Ask The Expert

Ask The Expert

Are these symptoms of Menopause?
Am I experiencing Perimenopause?
What should I expect from HRT?

Doctor, Are these symptoms of Menopause?   Q: I am an active 72 year old, who had a complete hysterectomy w/removal of ovaries at age 36 because of irregular periods and heavy bleeding w/clots. Have been on Premarin since the surgery, but now down to .3mg 2 X/week after experimenting with lower and lower doses due to problems w/cyclical migraines. Migraines now under control w/no other meds except Feverfew.  But continue to have other cyclical (every 2 weeks for 3-5 days) problems: acid reflux or IBS-type symptoms, stomach bloating, mild headaches, rash under breast & arm (always one-sided), mild depression, blurry vision when reading, and worsening of osteoarthritis symptoms (pain free usually at other times).  All these are definitely cyclical, stronger at lst time of the month than 2nd, but none are usually a problem during the rest of the month. Is it possible this conglomeration of symptoms can be due to hormone imbalance?  What tests would you recommend, if any?

A: I do not consider these symptoms a result of hormonal imbalance. I have no explanation for this. The dose and regimen of premarin (0.3 2x a week) is unusual. Nobody knows what the benefit will be, but I can construct a hypothesis why it is maybe useful. But the scheme will not cause complaints two times a month. 

Q: Can cortisone shots cause a menopausal woman to bleed lightly for a few days?

A: In early postmenopause it happens sometimes. In late postmenopause further analysis for postmenopausal bleeding is recommended.

Q: Hello, I am a 43 year old woman with Crohns disease.  I haven't had a period in over a year so had a FSH test done to see if I was in menopause.  It came back 75 and my doctor said I was in menopause and discussed ERT.  All of a sudden my periods are back on my usual 26 day cycle and this has been the 3rd month.  How can you have a period if you aren't producing estrogen?  Also my crohns has been less problematic.  Any insight would be appreciated.  Thanks.

A: High FSH does not prove menopause. It is a matter of definition. The formal definition for menopause is  after 12 months with no menstrual bleeding. No bleeding for a year with high FSH at the age of 43 suggests very strongly a postmenopausal status. But sometimes ovarian activity comes back for a while. It is unusual but not rare. And you can still expect early menopause. And with early menopause HRT is recommend for prevention of osteoporosis and cardiovascular disease.

Q: I am a 48 year old woman. For the last year I have had only 1 or 2 periods. I had been having hot flashes and night sweats really bad for about 6 months. Now they've stopped and I find that my hair is coming out. It started about Nov. I've been under a great deal of stress with job, kids and my mother being diagnosed with cancer. Also I had 2 minor wrecks in Sept. My neck hurt for about a month and then headaches. Could any of this have anything to do with my hair coming out? I've been taking prenatal vitamins and from what I can see on the side of my head my hair is coming in. I feel so embarrassed to go out sometimes, but I have to.

A: Stress is an important factor in hormonal disregulation. And hair loss is usually a matter of poor general health, and stress is not good for general health. Hair loss is nearly never so heavy that it comes to baldness. And it will stop again after several months. Try to diminish your stress factors.

Q: I am 32 years old, have been on the pill ever since I was 18.  I stopped taking the pill back in January and did not get my period.  About a couple of months ago I started having some intermittent low back pain and abdominal discomfort.  I went to my OB-GYN and she did some blood tests.  Apparently I have an elevated FSH (she tested twice) and so she thinks I am in early menopause.  She gave me provera to bring my period down but it didn't work. Now she is given me estrogen first for a month with the progesterone to see if that works.  I have an ultrasound scheduled in a few weeks.  Could the elevated FSH (or premature ovarian failure) be an indicator of ovarian cancer?  What are the possible causes for POF?  Could my back pain and abdominal discomfort be a sign of ovarian cancer or related to the lack of menstruation?

A: High FSH is not related with ovarian cancer. Premature ovarian failure can be caused by autoimmune disease, by genetic predisposition, by surgical interventions, by chemotherapy. But in most cases no reason is found. But with POF on the age of 32 a thorough investigation by a gynecologist is strongly advised.

Q: I am a 51 year old woman. Is the growth of moustache and beard in women of this age related to menopause and if yes, by which hormone is this caused. I am on Premarin since 2 years. Thanks for your response and regards.

