

MENOPAUSE

MONDAYS

The Girlfriend's Guide to Surviving and Thriving During Perimenopause and Menopause

Ellen Dolgen & Jack Dolgen

Smashwords Edition

Copyright © 2015 Menopause Mondays, LLC

Smashwords License Statement

This ebook is licensed for your personal enjoyment only. This ebook may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each reader. If you're reading this book and did not purchase it, or it was not purchased for your use only, then please return to your favorite retailer and purchase your own copy. Thank you for respecting the hard work of this author.

Parts of this book were previously published in 2011, under the title Shmirshky: the pursuit of hormone happiness., Hyperion, New York

The author does not give medical advice or engage in the practice of medicine, and no doctor-patient relationship is offered or created.

All statements and information herein are for informational or entertainment purposes only and are not meant to replace the services of a physician. All readers should consult their own physicians about any symptoms that may require diagnosis or medical attention or before pursuing any course of treatment.

The author does not recommend, endorse, or make any representation about any tests, practices, procedures, treatments, services, opinions, health care providers, physicians, or medical institutions that may be mentioned or referenced.

The names and identifying characteristics of some people and places in the book have been changed for the protection and privacy of those individuals.

Menopause Mondays logo design by Marika van Adelsberg

Special thanks to:

Elizabeth Stein/Seventh Child, Inc.

Dusan Stankovic/Internetize.Me

Menopause Mondays TM, and all other trademarks and logos associated with Menopause Mondays TM are valuable trademarks owned by Menopause Mondays, LLC.

All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without the written permission of the publisher Menopause Mondays, LLC.

Library of Congress Cataloging-in-Publication Data

Ellen Dolgen and Jack Dolgen.

Menopause Mondays: A Girlfriend's Guide to Surviving and Thriving During Perimenopause and Menopause by Ellen Dolgen and Jack Dolgen. - 1st ed.

ISBN 978-0-9962663-0-7

FIRST EDITION

10 9 8 7 6 5 4 3 2 1

## Dedication

I was told the number eight is good luck in the Chinese culture. The number eight (Ba in Chinese) has a similar pronunciation to 发 (Fa, meaning wealth or fortune), which is why eight represents good luck.

To get an idea of how seriously the Chinese take the importance of the number eight, the Beijing Olympic Games commenced at exactly eight minutes after eight o'clock on the eighth day of the eighth month in 2008. In China, when people choose telephone numbers, mobile numbers, house numbers, car identification numbers and important dates, eight is usually their first choice.

And now eight is _my_ lucky number. My first grandchild, Aviva, was born at 8 A.M. on the eighth day of the eighth month of 2014!

The first time I held Aviva, shortly after she was born, my heart was flooded with maternal love and my protective gene went into overdrive. After I checked her fingers and toes, philosophical thoughts bounced around my head like pinballs in an arcade. How can I make sure that she loves herself, is confident and proud of who she is, and doesn't waste time being so crazy critical of herself? Could I help her be her own best friend? Could I make sure that she doesn't let anyone or anything hold her back from anything and everything that she wants to do in her life?

This book is dedicated to Aviva and all the little girls of this generation. Know that I will always be here for you, and when I am not here physically, my love force shall surround you forever. It is my hope that you girls will be your own best friend, an advocate of your own health. I envision the sisterhood torch being carried by this next generation, with pride and good health, and to greater heights than my generation can possibly imagine!

