The Season of our Discontent
By Sylvia Wrobel, Photography by Jack Kearse
On a sweltering summer evening, a group of six women gather around a candlelit table covered with sparkling glasses, deviled eggs, peach salad, North Carolina trout, and roasted sweet potatoes.
Despite having just met, the women—all in their early 50s—are talking like old friends, sharing stories of night sweats, crying jags, hot flashes, and brain fog. Laughter floats through the humid air, amplified by the instant camaraderie that common frustrations can forge.
"I just can't run as far or fast as I used to," says one woman, an avid runner whose mile speed has rapidly diminished. "It happened so dramatically and quickly."
"Nights are the worst for my hot flashes," she adds. "I have a fan and a space heater next to each other in the bedroom."
"After a few nights of no sleep, I will cry about anything," says another.
No matter the individual symptoms, the women's questions centered on a common theme: How long does this last?
"Well, usually two to five years for the most severe symptoms, but up to 12 years," says obstetrician/gynecologist Mary Dolan, one of a handful of certified menopause practitioners in Georgia. "And technically forever, since what we are talking about is a lack of periods and a diminishing of estrogen."
A lot is happening during this time in a woman's life, says Dolan, from physical changes to emotions surrounding children leaving home and caring for aging parents. Many doctors and even specialists are not trained in how to treat women during this phase. "Other health concerns, such as heart conditions or breast cancer, tend to get more attention," she says. "After all, you don't die from menopause."
But how you deal with issues that arise during this hormonal shift can influence your physical and mental health over the long run, impacting everything from bone density to cardiovascular conditions.
That's why a place where practitioners are well versed in women's health, midlife challenges, and the latest effective therapies for aging well is vital to treating this target demographic, says Dolan, director of the new Emory Midlife and Menopause Center. Located on the seventh floor of the Doctor's Building at Emory Saint Joseph's Hospital, the clinic is a large airy space with one wall overlooking the Atlanta skyline. Clinics specializing in women's health during midlife exist at just a handful of other academic health centers—Harvard, UC San Diego, Mayo.
Ira Horowitz, head of the Emory Women's Center (of which the new clinic is a part), says that historically, women going through menopause have been overlooked by the medical establishment. "Even obstetrician-gynecologists can focus too much on a woman's fertile years, as opposed to her whole lifespan," he says. "Understanding a woman's midlife and menopausal needs will be more and more important as our population ages."
Fifty-one is the average age when women have their final menstrual period. But Dolan, director of the Midlife and Menopause Center, says she and her colleagues are concerned about "menopause, the big picture"—what happens to women in the years before, during, and after that last period.
Not your mother's "change of life"
Dolan, director of the Emory Midlife and Menopause Center, became focused on menopause—especially non-estrogen options for its treatment—during a fellowship as an Epidemic Intelligence Service officer at the CDC, when she saw the effects of surgical or chemotherapy-induced menopause on young women with breast cancer.
Dolan sees 50 to 60 patients a week. The typical patient is in her mid-40s or early 50s, and experiencing problems related to the changes of perimenopause.
For some, menopause happened suddenly, following surgical removal of the ovaries, certain forms of chemotherapy, or other medical conditions affecting estrogen production. Others experienced classic perimenopausal symptoms— abnormal periods, hot flashes, trouble sleeping, mood swings—leading up to their last period. And some thought menopause was behind them, only to find themselves facing recurring urinary tract infections, vaginal pain, or sexual problems.
Many of Dolan's patients are seeking a second opinion and have questions about hormone replacement therapy (HRT), which lost popularity after a major study showed that it increased women's susceptibility to some serious diseases and risks. Other research, however, has shown that if the right hormones are used in the correct way, they can still be of benefit to some women.
Dolan calls the years around menopause "a good time for women to pause, focus on themselves—sometimes for the first time in years—and take stock of what they need to do to maximize their health and well-being. Our job is to help them do that."
