Menopause and Hair Loss

What causes hair loss?

The precise cause of the hair loss is unclear, but in majority of cases appears to be genetically determined and is an inherited alteration in the way individual hair follicles metabolize the sex hormone testosterone. This type of hair loss is known as androgenetic alopecia or genetic balding. Almost all women experiencing this type of hair loss have normal hormonal function including, normal testosterone levels, normal menstrual function and fertility. Affected women are believed to undergo a higher rate of conversion of testosterone to its more potent form dihydrotestosterone (DHT). The higher level of DHT in the hair follicle is believed to be the mechanism responsible for the hair loss.

While most assume balding is a male problem it occurs about equally in both sexes, affecting 50% men and 40% of women by age 50. The hair loss experienced in women is usually milder and begins between the ages of 12-40 years of age.

Are there non-inherited forms of hair loss in menopausal women?

Women who do have abnormally high levels of male sex hormone may also experience thinning of scalp hair. Signs of abnormally high levels, include an increase in body, or facial hair especially if appearing in a masculine pattern of distribution, severe cystic acne, abnormal menstruation, breast secretions and clitoral enlargement. Women who are experiencing these problems should speak to their doctors about a referral to a physician who is experienced in diagnosing and treating these problems.

Additional problems that have been associated with hair loss in menopausal women include anemia, thyroid disorders, syphilis, fungal infections, connective tissue diseases such as Lupus, hormone secreting tumors, significant weight loss and stressful life events. Alopecia areata, a condition of localized balding is considered by many to be an autoimmine disease. Traction alopecia is a form of hair loss associated with excess traction on the hair either during styling, or by habitual tugging by the woman herself.

What about poor scalp circulation and clogged hair follicles?

Commonly used explanations for hair loss put forth by those selling over-the-counter remedies for hair loss, such as poor scalp circulation and clogged hair follicles have been found to have no role in hair loss. To my knowledge the products they sell are of no benefit.

Can medication cause hair loss?

Treatment with cancer chemotherapy is well known to be associated with hair loss. Medication-related hair loss is not fully understood, but thought to be due to a disruption of the normal anagen/telogen phases of hair growth. The hair loss may be reversible when the medication is discontinued. One research study evaluated the reasons and rates of removal of subdermal levonorgestrel implants (Norplant) a medication used for contraception. Among those desiring removal, hair loss was cited as the reason 13.6% of the time. Medication-induced hair loss is an occasional side effect of antidepressants and other psychoactive drugs. In these cases stopping the medication usually results in regrowth of the lost hair. Other medications that have been implicated by some in hair loss include cholesterol lowering medication, oral contraceptives and blood thinners.

Testosterone replacement at appropriate levels is rarely associated with hair loss, but may be a factor in some susceptible women. Women who experience this problem, but desire to use testosterone replacement because it enhances their quality of life may find that taking spironolactone while on testosterone replacement prevents the problem.

Hair Loss Treatment Options

Topical minidoxil solution (Rogaine) is FDA approved for the treatment of hair loss in women with androgenetic alopecia. Finasteride (Propecia), is presently the most effective medical treatment for men. Given orally at prescribed doses it promotes hair growth and prevents further hair loss in a significant proportion of men with androgenetic alopecia. It is thought to work by inhibiting the conversion of testosterone to DHT. Although some research suggests it is effective for this type of hair loss in women it is not FDA approved for this use because of a known risk of fetal malformations. Regardless, some physicians currently use it in women who are not at risk of pregnancy. Spironolactone (Aldactone), a medication with mild diuretic properties has been used with success in some cases. The rationale for its use is based on the belief that it interferes with the ability of androgens to bind to the receptors in the hair follicle thereby not allowing DHT to exert its effect.

If a form of treatment is found to be effective it should be continued indefinitely assuming there are no negative side effects, or advised to do so by a knowledgeable physician as stopping the treatment results in a return of hair loss.

Hair replacement surgery is an option for some women. The best candidates for this type of treatment should have areas of dense hair growth at the back or sides of the head available for transplantation. Women in whom a medical or surgical approach is not effective, not feasible, or not desired may choose to use a wig, or hair extensions.

Do I need to see a doctor if I am having some hair loss?

Hair loss in menopausal women is perceived uniquely by the individual woman experiencing it. Nonetheless, in some it is capable of negatively impacting self-esteem and quality of life. Every woman affected should address the problem in the manner she feels is most appropriate for her. However, it is important for women with undiagnosed hair loss to be appropriately evaluated by a physician for causes of hair loss other than androgenetic alopecia as there are a number of underlying medical conditions that may mimic this condition.

Menopause Overview
This page defines and discusses menopause, surgical menopause and premature menopause...

Menopausal Symptoms
A woman may experience a number of changes in the way she feels at or prior to menopause. We call these changes the "symptoms" of menopause. This page defines and discusses menopausal symptoms and their treatment...

Sex and Menopause
Loss of sexual desire and ability to participate in and enjoy sex is not a normal part of aging. Dr Nosanchuk explains why a menopausal woman's desire to have sex and her capacity to physically participate in sex are both affected by her menopause... 

Menopause & Weight Gain
Dr Nosanchuk discusses the factors that influence weight gain in menopausal women...

Menopause & Migraine
This section discusses the nature of migraines and its relationship to menopause and hormone levels. In addition it provides strategies that may reduce the number and frequency of headaches...

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Menopause and Migraine

What is Migraine?

Migraine is an inherited or acquired combined disorder of the nerve and vascular tissue of the brain. The manifestation of this disorder is the headache, which occurs intermittently as a result of a stimulus or "trigger." In those affected, the frequency can vary markedly, and the headaches can occur rarely or on a daily basis. Common triggers include, odors, flashing lights, stress, lack of sleep and other various stimuli. Hormones can act as a trigger and a common variety of this is what is called "menstrual headache." This type of migraine is usually related to the fall in estrogen levels that occurs prior to menstruation. It is also likely that progesterone sensitivity plays a role as well in many women.

I have recently become menopausal and I am having trouble with migraine headaches. Why?

If migraine headaches occur initially, or become significantly worse following menopause, especially a surgical one, the possibility that it is related to your menopause and its associated hormonal alterations is certainly a reasonable consideration.

Is this because of my hormone replacement therapy / HRT?

When migraine occurs in post menopausal women there a number possibilities that can be considered.

Migraine usually does not occur as a result of estrogen itself, but rather changes in estrogen levels. The fall in estrogen levels that occurs at menopause can trigger migraine. This is particularly true when the menopause is surgical and the fall in hormone levels is abrupt. Regimens in which the estrogen levels vary widely, such as estrogen injections given on a monthly basis can potentially trigger migraine as the estrogen levels are very high immediately following the injection and fall off rapidly.

In some instances women who take oral estrogen preparations suffer from migraine triggered by substances produced as a byproduct of the inherent "first pass liver metabolism" of oral estrogen.

If the woman has a uterus and the headaches occur during the time she is taking the progesterone component of her hormone replacement therapy regimen, one would expect that they are due to either the progesterone, which has anti estrogenic affects, and/or falling estrogen levels if her regimen includes stopping her estrogen prior to her withdrawal bleeding.

What to do?

The first thing to do would be to see a neurologist to make sure that the headaches are not due to another problem. The neurologist can also discuss whether it would be better to treat the individual headaches if they do not occur too frequently, or to prescribe preventative therapy if they do.

Should I change my hormone replacement therapy / HRT regimen?