## Table of Contents

Dedication

A Note from Ellen

**Part One: Welcome to the Party: Perimenopause and Menopause**

Chapter 1

> You Are Not Alone

Chapter 2

> The Change: Perimenopause and Menopause 101

**Part Two: Are We Having Fun Yet? Symptoms of Perimenopause and Menopause**

 Chapter 3

> Memory Loss and Brain Fog

Chapter 4

> Night Sweats and Hot Flashes

Chapter 5

> Irregular Periods (Abnormal Uterine Bleeding)

Chapter 6

> Stress, Anxiety, Irritability, Depression, and Mood Swings

Chapter 7

> Weight Gain

Chapter 8

> Insomnia and Fatigue

Chapter 9

> Vaginal Dryness and Pain During Sex

Chapter 10

> Loss of Libido

Chapter 11

> Migraine Headaches

Chapter 12

> Incontinence and Other Urinary Symptoms

  **Part Three: Get Me Out of Here! Getting Help for Menopause Symptoms**

 Chapter 13

> Finding a Menopause Specialist

Chapter 14

> Getting Tested for Menopause (and Fertility)

Chapter 15

> Hormone Therapy

Chapter 16

> The Hormone Therapy Controversy Debunked

Chapter 17

> Breast Cancer and Menopause

Chapter 18

> Ease Menopausal Symptoms with Food

Chapter 19

> The ABCs of Vitamins and Supplements

Chapter 20

> The Impact of Smoking on Menopause

Chapter 21

> Surgically Induced Menopause (Hysterectomy and Oophorectomy) and Premature Menopause

Chapter 22

> Compounding Pharmacies

Chapter 23

> A Word About Menopause in the Workplace

**Part Four: ** **Keep the Party Going: Preventing Long-Term Health Problems**

Chapter 24

> Osteoporosis

Chapter 25

> Heart Disease

Chapter 26

> High Blood Pressure

Chapter 27

> Thyroid Problems

Chapter 28

> Share Your Story

Conclusion

## A Note from Ellen

My perimenopause/menopause journey began in my mid-40s, although it would be years before I knew that's what was going on with me. After lots of research and sleepless nights, I realized I was in perimenopause!  I learned that there are over 30 symptoms of menopause. I was furious no one had educated me about this.

While still in my brain fog, I searched for a good menopause specialist, all the while sleepless, withdrawn, weepy, grumpy, and hot flashing. Never one to give up, I began writing my first book, even though I didn't know a Word document from a pdf!

I had to fight the daily negative chatter in my head that was constantly yelling, "Are you crazy? You can't write!"  But it was important to me that no one else suffered needlessly like I had, so I persisted. Needing all the support I could muster, I reached out to my loving children and husband, and soon the book became a family affair.

My son, Jack, was visiting from New York City. I printed out all of the chapters, spread them out on the floor, and said, "Can you help me with this?" Poor Jack, his Mom was lost in menopausal hell. There was no way could he say no! Together, we wrote _Shmirshky: think inside the box_. My daughter, Sarah Dolgen Shaftel, assisted with the PR effort. My husband, David, encouraged and supported my mission, while at the same time dealing with my often tumultuous menopausal symptoms! (If asked privately, David might tell you that this is more than a bit of an understatement!)

Soon after Jack and I self-published the book, it was picked up by a major publishing house and became _Shmirshky: the pursuit of hormone happiness_.

Despite this ongoing effort to  get the facts out about menopause, I unfortunately often meet women who are experiencing symptoms like hot flashes, night sweats, heart palpitations, insomnia, and other such lovely blessings of "the change," and are still clueless about what is happening to them. They think that the cause is some mysterious virus that's going around, or worse, that it's all in their heads. Wrong!

I was left with the question, how does one reach lots of people effectively and quickly? Start a blog!  So Jack and I created EllenDolgen.com, and my Menopause Mondays Blog and Health News Flash was born. Thanks to social media, I  reach hundreds of thousands of women (and men) all over the country! I have appeared on countless TV talk and news shows (The Today Show, Rachel Ray, The Doctors, NBC Nightly News, and Katie, to name a few). I was honored to be asked to be one of the original contributors to Huffington Post 50. Over these past years, my weekly blog has been syndicated on over a dozen health sites.

As we all know, you can't leave your menopause on the kitchen counter when you go to work. Seeing a need for worker and employer education,  I founded a women's health and wellness program that provides corporate education events for businesses, healthcare institutions, and other organizations, and  produce  Menopause Mondays Parties™ for organizations across the country.

