The Hot Topic

by Christa D'Souza

  My wonderful oncologist Carmel, meanwhile, rather rolls her eyes when I go in for my six-monthly check-up and sees that I have decided to go down the hormones route. I can do what I want with my own body is her general message but, if I want her opinion, she suggests I don’t. Why would I want to put more oestrogen into my body, when I have oestrogen-positive cancer? she wonders. Especially when I am already at risk by being a drinker? Is it because I want to rekindle my sex life? This social pressure that we’re all under to be having fantastic sex for the rest of our lives, she sighs. It’s so exhausting. Isn’t there life beyond sex, at some point?

  Back and forth, back and forth. Part of me feels morally weak for wanting to take the edge off. Isn’t it just delaying the inevitable? My symptoms are not as bad as a lot of other women’s are, after all. Not just that. Do refugee mothers in Calais complain about hot flushes and expanding waistlines? Do the majority of Japanese women? As anthropologist Margaret M. Lock posited in her groundbreaking book Encounters with Ageing (1995), maybe it is not just the diet of soy that accounts for the lower rate of menopausal symptoms in Japanese women; maybe it is because the menopause is seen as a natural part of the ageing process as opposed to a disease involving physical and emotional decline.

  Perhaps, says Susan Bewley, Professor of Complex Obstetrics at Kings College London, and a vocal critic of the latest NICE guidelines regarding hormones, it is really a problem of culture and perception more than anything else. ‘If your status was raised by menopause, if you were treated as the wise woman, listened to, regarded, if people sat at your feet listening to your stories,’ she told Zoe Williams in the Guardian in a comment piece about reversible menopause, ‘and the older men still found you very sexually attractive, what would be the problem?’

  Nonsense, thinks Dr Erika Schwartz, author of Don’t Let Your Doctor Kill You, whose glamorous Fifth Avenue practice above Prada’s NYC headquarters I visit to get, as it were, a second opinion. ‘Once you lose your hormones you are nothing more than roadkill. So you have two options. You can make a conscious decision that from now on, it is all about you, that you are going to do something you have never done before, which is put yourself first. Or you can continue in the way you want to continue until you drop dead. If you don’t think that, explain to me why most older women who do not take hormones don’t have their brains, are alcoholics, are fat and miserable, and impossible to live with. I’ve yet to see a woman in her sixties or seventies who’s not on hormones who is doing something really wonderful unless she already had some major mission in life she wanted to achieve.’

  The former director of a medical trauma centre in upstate New York and a co-founder of the Bioidentical Hormone Initiative, a nonprofit organisation dedicated to training doctors in how to treat age-related hormonal imbalances, Schwartz is also the founder of Evolved Science, a members-only preventive healthcare service (a branch has recently opened in London’s Belgravia).

  On the window sill in her New York office are pictures of children – I assume they are her children but in fact they are her grandchildren. Dressed in a tight black dress and Acne platform heels, Schwartz is a hybrid, kind of, of Joan Rivers and Charlize Theron and looks shockingly young for her age… which is 65.

  I reiterate my concerns about having had oestrogen-positive breast cancer. ‘Listen, lemme tell you something,’ she says, crossing and uncrossing her shapely bare legs. ‘If you don’t take hormones you are going to wind up in trouble from every point of view. Brain. Bone. Heart. Your cancer. Not your cancer, because you never own cancer, but let me tell you, you didn’t get breast cancer because you had too many hormones in your body. There are a million other reasons why you got cancer and one of them is that as you get older, your risk of cancer goes up independent of anything else. Even with Premarin, your risk of cancer goes down. Even with them, I’m saying you are better off [on the cancer front]. With oestrodil [that’s the oestrogen derived from plant sources] you can really bring it down.

  ‘Look,’ she goes on, pausing briefly to point out the figure of Donald Trump emerging onto a balcony on the opposite building, ‘nobody actually knows the significance of oestrogen-positive cancer. Scientifically, it is used as a bit of an intimidation tactic. Is it fuelled by oestrogen or is it that you need more oestrogen? What kind of oestrogen…?’

