Approach to Menopause
Every day, in hundreds of doctors’ offices,
the same conversation takes place between women going through
menopause and their doctors. The doctor writes out a prescription
for estrogen pills or patches, saying they will replace the
hormones her body ought to be making. They will cure her hot
flashes, slow her bone loss, and reduce her risk of a heart
attack. The patient asks if the pills cause cancer. The doctor
acknowledges that there is an increased risk of uterine and breast
cancer, but argues that the benefits to the heart and bones are
worth taking the chance.
Other risks enter into the discussion:
strokes, blood clots, and water retention, among others. Women who
have seen friends or relatives die of cancer or stroke might not
find this very reassuring. They may have menopausal symptoms, and
they would like a solution. But they are looking for something
safe, that doesn’t cause more problems than it solves.
Take heart: there are dietary steps, other
lifestyle changes, and natural hormone preparations that can make
menopause much more manageable. They are better for your heart and
bones than estrogen prescriptions could ever hope to be, and they
accomplish these things without the side effects of estrogens.
Premarin is a commonly prescribed estrogen
preparation from Wyeth-Ayerst Laboratories. Although doctors
sometimes describe it as “natural” for women, it is actually a
horse estrogen. On farms in North Dakota and Canada, 75,000 mares
are impregnated and then confined from the fourth month through
the end of their eleven-month pregnancy so their urine can be
gathered in a collection harness called a “pee bag.” After they
give birth, the mares are reimpregnated. Their foals usually end
up as horse meat, and the urine estrogens are packed into pills.
The trade name “Premarin” is simply a condensation of the words
“pregnant mares’ urine”—hardly a natural substance for human
beings to swallow. While Premarin contains estradiol and estrone,
two types of estrogen which are made in humans, it also contains
an enormous amount of equilin, a horse estrogen that never
occurs at all in humans.
Estrogen supplements increase the risk of
blood clots and can cause high blood pressure, gallstones, vaginal
bleeding, nausea, weight gain, breast tenderness, skin
discolorations, headaches, and depression. They also increase the
risk of uterine and breast cancer and make existing cancers much
more aggressive. Women taking estrogen supplements have 30 to 80
percent more breast cancer risk than other women.1-3
If progesterone is added to the regimen, it
removes the increased risk of uterine cancer, although it does not
counteract the higher risk of breast cancer. Synthetic progestins
have side effects of their own, sometimes causing breast
tenderness and fluid retention, and making depression worse.
So why are so many doctors prescribing them?
Partly to treat menopausal symptoms. But more of the push for
estrogens relates to osteoporosis and heart disease. Happily,
there are healthier solutions for both problems.
At around age 50, the ovaries stop producing
estrogens. The adrenal glands (small organs on top of each kidney)
continue to make estrogens, as does fat tissue. But the ovaries
have produced the greatest share of the body’s estrogens for
decades, and when they quit, the blood levels of estrogens drop
Many women go through this change feeling
fine, both physically and psychologically. Nonetheless, some women
are bothered by symptoms, including hot flashes, depression,
irritability, anxiety, and other problems.
There Is No
Japanese Word for Hot Flashes
It has long been known that menopause is
much easier for Asian women than it is for most Westerners. In a
1983 study, hot flashes were reported by only about 10 percent of
Japanese women at menopause, compared to about two-thirds of women
in America and other Western countries.4 And bone
strength is not assaulted to the extent it often is among Western
women. Broken hips and spinal fractures are much less common.
The most likely explanation is this:
throughout their lives, Western women consume much more meat and
about four times as much fat as do women on Asian rice-based
diets, and only one-quarter to one-half the fiber. For reasons
that have never been completely clear, a high-fat, low-fiber diet
causes a rise in estrogen levels. Women on higher-fat diets have
measurably more estrogen activity than do those on low-fat diets.
At menopause, the ovaries’ production of estrogen comes to a halt.
Those women who had been on high-fat diets then have a violent
drop in estrogen levels. Asian women have lower levels of estrogen
both before and after menopause, and the drop appears to be less
dramatic. The resulting symptoms are much milder or even
More evidence of the diet link comes from a
fascinating study by a medical anthropologist from the University
of California who interviewed Greek and Mayan women about their
experience of menopause.5
The Greek women were subsistence farmers.