It would make sense to use a non oral regimen of hormone replacement therapy, preferably one that results in consistent hormone levels. Ideally, this would be an estrogen patch or gel, or subcutaneous hormone implants. Some menopausologists feel that migraine can occur as a result of testosterone deficiency especially when there has been a surgical removal of the ovaries and have had some success by replacing testosterone levels along with estrogen. Physicians who use subcutaneous hormone implants may be particularly successful when this is the problem. They are able to replace the estrogen and testosterone in a manner where after the initial rise in hormone levels occur, the day to day change in hormone levels is fairly small. I had some success using this method in selected patients, however the headaches returned when the hormone levels dropped below a critical point which was unique to each individual. At that time, ideally, implantation of hormones would be repeated. Testosterone patches in appropriate doses for women are not made in the United States, and so one of the available male replacement patches would have to be cut to an appropriate dosage size or a testosterone gel would have to be obtained from a compounding pharmacy. In either case, blood could be drawn to monitor levels to ascertain that the levels are in the desired range.

Menopause Overview
This page defines and discusses menopause, surgical menopause and premature menopause...

Menopausal Symptoms
A woman may experience a number of changes in the way she feels at or prior to menopause. We call these changes the "symptoms" of menopause. This page defines and discusses menopausal symptoms and their treatment...

Sex and Menopause
Loss of sexual desire and ability to participate in and enjoy sex is not a normal part of aging. Dr Nosanchuk explains why a menopausal woman's desire to have sex and her capacity to physically participate in sex are both affected by her menopause...

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Menopause and Weight Gain

Menopause and Weight Gain

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The results of a number of medical studies indicate that menopause is associated with a progressive increase in weight, and a redistribution of body fat to the abdominal region. Although being overweight is a risk factor alone, the redistribution of fat tissue further increases the risk of cardiovascular disease and diabetes.

COULD YOU EXPLAIN ABOUT THE REDISTRIBUTION OF FAT TISSUE?

Prior to menopause the majority of most women have their body fat concentrated in the area of their hips and thighs giving them a pear-shaped body. This is good because women who have pear-shaped bodies are at a lower risk of heart disease and diabetes. Following menopause, many women tend to undergo a redistribution of their body fat to the abdominal region, which increases their risk of heart disease and diabetes.

DOES HRT CAUSE WEIGHT GAIN AND THE CHANGE IN THE DISTRIBUTION OF FAT TISSUE?

No it doesn’t. In fact, it seems to help prevent weight gain and the redistribution of fat. This is substantiated by the results of studies published in a number of respected medical journals.

In study published in November 1998, in Maturitas, The Journal of The International Menopause Society, the researchers found that in the patient population studied, HRT was actually associated with a small reduction in body weight. This seems to be related to the affect of HRT on leptin, a hormone produced by fat tissue cells. It has recently become evident that Leptin, may be an important determinant of body fat and this is a subject of research at this time.

A study published in the American Journal of Obstetrics and Gynecology, published in January 1998 studied the relationship between HRT and body size. In this study the researchers found that HRT users were leaner that nonusers, had less abdominal fat and a lower percentage of total body fat.

WHAT FACTORS INFLUENCE WEIGHT GAIN IN MENOPAUSAL WOMEN?

In order to maintain the same weight, it is necessary to take in the same number of calories as you burn. If you take in less, you lose weight and if you take in more, you gain weight. This balance is influenced by a number of interrelated factors, including the aging process, hormone deficiency and lifestyle issues.

As a part of aging process our metabolism slows and we burn fewer calories. One often hears, "I can’t understand it, I’m eating the same as I ever did and I’m gaining weight." Unfortunately, every year we live our daily caloric requirements diminish. If we don’t change our diet and reduce the amount of calories we take in, we gain weight.

Being hormonally deficient appears to increase weight gain by a number of pathways.

Estrogen deficiency seems to interfere with the normal action of leptin to control appetite and increase the amount of calories burned.

Testosterone deficiency results in a loss of muscle tissue or lean body mass. The lower the levels of testosterone, the greater the potential for loss of lean tissue. Lean body mass burns calories at a higher metabolic rate and any reduction reduces caloric requirements and enhances weight gain. This loss of lean tissue was long thought to be an inevitable accompaniment of the aging process. However, the relationship of testosterone deficiency to loss of muscle mass has become apparent in more recent years.

The worst deficiencies occur when the ovaries have been removed or compromised by surgery. Accordingly, many of these women experience significant weight problems. This appears to be related to the incurred deficiency of both testosterone and estrogen.

Lifestyle issues are important as well and are influenced by hormone levels. Exercise and diet play an important role in preventing weight gain and the maintenance of muscle tissue.

Diet obviously affects weight and any intake of calories in excess of those burned results in weight gain.

Exercise increases caloric expenditure and is a requirement for preserving muscle mass. However, regular exercise may be difficult for hormonally deprived women. Low hormone levels, especially low testosterone levels are associated with lack of energy. In addition, many estrogen deficient women are chronically fatigued from sleep deprivation associated with frequent nighttime flushing episodes.

The hormone deficiency associated with menopause may induce psychological changes, such as a lowered sense of emotional well being and a diminished self-esteem. These factors may decrease the motivation to exercise and follow a healthy diet.

IS THERE ANYTHING I CAN DO TO PREVENT MENOPAUSAL WEIGHT GAIN?

Yes, there are a number of strategies that can make a significant difference.

Appropriate Hormone Replacement Therapy

HRT users experience fewer problems with weight gain and redistribution of body fat. Estrogen replacement appears to enable leptin to perform its normal function of weight control. Leptin appears to help by making you feel full so you eat less and increasing the rate at which you burn calories.

The positive affects of estrogen replacement on emotional well being are well recognized. Enhanced self esteem and a positive attitude are motivating factors for adhering to a healthy lifestyle.

Testosterone replacement maintains lean muscle mass and energy levels. This enhances energy expenditure and the exercise potential.

A program of regular exercise is an important part of preventing postmenopausal weight gain. It raises caloric expenditure and promotes maintenance and formation of lean body mass. Ideally, a program of regular exercise should begin early in life, but it is never too late. Walking is one of the best forms of exercise for most people. It is low impact, can be done almost anywhere and as it is weight bearing, helps protect against osteoporosis.

When choosing a form of exercise, keep your health status and personal safety foremost in your mind. It’s important to speak to your physician first. With this in mind, any aerobic exercise program that raises energy expenditure above resting levels for at least 30 minutes, 3 or 4 times a week would be appropriate. Remember to start gradually.

A healthy diet is important. You knew I would get to this, didn’t you? In fact the women who seem to experience the least problem with weight gain at menopause are those who have adhered to a program of a healthy diet and regular exercise throughout their lives.

You can’t get around it. In order to maintain your present weight, you need to take in the same number of calories you use. If you take in less, you loose weight, if you take in more, you gain. In today’s world of tempting high calorie foods and oversized portions, controlling caloric intake is not easy. Many patients seem oblivious to the amount of their caloric intake.

SO WHAT'S THE SOLUTION TO NOT GAINING WEIGHT?

Well, one of the first tenets of diet-speak is to avoid high fat and sugar laden carbohydrate foods. This makes sense, these foods are high in calories. So, it helps if you choose low fat foods and limit carbohydrates to reasonable levels. A diet rich in whole grain foods, vegetables and fruit is desirable.

Next, it helps to be aware of exactly how many calories are in everything you put in your mouth. Start by reading labels. One brand of low fat ice cream may contain 140 calories and 2 grams of fat per ½ cup and the real stuff may contain 375 calories and 21 grams of fat for the same size portion. The same principle applies to all the foods that you eat. A tablespoon of mayonnaise contains 100 calories and 11 grams of fat. A tablespoon of yellow mustard contains no calories and no fat. Read the labels, it makes it a lot easier.