  When I get back to London I have made my decision. Dr Schwartz has gone on record saying she thinks swine flu is nothing more than a common cold, but she has an immensely encouraging, not to say reassuring, vibe about her. Plus, she looks bloody marvellous for 65. I go to my local chemist to get my prescription. It costs me £40 for three months’ worth.

  There are three potions: Oestrogel (which mimics the oestradiol produced by the human ovary), Testim (another topical gel containing the androgen, testosterone) and Utrogestan (a capsule that contains the progesterone).

  The first two have to be rubbed into my stomach and inner thighs once a day. The third, the progesterone, to ‘oppose’ the oestrogen, is to be taken the first seven days of every month (at night because it can cause drowsiness). For the first 24 hours I can’t help feeling like Alice in Wonderland, wondering which potion is going to affect me in what way. Oestrogen and progesterone, fair enough, I was on the mini-pill before going off to university in the late 70s… for about a week. But testosterone? As my children’s nanny wants to know, is it going to make me look like Fatima Whitbread? And, as I want to know, is it going to make me wanty to mounty the postman? What about the novel I thought I never had in me? What about acquiring a taste for theatre and poetry or perhaps even gardening? What about working on becoming, if not one of the leading thinkers of the 21st century, then at least the person my dog, if I had one, believed me to be? And for the next couple of days I cannot stop thinking about what this stuff is going to do to me – to the point, almost, of seeing things that are not there. The Ideal Hormones Show at Earls Court, and so on. And then, inevitably, I kind of forget, until about three weeks later, I realise the sleeplessness and hot flushes have disappeared. So, too, have the ridges on my nails (young nails, who knew of such a thing), although it doesn’t do anything for my saggy earlobes (yes, sigh, earlobes sag with age).

  Within a month I get my period back (oh, did I not tell you? Progesterone can give you a chemical bleed, the reason why it is entirely possible to ‘menstruate’ well into your seventies). Within three months (and, because I was feeling quite woozy with the progesterone, we had taken it down to seven days every alternate month, and we’d reduced the two pumps of Oestrogel to one), my meaty menopot, that extra duvet tog that seemingly had nothing to do with diet, had gone. If I overate, it came back, but it was accounted for, which made all the difference. I felt like my old self once again. Although, when I say ‘old’ self, what do I mean?

  This even hormonal keel was better than my old self. Much better. On the other hand, what was I going to do with all the saucy dreams, and this niggling ‘tickle’ the testosterone was giving me? The return of desire is all very well. But every day, all day? As my friend Rosa put it, ‘I suppose it’s quite a fun thing to try, to put that particular libidinous hat on for two or three weeks, but do I actually need it 24/7? Frankly, I’ve not got the time.’

  7

  SEX, SILVER LININGS AND AMBITION

  In talking about sex, it may be instructive to talk about the peri-menopause. The drink, as it were, in the last-chance saloon. The sun before it goes behind a very, very big cloud. Or, to put it more bluntly, those last remaining years when you can still have babies and your body is telling you to get out there and mate with someone, anyone, really, before it is too late.

  It can be a grey area, that time leading up to the change. The average length is four years, but for some women it’s a question of months, for others it may continue for ten years. Mine was somewhere in the middle and possible to identify properly only in retrospect. The one thing I did notice at the time was how my periods, after having been so erratic right from the get
-go, suddenly got ironclad regular, almost to the hour, but instead of being four weeks apart were now nearer three. Little did I know that this was my body giving me as many opportunities to reproduce as possible. It’s hard not to look at that body now with a degree of affection, thinking how desperate it was to achieve this. During these last two years, the flow was so heavy that no ST in the world was going to stem it – I needed a small mattress. The cramps got really bad, too, a sign that my progesterone levels were dwindling.

  Typically, it is in the last one to two years that the decline in oestrogen and progesterone accelerates, thereby giving temporary dominance to testosterone, the last of the hormonal troika to tail off. That’s the ‘male’ androgen produced by our ovaries, adrenal glands and fat cells, which supposedly makes us pushier, hairier and, crucially, hornier… though not necessarily for the partner we’ve lived with and loved and watched growing man boobs for the past however many years.