Menopause occurred at an average age of 47, compared to over 50 in
the United States. About three-quarters had hot flashes, but they
were considered normal events, however, and did not cause women to
seek medical treatment.
The Mayan women lived in the southeastern
part of Yucatan, Mexico. Menopause occurred earlier than in Greece
or North America, at an average age of 42. Unlike the experience
of Greeks and Americans, hot flashes were totally unknown among
Mayans, and, like the Japanese, they have no word for them.
Midwives, medical personnel, and the women themselves reported
that hot flashes simply do not occur, nor are they mentioned in
books on Mayan botanical medicine.
The difference between Americans and Greeks
and other Europeans on the one hand, for whom hot flashes are
common, and the Mayans and Japanese on the other, for whom they
are rare or unknown, appears to be diet. The Mayan diet consists
of corn and corn tortillas, beans, tomatoes, squash, sweet
potatoes, radishes, and other vegetables, with very little meat
and no dairy products. Like the traditional Japanese diet, it is
extremely low in animal products and low in fat in general. The
Greek diet, while rich in vegetables and legumes, also contains
meat, fish, cheese, and milk, as does the cuisine of other
countries in Europe and North America. Animal-based meals affect
hormone levels rapidly and strongly, and undoubtedly contribute to
the menopausal problems that are common in Western countries.
For women who are experiencing hot flashes,
there are useful steps in addition to the low-fat, vegetarian diet
which is strongly recommended for so many reasons. Regular aerobic
exercise helps. A vigorous walk every day or so, or any equivalent
physical activity, seems to alleviate hot flashes.
Andrew Weil, M.D., a well-known physician
and author, recommends trying the herbs dong quai, chaparral, and
damiana, two capsules of each taken once daily at noon, or, if
used as a tincture, one dropperful in a cup of warm water. Vitamin
E, in doses of 400 to 800 IU per day, has also been reported to be
helpful. People with high blood pressure should use no more than
100 IU per day. Jesse Hanley, M.D., a family practitioner in
Malibu, California, has found that certain Chinese herbs, called
Changes for Women, by Zand Herbal, and Menofem, by
Prevail, are helpful in reducing menopausal symptoms for some
women. These supplements are available at most health food stores.
For those women who are considering hormone
supplements, some preparations may be safer than others. Estrogens
that are commonly prescribed by physicians contain significant
amounts of estradiol, which is one of the forms of estrogen
that has scientists and many postmenopausal women concerned about
cancer risk. A different estrogen, estriol, appears to be
safer. The best evidence indicates that estriol does not increase
cancer risk.6-9 Plant-derived transdermal creams
containing estriol and smaller amounts of other estrogens are
available without a prescription. The estrogens pass through the
skin and enter the blood stream, reducing menopausal symptoms.
Creams containing pure estriol must be ordered by doctors, not
because they are more dangerous (they are not), but because the
process of concentrating them qualifies them as drugs, rather than
Dr. Hanley finds that a mixture of
plant-derived estrogens and progesterone is often helpful.
Transdermal creams containing estriol, estradiol, estrone, and
natural progesterone are very effective in reducing hot flashes.
Regrettably, less research has been done on
the use of estriol, compared to estradiol. Even though there is no
evidence of cancer risk with estriol, Dr. Hanley recommends that
if any estrogen cream, including estriol, is used, that it be
accompanied by progesterone to reduce the risk of uterine cancer,
and that it be monitored by a physician so it can be tailored to a
woman’s individual needs. “Whatever formula is used, it should
have some progesterone in it,” Dr. Hanley said. “Also, women
should cycle their hormones. The cream is used from day 1 to day
26 of the cycle, followed by 4 to 6 days off.” If additional
natural progesterone is used, it should be added for the final two
weeks (days 13 to 26) and stopped together with use of the cream.
Natural progesterone alone helps reduce
symptoms for some women. Progesterone and estrogen creams are
available from Professional Technical Services (800-648-8211),
Women’s International Pharmacy (800-279-5708), or Klabin Marketing
Solutions for Dryness
At menopause, vaginal blood flow falls.
Dryness and irritation can occur, and bacteria infections that
pass to the urinary tract are more likely.
