have not flashes and I have occasional night sweats ( maybe once or twice in a year.  The doctor that I am now seeing, says that I am too young to be going through menopause and that she wants me to stop taking the estrogen.  I did not take the estrogen today and felt tired, nauseated, fatigued, no appetite, moody.  I decided to take the Premarin again around 3:00 PM.  I feel better, but now I have a nagging suspicion after what the doctor said to me.  Am I crazy?  Please help?  My doctor is an HMO who I feel really does not care about me.  I cannot change doctors however because of my insurance.  Thank you.

Answer: Normal FSH is usually not seen in perimenopause. Maybe your doctors opinion is not so bad. But together with you he/she has to look for other causes and perhaps therapies for your symptoms/complaints. At the other hand, there is no objection against the use of premarin, especially not when you are happy with it and all complaints disappear.

Question:   I have been reading about natural progesterone as an "HRT'" for perimenopause and menopause.  There seems to be controversy concerning this approach as an HRT.  I was on the typical Premarin (.5?)and Provera (5mg) HRT and was experiencing PMS during the Provera days.  I also did not enjoy spotting and having periods again and both my parents died of cancer (ages 70 & 81).  I have been trying the natural progesterone cream prescribed by my doctor and now have hot flashes and night sweats again - however, I have stopped spotting and have not had a period  for 3 months.  Depression has also been an issue with me for about 4 or 5 years and Zoloft (100mg) seems to help.  I am 50 years old, in good physical health, exercise regularly and focus on eating nutritional meals.  I have noticed my energy level decreasing the past two or three years. I would like to not take any pills. Is there hope that all this may pass when I am post-menopausal?  Why is there controversy with the natural Progesterone Cream and the estrogen dominance theory?

Answer: The controversy regarding the natural progesterone cream is because some doctors state, without any proof, that the use of the cream is beneficial for many problems. And I agree that a lack of progesterone is the main problem in perimenopause with irregular bleeding. So the use of progesterone is beneficial, but in a formulation with adequate blood levels. That is with Prometrium but not with progesterone cream.

Question:  I recently was told Black Cohash would be good for my hot flashes. But I also take an aspirin a day. Somewhere I heard or read that Black Cohash contains the same thing as aspirin. I would hate to take too much aspirin. Could someone please advise?

Answer: Black Cohosh is the English name of Cimicifuga Racemosa. Some extracts contain a small amount of phytoestrogens, others not. The mode of action is unknown. Aspirin like effects are not mentioned in the list of side effects.

Question:  I wanted to know the effect that hyperprolactinemia has on PMS, PMDD, Perimemopause, & Menopause?

Answer: Hyperprolactinemia disturbs the menstrual cycle and especially ovulation. It does not influence (peri)menopause.

Question:  I have a friend in her mid 50's who had some testing done. The results were that she has very low progestrin. She wants to know if the progestrin level can be fixed with certain herbal vitamins, and proper diet. She's not too keen on medication. Other than this she's healthy.

Answer: Low progesterone is completely normal after menopause. The ovaries do not produce progesterone anymore when ovulatory cycle stops.

Question:  I haven't had a period in 2 years. I have been on Prempro for a year and a half. I am now having vaginal bleeding. What could be the cause?

Answer: It is very likely that Prempro is the cause. With Prempro (and all other regimens of continuous combined HRT) endometrial atrophy is seen and sometimes bleeding occurs from atrophic fragile blood vessels. But endometrial abnormalities has to be ruled out. Sometimes one is bleeding from polyps, and (very rare) from endometrial cancer. Vaginal sonography or hysteroscopy is indicated.

Question:  I am almost 50 years, had a total hysterectomy in January of 1987 and have been on hormone pills since then.  I have been told that hormone replacements can keep you from losing weight.  Is this true and is there another method in pill or patch that does not have this effect?

Answer: All estrogens have the same effect on weight and on distribution of body fat, regardless of the way of administration. With estrogens the increase in body weight is less than without estrogens. And the apposition of abdominal fat (the unhealthy fat) is prevented. With estrogens hip fat is more pronounced. Cardiovascular disease is strongly related to abdominal fat, and with estrogens the better distribution is seen.

Question: I started a natural progesterone 5 days ago because I was on prempro and did like all the stuff I read about it beside feeling not my self.  The problem is that I start bleeding very heavy w/clots and then stop and spot for a day or two and then the same thing over again.  I can't tell you what is my period or what is going on should I continue to use the cream and not get off (I know that you are suppose to stop for the time you are menstruating)  Can you help?

Answer: Natural progesterone is manufactured in many ways. Most progesterone creams do not increase the blood level of progesterone and are not safe for the protection of the endometrial lining when using estrogens. Brands like Prometrium (oral natural progesterone) and Crinone (vaginal cream with natural progesterone) are effective. When using natural progesterone cream before menopause (some women prefer that for PMS and other cyclic complaints), no estrogens are necessary because the ovaries produce enough estrogens unless the periods are 2-3 months apart. And extra progesterone is especially useful in the second half of the menstrual cycle (from day 15 to the start of the period). I doubt if most progesterone creams are effective for these complaints, but used in such a way they do not harm.

Question:  Can you please tell me if low estrogen levels will cause weight gain?  I am craving sugars & carbs, yet I am keeping track of calories and do aerobics and play tennis almost daily, yet I can't get a single pound of the 10 I have gained off.  I have low estrogen and after my next period I am to start taking stores.  Can you tell me if this will help me.

Answer: Estradiol levels are never to low in women with regular periods. There is a very large variation in estradiol levels. And a lab test has no use. Weight gain is not related to estrogens.

