Pharmaceutical companies and many doctors stress that things are dramatically different today. They cite several reasons for prescribing the new models of HT, including the fact that the modern therapies contain a lower dosage of estrogen and are combined with progestins (a form of progesterone), to balance the negative effects of estrogen. Nevertheless, there still may be a slightly increased risk of breast cancer, strokes, and heart attacks.
Today, one of the most commonly prescribed estrogens is Premarin. It’s referred to as a conjugated estrogen, and is considered the most natural estrogen available. And where is it extracted from? The urine of pregnant horses, of course!*
A Brief Look at Bioidenticals
Obviously, in the context of HT, the word “natural” is now most closely associated with bioidentical hormones, which are, alas, an area of as much controversy and confusion as HT in general. So what exactly are they? Definitions vary (of course!), though the Endocrine Society says they are “compounds that have exactly the same chemical and molecular structure as hormones that are produced in the human body.” But, unlike the actual estrogen and progesterone in your body, they are usually derived from sources such as soy and wild yams, and are often produced at a compounding pharmacy.
Those that are compounded by pharmacies are not FDA approved or regulated, but a new generation of FDA-approved bioidenticals is now being produced by certain pharmaceutical companies. Many clinicians recommend those that are regulated because you can at least be sure they are safe from impurities and contain what the labels say they do.
Regardless of how these substances are formulated, it’s clear that millions of women have been attracted to the concept of bioidenticals because they want nothing more than to get relief from their menopausal symptoms without the requisite risks and side effects typically associated with traditional HT. And yet, despite their most ardent supporters, the evidence is mixed and it’s simply not clear if bioidenticals are actually safer than synthetic hormones.
Deciding What’s Right for You
While most women let the severity of their menopausal signs play a dominant role in deciding whether to take HT, you should also be sensitive to more subtle factors that could tip the scales in your own particular case. Indeed, the development of bone loss, glucose intolerance, or even higher cholesterol should be discussed with an informed physician, as should other factors such as your family medical history. In any case, if you do ultimately choose to take HT, you should remember that every woman’s body and medical situation is different, and that the amount and type of hormones you take should be a function of your own specific health needs.
What Hormone Therapy Cannot Treat
It’s often tempting for menopausal women to look to HT as the magic pill that’s going to resolve all sorts of problems. The fact is that there are a number of things that HT will specifically not prevent, including depression, wrinkled skin, and weight gain. Alas, I’m afraid it’s true, your metabolism really does slow down as you age. But it’s also true that HT may make you feel better by treating the symptoms that cause your anxiety.
What Hormone Therapy Can Treat
There is no question that HT can relieve hot flashes and vaginal dryness. It also helps maintain the acidity of the vagina, making it more resistant to infections. And, far more significantly, most researchers agree that HT can help prevent osteoporosis. Still, it should be made clear that HT will help these specific problems only while you are taking the hormones. Once you discontinue, the problems will often return. This is particularly true with hot flashes. You should also remember that hormones will not restore bone density to their premenopausal level. It will only prevent bone loss for as long as you remain on the therapy.
Risks of Hormone Therapy
Despite the addition of progestins to counter the adverse effects of estrogen, HT could increase the risk of heart attack, stroke, blood clots, and breast cancer in certain women. This increased danger may be greatest for those who already have a higher risk, including women who have a family history of those conditions, are diabetic, or are substantially overweight. Finally, older women who are already postmenopausal are also considered at a significantly higher risk.
However, many clinicians still believe that HT, whether synthetic or bioidentical, has an important role to play for women suffering from serious menopausal symptoms, so long as they are still premenopausal, have no significant risk factors, and are prescribed the correct dosage and blend of estrogen in combination with progesterone.
Side Effects
In addition to the potentially increased medical risks, there can be annoying side effects. Among the more common are nausea (especially if taking high-dose estrogen), fluid retention, and fibroid enlargement. And some will continue to have cyclical vaginal bleeding, though it is usually shorter and lighter than typical menstruation.
HT: Balancing the Data
The reality of HT is that potentially serious problems need to be weighed against some very real and substantial benefits, with each individual woman judging how the pros and cons balance out when applied to her own personal situation. If you are considering HT, you will definitely need to consult with a clinician who is experienced in this field. This is clearly an important and complicated subject, and one with which I urge you to keep current. There are many factors to consider, but ultimately you can make a rational decision, as long as you are informed.
MENOPAUSE AND SEXUALITY
Menopause has a paradoxical effect on female sexuality. But just to set the record straight: it does not signal the end of a woman’s sex life! While it’s true that it tends to cause vaginal dryness, it finally frees women of the fear of pregnancy. The liberating feeling that results can be more than enough to compensate for the extra effort that it may take to become sexually lubricated. In fact, many women find their sex lives improve when they no longer have to worry about pregnancy or menstruation.
TESTOSTERONE AND WOMEN—WHO KNEW?