The team develops a personalized treatment plan for each woman coming into the center, based on her initial evaluation.
A symptom and health risk assessment
Evaluating and discussing appropriate treatment of menopausal symptoms, from hot flashes to mood changes to sexual problems such as decreased libido, diminished genital sensitivity, vaginal pain, or difficulty achieving orgasm.
Dealing with risks
Gauging aging and menopause-related hormonal changes, primarily through:
- a breast exam, referral for mammograms and other imaging modalities; prevention strategies for women at high risk of breast cancer, and gynecologic care for breast cancer survivors
- osteoporosis and bone density testing
- referrals, as needed, for colon cancer screening
- screening for pelvic organ prolapse, urinary incontinence, overactive bladder, and other problems, which are then treated by a urogynecologist on the Midlife and Menopause team
Bringing in other specialists as needed
While the center's core physicians—Dolan, Taniqua Miller, and Penny Castellano—are all gynecologists with special interest and training in menopause, the Midlife and Menopause Center is connected to a range of specialists for comprehensive care who see patients at the center on a regular basis. For example, gynecologic oncologists see women with (or at high risk for) ovarian and uterine cancers. Endocrinologists see women with excessive hair growth or loss or thyroid disorders. Gastroenterologists provide colon cancer screenings and treat irritable bowel or gluten sensitivity. Rheumatologists see patients for autoimmune conditions that can develop. Neurologists help with insomnia or migraines. Psychiatrists evaluate and treat severe mood swings or depression. In turn, they sometimes refer their patients to Dolan.
Hormonal changes can lead to loss of bone and muscle mass, digestive issues, and weight gain. Average gain is five pounds, but many women gain more.
Especially important, says Dolan, is the collaboration with the Emory Women's Heart Center, since cardiovascular disease remains the No. 1 killer of women in the United States, with risk factors increasing after menopause.
On changing nutritional needs
Hormonal changes can lead to loss of bone and muscle mass, digestive issues, and weight gain. Average gain is five pounds, but many women gain more. "Fat redistribution, often to the belly, is common," Dolan says. A woman's caloric needs go down by some 500 calories after menopause, she says, but simply lowering caloric intake isn't a good idea without taking into account other changing nutritional needs, such as more calcium for bone and teeth health.
Estrogen still an option
When it comes to menopause-related symptoms, Dolan and her colleagues have an array of treatments at their disposal. Each is personalized, taking into account a patient's symptoms, age, history, and preferences. Each is evidence-based, relying on research with large numbers of people similar to the patient. And yes, some of those treatments involve estrogen.
FDA-approved estrogen remains the single most effective treatment for hot flashes, says Dolan, but she understands why many women ask for an assurance that the benefits outweigh the risks. They may remember that, in 2002, almost six decades after women began using HRT, results from the large Women's Health Initiative (WHI) study showed that study participants taking estrogen and progesterone did lower their risk for hip fracture and colon cancer, but unexpectedly, they also showed a small but statistically significant increase in the risk of coronary heart disease, stroke, blood clots, and breast cancer.
Women using only estrogen had a lower risk of coronary heart disease, breast cancer, and hip fracture, but a slightly higher risk of stroke and embolism.
Use of systemic hormone therapy dropped by 80 percent almost overnight. Women were left confused and anxious. Nonprescription treatments flourished—some useful, some closer to snake oil remedies.
Today, estrogen replacement is back on the table, in part because of a closer look at the WHI study. As one of the original investigators recently wrote in the New England Journal of Medicine, the findings among the older women who participated in the WHI study are "now being used inappropriately in making decisions about treatment for women in their 40s and 50s."
The WHI study was designed to assess the risks and benefits of long-term hormone therapy for prevention of chronic disease in women ages 50 to 79. Many of the women in the study (average age, 63) were well past menopause when they began hormone replacement for the first time.
Estrogen remains the single most effective treatment for hot flashes, says Dolan, but she understands why many women ask for assurance that benefits outweigh risks.