Pharmaceutical companies have reached out to me to help them address women's health needs through various menopause awareness campaigns via round table discussions, videos and social media. All of this is done with one goal, and one goal only: to educate and prepare the sisterhood for perimenopause and menopause.

This eBook will help all women and the people who love them to have access to the best information available at **zero cost**. There should be no financial barriers to the information women need for their health.

 In the electronic pages that follow, you'll find detailed descriptions and solutions for the symptoms you or your loved one may experience (Part II: Are We Having Fun Yet?), I'll help you find a menopause specialist (Part III: Get Me Out of Here!), and explain what tests to ask for once you get there. You'll also learn about the latest studies on hormone replacement as well as alternative therapies and remedies.

We're loving advances in technology. The format we are using allows you to access outside links providing you more information and links that take you elsewhere _in the book_ for easy reference.

Finally, you can read about the real-life experiences of  women—and those who love them—as well as contribute your own stories so you, too, can help others experiencing the ups and downs of perimenopause and menopause. When we share, we learn from each other.

Think of me as your best girlfriend who happens to know a lot about menopause. I've devoted the last ten years of my life to helping women during this often difficult time. While I'm not a doctor or scientist,  I've "talked the talk" with menopause experts, so that I can "walk the menopause walk" with you and share the keys to this menopause kingdom. The most important thing you should know is that you're not alone. Approximately 50 million women are currently dealing with menopause in the United States. In fact, 6,000 women in the U.S. enter menopause every single day. That's more than 2 million women a year entering menopause. So take a deep breath and relax, we're all going through this together.

Are you ready?

Okay, let's get down to menopause business!

My motto is:  "Suffering in silence is OUT!  Reaching out is IN!"

# PART ONE

## Welcome to the Party

### Perimenopause and Menopause

# Chapter 1

## You Are Not Alone

When I was fourteen, all I wanted was to get my period. My girlfriends got theirs years before I did. I was so desperate for it that I even pretended I had it just to get out of gym class. Then, when I was sixteen years old, it finally arrived. I was ecstatic. I was sure that I was going to be "in" now. I had convinced myself that I'd suddenly be popular with boys, so I knew any minute guys would start flocking around me. I had been dreaming of this day for such a long time.

I put on my belt and pad (in those days, the only things with wings were birds) and waited to feel something magical. But there was no euphoria, just a pounding headache, cramps, a raging sea of hormones, and of course the monthly bloodbath. This was what I had been praying for? Are you kidding me?

For the next thirty years, I got used to it, but I never liked it. And I was certain I'd never miss it once it was gone.

And then I hit my mid-forties, and suddenly mind and body started behaving strangely. The very first time I noticed something was amiss, I was in a business meeting, and mid-sentence my train of thought wandered right off the rails. What was I saying? This kept happening, meeting after meeting, but I refused to accept that something was wrong. A few weeks later, in yet another meeting, without warning, heat began radiating up my body. It felt as though I was on fire. Perspiration was dripping down my face, trickling down between my breasts and settling in the inseams of my pant suit. I looked like I had just finished a Bikram Yoga class (you know that sweaty kind of Yoga)! There I sat, shocked and completely embarrassed.

I started to notice that I was not nearly as energetic as I used to be. I often needed to get into a hot bath just to warm up my feet. I couldn't seem to retrieve thoughts from my brain, and my mind would go blank midsentence.

It never occurred to me that I was beginning perimenopause. In fact, I didn't even know what it was or ever heard the term mentioned. Instead, I began worrying that these were the early signs of Alzheimer's disease or some other kind of dementia. All my life I had prided myself on being a masterfully organized, multitasking dynamo. I was not ready to lose that part of my personality.

During this time of confusion, I was lucky that my husband David was able to seamlessly jump in and finish sentences for me so as to spare me social embarrassment. After so many years together, he seemed to know what I was thinking. He sensed that my memory loss was horribly upsetting to me, so he sweetly mastered subtle ways to feed me facts. It was wonderfully kind of him.