It is important to learn to recognize and manage portion size. A particular brand of breakfast cereal may contain 110 calories and 2 grams of fat per ¾ cup serving before adding milk. Unless you have learned to recognize what ¾ of a cup of cereal looks like, it is easy to underestimate your serving size. If you know the portion size and caloric content of the foods that are available to you, then you can determine the number of calories you want to put in your body.

A traditional, (at least in the United States), breakfast of 2 fried eggs, toast and butter, orange juice and 3 strips of bacon contains 700 calories and 45 grams of fat. In contrast a breakfast of 1 serving of dry or hot cereal, ½ cup of skim milk and a piece of fruit is around 250 calories and 1 or 2 grams of fat.

A fast food lunch consisting of "2 all beef hamburger patties, special cheese and special sauce", a small order of fries and a soft drink, is in the range of 930 calories and 43 grams of fat. In contrast a sandwich consisting of 2 slices of whole grain bread, 3 ounces of white meat of turkey, sliced tomato and mustard, and a piece of fruit is in the range of 350 calories and 3 grams of fat.

There are a great number of hidden calorie sources to sabotage your efforts to manage your calorie intake. Liquid intake, is an often unrecognized source of calories. Alcoholic beverages, milk, soft drinks, fruit juices and soups, be aware of exactly how many calories and grams of fat each contain.

If you like to eat, controlling your weight isn’t easy. In fact for some people it’s almost impossible. If you’re reading this now, you’re thinking about it. That’s a good start. Fad diets, when they are successful at all, will not work in the long run. Everyone wants the miracle diet or pill that allows you to eat what makes you happy and get and stay thin. Unfortunately, the miracle doesn’t exist.

It’s no secret, what does work is a healthy lifestyle. A balanced diet, rich in whole grain foods, vegetables and fruit. A judicious program of regular exercise, suited to your age and health status. If you’re a menopausal woman, in addition to its other benefits appropriate HRT appears to help prevent weight gain.

If you can’t do it by yourself, get help. Go to meetings, join Weight Watchers, ask your physician for help, do whatever it takes. A few years ago, I saw a friend at a health club. She looked great, she had lost weight and really firmed up. I said, "Sue, how did you do it? You look great!" Her answer was, "Diet and exercise." I was disappointed that she didn’t have any "magic" to share with me.
Menopause Overview
This page defines and discusses menopause, surgical menopause and premature menopause...

Menopausal Symptoms
A woman may experience a number of changes in the way she feels at or prior to menopause. We call these changes the "symptoms" of menopause. This page defines and discusses menopausal symptoms and their treatment...

Sex and Menopause
Loss of sexual desire and ability to participate in and enjoy sex is not a normal part of aging. Dr Nosanchuk explains why a menopausal woman's desire to have sex and her capacity to physically participate in sex are both affected by her menopause... 

Menopause & Migraine
This section discusses the nature of migraines and its relationship to menopause and hormone levels. In addition it provides strategies that may reduce the number and frequency of headaches...

Menopause & Hair Loss

One of the concerns shared by women of menopausal age is the possibility of hair loss. The importance modern society associates with an attractively styled hairdo is reflected by a thriving multi-billion dollar industry involved in the cutting, styling, washing and coloring of hair. When hair loss occurs to a menopausal woman, it is certainly stressful, as this situation may diminish body image satisfaction and self-esteem. The impact can be devastating and affect psychological adjustment and quality of life ...

Sex and Menopause

Loss of sexual desire and ability to participate in and enjoy sex is not a normal part of aging. Dr Nosanchuk explains why a menopausal woman's desire to have sex and her capacity to physically participate in sex are  influenced by her menopause... 

Disturbance of sexual desire or sexual function was given as the primary reason for scheduling the initial appointment by approximately half of the menopausal patients seen in my office. Almost all of these patients had seen at least one physician prior to coming to my office and most two or more. Many women had sought out the services of a female physician in the belief that another woman would be more knowledgeable about menopausal issues and more sympathetic to their problems. Several each year came from out of state. Most ranged in age from 35-60, although some were as young as their 20's and some in their 70's. Almost all of the patients had had at least one unsuccessful treatment attempt by a physician. Half of these women related, that a physician had told them that since appropriate treatment had been provided and was unsuccessful, that their sexual problems "couldn't possibly" be related to menopause, or "maybe you're having a problem in your relationship", or "maybe you need to see a therapist" The most severe and life altering sexual problems were experienced by women who had undergone a "surgical menopause", especially if one or both ovaries were removed during the procedure. Almost all of the women who had undergone a hysterectomy had been assured that there would be no unpleasant effects following the surgery which could not be resolved with HRT, if needed. Many are unsuccessful in their repeated attempts to find someone who can help them, provide a rational explanation for their problems, or even believe them. Even though they are certain initially, that their sexual problems are due to their menopause/hysterectomy, many women begin to doubt themselves. They start to wonder if ..."maybe all those people are right, maybe I am crazy and all this is in my head". Ultimately, hopeless and feeling betrayed, they begin to doubt that their previous sexual state will ever be regained ...and stop looking.

Does all this seem a little strange and difficult to believe? Unfortunately, for many women it's a frighteningly familiar scenario.

It is possible for almost all of these women to regain their previous sexuality if the alterations in function are secondary to menopause, irrespective if it's natural or surgical. The "gold standard" for determining if the changes are secondary to menopause is simple; if you had a great sex life prior to menopause and following menopause you don't and you think it's related to your menopause ...you're probably right. If anyone tells you otherwise, they are almost always going to be wrong.

WHAT ARE THE EFFECTS OF MENOPAUSE ON A WOMAN'S SEXUALITY?

A menopausal woman's desire to have sex and her capacity to physically participate in sex are both affected by her menopause. This not to imply that the majority of women do not continue to function sexually following menopause, but rather that they are no longer able to achieve their optimum sexuality.

WHY DOES THIS HAPPEN?

These changes are a direct result of the alterations in sex hormone levels that precede and accompany menopause and are not related to aging. They are almost always preventable and/or reversible by appropriate HRT.

IS THIS A PROBLEM FOR EVERY WOMAN?

Yes ...and no.

Sex is an important quality of life issue for menopausal women but as with most things everyone has their own agenda.

To begin with, not every premenopausal woman has a strong sex-drive and the transition to a state of lessened sexual interest may not present a significant problem.

Some women who were highly libidinous and sexually active premenopausally, may welcome a diminished sex drive as it may present the opportunity for a less distracting life-experience. Some menopausal women reflect that they would prefer acts of intimacy such as "cuddling" as opposed to intercourse. In addition, a lower libido may lessen the sexual tension presented by fewer opportunities for sexual expression, as there is a diminishing pool of available companions due to increasing rates of sexual dysfunction, health problems and death. Health issues, divorce, alterations in living environment dictated by advancing age or finances, perceptions of aging, changes in body image and self esteem play a part as well.

However, it's important to not lose sight of how influential sex hormone levels are as a determinant of sexual attitudes and behavior. The catch-22 of low hormone levels that result in a diminished sexual interest is that there is no compelling need for those affected to remedy the situation, as they are usually quite content. Unfortunately, their partner may not be so content. Shared sexual intimacy in the context of a committed relationship enhances the existing spiritual bond and even subtle changes in pre-existing patterns of sexual behavior and response are readily discernable by a partner and can be a source of distress. This can result in significant conflict in a relationship and is compounded by the frequent perception that the changes are an inevitable aspect of aging, unaware of the role diminishing hormone levels has played or the potential value of HRT if desired.