Newer studies would show that this was not the way HRT should be used—that the therapy works best and with fewer risks when begun within six years of menopause. "In general, starting earlier is better than starting later," Dolan says.
Thanks to a number of studies that took age, timing, and type of hormone into account, leading medical groups devoted to menopausal medicine now recommend systemic hormone therapy for women with moderate to severe hot flashes and with no contraindications to its use. Today's view, says Dolan, is that HRT is safe and beneficial when the right formulation is given to the right woman through the right delivery system, beginning and ending at the right time.
Women who begin HRT within six years of menopause also show less plaque buildup, indicating lowered risk for atherosclerosis.
If estrogen therapy is started 10 or more years after menopause, this benefit is not seen.
How long the therapy continues also matters, says Dolan. In general, five years of use does not appear to increase the risk for breast cancer.
Some women take supplements for decades with no ill effects. "I have some patients who are 80 and still on hormones," she says.
What Dolan recommends most often for HRT are natural FDA-approved hormones, manufactured to be chemically identical to hormones produced in a woman's body, primarily by the ovaries, during the reproductive years.
She uses the lowest dose estrogen (estradiol) that will successfully relieve a woman's hot flashes and other menopause symptoms, combining the estradiol with enough progesterone to protect the uterus from cancer.
Estradiol is available as an oral tablet, as is progesterone. The FDA also has approved estradiol delivered by transdermal patches, creams, and sprays. Vaginal dryness and pain can be treated with creams or tablets placed directly in the vagina or with vaginal rings that stay in place, delivering low-dose estrogen. While this localized approach can be very successful for vaginal dryness and pain, it does not help combat hot flashes.
For women who prefer not to use estrogen or for whom estrogen is contraindicated—those with a strong family history of breast cancer, for example—a nonhormone drug, Brisdelle (low-dose paroxetine, or Paxil), is approved by the FDA for hot flashes. Other drugs approved by the FDA for depression, epilepsy, migraine, and nerve pain also work better than placebos in treating hot flashes and other symptoms.
Dolan's team also has advice on simple lifestyle changes that can help: avoiding alcohol or caffeine; lowering stress through meditation, yoga, or massage; slow, deep, abdominal breathing, in through the nose and out through the mouth; frozen cold packs (or a bag of frozen peas) under the pillow, turning for coolness.
Studies have found that one or two servings of soy foods daily help reduce hot flashes for some women, Dolan says, but cautions that many products sold over the counter as menopause aids are not FDA-approved and little is known about their safety.
Women's health at midlife and beyond has been too often ignored by clinical medicine in the past.
A parallel goal of the Emory center is to train the next generation of physicians to be aware and sensitive to these issues and therapies, Dolan says, since women's health at midlife and beyond has been too often ignored by clinical medicine in the past.
Patients also have the opportunity to participate in ongoing Emory research, such as a current study looking at changes in the vaginal microbiome (the trillions of microbes that live on and in the body) during menopause.
As night begins to fall, the women at the dinner gather closer to the candles and start asking Dolan more personal questions.
"Do men have a version of menopause?" one asks.
No, replies Dolan, but there are aging issues for both genders.
"If you take HRT, when you go off the hormones, do you have to go through menopause all over again?"
Not really, Dolan replies. "Since you can taper down, and let your body adjust, it's won't be nearly as severe."
What can you do about symptoms like dryness or thinning of the vagina walls?
Medications can help, Dolan says, as well as special lubricants. Staying sexually active is not only possible but recommended, she adds.
"Use it or lose it," someone jokes.
The group asks if there are proven methods for reactivating a reduced libido.
"Bibliotherapy has been suggested," says Dolan.
"So, Fifty Shades of Grey?" one woman suggests, to laughter.
"Whatever works for you," Dolan says.
And with that, the women—amid hugs and goodbyes—walk off into the sultry night, sweaty but hopeful, ready to take on whatever comes next.