Though we normally think of testosterone as an exclusively male hormone, the reality is that women produce small amounts of it from puberty onward. True, men produce about 20 times as much as women do, but the tiny amount that women produce is essential for much of their well-being. Unfortunately, though, as they age, and especially as they approach menopause, their testosterone levels may fall so much that it can cause dry skin and brittle hair as well as some truly disconcerting symptoms, including a loss of:
•sexual desire and sensitivity
•vital energy or feelings of well-being
•mental sharpness
•muscle tone
•pubic hair
•calcium from bones, contributing to possible osteoporosis
•muscle tone in the bladder and pelvis, resulting in urinary incontinence
Over the last few years, testosterone supplementation has emerged as an increasingly popular therapy for women during perimenopause and after. There are also other groups of women who suffer from testosterone deficiency and could benefit from such supplementation, including those who have had a hysterectomy (even if the ovaries have been left in place), those who have had chemotherapy resulting in loss of ovarian function, and those who go through menopause earlier than the average age of around 51.
The evidence for testosterone treating most of the symptoms above is mixed, but it does appear to have encouraging results in dealing with lack of sexual desire and libido. Regardless, though, if you are considering testosterone supplementation, you will need to find a clinician who is familiar with this therapy, not least because it’s crucial that you take the appropriate dosage.
FERTILITY AWARENESS FOR BIRTH CONTROL DURING THE PREMENOPAUSAL YEARS
Some medical practitioners warn against using natural birth control when you begin to have menopausal signs, because of the irregularity of cycles during this time, but this advice shows a misunderstanding of how the Fertility Awareness Method works. Yes, it is true that cycles tend to become more sporadic for
women in their 40s, but the key to FAM is that each individual day is observed for possibly fertile conditions, and thus the cyclic consistency is almost irrelevant.
What is relevant is that many premenopausal women may have fertile cervical fluid patterns for increasingly longer periods of time (such as preovulatory sticky day after day). This is both the potential frustration and irony of FAM in the years approaching menopause, for while the method’s conservatism may tell a woman she is fertile more days than ever, the fact is that as she ages, her potential fertility is diminishing rapidly.
The truth is that using FAM during the menopausal years can be confusing, but, depending on your own particular cycles, it may also be easier than ever before. Indeed, you may go for months at a time with nothing but dry, infertile days. Regardless, using FAM will provide you with an amazing window into the workings of your body as it travels through “yet another change.”
How to Determine Whether You Are Near Menopause
Using FAM during menopause may involve some modifications, but before using the special guidelines, you obviously need to determine how close to menopause you actually are. As discussed previously, you will generally have distinct symptoms to alert you, in addition to the fact that you will most likely be in your 40s as the transitional time arrives. As you know, the most distinct signs signaling the premenopausal transition period are menstrual cycle irregularities, hot flashes, and vaginal dryness.
An alternative way to determine how soon you will go through menopause is to have the very test developed to determine your chances of having a baby—the antral follicle count discussed here. While its purpose is to predict how many eggs a woman has left in her ovaries (her ovarian reserve), the information gleaned can be useful regardless of whether or not you want to achieve a pregnancy.
CHARTING YOUR FERTILITY SIGNS AS MENOPAUSE APPROACHES
If you decide that you want to chart your cycles for birth control, brace yourself for quite a ride. You can still use the method effectively, but this phase may be a challenge. Whatever your choice, charting will reflect your hormonal changes, giving you a sense of control over your seemingly unpredictable body.
When charting premenopausally, anticipate significant changes in your typical fertility pattern. Each of your fertility signs will reflect your new hormonal fluctuations as your body prepares for the cessation of ovulatory cycles.
Waking Temps
One of the most obvious reflections of your diminishing fertility will be your waking temps. Rather than seeing the usual thermal shifts every cycle, you will start seeing new variations. Initially, you may notice that your cycles become shorter and more frequent, and thus your thermal shifts occur sooner than usual. In addition, you may notice that the number of postovulatory temps decreases, reflecting shorter luteal phases than you used to have.
And finally, you’ll notice more and more anovulatory cycles, in which your temps remain low throughout, indicating that you didn’t release an egg. All of these variations in your temperature pattern are absolutely normal as you approach menopause, and should serve only to remind you of the benefits of charting to help you understand what is happening in your body.
I myself had reached that magical perimenopausal age of 50 when I went in for my routine annual exam. When my doctor asked me whether I was still cycling normally, I responded that yes, I was, but that I had several really short cycles as well, averaging only 18 to 22 days. Of course, if I were trying to conceive, that would be problematic, but I wasn’t. She still expressed concern, stating that I should get an endometrial biopsy to determine what was causing all of that “dysfunctional bleeding.”
Were it not for my illuminating charts (this was my 322nd cycle, after all!), I would have subjected myself to a totally unnecessary procedure. But I was able to assure her that not only were my cycles normal, but I was still having absolutely obvious thermal shifts with normal luteal phases. That was all she needed to hear—that the bleeding was indeed from ovulation and not from a worrisome condition or disease.