I am reminded of a patient who was referred to me in the mid-80's for treatment of Osteoporosis. She was a widow, about 60 years old and had been without the benefit of HRT for several years having experienced a natural menopause in her late 40's. As part of her treatment program I prescribed a program of HRT. Her initial patient interview had revealed that she had a diminished sex drive and I mentioned that the HRT might increase her libido. She responded angrily, "I don't care about that". I continued to see her for follow-up care and about six months later she came in with a male friend, who had been her grocer, in tow. They looked like teenagers, faces flushed and holding hands as they revealed plans for their impending marriage. It was a very educational moment for me. Hormones, or lack of them are capable of having potent effects on sexual attitudes and behavior.

Part 2 - Sex & Libido - Hormone Replacement Therapy

This section addresses the role of sex hormones in maintaining libido and sexual function. It discusses the manner in which a natural, or surgical menopause, or medications may affect the sexual experience and provides treatment options to restore sexual desire and function.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Menopause Symptoms

Menopause Symptoms

WHAT CAUSES MENOPAUSAL SYMPTOMS?

They are directly related to the decline in sex hormone levels that accompany menopause. As hormone levels begin to diminish several years before menopause, women may begin to experience symptoms sometime prior to the actual cessation of their regular menstrual cycles. The symptoms are often more closely correlated with falling levels rather than low levels.

WILL I HAVE MENOPAUSAL SYMPTOMS?

Every woman’s menopausal experience is unique; she may experience all of these symptoms or none of them. Some women may find the transition barely noticeable while others find it life altering. Menopausal women who experience no symptoms at all may be less inclined to consider hormone use if they believe HRT is only for the relief of symptoms and are not aware of its preventive health care benefits.

WHAT ARE THE SYMPTOMS OF MENOPAUSE?

  • Hot flashes/heat intolerance/sweats/chills
  • Insomnia/fatigue/problems with memory and concentration
  • Depression: diminished sense of well being, loss of self confidence, mood swings, irritability, headaches 
  • Palpitations 
  • Decreased interest in sex
  • Muscle/joint pain 

Hot Flashes, Sweats, Heat Intolerance and Chills:

The hot flash or the more descriptive term the hot flush is the symptom commonly associated with menopause. Many people are under the impression that hot flushes are the only significant manifestation of menopause, other than the cessation of regular menstrual cycles. When you here someone say, "I’ve gone through menopause", or "I can’t wait until I’m done with menopause", it is likely that they equate no longer having flushes as a sign that they have "gone through" menopause. However, no one "goes through" menopause. Once you become hormonally deficient you remain so for the rest of your life.

About 75% of women experience hot flushes, heat intolerance or sweats sometime during or prior to their menopause. Although these symptoms resolve within two years in most of those affected, they may last five years or more in approximately 20% of women. I have had patients in their 80’s in whom these symptoms persisted. Some patients experience chills in a similar fashion to the hot flush and it is likely a variant of the same phenomenon.

The hot flush can range from a barely perceptible feeling of warmth to intense heat of the chest, neck and head and can be accompanied by profuse flushing and sweats. Many women develop chronic heat intolerance in lieu of or in addition to flushing. They will often wear light clothing in the middle of the winter and prefer to set the thermostat in their homes at a level that is noticeably cool for the rest of their family. One patient told me that in the middle of the winter she would stand in her unheated garage several times a day as it was the only place she could find at least temporary relief for her discomfort. These patients are very uncomfortable in warm weather and many have told me that vacationing in a tropical climate was out of the question for them.

Mild flushing episodes can often be ignored but as they progress in intensity they can become annoying, distracting, embarrassing and in the worst case scenarios debilitating. Menopausal women often know when the flush is about to begin before they are aware of any sense of heat or flushing. Usually, women who have undergone ovarian removal experience the most severe symptoms and there may be associated nausea, urinary urgency or an impending sense of doom. The flushes can last from several seconds to as long as thirty minutes and sometimes as long as an hour and can occur from rarely to every ten to thirty minutes. They tend to be more frequent and severe during the night and often disturb sleep. Associated sweats may be so severe as to necessitate a change of sleepwear.

Women experiencing severe flushes may be unable to work and have difficulty performing the routine activities of daily living. A menopausal woman who is delivering a business presentation and has a severe flushing episode may find it difficult if not impossible to continue. Stressful situations, warm temperatures, alcohol, hot food, warm clothing and exercise are frequently precipitating factors. A menopausal woman’s difficulty with flushes tends to be taken lightly by those never having experienced the symptom, including other women. One will sometimes hear the phrase, "get over it", spoken by people insensitive to how disturbing and unpleasant a flushing episode can be.

There is a story which appeared in a national news magazine a few years ago written by a woman who had recently become menopausal. In the article she describes how she felt during a flushing episode on a cold winter day while walking in a large northeastern city. Despite the cool weather and her open coat she was in considerable discomfort. Sweating profusely, she thought, "I’m sorry mom!", as she remembered how years before she had lightly dismissed her mother’s readily apparent distress with similar flushes. The woman was remorseful for her failure to have been more supportive. Hot flushes, often the butt of jokes about menopause, may not be amusing to a menopausal woman whose quality of life is affected by them.

What causes hot flushes, sweats and heat intolerance?

These symptoms occur as a response to changing hormone levels which induce confusion (doctors refer to this as "vasomotor instability") in the temperature regulating mechanism of the body. Your body "thermostat", located in an area of the brain called the hypothalamus", is intermittently fooled into believing that your body temperature should be lower. To accomplish this the "thermostat" sends signals that cause warm blood located in the core of your body to be brought to dilated blood vessels in the surface of your skin where it can be cooled by the surrounding air. The "sweats" some women experience is a more extreme cooling measure. Evaporation of liquid in the form of perspiration from the skin is utilized to reduce body temperature. If you recall how chilled you feel when you get out of a swimming pool or a bath, you can see how effective evaporation is as a cooling mechanism.

Is there a treatment for hot flashes, sweats and heat intolerance?

Hormone replacement therapy, using estrogen and if needed testosterone, is the most effective treatment. All the regimens of HRT in routine usage today will relieve the majority of menopausal women of these symptoms. Whichever regimen is used, must be taken on a regularly basis for as long as a month to resolve symptoms. If a program does not prove to be effective, a slightly higher dose of the same preparation can be tried and if this is not successful one of the other routes of administration should be given a trial. I have found that changing preparations that are administered using the same route of administration is not as effective in relieving resistant symptoms as changing to a preparation that utilizes an alternate route of administration.

The treatment program that is almost always successful even if symptoms have been longstanding and resistant to other methods of hormone replacement is subcutaneous implantation of the appropriate dose of estradiol and, if indicated, testosterone. I have seen patients who had symptoms for as long as thirty years or more in spite of various types of HRT treatment, whose symptoms resolved with this route of administration. One of these patients was in her early 80’s and had experienced flushes and sweats from the time of her hysterectomy around age 40. Another told me that until she had the subcutaneous implantation she had slept in a chair for over 20 years, as she was too uncomfortable sleeping in a bed.

Although not as effective, patients who cannot or prefer not to take estrogen may be treated with progesterone. Historically Provera, (medroxyprogesterone acetate) and Megace, (megestrol acetate) have been used for this purpose.

For a more in depth information about hormone replacement therapy, look at the About Hormone Replacement Therapy, Methods of Hrt and Regimens sections of the web site.

Some women are more comfortable with treatments they are able to obtain themselves without a prescription at a drug store, health food store, or from a herbalist. These therapies are sometimes used as complementary therapies along with prescription treatments. Non prescription therapies are advertised widely and are available at the local pharmacy. One of the most popular is vitamin E taken in a dosage of up to 400 IU daily. Natural and alternative therapies include foods containing plant estrogens called phytoestrogens and herbal remedies. Soy is an excellent source of phytoestrogen and a daily intake of soy products may be helpful. Herbal remedies that are reputed to have estrogenic activity include Dong quai, Ginseng, and Gotu kola. Unfortunately, there has not been enough research in this area and much needs to be done to establish proper dosage, safety and efficacy. Although some women may find that some of their symptoms are alleviated by these therapies, there is no evidence at present that they prevent long-term consequences of lowered hormone levels.
Menopause Overview
This page defines and discusses menopause, surgical menopause and premature menopause...