A: No, with Premarin you cannot expect a moustache and beard. A surplus of androgens can cause extra hair. But the source of extra androgens has to be sought.

Q: I remember reading in a old medical book (from the 50's), a table that gave a approximation as to the start of menopause in relation to the start of menses.  If I recall, the earlier menses began, the sooner menopause would begin.  Is there any truth to this?

A: There is no relation between the age of menarche and the age at menopause. The old books are incorrect.

Doctor, am I experiencing Perimenopause?  

Q: I am a 42 year old woman and believe I am perimenopausal.  I do have irregular periods but my main problem is I cannot stay asleep. I was on zoloft which helped for a few months, now the sleeplessness is back with a vengeance.  Not only do I wake up sometimes only after an hour but I am fidgety, itchy and must get out of bed.  I can't even concentrate to read.  My doctor put me on trazodone and for the first 2 nights I slept like a baby. Now it's been 2 weeks and I'm back to not sleeping.  In your opinion, should I keep trying antidepressants until one of them works or would perhaps a low dose of estrogen help more.  Am I doomed to be awake the rest of my life?

A: This is really a troublesome issue. I do not think that estrogens will be helpful. In the early perimenopause the ovaries produce enough estrogens. Go further with the advices of your doctor.

Q: I am 56 and have been having hot flashes now for 10 years. I was just wondering how long do these hot flashes continue? I don't have them as bad as I use to but I am still having them. I figured this should all be over with by now.  I am not on any type of estrogen therapy.

Nobody knows. At the age of 60 about 20 percent of all women still have hot flashes. 

Q:  I am 30 years old and I had a partial hysterectomy when I was 26. I have one ovary. For a while I have had a trouble with my memory. It is hard for me to do my job well, and I forget about or have to really think about how to do things that normally come to me without much thought. I forget that I have memory loss sometimes when I talk to the doctor. There are some days when I am so tiered that I can not sit up to help my kids with their homework. I have recently begun to notice hot flashes and I have a skin condition on my neck, shoulders and upper arms caused by the sweating. Should I talk to my doctor about some kind of hormone therapy?

A: First of all a diagnosis has to be made. The function of the ovary can be checked by measuring FSH and estradiol.

Q: I am a 39 year old, physically active female that started having irregular menses 2 years ago. Hemochromatosis runs in my family and I had an iron saturation rate of 80%, however I was told not to worry and this has nothing to do with and menses issue. However I just read that fsh can be tied to hypothyroidism and hemochromatosis. Should I be pursuing this if the gynecologist has told me that there is no direct correlation?

A: I am not aware of any correlation between hemochromatosis and cycle problems. Hypothyroidism can disturb the menstrual cycle indeed.

Q: I am 48 years old and in good health.  I had surgery 5 years ago for fibroids (the Doctor removed 10 in varying sizes).  I still have regular periods and haven't noticed too much difference in my periods except acute anxiety that starts a few days to a week before my period.  What is your opinion about a possible relationship between anxiety and PMS /perimenopause?

A: Symptoms arising a few days before the menstruation are suggestive for PMS. PMS is often aggravated in the years preceding perimenopause. Anxiety can be a PMS symptom.

Please check-out our PMS/PMDD collection for more information.

Q: I am 39 years old. I have had regular normal periods till May of this year.  I went to the doctor and he did a FSH and it was 106...I have not had any perimenopausal symptoms at all.  My period has not changed as far as the length and flow. Is there a chance that my FSH was high because it was drawn during the month that I missed my period? My OB/GYN put me on medication to start my period. I had to take it for 10 days and I was told that my period would not come till maybe 10 to 14 days after taking my last pill. It came the day I took my last pill. Can I still get pregnant during this perimenopause? Can I be in perimenopause without symptoms?  If I was to get pregnant during this time, would it be a high risk pregnancy?

A: Such a high FSH is usually to do to laboratory problems. In some women other compounds disturb the test. FSH is not reliable under those conditions. With no complaints and a regular cycle, just forget the FSH. Pregnancy is always possible as long as the ovary functions. Only after a prolonged period of amenorrhea of 12 months we consider a pregnancy very very unlikely. With increasing age, the risk of pregnancy diminishes.