  ‘It happened like clockwork, to a group of us right before we hit 50,’ explains 55-year-old music producer Sarah, ‘we felt like a real demographic, so we called ourselves the 49ers. I’d got to a point where I knew no one was going to rip my clothes off in a fit of lust ever again and I just wasn’t ready to say goodbye to that feeling. I suppose I’d gotten to the stage in my life where I didn’t really care about the consequences and I went a bit mad, wearing glittery eye make-up, sleeping with much younger men, taking drugs and generally trying to keep the party going for as long as possible. Now I’m out of it, I can pick a 49er out in a crowd instantly. It’s a real look: a hunter but at the same time slightly hunted.’

  ‘Looking back it seems rather pathetic: older woman – too old to be a cougar, in fact – on the pull, but at the time, it was so exciting,’ says another friend, a writer, now 55 and a year into menopause proper. ‘It almost felt like I was making up for lost time, wanting to have those golden sexual experiences I never had at college or in my twenties because I was so screwed up about my body and too frightened and embarrassed to ask for what I wanted.

  ‘I wasn’t bogged down with childcare, I felt more confident about myself and my body than I’d ever done in my life, having managed to get down to the weight I was before I had kids. I couldn’t remember the last time someone of the opposite sex had made a pass at me, so when it happened it was like a light being switched on. Or more like a flower blossoming in time-release photography. I’d always thought it quite crummy, the idea of cheating, and yet here I was doing just that. I couldn’t bear the idea of going to my deathbed never having slept with anyone other than my husband ever again. To be really honest, I couldn’t bear the idea of sleeping with my husband again.’

  If oestrogen is the hormone of compliance, the ‘Ladybird mum’ hormone as one friend of mine describes it, then testosterone is the hormone of infidelity. It is also the hormone of novelty. Meaning, if you suddenly find yourself seeing the personal trainer in a whole new light or, gah, thinking inappropriate thoughts about your 18-year-old son’s friends, don’t worry, it’s all perfectly normal; there are others out there just like you.

  ‘We’re programmed to seek out an alpha male with the best possible genes, not the prince who’s charmingly slumped at our side,’ says psychopharmacologist Dr Julie Holland, author of Moody Bitches: The Truth about the Drugs You’re Taking, the Sleep You’re Missing, the Sex You’re Not Having and What’s Really Making You Crazy. ‘Older women are more likely to get aroused when in the company of younger, novel, pheromone-secreting men. We naturally pursue youthful specimens because there is less chance of genetic damage in younger DNA.’

  Not that everyone becomes a member of the 49er club. Nor do they lose their libido the moment they stop bleeding for good. Look at the author Diana Athill who famously had a voracious sexual appetite right up until her mid-seventies. If, however, you are in the throes of feeling like a sex-mad teenager all over again, I’d say enjoy it while you can. Because chances are, when your periods stop for good, so will all trace of sexual desire. And that can be for some of us, far above and beyond the weight gain and the hot flushes and the sleepless nights, the harshest toke of all.

  ‘I suddenly realised everything that had motivated me had been towards erotic possibility and attraction and all that shit,’ says Sarah. ‘I didn’t know what I was for any more. You think you are an individual and have a free will, but what I discovered was that I had been run by hormones and I couldn’t argue with that. It was, at first, devastating to adjust to.’

  ‘I still remember that cold, panicky feeling of, what? But I love sex!’ says my friend Anna, 54 (interestingly, one of the few women I talked to who considered sex the cornerstone of her relationship). ‘And I’m really good at it. It felt like I was closed for business, like the end of the world. Had that been my lot?’

  This is where testosterone supplementation comes in, still a controversial subject in the US, where it has not been approved by the FDA for female use. (Although at least 26 different testosterone products have been licensed for male use in the US, if doctors want to prescribe them for female patients, they have to do it ‘off label’.)