Sex and Menopause
Loss of sexual desire and ability to participate in and enjoy sex is not a normal part of aging. Dr Nosanchuk explains why a menopausal woman's desire to have sex and her capacity to physically participate in sex are both affected by her menopause... 

Menopause & Weight Gain
Dr Nosanchuk discusses the factors that influence weight gain in menopausal women...

Menopause & Migraine
This section discusses the nature of migraines and its relationship to menopause and hormone levels. In addition it provides strategies that may reduce the number and frequency of headaches...

Menopause & Hair Loss
One of the concerns shared by women of menopausal age is the possibility of hair loss. The importance modern society associates with an attractively styled hairdo is reflected by a thriving multi-billion dollar industry involved in the cutting, styling, washing and coloring of hair. When hair loss occurs to a menopausal woman, it is certainly stressful, as this situation may diminish body image satisfaction and self-esteem. The impact can be devastating and affect psychological adjustment and quality of life ...

Menopause Overview

Appointments with Dr. N can be made by calling (248) 644-7200 10AM to 6PM M-F and speaking to Caroline

WHAT IS MENOPAUSE?fullsizerender

Strictly speaking menopause refers to that point in time that normal or physiologic menstrual bleeding stops. The period of time prior to menopause is referred to as premenopause and the time after as postmenopause. However, as a practical matter the term menopause is used loosely to describe the menopause and postmenopause collectively.

WHY AND WHEN DOES IT HAPPEN?

A "natural menopause" most often occurs between the ages of 48-52 and is recognized by cessation of the monthly menstrual cycle. When a woman is born, her ovaries contain approximately one million follicles, or eggs. At puberty she has about 600,000 or so remaining. It is these follicles that are responsible for the production of estrogen, the hormone that will transform her physically and mentally into an adult female capable of reproduction. She uses up about 1000 of these eggs or follicles every month in this process. After about 400 months of reproductive ability, at an average age of 48-52 her ovaries exhaust their supply of available eggs. In the absence of these estrogen-producing follicles, estrogen levels fall below the point necessary to trigger ovulation and cause physiologic uterine bleeding.

WHAT ARE THE OTHER TYPES OF MENOPAUSE?

A surgical menopause or hysterectomy refers to a menopause that is induced by a surgical removal of the uterus. If the ovaries are removed at the time of surgery the fall in hormone levels of both estrogen and testosterone is sudden and severe. Testosterone plays an important part in maintaining energy levels, sex drive and in a number of other important functions. If the ovaries are not removed, they may continue to function and produce adequate levels of estrogen and testosterone, until the time that a natural menopause would have occurred. However, as it turns out, in as many as 50% of these cases, the retained ovaries cease to function normally within three years after surgery. It's easy to see why a surgical menopause/hysterectomy has a greater potential to disrupt health and the quality of life.

A premature menopause refers to a menopause that occurs prior to age 45.

Additionally, menopause can be induced by chemotherapy, infection, trauma or autoimmune disease.

Menopause occurs earlier in smokers and is a result of a smoking related reduction in estrogen levels.

WHY IS IT IMPORTANT TO KNOW ABOUT MENOPAUSE?

No one "goes through menopause." When a woman becomes menopausal and hormone levels fall, she will remain hormonally deficient for the remaining 1/3 of her life span. This is a normal and expected occurrence. However, as natural as this event is, it is not benign.

The long-term consequences of hormone deficiency include the potential to impair quality of life, and negatively impact health and longevity. . There is an associated increase in coronary artery disease, osteoporosis and strokes.

What most women mean when they say that they have "gone through menopause," is that they are no longer having the symptoms that are commonly associated with menopause. However, even if symptoms subside, any negative affects of hormone deficiency continue, although there may not be an awareness of them. For instance, the first sign of coronary artery disease may be a fatal heart attack and the first sign of menopausal bone loss is usually a fracture.

One way of looking at menopause is to think of it as the opposite of puberty. At puberty, rising sex hormonal levels stimulate the development of breasts, auxiliary and pubic hair, muscle mass, bone mass, feminine fat distribution, sex-drive and all the rest of the changes we refer to as "secondary sexual characteristics". But, sex hormone levels do more than play the major role in the development of these tissues; they are also necessary for their maintenance and optimum function. When sex hormone levels fall, the dependent tissues lose their integrity and their ability to perform their intended role.

WHAT ABOUT HORMONE REPLACEMENT THERAPY?

A program of Hormone Replacement Therapy, (HRT), is capable of preventing the negative effects of hormone deficiency, but many women are unaware of its potential benefits. Frequently, they are frightened and confused by a cloud of "myths and misinformation," which obscure the value of hormone replacement therapy / HRT as a health maintenance prerogative. The concept that "safest" approach to menopause is to not interfere with it is contradicted by a wealth of information that denies its validity. If you have symptoms and problems related to hormone deficiency, the most appropriate and effective treatment is to replace the hormones that are missing. Nothing ... is as effective. However, for optimum benefit, an hormone replacement therapy / HRT program often needs to be individualized.

WHAT ABOUT NATURAL AND ALTERNATIVE THERAPIES?

Many women are just not comfortable with hormone replacement therapy / HRT, and/or prefer what they consider to be a more "natural" approach in the management of their menopause. There are some products that have been used for many years, such as Oil of Primrose, and others such as plant based Phytoestrogens that have recently become popular. So far, there is not much known about their safety and there is nothing to suggest they can resolve menopausal symptoms or prevent the long-term consequences of hormone deficiency. There are ongoing studies underway that should help to define these issues.

In the meantime it is prudent to carefully evaluate any therapies that seem to be out of the mainstream. One important yardstick that is helpful in assessing the sincerity of someone, who is expounding on the miraculous effectiveness of a particular therapy, is to know if they profit financially from its sale. Don’t be surprised, if someone who extols the virtue of a specific product has a financial arrangement with the manufacturer that rewards him or her for their ardor.

Menopausal Symptoms
A woman may experience a number of changes in the way she feels at or prior to menopause. We call these changes the "symptoms" of menopause. This page defines and discusses menopausal symptoms and their treatment...

Sex and Menopause
Loss of sexual desire and ability to participate in and enjoy sex is not a normal part of aging. Dr Nosanchuk explains why a menopausal woman's desire to have sex and her capacity to physically participate in sex are both affected by her menopause... 

Menopause & Weight Gain
Dr Nosanchuk discusses the factors that influence weight gain in menopausal women...

Menopause & Migraine
This section discusses the nature of migraines and its relationship to menopause and hormone levels. In addition it provides strategies that may reduce the number and frequency of headaches...

Menopause & Hair Loss
One of the concerns shared by women of menopausal age is the possibility of hair loss. The importance modern society associates with an attractively styled hairdo is reflected by a thriving multi-billion dollar industry involved in the cutting, styling, washing and coloring of hair. When hair loss occurs to a menopausal woman, it is certainly stressful, as this situation may diminish body image satisfaction and self-esteem. The impact can be devastating and affect psychological adjustment and quality of life ...

Sex & Libido With HRT

Appointments with Dr. N can be made by calling (248) 644-7200 and speaking to Caroline

This section addresses the role of sex hormones in maintaining libido and sexual function. It discusses how a natural, or surgical menopause, or medications may affect your sexual experience and provides treatment lisa-editedoptions to restore your sexual desire and function.