ALL ABOUT THE HORMONES: During perimenopause, hormonal levels fluctuate. Fairly minor and temporary drops in estrogen are responsible for the infamous hot flashes. Other hormones produced by the ovaries also change: progesterone (which prepares the lining of the uterus for a fertilized egg) and testosterone (sometimes called the "male hormone" but important to women's sexual health as well). As these levels fluctuate, menstrual periods become erratic: longer, shorter, heavier, lighter, more or less frequent. Fertility goes down but does not necessarily go away until after a woman's last period.
THE DOWN SIDE: Changing hormones or side effects like sleep deprivation can cause "mental fog" or memory lapses, and it becomes more difficult to concentrate or multi-task. Some women experience severe mood swings or depression for the first time. Women with a history of postpartum depression or severe pre-menstrual syndrome (PMS) may have a more difficult transition through menopause. Those with pre-existing depression or other psychiatric disorders may find that once-effective medications no longer work as well due to hormonal changes. Changes that occur with menopause include a higher risk of cardiovascular disease and rises in blood pressure, LD cholesterol (the bad one), and triglycerides. Postmenopausal women also have a significantly higher incidence of breast, ovarian, and other gynecologic cancers.
FOR MORE: Some of the useful fact sheets given to patients at the Midlife and MenopauseCenter are available at menopause.org, the website of the North American Menopause Society (NAMS).
Lost that Loving Feeling?
The impact of estrogen on brain function is well known to scientists—and to women who experience changes in memory, mood, and sexual desire, all related to falling estrogen levels.
Estrogen replacement can ease these problems but also can have unwanted side effects. But what if estrogen could be delivered directly to the brain, bypassing other parts of the body? A study at the Yerkes National Primate Research Center is testing a way to do just that.
Menopause experts at North Texas Health Sciences Center and the University of Maryland recently synthesized a compound that binds together estradiol (biologically identical to naturally occurring estrogen) and the antioxidant quinol. When injected into mice whose ovaries had been removed, the compound traveled throughout the body, the estrogen apparently unrecognized by the body's many estrogen receptors, until it reached the brain. There, an enzyme found only in the brain stripped away the quinol, liberating the estradiol and allowing it to bind to the receptors and get to work. Estrogen-related changes could be seen in the mice's brains, with no evidence of estradiol anywhere else.
For the next research step, the team called Emory neuroendocrinologist Kim Wallen. He and neuroscientist Mark Wilson have spent years studying hormonal changes in rhesus monkeys living in a large social colony at Yerkes. They began testing the compound on seven monkeys who'd had their ovaries removed. Beyond the precise targeting of the brain, Wallen is interested to see if it will counteract the fact that sexually active rhesus females lose all interest in sex as soon as their ovaries are removed and estrogen levels plummet. Can this interest be rekindled by the brain boost? Stay tuned for the results.
BY THE NUMBERS
Menopause is official when a woman has not had a period for 12 consecutive months.
Median age of a woman's last period is 51.
Perimenopause usually lasts from 2 to 5 years.
1 in 4 perimenopausal women is still ovulating and at risk for pregnancy.
3 in 4 perimenopausal women report hot flashes or night sweats.
Nearly 50% of women experience drying and atrophy of vaginal tissue, which can adversely affect sexual health.
Following menopause, women experience a marked increase in cardiovascular disease, the No.1 killer of women.
Postmenopausal women are 2.7 times more likely to have heart disease than age-matched premenopausal women.
Women over 50 have the greatest risk of developing osteoporosis.
Estrogen deficiency causes 75% or more of the bone loss in postmenopausal women, placing them at increased risk for bone fracture.
Emory's ob/gyn department has 4 faculty members who are NAMS (North American Menopause Society) Certified Menopause Practitioners: Drs. Mary Dolan, Penny Castellano, Victoria Green, and Taniqua Miller.