QI am a 35 year old with a problem. My menstrual cycle is never regular, it hasn't been since I had a tubal 12 years ago.  I have very bad cramping two days before with nausea, cramping the first two days of my cycle, and the last two days of my cycle.  My cycle lasts from 3-5 days.  Medication will help the pain at times. Around my third day, I hardly bleed, the the fourth day it is like a river, as for the first and second day.  I pass very dark clots at times.  I also feel a flutter once in a while. I get day and night sweats then a cold chill.  I'm very irritable with everyone. I bleed heavily, using a super long-heavy sanitary napkin in an hour.  I am thinking of getting a tubal reversal, but unsure of another pregnancy.  My doctor says my cycle is just irregular.  I was on the pill but it did not help.  What do you suggest?

A: This is not a perimenopausal problem. When oral contraceptive pills do not help to regulate the periods and the periods are still heavy, further analysis by a gynecologist is recommended.

Q: For the past few months my wife has been experiencing extremely (more than usual) painful ovulation, so painful that at times she can't get out of bed. She has never been a heavy bleeder during her cycle, but lately she has been. Her cycle has been starting sooner and lasting longer. Her mood swings when she ovulates and when starts her cycle have been unbearable. She has complained of being hot at night when its cool, she is depressed all the time, has no sex drive at all, doesn't want to be around anyone and says that she is unhappy and does not know why. All of this has had a major affect on her and on her family. She is 38 years old and up until recently she has not had any problems  Any suggestions?

A: Perimenopause is characterized by failure of ovulation and lack of progesterone. Your story is quite another one. When ovulation is painful, ovulation inhibitors (birth control pills) is the solution. With BCP all ovulation problems disappear and usually the periods are far less heavy.

Q: I am 49 years old and in the last year had began to experience hot flushes.  When they became more intense, my doctor ran the usual blood work, which indicated that my estrogen level was slightly low. Because of the severity of the flushes, he started me on Prempro (2.5Mg.).  After 4 weeks, I returned informing him of no change. He increased the dosage to 5Mg. After an additional 4 weeks and still no relief, he gave me an injection (lowest dosage) of Depo-Provera.  It has so far been 2 weeks and still no relief. They have affected by work, everyday functions.  They last anywhere from 15-30 minutes each and I've been having an average of 5-6 a day. What's next?

A: An increase in estrogens is better than an increase in progestagens. When 0.625 is not enough, go to 1.25 or sometimes even 2.5 mgs. Sometimes the absorption in the intestine is not working very good, or the first pass through the liver eliminates the estrogens too soon. Patches will overcome these problems. So, more possibilities exist.

Doctor, am I experiencing Perimenopause? 

Q: I am 43 years old with 2 teen aged children.  I experience hot flushes accompanied by night sweats in bed from time to time, vaginal dryness, weight gain and almost total loss of libido.  The loss of libido is either from my past use of an antidepressant Zoloft or my age I don't know for sure.  My periods are normal they usually run about 3 days, but some periods I will experience huge blood clots, other periods are lighter with very few blood clots, but almost always some clotting.  Am I normal or do you feel that I need a D&C?

A:  Many women experience changes in menstrual flow before menstrual irregularity starts. Only when the amount of blood loss causes anemia, further investigation is advisable. D&C is an invasive diagnostic procedure and not for problems as you describe. Sonography is the first level of diagnosis with menstrual abnormalities.

QI am a 43 year ole female. I have usually always been regular with my periods until this past month. I was 2 weeks late and then it was just spotting. I have been also experiencing low back pain, something that I have not experienced before. I am wondering if this could be the start of menopause. I do not have night sweats or any other symptoms of menopause. What do you think?

A: Probably this is an anovulatory cycle. When ovulation is delayed or does not come at all in a cycle, the follicle can be maintained for a longer time and produces estrogens and no progesterone. Without progesterone, the growth of the endometrium lining goes further and from this to strong proliferated lining spotting occurs. Sooner or later a breakthrough bleeding will follow and sometimes this can be very heavy and prolonged. This kind of anovulatory bleeding is seen very often during perimenopause. The treatment (if necessary) is a course of progesterone. Or oral contraceptive pills.