There just doesn’t seem to be any way of getting around it. If you’re menopausal and want to be at your optimum sexually, you need to replace your hormones. Menopausal women, without the benefit of hormone replacement, may be capable of enjoyable and satisfying sex. They may be capable of great sex. But ultimately they loose the potential, as least as far as sex is concerned, to be the best they can be.

A healthy lifestyle, a positive attitude, exercise, a loving, giving, patient and understanding partner …all are important. But, they cannot substitute for adequate hormone levels. It is clear and unequivocal; the integrity of the sexual experience is dependent on sex hormones.

WHAT IS DESIRE PHASE DISORDER?

Diminished hormone levels interfere with optimum sexual function by their affect on sexual desire and hormonally sensitive tissues.

Sexual desire, or libido, consists of thinking about sex, fantasizing about sex, the development of "sexual tension" and the awareness of a need for sexual release. Some people may call feeling this way as being "horny". It motivates us to initiate and participate in sex and if circumstances require, search for a sexual partner.

Lack of, or diminished sexual desire and loss of sexual motivation is sometimes referred to as a "desire phase" disorder.

ARE THERE DIFFERENCES IN HOW WOMEN ARE AFFECTED?

A postmenopausal woman’s decrease in libido can range widely, from a barely noticeable fall in sexual interest to a "sexual aversion" where the very thought of being touched in a sexual context is repulsive. A number of patients have told me, " I feel dead from the waist down", to describe their lack of sexual interest. Several who were affected to a lesser extent have shared, that although they really had no interest in sex or in initiating sexual contact, once they were aroused by sexual direct stimulation, the sexual activity was enjoyable and orgasm was possible. Not all women are concerned over their loss of libido and have no interest in restoring it. It is like not being hungry, you're not worried about eating. Other women are devastated by their loss of sexual desire are interested in pursuing any reasonable treatment that will allow them to regain their previous sexuality.

Unfortunately, many women who express a concern about a lowered sex drive are referred to a psychiatrist, counselor or psychologist, before even a cursory analysis of their hormonal status and/or Hormone replacement therapy program is considered. Certainly, stressful life events, health, psychological or relationship problems influence libido, but these factors should only be considered along with the menopausal woman’s hormonal status.

WHAT CAUSES A DECLINE IN SEXUAL DESIRE?

The decline in sexual desire is likely a direct result of diminished sex hormone levels on the brain itself. Although estrogen plays a part, the hormone that has been shown to be most closely associated with sex-drive is testosterone.

The ovary, although incapable of producing estrogen after a "natural" menopause, may continue to produce significant amounts of testosterone for several years. This is the reason why many women maintain a good sex-drive for a considerable length of time. These testosterone levels provide additional benefits to the naturally menopausal woman. Tissues of the body are able to convert some of this circulating testosterone to estrogen. This is the mechanism by which naturally menopausal women have fewer and less severe symptoms and health problems usually attributed to sex hormone deficiency. If a postmenopausal woman were to undergo removal of her ovaries, this benefit would be lost.

WHAT ABOUT PREMENOPAUSAL WOMEN WHO HAVE HAD A HYSTERECTOMY?

If the surgery is performed prior to menopause and the ovaries are preserved and their hormone secretion is unaffected, there may be no change in libido following the post-operative healing period. In fact, some women experience a post-surgical increase in sexual desire if prior to the surgery they had been distracted by heavy bleeding or significant pelvic pain. There is evidence, however that in this group of patients, ovarian failure occurs up to 50% of the time within 3 years following the surgery. If this happens, a diminished libido and other menopausal symptoms would reflect the decline in hormone levels. Unfortunately, some physicians are not aware of the frequency of ovarian failure following hysterectomy. I have seen many patients who were in this category whose physicians refused to believe their loss of desire and sexual issues were related to their surgery.

If the surgery is performed prior to menopause and the ovaries are removed, the fall in estrogen and testosterone levels is abrupt and severe. As would be expected this type of surgically induced menopause almost always, results in a dramatic fall in sexual desire.

IS THERE ANYTHING ELSE THAT CAN CAUSE PROBLEMS WITH MY SEX DRIVE AFTER MENOPAUSE?

Significant health problems, depressive illnesses, relationship problems and certain medications can affect libido.

WHAT ARE SOME OF THE MEDICATIONS THAT CAN CAUSE A PROBLEM?

A class of anti-depressants, SSRI’s frequently depress both libido and potential for orgasm. SSRI’s can do this so effectively in some patients that it is used as a treatment for obsessive sexual preoccupation and premature ejaculation.

I have had several patients express a concern over a fall in their libido who had recently begun treatment with an antidepressant, not realizing that their medication was responsible. Occasionally, delayed ejaculation or inability to ejaculate develops in men who are not aware of this side effect and can lead to conflict in a relationship if the couple is not aware the problem is due to the antidepressant.

Orally administered estrogen replacement medications and oral contraceptives are absorbed by the gastrointestinal tract and reach the liver in a "bolus". This so called "bolus effect", induces the liver to increase its production of a substance, "sex hormone binding globulin" (SHGB) which binds to circulating testosterone, leaving less "unbound" or "free" testosterone available to maintain libido. This is not well known and is often not recognized as a cause for a diminished libido.


HOW EFFECTIVE IS HORMONE REPLACEMENT THERAPY IN MAINTAINING LIBIDO?

It is very effective. Optimum regimens of hormone replacement will almost always maintain or restore libido. This will often take 4-8 weeks of treatment and it helps if you are aware of this ahead of time.

Many women, especially those, who have had a surgical menopause, will need a regimen that includes testosterone replacement. This may include some women who choose an oral regimen due its effect on SHBG levels as described above. Testosterone can be given by most of the routes of administration, including injections, gels and subcutaneous implants. When nothing else seems to work, subcutaneous implants rarely fail to reestablish libido.

In the late 1980’s, a television journalist who had interviewed me for some news segments, which dealt with menopausal issues, called me with a request. He shall remain unnamed for his own protection and journalistic credibility. He wanted to know if I could find a woman for an on-air news segment interview, "over 50", and "still having sex". After a brief period, during which I was recovering from having been rendered speechless, I told him that I was sure I could find someone. We made arrangements for the interview to be shot at my office the following week.

The television journalist and his camera crew appeared at the appointed time. I introduced them to June, an attractive, very sexual, woman of 80, who had been on hormone replacement therapy for over 30 years. The interview was broadcast on the evening news the following day to a potential audience of several million. June was an educated and sophisticated woman who was anything but shy. She informed the journalist and the viewing public, that she enjoyed sex, had intercourse on average twice a week …and was orgasmic.

I was chuckling for days. On the way out she told me that she probably would have had sex more often had she been getting along better with her husband. I was pretty impressed with her. I was pretty impressed with both of them.

Yes …appropriate hormone replacement therapy is very effective in maintaining libido.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Sex and Menopause

 Appointments with Dr. N can be made by calling (248) 644-7200 and speaking to Caroline

 Loss of sexual desire and ability to participate in and enjoy sex is not a normal part of aging. Dr Nosanchuk explains why a menopausal woman's desire to have sex and her capacity to physically participate in sex are  influenced by her menopause... 