I made a habit out of making jokes about my memory loss, and just kept laughing it off, hoping it was just a fluke, and that perhaps tomorrow I would wake up back to my old self.

I had always been a happy person and not interested in being sick or "less than.'' I didn't talk about this with anyone because talking about it would make it real. Instead, the voice in my head kept secretly chanting that age-old woman mantra: "I am fine. I am fine. I am fine."

When a woman says she is "fine," this is the first sign of "the cover-up." It's not that we don't want to be honest with those we love, but rather that we aren't being honest with ourselves. Perimenopause and menopause were a huge secret and taboo for our grandmothers and mothers. In the 21st century, it is—shockingly—still very much a  "hush hush" subject, not to be openly discussed. Crazy, right?!

For some, it can be embarrassing to admit they're experiencing perimenopause or menopause—especially with our society's preoccupation with staying young forever. The changes our bodies and minds go through during this transition are challenging and, at times, even depressing. Hiding from yourself is not a solution.

Isolating yourself from those you love will only cause unnecessary breakdowns in your relationships, perhaps even to the point of divorce. Think I'm exaggerating? Not long ago, I was a guest on an advice program on Playboy Radio (I was fully clothed, but I'm a Phonemate now). Caller after caller—all men—told me stories of what their wives were going through and how it was destroying the intimacy in their relationships, because they didn't know where to turn for help or even how to talk about it. For one man, it was too late: "When we tried to have sex, no matter what we did, it hurt her. I didn't want to hurt her, so we abstained. We became roommates for five years, barely speaking to each other until we finally split up. She is still the love of my life. I wish had known that this was menopause. I thought she didn't love me anymore. Maybe, we could have found a menopause specialist and saved our marriage."

So talk to the people in your life, talk to a menopause specialist, and talk to your partner. Let them know what's going on with you, and let them help you. Suffering in silence is an unacceptable way to live.

Each woman will have her own journey. Each of our bodies is different. But we can and will get through this together.

# Chapter 2

## The Change: Perimenopause and Menopause 101

Archie Bunker: I know all about your woman's troubles there, Edith, but when I had the hernia that time, I didn't make you wear the truss. If you're gonna have the change of life, you gotta do it right now. I'm gonna give you just 30 seconds. Now c'mon and change.

Edith Bunker: Can I finish my soup first?

\--- _All in the Family_ , Season 2, Episode 15: "Edith's Problem" (January 1972)

Every woman you know is going to go through menopause someday. Basically, menopause is the tampon-free time in a woman's life. Sounds breezy, right? Who wouldn't want to live without her period? Remember what puberty was like, with all the physical changes in your body and teenage moodiness? Well, the transition from the tampon-wearing time in your life to the tampon-free time can be even more challenging.

As it turns out, perimenopause and menopause isn't just the simple cessation of a bodily function. It can be your brain, your body, and your life, transforming into something you're totally unfamiliar with. You may begin to question your sanity, relationships, hormones, genetics, sex drive—everything! For many women, it's an every day, all day, and all-consuming hurricane of bodily betrayal; for others, it's a mere blip on the hormonal radar.

**The Process Begins with Perimenopause**

A huge part of my mission is to educate and inform _young_ women as to what to expect when you're expecting perimenopause and menopause. That is why I created this music video, "A Singing Uterus Explains Perimenopause and Menopause."  A singing uterus... what's not to love? Laugh, learn, sing and dance! "This is one smart uterus!" Help spread the word!

According to menopause.org, the website of the North American Menopause Society, perimenopause is defined as the "gradual transition between the reproductive years and menopause (the cessation of menstrual periods)." Perimenopause generally lasts from six to ten years, a time that is often filled with all sorts of not-so-fun symptoms that we typically associate with the word menopause, but in fact begin much earlier.

  * How do you know if it's happening to you?

  * You might begin worrying that you're losing your marbles.