Q: I am a 36-year-old female. I have had a period since age 11. The last few months, I have had an EXTREMELY light period (hardly anything). What does come out, is brownish. I am on birth control pills. I've never had heavy bleeding, always on the light side, but this is hardly anything. I do have pain and cramps, sometimes, very bad. I used to menstruate about 5 days, but now lasts about 1-2 days. I have one child, that I had when I was 20. I had a laparoscopy about 6 years ago to remove scar tissue. One incidence of precancerous cells that were taken care of with a cream. Normal pap smears since then. Could I be starting menopause?

A: No, this is not menopause. This is a side-effect of birth control pills without any consequence.

QI am 39 years old and have been experiencing the following symptoms for the past 7 months.  Insomnia during my period and ovulation, between 4 to 6 nights each and every month.   Breast tenderness during ovulation, increased fatigue, decrease in sexual desire, irritability, stress, shortness of menstrual cycle by 4/5 days and increased PMS symptoms.  On the nights that I have difficulty sleeping the same scenario occurs...I am almost asleep and I wake up so quickly & intensely that I have to get out of the bed.  I am also extremely agitated during the times. It is usually 2:30-3:00 am before I fall asleep.  On other nights I sleep so lightly that my husband cannot be in the bed with me because every movement wakes me up & I have difficulty returning to sleep.  What is your opinion?  Could I be in perimenopause?  What tests can confirm this?  What are my options at this time?  The doctor, who I saw just once for a 5 minutes session wanted to put me on Zoloft.  I was not willing to do this.  There has to be other avenues to take. Thanks!

A: Why thinking of perimenopause? No typical complaints can be recognized in this story. It is true that PMS can be aggravated in the years preceding perimenopause. And an antidepressant is also good for PMS symptoms. The advice of your doctor to use Zoloft sounds reasonable.

Please check-out this great article called, "Selective Serotonin-Reuptake Inhibitors Effective in Treatment of Severe PMS." 
Visit the PMS/PMDD Collection for more information.

Q I'm 45 years old and had a hysterectomy about 10 years ago; however, I still have both ovaries.  I've been having symptoms of perimenopause, but since I don't have periods, it's difficult to tell for sure.  I went to the doctor about 6 months ago and my FSH levels were normal.  About every two or three months, I experience something like severe PMS and get very emotional and irritable.  I've been waking up hot every hour or two at night - sweating  and burning up.  I my skin gets hot and flushed during the day occasionally, but nothing like what I experience at night.  My doctor says I am too young to be experiencing periomenopause.  What do you think?  Could my FSH levels be fluctuating and showing normal by the time I go to the doctor?

A: Age is not an important factor in perimenopause. So you are not too young for perimenopause. But normal FSH is certainly not a sign of perimenopause. It is true that FSH can fluctuate very much and so do estrogens. You can start a trial with the use of estrogens during a few months and when symptoms decline with estrogens then continue. But when you experience the same symptoms with estrogens, another cause has to be found.

QI am 36 years old and had started perimenopause at age 34. At that time my doctor put me on the mircette birth control pill for a year and than put me on the Climara Patch.  Within last two month my symptoms have redeveloped and now the doctor wants to put me back on the birth control pill.  Should I consider? I have had every test you can imagine was done, from a complete thyroid examination, including Iodine and x-rays  to an Upper and Lower GI with a complete heart examination, and sugar and blood tests. My symptoms included night sweats, hot flashes, hot flushes/excessive sweating, lightheadedness or dizziness, muscle pain poor memory and concentration irritability, mood changes, vaginal dryness.  What do you think?

I would like to know now whoever said perimenopause could not start in your 30's?  Are there not facts out now about perimenopause can begin sometime in your 30's?  Doctors are not treating the patients anymore they are treating the range in numbers. I had a tubal when I was only 23 years of age.  

A: With every test done, and of course among them FSH with repeated high results, the diagnosis of perimenopause has to be considered strongly. And when low dose birth control pills controls in an excellent way all symptoms of perimenopause, there is no reason to use them for a very long time. The start of ovarian failure has nothing to do with any sterilization procedure. Nor with age. It is caused by the amount of follicles in the ovaries and that is determined already before birth. I do not know why so many doctors tell that perimenopause can not start in the thirties. Sometimes it starts 10 years before menopause (the last menstruation ever). And 10% of all women experience menopause before the age of 45. From these figures alone, you can consider the start of perimenopause in the thirties not unusual.