Disturbance of sexual desire or sexual function was given as the primary reason for scheduling the initial appointment by approximately half of the menopausal patients seen in my office. Almost all of these patients had seen at least one physician prior to coming to my office and most two or more. Many women had sought out the services of a female physician in the belief that another woman would be more knowledgeable about menopausal issues and more sympathetic to their problems. Several each year came from out of state. Most ranged in age from 35-60, although some were as young as their 20's and some in their 70's. Almost all of the patients had had at least one unsuccessful treatment attempt by a physician. Half of these women related, that a physician had told them that since appropriate bedtreatment had been provided and was unsuccessful, that their sexual problems "couldn't possibly" be related to menopause, or "maybe you're having a problem in your relationship", or "maybe you need to see a therapist" The most severe and life altering sexual problems were experienced by women who had undergone a "surgical menopause", especially if one or both ovaries were removed during the procedure. Almost all of the women who had undergone a hysterectomy had been assured that there would be no unpleasant effects following the surgery which could not be resolved with HRT, if needed. Many are unsuccessful in their repeated attempts to find someone who can help them, provide a rational explanation for their problems, or even believe them. Even though they are certain initially, that their sexual problems are due to their menopause/hysterectomy, many women begin to doubt themselves. They start to wonder if ..."maybe all those people are right, maybe I am crazy and all this is in my head". Ultimately, hopeless and feeling betrayed, they begin to doubt that their previous sexual state will ever be regained ...and stop looking.

Does all this seem a little strange and difficult to believe? 

Unfortunately, for many women it's a frighteningly familiar scenario.

It is possible for almost all of these women to regain their previous sexuality if the alterations in function are secondary to menopause, irrespective if it's natural or surgical. The "gold standard" for determining if the changes are secondary to menopause is simple; if you had a great sex life prior to menopause and following menopause you don't and you think it's related to your menopause ... you're probably right. If anyone tells you otherwise, they are almost always going to be wrong.

WHAT ARE THE EFFECTS OF MENOPAUSE ON A WOMAN'S SEXUALITY?

A menopausal woman's desire to have sex and her capacity to physically participate in sex are both affected by her menopause. This not to imply that the majority of women do not continue to function sexually following menopause, but rather that they are no longer able to achieve their optimum sexuality.

WHY DOES THIS HAPPEN?

These changes are a direct result of the alterations in sex hormone levels that precede and accompany menopause and are not related to aging. They are almost always preventable and/or reversible by appropriate HRT.

IS THIS A PROBLEM FOR EVERY WOMAN?

Yes ...and no.

Sex is an important quality of life issue for menopausal women but as with most things everyone has their own agenda.

To begin with, not every premenopausal woman has a strong sex-drive and the transition to a state of lessened sexual interest may not present a significant problem.

Some women who were highly libidinous and sexually active premenopausally, may welcome a diminished sex drive as it may present the opportunity for a less distracting life-experience. Some menopausal women reflect that they would prefer acts of intimacy such as "cuddling" as opposed to intercourse. In addition, a lower libido may lessen the sexual tension presented by fewer opportunities for sexual expression, as there is a diminishing pool of available companions due to increasing rates of sexual dysfunction, health problems and death. Health issues, divorce, alterations in living environment dictated by advancing age or finances, perceptions of aging, changes in body image and self esteem play a part as well.

However, it's important to not lose sight of how influential sex hormone levels are as a determinant of sexual attitudes and behavior. The catch-22 of low hormone levels that result in a diminished sexual interest is that there is no compelling need for those affected to remedy the situation, as they are usually quite content. Unfortunately, their partner may not be so content. Shared sexual intimacy in the context of a committed relationship enhances the existing spiritual bond and even subtle changes in pre-existing patterns of sexual behavior and response are readily discernable by a partner and can be a source of distress. This can result in significant conflict in a relationship and is compounded by the frequent perception that the changes are an inevitable aspect of aging, unaware of the role diminishing hormone levels has played or the potential value of HRT if desired.

I am reminded of a patient who was referred to me in the mid-80's for treatment of Osteoporosis. She was a widow, about 60 years old and had been without the benefit of HRT for several years having experienced a natural menopause in her late 40's. As part of her treatment program I prescribed a program of HRT. Her initial patient interview had revealed that she had a diminished sex drive and I mentioned that the HRT might increase her libido. She responded angrily, "I don't care about that". I continued to see her for follow-up care and about six months later she came in with a male friend, who had been her grocer, in tow. They looked like teenagers, faces flushed and holding hands as they revealed plans for their impending marriage. It was a very educational moment for me. Hormones, or lack of them are capable of having potent effects on sexual attitudes and behavior.

Part 2 - Sex & Libido - Hormone Replacement Therapy

This section addresses the role of sex hormones in maintaining libido and sexual function. It discusses the manner in which a natural, or surgical menopause, or medications may affect the sexual experience and provides treatment options to restore sexual desire and function.

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Part 3: Progesterone, Progestins & Progesterone Cream

It is medically prudent if you have not had a hysterectomy and still have your uterus that your HRT regimen include progesterone. The rational for this is that estrogen stimulates lining of the uterus to become thicker and progesterone prevents over stimulation. Before you reach menopause your natural cycle produces progesterone to accomplish the same process. Unfortunately, menopausal women often discontinue hormone replacement because of progestin associated side effects. 

The challenge presented, is how to individualize a regimen, that allows menopausal women to receive the documented health and quality of life sustaining benefits of estrogen replacement, while both adequately protecting the uterus and avoiding any potential progestin related side effects.

What exactly are progesterone and progestins?

Progesterone is a naturally occurring hormone produced by the ovary following ovulation in premenopausal women. Progestins, are synthetic products, which mimic the effects of progesterone. The term progestogen, is used to describe hormones that provide progesterone-like activity, and this includes both progesterone and progestins. Although it may seem a little confusing at first, when I am referring to both progesterone and progestins collectively, I will use the term progestogen.

What kind of side effects?

Many women are intolerant to progesterone and progestins experiencing unpleasant symptoms, ranging from mild, to severe and life altering. Other menopausal women object to the withdrawal bleeding that may accompany progesterone and progestin use.

In addition, there is evidence that some progesterone, or progestin regimens may interfere with the beneficial effects of estrogen.

Will I definitely have unpleasant symptoms while using a progestogen?

No, the majority of women may not experience significant symptoms while using a progestogen. However, those women who do are often discouraged from continuing their HRT program.

What unpleasant symptoms can accompany progestogen use?

Unpleasant symptoms may include irritability, fatigue, depression, diminished libido, emotional volatility, breast tenderness, muscle aches, fluid retention, constipation, uterine cramping, changes in appetite, headaches and insomnia. Some women may experience none of these symptoms while others may experience all of them.

What kind of problems can "unopposed" estrogen stimulation cause?

"Unopposed" estrogen administration may result in irregular and excessive vaginal bleeding and abnormal changes of the uterine lining, including estrogen-induced endometrial cancer. Progestogens downgrade the sensitivity of the estrogen receptors in the uterine lining and reduce the frequency of these problems. It is so effective in preventing excessive stimulation of the uterine lining, that appropriate administration of progestogen, lowers the incidence of endometrial cancer to below that of non-users of HRT.

How do I include a progestagen in my HRT regimen?

There are 2 basic regimens, along with some variations.

In the first the estrogen is given continuously and the progestogens are taken for 10-12 days each month. In this method, after finishing the progestogen, women using this regimen will usually have what is referred to as "scheduled withdrawal bleeding," beginning 1-7 days after the final progestogen dose each month. This is referred to as "sequential therapy." Some women find the bleeding unacceptable and are less likely to continue HRT.

In the second method, estrogen and a smaller dose of a progestogen are combined and taken daily. This is often referred to as "continuous-combined therapy." The rationale for this regimen is to prevent any vaginal bleeding, but some women experience persistent spotting, or bleeding. This regimen is available in both oral and transdermal formulations. It is recommended by many experts and has gained wide patient and physician acceptance in the United States.

Which method do you recommend?

I almost always suggest sequential HRT regimens. On the surface it might seem more attractive to use continuous-combined therapy and avoid any withdrawal bleeding, but this method may be less optimal than using a progestogen for 10-12 days each month.