What is to be done? First of all, even after
the ovaries stop, the adrenal glands and the fat tissue continue
to contribute to estrogen production after menopause. In addition,
phytoestrogens in plants provide weak estrogen effects. Soy
products, such as tofu, tempeh, and miso, contain huge amounts of
these natural compounds.
The plant-derived estrogen and progesterone
creams described above can be helpful. Used on a regular basis,
these creams maintain a moist vaginal lining. They should not be
used as a sexual lubricant however, as an older couple learned the
hard way. A letter to the editor of the New England Journal of
Medicine described a 70-year-old man who developed an
enlarging left breast.10 He went to see his physician
who removed the mass. Several months later, the same thing
happened on the right side. It suddenly struck him that his wife
was using a vaginal estrogen cream, not only twice a week to treat
vaginal dryness, but also as a sexual lubricant two or three times
per week. As gratified as his doctor may have been to learn that
this older couple was still maintaining frequent conjugal bliss,
the doctor had to conclude that the estrogen cream had caused the
man’s breast enlargement. They switched lubricants and his
enlarged breast went away. Estrogen cream is a medication, not a
lubricant, and it goes through any skin it touches. Many women
prefer to avoid hormone creams entirely and use ordinary
lubricants or moisturizers instead.
Psychology of Menopause
Hormone shifts can affect moods. To the
extent that these shifts are smoothed out by dietary steps,
psychological effects are more manageable. Here are the most
common psychological accompaniments of menopause:
Anxiety. Women who have never had a
problem with anxiety before may become more self-conscious and
more worried about minor events. In some cases, panic attacks
occur. Mental health professionals have a variety of effective
treatments. Many people feel much better just knowing what the
The most important piece of advice is not to
let anxiety restrict your activities. When anxiety or panic
disorders cause people to avoid stressful situations, the result
can be an ever-tightening leash that keeps them from enjoying
life. Anxiety can lead to avoidance of many aspects of normal
life. Prompt treatment prevents this.
Depression and Irritability.
Depression seems to be particularly common when menopause is
medically induced, e.g., after removal of the uterus and ovaries
because of illness. Irritability is also common.
To the extent that depression, irritability,
or anxiety need treatment, it is important to explore the full
range of available options. The first step is to get your diet in
order and to get regular exercise to help stabilize hormone shifts
and reduce physical symptoms that can aggravate mood problems.
Psychotherapy can be very useful, and new short-term techniques
have demonstrated their effectiveness at considerably less
investment than is demanded by traditional therapies. New
anti-depressants and antianxiety drugs have emerged in the past
years which have fewer side effects than older medications.
Poor Memory and Concentration. Some
women find that menopause brings occasional memory lapses, often
related to reduced ability to concentrate. This can be upsetting
and annoying, but happily it seems to go away on its own with
Restoring Strong Healthy Bones
Osteoporosis—thinning of the bone tissue—is
common, particularly among Caucasian women, after menopause. The
cause is not an inadequate calcium intake, ordinarily. The problem
is abnormally rapid calcium loss, aggravated by the following five
1. Animal protein. When researchers
feed animal protein to volunteers and then test their urine a
little later, it is loaded with calcium, which comes from their
bones. Here’s why. A protein molecule is like a string of beads,
and each “bead” is an amino acid. When protein is digested, these
“beads” come apart and pass into the blood, making the blood
slightly acidic. In the process of neutralizing that acidity,
calcium is pulled from the bones. It ends up being lost in the
urine. A recent report in the American Journal of Clinical
Nutrition showed that when research subjects eliminated meats,
cheese, and eggs from their diets, they cut their urinary calcium
losses in half.11 Switching from beef to chicken or
fish does not help, because these products have as much animal
protein as beef, or even a bit more.