QMy wife is 49 and experiencing perimenopause.  She gets the usual hot flashes, forgetfulness, aches and pains in the joints, she has gained 6 kgs. in a month. She suffers from migraines and recently she has been having frequent attacks.  She has been regularly taking Betapyn (500mg) once and recently was prescribed SIBELIUM as a preventive against migraines. She has not had her periods for over 2 months and  a few days ago, began spotting. A hormone profile test indicates she is estrogen dominant, which may be causing her system to go haywire.  Should a HRT  be prescribed?  Her gyaenocologist wants to prescribe Premarin/Provera in about a month's time.  Her Cholesterol levels are on the borderline, and she had ECG and Stress Analysis test done- all normal, although the doctor feels she might be slightly hypertensive-her normal BP is 100/70 or 90/60.  Lately its been at 120/80 or 130/90.  If she is Estrogen dominant, shouldn't she just take Progestrone without additional estrogen?

A: In perimenopause, and especially in early perimenopause, most women have enough estrogens, sometimes even high levels. And the problem in that period is a shortage of progesterone. Anovulation is the cause of that deficiency. With courses of progesterone or progestagens for 10-14 days every second half of the cycle (starting with day 15 = 2 weeks after the start of the menstrual period) the problem of menstrual irregularity is over. And in most women hot flashes disappear also with such a regimen. Another possibility is the use of oral contraceptive pills, bit ussually this is not advised for women with migraine. Premarin/provera is also an option, provided that the provera is dosed high (at least 10 mgs). But provera alone in the second half of the cycle is usually sufficient.

QI am a forty seven year old woman.  I started weight lifting and cardio last December.  I average about 3-4 days per week in the gym.  After this life change along with an impending divorce my periods changed to about every 60 days.  An FSH test showed hormone levels well within the normal range.  I do not have any of the "normal" signs of menopause.  Is this just a normal sign of aging?  My doctor keeps telling me not to worry about it.  Frankly, I would be happy to NEVER have any cycle.

A:  I agree completely with the opinion of your doctor. Do not worry about the fact that you have no climacteric complaints. FSH can fluctuate and is not a reliable indicator. Especially with cycle irregularity, sometimes normal FSH and 2 weeks later high FSH is seen or vice versa. At the age of 47 cycle irregularity is normal and 20-30% of all women will never experience any climacteric symptoms. And sooner or later the menstruations will stop spontaneously.

Q I have been extremely hypertensive for approximately one week.  The elevated blood pressure was first uncovered when I sought treatment for what I believed to be a hormone-related migraine, which I began about 4 years ago to get infrequently during the 4th day of menstruating. (Approximately once annually.)  My BP elevated to stage 3 by the middle of the week.  I am 49 years old and have been taking Triphasil bcp for many years.  I have had very few symptoms of perimenopause over the past 18 months:  very infrequently I have had light hot flashes and night sweats.  I'm not sure about heart palpitations, as I also have MVP with insufficiency, which occasionally gives me a problem.  Although my mother is deceased, so I can't confirm, I don't believe she entered menopause until she was older than I.  My MD is conducting a number of tests, but I'd like your opinion.  My Internet research  for  perimenopausal hypertension has not resulted in anything of significance.  Thank you.

A: Hypertension has nothing to do with menopause, but with aging. The normal work up for hypertension has to be done also in perimenopause. Birth control pills can induce hypertension but this is unlikely after many years of use. Migrain attacks in the week without the anticonseptive pills can be prevented by taking a low dose of estrogens during that week. The migrain attack is usually provoked by the sudden drop of estrogens.

Q I am 45 years old and have had bleeding between periods  and passed blood clots also. I went to the doctor and he put me on birth control pills and during the time I was on them about six months  I didn't have any problems during that I was taking the pill. I have been off the pill for two months and had  my regular period about two weeks ago  and now started again and now passing several blood clots. Is this perimenopause or what?

A:  Perimenopause is characterized by menstrual irregularity. The main problem in that period is ovulatory disturbances. Your story is very suspect of the start of the perimenopausal years.