Why?

There are many women who are users of continuous combined-therapy and are happy with this regimen. They have good control of menopausal symptoms, are not bothered by the daily progestogen dose and are able to avoid any withdrawal bleeding. For women who consider scheduled vaginal bleeding unacceptable and would not use HRT if it necessitated bleeding, continuous combined therapy is likely the best option.

Nevertheless, there is preliminary research evidence that suggests that a commonly used oral continuous-combined HRT formulation containing conjugated equine estrogen and medroxyprogesterone may interfere with the cardioprotective benefits of estrogen.

In addition, studies funded by the National Cancer Institute demonstrated an increase in the incidence of lobular carcinoma, a relatively uncommon form of breast cancer in patients using this formulation. The over all increase in cancer risk appears to be small and further studies are needed to define the issue, however for the moment, it might be more prudent to use either sequential therapy, or a non oral formulation of continuous-combined therapy.

There are alternate oral continuous-combined formulations and the status of these preparations relative to the aforementioned studies will be addressed in ongoing and future research.

If a woman has had a hysterectomy does she need to take a progestogen?

If the uterus is not present, there is no need for a progestogen, natural, or synthetic. Some make the argument that progesterone should be used "for balance," in women without a uterus, as it more closely resembles a woman's natural cycle. I do not recommend this as a premenopausal woman's progesterone level is for practical purposes nearly undetectable for most of the ovulatory cycle and there is no reason to unnecessarily expose her to any potential negative consequences of progestogen use.

There is one subset of women who have had a hysterectomy where progestogen replacement would be a consideration. Those women who have had a surgical menopause because of endometriosis and residual endometrial tissue is known, or suspected to remain in the body. There have been a few cases reported in the medical literature where residual endometrial tissue has undergone malignant transformation. This is rare, but if residual endometriosis is a consideration, 10-12 days of a progestogen at 1-3 month intervals would be reasonable.

I suffer from a number of the symptoms you mention while using a progestin, is there any way to lessen the problem?

In some, but not all cases, it is possible to diminish the impact of these problems by changing the type, dose, schedule, or route of administration of the progestogen, but ultimately the symptoms are a direct effect of the progestogen, whether synthetic or natural. Many women have fewer symptoms when using a product such as micronized progesterone, either from a compounding pharmacy, or from the local pharmacy, where it is sold under the name of Prometrium. Women who are allergic to peanuts should not use this compound, as it contains peanut oil. Some women find they experience fewer symptoms when using a progestogen by the vaginal route, either in suppositories, or in cream form.

One strategy that is useful is to increase the progesterone free interval to 2, 3, or 4 months taking care to monitor for signs of endometrial overstimulation. Some doctors have had good results with the use of a progestin-releasing intrauterine device, which some research indicates is capable providing endometrial protection. However, in some women it is virtually impossible to include a progestogen in their HRT regimen due to the severity of the negative effects. In this extreme situation, it may be necessary to leave the progestogen out of the program entirely. However, users of unopposed estrogen who have a uterus should be monitored carefully, without exception, for the development of abnormal changes of the uterine lining.

I have heard a lot about natural progesterone skin creams, including one that contains Yam progesterone. Is this a good thing for me to use?

I do not believe there is any benefit to using progesterone skin creams, as they do not provide any protection from the long-term negative health consequences of hormone deprivation. Yam and other plant progesterones, cannot be metabolized in the human body, unless they are modified pharmaceutically and any suggestion that they provide benefit, other than skin lubrication, is without basis. Progesterone skin creams that purport to be "natural," often contain micronized progesterone as the active ingredient. There is one study that suggested that a progesterone skin cream was mildly beneficial in reducing the severity of hot flashes.

There are those that recommend the use of progesterone skin cream as it is "natural" and counteracts any "estrogen dominance." However, the defining feature of menopause is ovarian failure and its accompanying estrogen deficiency. As such, by definition, all menopausal women are estrogen deficient and the concept that they are suffering from "estrogen dominance," is not plausible. These products are very effectively marketed and I believe that careful scrutiny will reveal that a significant number of those who advocate their use profit by their sale.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

 

Part 2: Unpleasant Side Effects

Side effects … Why they occur and strategies to avoid them.

Most unpleasant side effects of HRT, are related to (1) the oral route of administration, (2) progesterone and progestins and (3) the physiologic action of the hormone on its target tissue.

Side Effects Related To The Oral Route Of Administration:

The most frequent unpleasant hrt side effects associated with the oral route of administration are nausea, vomiting and loss of appetite. These hrt symptoms can be due to either a direct effect of the hormone replacement on the lining of the stomach, or secondary to the affect of the rapidly rising hormone levels on the brain. In the latter case this is not unlike “morning sickness.” If the symptoms do not resolve after a few weeks a reduction in dose, or switching to another oral product may be in order. If this does not alleviate the symptoms a change to a non-oral route of administration will be likely be required.

When a hormone is taken orally it is absorbed by the gastrointestinal tract and transported “en masse,” or as a “bolus” to the liver. This is referred to as the “first-pass” affect. During this passage the absorbed hormone alters the normal production of liver proteins. While most women seem to be unaffected in some women the alteration in the blood levels of these substances have the potential to cause an elevation of blood pressure and/or an increase in the frequency of migraine headaches.

Side Effects Unrelated To The Oral Route Of Administration:

One problem that is not specific to the oral route and can occur with any route of administration is breast tenderness. It can be perfectly normal for a woman who has been hormonally deficient to have breast soreness beginning a few weeks after starting estrogen replacement. Low estrogen levels can result in an involution of breast tissue and when the breast tissue is stimulated by estrogen replacement the breast tissue can be sore and tender for 2-3 months as the breast tissue regenerates. Women who have been estrogen deficient may notice a reduction in breast size and then notice a return to their pre-deficient state after taking replacement estrogen. If a woman does not recognize the reason for the breast soreness, she may suspect the discomfort has a more serious origin, become frightened and stop her HRT. If the tenderness persists for more than 2-3 months, a reduction in dose may be required. Of course it would be prudent for her to discuss this with her physician and have an examination if it persists, or if the physician believes it is warranted.

It is also possible to experience allergic reactions to HRT preparations. Women who are allergic to peanuts need to be aware that some hormone replacement preparations including Prometrium contain peanut oil and are capable of producing serious allergic reactions in those who are susceptible. Many women are allergic to the adhesive in transdermal estradiol patches, or find that they are intolerant to the vehicle in the patch resevoir that contains the medication. In some instances this can be resolved by using another brand of transdermal estrogen patch.

One frequent reason given by women for not starting HRT, or discontinuing its use is the prospect of continued uterine bleeding. A woman who has an intact uterus and is an estrogen user requires the use of a natural, or synthetic progestin to prevent potential overstimulation and the development of abnormal changes of the uterine lining. Women who are on a program of sequential therapy in which the progestin is give for 10-12 days a month will experience an expected withdrawal bleeding. HRT preparations are available that contain a combination of estrogen and a smaller dose of progestin which have been designed to be taken daily and prevent any uterine bleeding. These preparations are widely used and are preferred by many physicians, but others have a concern about the affects of daily use of progestins. Most women tolerate this combination well, but others are intolerant to daily use of even a small dose of progestin and/or find that they continue to experience spotting, bleeding, or cramping while using it. The subject of progestin and progesterone intolerance will be addressed further in the next section.

Many women are concerned that weight gain may occur if they use HRT. The research evidence does not support this and suggests that women who are users of HRT are actually less likely than non-users to put on extra pounds. This is discussed in the section of the web page, Menopause & Weight Gain.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.