  Not that testosterone is the only hormone responsible for our sex drive. Oestrogen is too. Our thyroid glands, they play a big part in our libido too. Nor is testosterone solely connected with sex drive. Like oestrogen (to which testosterone can be converted in both the female and male body), it has an effect on memory and cognitive skills and is connected with a possible decrease of beta-amyloid and plaque build-up in the brain, with some studies suggesting it might help prevent against Alzheimer’s.

  Testosterone levels in women have also been linked to better bone density and, in female athletes, to lower body fat and higher muscle mass. (I know, I perked up when I first heard about that, too.)

  There is evidence it may aid in the protection of our hearts. In 2010, research published in the Journal of Clinical Endocrinology & Metabolism showed that post-menopausal women with low levels of testosterone had an increased risk of cardiovascular disease. Another small study found that women with heart failure gained physical strength and the ‘ability to function properly’ when they started to take a testosterone supplement. There is also evidence from researchers at Wright State University in Ohio that it might help protect against breast cancer.

  A paper in Maturitas, the official journal of the European Menopause and Andropause Society, said in September 2013 that, while conventional combined HRT raises the risk of breast cancer slightly, the addition of testosterone appears to cut that risk significantly.

  Bingo wings and thinning hair, leaky bladders and painful intercourse through vaginal dryness… anecdotally, it can help with all that too. Sounds too good to be true? Hell, look at Jane Fonda. If that’s her secret, there has to be something there.

  The main reason, though, that doctors prescribe it (or its precursor, the steroid hormone DHEA) for their menopausal patients is for a flagging or non-existent libido, and for many women it has had a transformational effect. But is it the magic pill?

  I have a friend who conceived a couple of years ago via IVF, and subsequently underwent the menopause at the age of 45, for which she was prescribed HRT. She is, she says, on the highest dose of testosterone the doctor will allow her to take as she is fairly new to her marriage and was keen to get back into the swing of things as soon as possible after the birth. ‘But it hasn’t done a thing,’ she says. ‘No effect whatsoever, as if I’m just one of those rare unlucky women – like those rare unlucky women for whom the epidural doesn’t work. And sex was a fundamental part of my life before, so I really don’t know what to do. I’m hoping it’s because I am so in love with my baby, but a big part of me thinks, that’s it, that’s the end.’

  Meanwhile, if testosterone is 100 per cent safe, why won’t the FDA approve it for female use? Dr Mary Gallenburg, senior gynaecologist at the Mayo Clinic in the US, for one, warns that long-term studies on its safety in menopausal women with a history of breast or uterine c
ancer or those who have cardiovascular or liver disease are still lacking. Furthermore, excessive doses in women, have been linked to male-pattern hair loss, adult acne, a deepening of the voice and even clitoromegaly (an abnormally enlarged clitoris).

  Put off? Well, luckily there are alternatives. According to US sexual-health expert and urologist Dr Jennifer Berman, we ignore the aphrodisiacal effects of omega fatty acids – those found in salmon, avocado and blueberries – at our peril. To supplement that, there are all sorts of sophisticated new sexual aids on the market, many of which are available through her sister, Dr Laura Berman. Heard, for example, of the Eros machine? A suction device that you fit over your bits ‘to increase blood flow to the clitoris and surrounding vulval areas which therefore enhances sensitivity’?

  And what about mindset? It would be mad not to take that into account. For isn’t desire just as much a brain as a body thing? And isn’t it true that it wanes and waxes in exact proportion to mood and situation? As a recent study published in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolism revealed, levels of testosterone and naturally occurring hormones may actually play quite a limited role in driving menopausal women’s libido.

  ‘While levels of testosterone and other reproductive hormones were linked to women’s feelings of desire and frequency of masturbation, our large-scale study suggests psycho-social factors influence many aspects of sexual function,’ says one of the study’s authors, John F. Randolph, Jr, MD, of the University of Michigan Medical School in Ann Arbor. ‘A woman’s emotional well-being and the quality of her intimate relationship are tremendously important contributors to sexual health.’