2. Sodium (salt). If you throw salt
on a slippery sidewalk, it dissolves the ice; if you sprinkle it
on your food, it can dissolve your bones, albeit by a different
mechanism. Salt apparently increases calcium losses via the
kidneys. For an average person, cutting sodium intake in half
reduces the daily calcium requirement by about 160 milligrams.12
Grains, vegetables, fruits, and beans are very low in sodium
unless salt is added to them. Snack foods, canned foods, dairy
products, and meat tend to drive up the amount of sodium in the
3. Caffeine. Whether it comes in
coffee, tea, or colas, caffeine is a weak diuretic that causes
calcium loss via the kidneys.13
4. Tobacco. Long-term smokers have 10
percent weaker bones and a 40 percent higher risk of fracture.14
5. Sedentary lifestyle. Bones that
have nothing to do lose their strength.15
When you eliminate these calcium-wasters,
you need less calcium in your diet. However, you will always need
some calcium. If you get very little calcium, say, less than 400
milligrams per day, you may not be giving your body the calcium it
Although many people try to get their
calcium from milk, only about 30 percent of calcium in dairy
products is absorbed. The remaining 70 percent never makes it past
the intestinal wall and is simply excreted with the feces. Milk
products also contain lactose sugar, animal proteins, and frequent
traces of antibiotics and other contaminants.
The healthiest calcium sources are “greens
and beans.” Green leafy vegetables are loaded with calcium. One
cup of broccoli has 178 milligrams of calcium. What’s more, the
calcium in broccoli and most other green leafy vegetables is more
absorbable than the calcium in milk. An exception is spinach,
which tends to keep its calcium to itself. Beans, lentils, and
other legumes are also loaded with calcium. If you make green
vegetables and beans regular parts of your diet, you’ll get two
excellent sources of calcium.
You don’t need to eat six cups of broccoli
or huge servings of beans to get enough calcium. A varied menu of
vegetables and legumes can easily give you all you need, and the
amount your body needs is far less when you steer clear of meats
and the other calcium-depleters. The World Health Organization
recommends a daily calcium intake of just 400 to 500 milligrams
If you decide to add extra calcium,
calcium-fortified orange juice is a good choice. It contains more
calcium than milk, and it is in the form of calcium citrate, which
is much more readily absorbed than that in milk or in calcium
HEALTHFUL CALCIUM SOURCES
(content in milligrams)
|Black turtle beans
(1 cup, boiled)
|Broccoli (1 cup,
|Brussels sprouts (8
(1 cup, boiled)
|Celery (1 cup,
|Chick peas (1 cup,
|Collards (1 cup,
|Corn bread (1
|Figs, dried (10
|Great northern beans
(1 cup, boiled)
|Green beans (1
|Kale (1 cup,
Kidney beans (1
|Lentils (1 cup,
Lima beans (1
|Navel orange (1
|Navy beans (1 cup,
|Onions (1 cup,
calcium-fortified (1 cup)
|Pancake mix (1/4
cup, 3 pancakes)
|Pinto beans (1
|Raisins (2/3 cup)
|Soybeans (1 cup,
|Sweet potato (1
|Tofu (1/2 cup)
|Vegetarian baked beans
|Wax beans (1 cup,
|Wheat flour, calcium
enriched (1 cup)
|White beans (1
Source: J.A.T. Pennington,
Bowes and Church’s Food Values of Portions Commonly Used.
(New York: Harper and Row, 1989.)
* package information
As sunlight touches the skin, it turns on
the natural production of vitamin D, which helps your digestive
tract absorb calcium from foods and makes your kidneys hold onto
it as well. For those who get infrequent sun exposure, any common
multivitamin containing 5 micrograms (200 IU), taken daily,
provides adequate vitamin D. For people who never go outdoors due
to chronic illness, 10 micrograms (400 IU) is recommended. Higher
doses of vitamin D can be toxic and should be avoided.
Strength to Bones
Natural progesterone stimulates the bones to
rebuild healthy bone tissue in areas where it has been lost.
Unlike estrogens, it has no known serious side effects. In a study
of 100 postmenopausal women, the average patient had a 15 percent
increase in bone density after three years of treatment.16
What makes this so remarkable is that doctors have been looking
for ways to slow the rate of bone loss, and most never dreamed it
would be possible to actually build bone. But an increasing number
of clinicians are finding exactly that.17,18
Altered forms of progesterone, called
progestins (e.g., Provera), are heavily promoted by drug
companies and are commonly prescribed by doctors. But these
unnatural chemicals do not quite fit into the body’s systems for
using and eliminating progesterone. They are the biological
equivalent of using the wrong replacement part in your car’s
engine. While the pharmaceutical companies’ financial machinery
hums along just fine, your biological machinery can have a
multitude of side effects, ranging from facial hair growth and
depression to heart disease, liver problems, and even breast
cancer. The body was built to use natural progesterone, not
Here is how natural progesterone is used:
Usually, a two-ounce jar is used up each month. Later, the dosage
may be reduced to one ounce per month. In postmenopausal women,
the cream is usually used each month for two to three weeks, then
stopped until the beginning of the next month. In women who have
not yet stopped menstruating, the cream is usually used from about
day 13 to day 26 of the menstrual cycle. To maintain its effect,
it is discontinued for at least five to seven days each month.