Q:  I am 45 years old and had my first child at age 40. Immediately after giving birth I had a d&c and lost 2 whole pints of blood.  One month later I had a partial hysterectomy (ovaries still intact)  and had to have another blood transfusion (2 more pints).  Before becoming pregnant I was taking Triavil.  My DO now has me on Paxil.  It seems ever since I gave birth I have been extremely tired.  The past 1 1/2 years I have been experiencing hot flashes, sleeplessness, tired, mood changes, night sweats, no sex drive and absolutely NO energy.  I have had many blood tests over the past 1 1/2 and only on the past two blood tests has anything showed.  I was diagnosed with Epstein Barr however on the last blood test it showed that it was (I guess) in remission? I have told both my OBGYN and DO about all my symptoms and the DO told it was possible that I was premenopausal.  I don't mind the hot flashes, sleeplessness, mood changes, night sweats but I can't stand not having any energy.  All I want is my energy level to be where it was before pregnancy.  Please give my any suggestions.  Thanks!

A: Perimenopause and depression are frequently seen together. Maybe the hormonal instability with the hot flashes is the key problem, maybe a depression. You can try HRT for 3 months. When the lack of energy is still there, even after the disappearance of the flushes, an antidepressive therapy could be more appropriate. Discuss this with your doctor.

Q:  I am 37 years old, have always had a 28 day cycle with moderate cramping and bloating and no moodiness.  In the past 12 months my cycle is getting shorter (25 days apart now), I am experiencing severe cramps and HEAVY flow some months, very light others.  For the past 3months I've been experiencing night sweats, sometimes 2 or more times a night.  The worst part are the completely irrational mood swings for about 3-4 days before my period starts. Other than those 3-4 days I am my normal, happy -go-lucky self.  During those mood swings I don't even recognize myself and sometimes feel like I can't think straight or function at home or at work.  Do you have any advice for me?

A:  PMS worsens frequently during the years before perimenopause. Sometimes birth control pills will give relief and certainly they will regulate your menstrual cycle with less bleeding. When PMS symptoms are severe, serontonin-reuptake inhibitors (like Prozac) can be very helpful.

Please check-out our new collection devoted to PMS/PMDD for more information.

Q I am 25 years old and have been having menopause symptoms for the past year and a half.  It started when I stopped nursing my son.  My periods became very heavy with a lot of  large clots, I had night sweats, hot flashes the works.  I thought that it was just my hormones readjusting.  My periods gradually got lighter and lighter (although regular) to the point where now I just spot for a few days.  I would like to add that before this my periods were NEVER regular.  The night sweats,  hot flashes,  fatigue, severe mood swings and  and weight gain have since gotten worse.  I've tried telling my doctor but no one believes me.  I have gained 15 lbs in 3 months.  I am a runner and I eat pretty well, so I know that I shouldn't be gaining this weight.  I'm frustrated and depressed with the whole situation.  I really don't know what to do next.  Can you help?

A: It is very unlikely that this is perimenopause. Perimenopause can start at every age, but at 25 it is very, very rare. Is there an anxiety disorder? This can mimic all symptoms of perimenopause. Maybe you can check the hormone levels by a gynecologist or a gynecologic endocrinologist.

Doctor, What should I expect from HRT?   

Q:  I am 41, having horrible mood swings with some hot flashes (my face feels like it's on fire), and my Dr. had just prescribed Activella for me. Each tablet contains estradiol 1mg and norethindrone acetate 0.5mg. What all can you tell me about it?  I am especially concerned about any weight gain as at this age it comes on a lot easier. How is it for the heart and bones?

A: Activella is designed for use in the postmenopause. It is a low dose continuous combined hormone replacement regimen. When used by women with irregular periods, bleeding troubles can be expected. In early perimenopause the use of oral contraceptive pills is much more efficient or otherwise a sequential combined regimen. Estrogens or progestogens will not increase weight.

Q: Will taking birth control pills mask menopause or perimenopause symptoms? What symptoms will still be present? My prescription for birth control pills was changed in March.  Since then my periods have become less and less each month until this month when I didn't have one at all.  Is this the different pill or could there be another medical reason?

A: Birth control pills will mask all perimenopausal symptoms. Withdrawal bleedings or missing periods have nothing to do with menopause, but only with the composition of the pill. Maybe, you have now a lower estrogen dose?