Cervical Fluid
As the number of your ovarian follicles decreases, you will stop ovulating as often. So you will produce progressively less estrogen, which in turn will decrease the amount of fertile-quality cervical fluid you have. For example, if you used to have three days of eggwhite per cycle, you may now have only one day, if any. Yet without ovulation, progesterone won’t be present to rapidly dry up what cervical fluid there is, so it may become harder to identify your Peak Day.
Your usual fertile pattern of cervical fluid may change to more days of either dry, sticky, or even a watery secretion, without any of the fertile characteristics, such as being stretchy, clear, or lubricative. Your vaginal sensation may also become continuously dry or sticky. Or you may experience sporadic wet patches of cervical fluid as your body still makes noble attempts to ovulate.
Cervical Position
Observing your cervix during confusing phases of anovulation can be especially helpful. You will probably notice that as menopause approaches, your cervix is more often firm, closed, and low, confirming longer phases of infertility and clarifying ambiguous cervical fluid or temperature patterns.
Secondary Fertility Signs
Along with the obvious changes you may notice in your three primary fertility signs, you will probably see changes in your secondary signs as well. You may even notice certain fertility signs for the first time, as discussed below.
Midcycle Spotting
If you’re someone who never used to have midcycle spotting around ovulation, you might be surprised to start experiencing it now. Its appearance is due to the fact that ovulatory spotting tends to be more common in long cycles, and one of the hallmarks of premenopausal cycles is their increasingly longer lengths.
Mittelschmerz
If you are used to having midcycle pain around ovulation, you may notice that you don’t experience it as often as you stop ovulating as frequently.
Breast Tenderness
One of the nice benefits of anovulatory cycles is that you don’t usually experience the postovulatory breast tenderness characteristic of normal cycles. This is because no progesterone is released to cause the discomfort.
THE CONTRACEPTIVE RULES AS MENOPAUSE APPROACHES
Once you have determined that you are indeed experiencing menopausal signs, the way you will use Fertility Awareness can be fairly straightforward: You should follow all the standard rules of FAM for birth control discussed in Chapter 11, except that you should not rely on the First 5 Days Rule.
What this means in practice is really quite simple. Chart your cycles as you always have, but you should no longer assume that the first 5 days of the cycle are infertile. The reason for this is that your premenopausal cycles are subject to hormonal fluctuations that may cause a dramatically early ovulation. Again, we are dealing with degrees of risk. Although there is little data to cite, it’s likely that the first 3 days of a period are nearly as safe as the first 5 days were before you had that initial hot flash. But, to be most conservative, you should assume you’re fertile until you can verify a dry day, which as you know, is essentially impossible to detect while you’re bleeding.
“Hard” Cycles, “Easy” Cycles
As menopause draws closer, you may find that you go for months without any dry days. Instead, you might have a continuous and extended preovulatory pattern of sticky days, perhaps interspersed with patches of wet cervical fluid. The occurrence of unchanging cervical fluid day after day is called a Basic Infertile Pattern (BIP) and is very common in premenopausal women. In such a case, you will need to to use the BIP rules discussed in Appendix J. They allow women with a sticky BIP to count more days as infertile than would be possible under the standard FAM rules. However, the BIP rules are admittedly more difficult to follow, and as you will read there, they are somewhat riskier for premenopausal women.
Understandably, you might decide that using them is simply not worth the trouble. Yet before you decide
anything definitively, I would encourage you to continue charting for several months. Aside from the fascinating record you’ll have of your reproductive system going through the throes of biological angst, it’s almost certain that your cycles will become both increasingly longer and dryer, making FAM easier than ever, as seen in Sandy’s charts below.
Sandy’s first chart. A challenging premenopausal Basic Infertile Pattern. Sandy has the misfortune of having a premenopausal BIP of sticky, day after day, interspersed with wet patches.
Sandy’s second chart. An easy premenopausal Basic Infertile Pattern. Later, Sandy develops a BIP of dry day after day. With charts like this one, FAM for birth control will be a breeze.
Sandy’s third chart. The easiest premenopausal pattern of all. Over time, Sandy stops ovulating altogether, as evidenced by continuous dry days with no thermal shift.
When all is said and done, each couple will have to decide what is best for them. You might decide that it’s not worth waiting for easier cycles. If this is the case, you may want to consider more permanent forms of contraception. Personally, I feel that vasectomy for your partner is a better option than tubal ligation, because it’s a cheaper and less invasive procedure with fewer possible complications. But whatever you choose, remember that you are considered potentially fertile for a full year after your last period.
MAINTAINING YOUR SANITY THROUGH THE MENOPAUSAL YEARS
In the end, how easily you glide through menopause will be determined in large part by your expectations before you get there. While the various menopausal signs can be a nuisance, they certainly don’t have to be traumatizing. Reasonable solutions are available, so keep a sense of humor, and know that you’re hardly alone.
Taking Charge of Your Fertility Page 34