It is spread on areas of thin skin, such as
the insides of the arms or legs, the neck, upper chest, and
abdomen, covering as wide an area as possible and varying the
areas to which it is applied. It takes a while for progesterone to
build up in the fat tissue, so it may take two or three months to
Because progesterone facilitates the effects
of thyroid hormone, women taking thyroid medications may need to
reduce or discontinue their thyroid medications after beginning
progesterone, which should be done in consultation with their
Postmenopausal women who are taking
estrogens are often advised to cut their estrogen dose in half
when starting progesterone, because progesterone temporarily
increases the body’s sensitivity to estrogen. Many women find that
they no longer need estrogen at all after a few months using the
Women who are currently using an artificial
progestin, such as Provera, can easily switch to natural
progesterone, but should taper off the progestin gradually. A
typical regimen would be to cut the progestin dose in half for the
first month that progesterone cream is used. In the second month,
it should be cut in half again, using it every other day, if
necessary. By the third month, the progestin can be safely
While prescription estrogens are sometimes
used to reduce the risk of heart disease, a combination of a
vegetarian diet, daily modest exercise, smoking cessation, and
stress reduction is much more effective, and has been shown to
actually reverse existing heart disease in 82 percent of
patients. And while estrogens increase cancer risk, these healthy
lifestyle changes actually reduce the risk of cancer and several
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postmenopausal hormone use and risk of breast cancer: 12-year
follow-up from the Nurses’ Health Study. Cancer Causes and Control
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3. Bergkvist L, Adami HO, Persson I, Hoover R, Schairer C. The
risk of breast cancer after estrogen and estrogen-progestin
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4. Lock M. Contested meanings of the menopause. Lancet
5. Beyene Y. Cultural significance and physiological
manifestations of menopause: a biocultural analysis. Culture,
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6. Follingstad AH. Estriol, the forgotten estrogen? JAMA
7. Heimer GM. Estriol in the postmenopause. Acta Obstet Gynecol
Scand 1987;Suppl 139:3-23.
8. Molander U, Milsom I, Ekelund P, Mellstrom D, Eriksson O.
Effect of oral oestriol on vaginal flora and cytology and
urogenital symptoms in the post-menopause. Maturitas
9. Gerbaldo D, Ferraiolo A, Croce S, Truini M, Capitanio GL.
Endometrial morphology after 12 months of vaginal oestriol therapy
in post-menopausal women. Maturitas 1991;13:269-74.
10. DiRaimondo CV, Roach AC, Meador CK. Gynecomastia from exposure
to vaginal estrogen cream. N Engl J Med 1980;302:1089-90.
11. Remer T, Manz F. Estimation of the renal net acid excretion by
adults consuming diets containing variable amounts of protein. Am
J Clin Nutr 1994;59:1356-61.
12. Nordin BEC, Need AG, Morris HA, Horowitz M. The nature and
significance of the relationship between urinary sodium and
urinary calcium in women. J Nutr 1993;123:1615-1622.
13. Massey LK, Whiting SJ. Caffeine, urinary calcium, calcium
metabolism and bone. J Nutr 1993;123:1611-4.
14. Hopper JL, Seeman E. The bone density of female twins
discordant for tobacco use. N Engl J Med 1994;330:387-92.
15. Mazess RB, Barden HS. Bone density in premenopausal women:
effects of age, dietary intake, physical activity, smoking, and
birth-control pills. Am J Clin Nutr 1991;53:132-42.
16. Lee JR. Osteoporosis reversal; the role of progesterone.
International Clin Nutr Rev 1990;10:384-91.
17. Prior JC. Progesterone as a bone-trophic hormone. Endocrine
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This article is condensed from
Eat Right, Live
Longer, by Neal D. Barnard, M.D., Harmony Books, 1995.