Q: I'm not sure when to wear my patch. I still have my periods. My doctor said to put one on when my symptoms are the worst. Memory loss and confusion are my worse symptoms, which seem to be all the time. Should I wear my patch all the time? Thank You.

A: You need to ask this question of your own doctor. I do not know which patch is prescribed: estrogen only or a combined patch. Usually patches are worn all the time. When you are not postmenopausal the best regimen is continuous estrogens and monthly (10-14 days) progestagens.

Q:  I am 47. My doctor has recommended trying birth control pills to reduce hormone fluctuations throughout cycles.  What pill would you suggest?  In your opinion, what is the best one on the market to use for my intentions?

A: Low dose combination pills are the best. They contain 20-30 micrograms of ethinylestradiol and a progestagen. There are rumors about the risk of thrombosis with the progestagens gestoden and desogestrel. So, make your choice from the available products.

Q: I am a 64 yr old female, and my Dr. has had me on promentrium for two years, 100mg.once a day. I am also on the dot estrogen patch. I have been on the patch for 14 yrs. How long do women usually stay on ERT? I see my Dr. yearly, but I was wondering because I have read that 10 years was the maximum time to be on ERT. What is your opinion? Thank you for your time, and your opinion.

A: When using estrogens by women with an intact uterus, progesterone is absolutely necessary and daily 100 mg prometrium is an appropriate dose. After hysterectomy progesterone is prescribed only in a few very exceptional indications. The duration of use of ERT or HRT depends on the indication. Sometimes lifelong use is advised. But remember that with long term use (10-15 years or longer) a small extra risk for breast cancer arises. Discuss this with your doctor.

Q: I have been taking femhrt for over a year, and every now and then when I have taken approximately 15 of the 30 pills, I experience a very small amount of vaginal bleeding which lasts for a very short time and then goes away.  Is this normal?  Any help you can give me will be greatly appreciated.

A: With continuous combined HRT, spotting is seen in most women using this kind of therapy. When this persists a sonographic investigation for the thickness of the endometrial lining is advised and sometimes an endometrial biopsy is performed. Nearly always an atrophic endometrium is seen. There is no reason to worry, because serious causes like endometrial cancer is very rare with this kind of combined therapy. But you have to mention it to your gynecologist at your next visit.

Q: I have been told that after age 35 if you smoke, ( 1-2 packs a week for me) it is not a good idea to be on birth control pills of any kind for fear of blood clots. Is this true? Also I am 44 and have been experiencing mood swigs, irregular periods ( short ones at first, then none, then every other week almost). They did a biopsy and it was benign, now they want to remove a polyp see if this is causing the irregular bleeding. The bleeding seems to be normal now, is this removal of the polyp really necessary? Also I am on hormones because of bad night sweats and hot flashes on and off for the last  6 months to a year.  Thank you for any information you could provide.

A:  The combination of smoking and the use of birth control pills causes a higher risk of cardiovascular disease, not for thrombosis. Smoking cause 800% increase of myocardial infarction (and of course lung cancer), oral contraceptives a 50% rise of the risk. The combination equals 1200%. In young women the absolute risk of myocardial infarction is very low and the 1200% increase remains a very small risk. But above 35 the risk becomes substantial. So quit smoking and continue birth control pills. An endometrial polyp can cause abnormal bleeding and is usually removed when diagnosed.

Q: Can estrogen replacement cause seizures?

A: Yes, it can. Estrogens decrease the level of excitability. So seizures can break through easier. Progesterone and progestogens are protective against seizures. With combined regimens (estrogens+progestogens) no problem is seen. This is a reason for some women to take combination therapy even after hysterectomy.

Q: I had a mammogram about 4 months ago,  my Dr. put me on femhrt. Since I had the mammogram, my breast have been really sore and still are.  Is it the femhrt? What could it be? I am getting scared it might be something else. Does the femhrt tablets have side effects like that? Thank you for your help and time.

A: The best way to handle side effects of a drug is to discuss them with the doctor who has prescribed them. Sore breast is a common side effect of all HRT, especially in the first months of use. So is spotting, especially with continuous combined HRT like Femhrt.