Question:  I am 47 years old and in the last six months my periods became abnormal. I'd have   a normal period then skip a month . Then I would have two in one month and so on. It has been three months now since I have seen anything. I experienced tender breasts last week, I even went out and bought a home pregnancy test knowing I had my tubes tied twenty tears ago. The test was negative. My sister suggested black cohosh and primrose. Will this help me get back to somewhat a normal monthly period or is this to be expected? Both my mother and aunt died of breast cancer.

Answer: This is the picture of annovulation. Your ovaries are still producing estrogens and because of no ovulation a so called persistent follicle exists. This produces a lot of estrogens and causes breast tenderness. The treatment is an adequate course of progesterone or progestagens. This will induce a withdrawal bleed. The persistent follicle will disappear spontaneously, but without progestagens there is a certain risk of heavy prolonged bleeding at that time. Black cohosh and/or primrose in that situation is something for believers. The benefits of that herb has grown to almost religious proportions. And its effectiveness is not proven through scientific evidence.

Question:  I had a hyst with bso in February and am on a morning and evening dose of Premarin. I am still suffering from night sweats and insomnia. Do you have any suggestions?

Answer: Increase the dose or switch to another formulation (patches). The absorption of estrogens is variable. A standard dose is to high for some women and to low for others. Especially shortly after BSO a high dose is often necessary.

Question:  I was diagnosed with breast cancer 10 years ago.  I had a lumpectomy, radiation, and chemo.  I was 47 at the time.  My periods were very regular.  After my first chemo treatment I never had another period and my sex drive is very low.  What happened to me?

Answer: I suppose that with chemotherapy irreversible damage occurred to the follicles in your ovaries. This is a normal side effect of chemotherapy. Without ovarian function hot flashes start.

Question: I am 43 and experienced ovarian decline/failure after hysterectomy a little over 12 months ago. I was finally successful finding an estrogen regime for me (Sandrina 1mg gel) and have been on that for 3 months. I have not ovulated since I have been on it. The first two months were fine and I felt good, however now I feel like my body is attacking itself - rare hot flushes but heat intolerance, aching bones, inflammation of gums, a flu-like feeling and occasional raised lump in my neck above and to the left of my thyroid gland. Tests reveal low but normal TSH and free T4. I have a family history of thyroid problems on my mother's side. I also have a family history of osteoporosis on that side, although the ones affected did not take ERT. Should I try lowering the dose to 0.05 - does it reactivate the receptors after 3 months? If I do this and am successful I may find that my bladder worsens though. I had detrusor instability and slight incontinence after voiding when on my previous regimes of estrogen. Sandrena has improved that.

Answer: Not lowering the dose but increasing the dose will be helpful. 1 mg is a very low dose. Also the area of application is important. The bigger the application site, the lower the resorption. Maybe you changed the area.

Question:  I had my ovaries removed 7 years ago.  Are vitamin/herb supplements natural estrogen replacements?  I have changed estrogen at least four times in this period of time.  Each has had negative side effects.  I have considered using the supplements as an alternative but I have been concerned that they will not really provide what I need.  I was told that herbal supplements are natural estrogen replacements.  have any studies been done that I can read to understand more about estrogen replacement and herbal/vitamin supplements.

Answer: Vitamins and herbs are not an alternative for estrogens. But a healthy life style with healthy food and enough exercise and no smoking is certainly an alternative for estrogens. And when the use of herbal supplement is a manifestation of such a healthy life style, the missing of your estrogens is of less concern than with a sedentary life, smoking and a saturated fat diet.

Question:  I have been on .625 m. cenestin and 100 m. prometrium for almost two months now.  Can one or both of these cause me to feel and look bloated?  I didn't have this problem before taking this combo.  (I previously took 1mg. estradial and progesterone cream.) I am really frustrated with this feeling.  Any insight?

Answer: Maybe the dose of estrogens is somewhat high for you, although it is the usually dose. But in some women the absorption is much better than in others. Try 0.3 mg conjugated estrogens together with 100 mg prometrium.

Question: I had a total hysterectomy 1 year ago and started on HRT immediately.  I started with Premarin tablets  but I didn't care for the smell of it.  In addition, I started having severe migraines frequently.  So,  my doctor switched me to Estrace 2 mg.  In addition, I started using Premarin cream for vaginal dryness.   The migraines continued and my acne  got a lot worse.  I've dropped the Estrace to 1 mg.  and the Premarin cream to 5 mg but the acne is getting worse.  The migraines  seem to have gotten better.  Any thoughts on how to handle this?   

Answer: Migraine is always a problem with hormonal therapy. The best advice is to find the best combination by trial and error. The fluctuations in estrogen level are important. This led to the advice to use patches for estrogen replacement because of the more steady estrogen levels with patches compared with tablets. Acne is influenced by androgens. Usually androgens are bound to SHBG (sex hormone binding globulin). And SHBG increases with oral estrogens. In that case you had to expect an improvement with the higher dose of estrogens and a worsening by lowering the dose.

Question:  I am 42 and recently diagnosed with perimenopause.  I am a smoker and also take Synthroid for hypothyroidism. My physician is recommending a low dose birth control pill. Is this safe for me?  If not, can you recommend a safe and effective treatment?  Also, will my thyroid medication need adjusting with HRT?

Answer: The only safe treatment is: quit smoking. Smoking and birth control pills increase the incidence of cardiovascular disease 12 times. But without smoking only 1.5 times. Thyroid treatment is not influenced by HRT.


Opinions expressed here are for educational purposes only and, as such, do not constitute and should not be interpreted as initiation of a physician-patient relationship. This information is not intended to supplant the need for you to consult with your physician prior to choosing therapeutic options and/or interventions.

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