Q:  I started on FEM HRT September 2000, my last period being in August.  I was diagnosed this week with a 'grapefruit' sized (benign as far as the sonogram showed) cyst on one of my ovaries.  As far as I know, I have never had cysts before.  My OB/GYN suggested I have the cyst and both ovaries - for safety's sake - removed immediately. My questions are: could the HRT have caused this cyst to start/grow?  How dangerous is having a cyst this large at my age? (55).  Is there greater risk for ovarian cancer if I don't have this operation?   Is one HRT better than another?

A: HRT does not cause ovarian cysts. Most ovarian cysts disappear spontaneously and a surgical procedure is not necessary. This is for unilocular cysts with a smooth inner surface. Our policy is with a cyst of the size of a grapefruit with benign aspect on sonography to wait for three months and to perform adnectomy if the cyst persists. The chance of malignancy in a simple cyst is about 0.7-3% When ultrasound appearance is not a simple cyst (multilocular or with papillaire formations inside) ovariectomy is advised immediately.

Q:  I hope you can help me. Two years ago I had a total hysterectomy and put on premarin 125. I felt fine for about a year, then I noticed hot flashes and moodiness although not bad. Last year I told my doctor I was feeling depressed, he thought it was due to the fact I lost my sister and said talk to a psychologist, I didn't. I am still on premarin but recently ran out.  Lately I am driving my family nuts, I am like angry, horrible mood swings, not like any other, I have hot flashes, and feel down most of the time.  Can this be caused by the going without my hormones for a week and my body needs to re-adjust? My doc wanted to put me on estratest last time but because of the male hormones I was afraid I would grow facial hair.  I am lost and don't know what to do. Can you please give me some advice please? I would really appreciate it.

A: The premarin does prevent most of your hot flashes. So take this again now all climacteric complaints are evident after stopping. Depression can be regarded as a perimenopausal symptom when serious hot flashes are present. But usually depression is a condition caused by life-events and has to be treated with antidepressants or by a psychologist. I do not expect that androgens will be helpful as an antidepressant and I agree with you that there is always a risk of androgenic side-effects with estratest.

Q:  I am a woman 57 years old and had Ovarian Cancer in 1989. I would like to know which hormone you would feel is the best today?  I have taking Estratest Tabs, I have tried Femhrt, Premarin .625mg,  prempro.  The Estratest tabs have help with my osteoporosis.  Thanks for any help you can give me.

A:  FemHRT and Prempro contain estrogens and progestagens. Premarin only estrogens. Estratest estrogens and androgens. For osteoporosis all of them are good. Without uterus no reason for progestagens is present anymore. Androgens are welcome with HRT when libido is bad and general wellbeing is poor (especially after ovariectomy). So the advice depends of your particular situation. From the brand names in your list, I will choose Premarin or Estratest.

Q:  I'm a 52 year old who still gets regular periods. They last approximately 3-4 days. I was getting them approximately every 24-25 days for years.  Then about six months ago, I started getting them every 19-21 days.  My GYN suggested I started taking medroxyprogesterone on the 16th day after my period started and I was to take it for 10 days.  I got incredible headaches from taking this, not to mention my periods worsened considerably.  I stopped taking it two months ago.  My period that I got after I stopped taking it lasted seven days with heavier bleeding than normal.  Now 26 days later, I still haven't gotten another period even though I have all the symptoms. Could this be a side effect from having this medicine in my system?  

A:  When medroxyprogesteroneacetate induces side-effects, progesterone (prometrium 200 mg per day) will be a good alternative. After stopping the progestagen, within a few days the effect is over. The reason of not having a period now is in your ovaries and a normal part of perimenopause.  It has nothing to do with the MPA in the recent past.

Please check-out this great article called, "Perimenopausal Bleeding - What's Normal?" by Paul D. Indman, MD, USA, Editorial Advisor.

Q:  I am 32yrs old. At the age of 23 I had a hysterectomy due to endometriosis. My hot flashes have not subsided. People say they do, after a while. I was told that if you have something wrong in your body, that your hot flashes are set off. They come more often than usual. My hot flashes have been coming on so bad, I can't stand it! I feel like passing out. Please help me!

A: It is important to know what the activity of your ovaries is. With endometriosis ovaries are sometimes completely damaged. When you are really already in menopause, you can use HRT against your symptoms. With a flare-up of endometriosis symptoms during HRT, one has to choose for a combination regimen: daily combination of estrogens and progestagens despite the absence of an uterus.

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