  * Although your eyes are suddenly dry and itchy, the least little thing brings big wet tears to your eyes. In contrast, "down south," your vagina feels like it took a trip to the desert.

  * You are grumpy, depressed, irritable, hypersensitive. You have erratic mood swings. You feel lonely, yet all you want is to be alone.

  * Your once every-28-days-like-clockwork periods begin to act weird: they get really heavy and last for weeks, then they disappear for months at a time, only to return unannounced like some nightmare mother-in-law for a quick drop-in (spotting).

  * Your internal thermometer goes haywire. First, you mysteriously wake up in the middle of the night and find your pj's are drenched in sweat. What's worse, you find yourself overwhelmed with waves of tropical heat during the day, that drive you to stand in front of an open refrigerator pretending to be looking  for a yogurt.
  * You no longer sleep through the night.
  * You find yourself staring in the mirror, startled at the changes you see; your skin is as dry as an old glove, but may also be breaking out like a pubescent teenager's.
  * You don't feel sexy anymore or lose interest in intimacy with your partner.  
  * You may feel like you have to pee all the time or have symptoms similar to a urinary tract infection.
  * You have intense food cravings and your appetite is insatiable; your clothes are getting tight; and you are being a total crabass to everyone around you.
  * You may find that you are having migraine headaches.
  * And there may be hidden symptoms too, like a decrease in fertility that you won't know about until you start trying to conceive, and find it's not happening as easily as you thought it might.

**When Does Perimenopause Begin?**

Like a bad house guest, perimenopause arrives unscheduled, uninvited, and sticks around a lot longer than you'd like it to. To add insult to injury, it tends to start a lot sooner than you might think. You might start noticing changes to your menstrual cycle or internal thermostat before you notice your first gray hair. Most women begin perimenopause in their early to mid-forties, but some women start to experience symptoms in their thirties. There are many factors that contribute to menopausal timing, including genetics and medical or surgical history. Women who undergo an oophorectomy or radical hysterectomy, in which the ovaries are removed, jump right past perimenopause into full menopause. This is what the actress and filmmaker Angelina Jolie experienced, and publicly acknowledged in March of 2015.

**When Does Menopause Begin?**

When you've been without a period for 12 consecutive months, you have graduated to menopause. Congratulations! Sorry there is no official cap and gown ceremony for this graduation, but the good news is you can start spending your tampon allowance on something a lot more fun. The bad news is that while the bloody part of your life may be over, the other symptoms that began in perimenopause (like hot flashes and mood swings), may continue for years after you've had your last period.

The average age for reaching menopause in this country is 51, but that's just an average. The timing, just like the symptoms, is different for every woman.

**Menopause Symptoms**

There are many symptoms typically associated with perimenopause and menopause—and there's no rule about when they begin or end; some women experience symptoms during perimenopause, some right at menopause, and some in the years after menopause. Each woman may experience one or many of these, and to different degrees. Some women breeze through perimenopause and menopause with few symptoms, while others deal with a tremendous number of challenges. I have one friend who believes that every hot flash in the universe is telling her, "Step aside, you old bat. You are no longer useful here." I am not buying it!  We are here to solve our problems, not give into them!

FYI, hot flashes, night sweats and other symptoms of menopause typically affect women much longer than previously thought, a median of 7.4 years, according to a study published in _JAMA Internal Medicine_. The study looked at a group of nearly 1,500 women with frequent symptoms of the onset of menopause and found significant variations in duration of menopausal vasomotor symptoms (VMS) between ethnic groups.

Be sure to download my Menopause Symptoms Chart  to keep track of your symptoms and help you effectively communicate with your doctor about how you feel. If we understand things, we can begin to deal with them, so let's divide the symptoms up into two categories:

**Physical Symptoms**

  * Hot flashes or flushes (day)

  * Night sweats

  * Insomnia
  * No energy/exhausted
  * Abnormal uterine bleeding—heavy, light, irregular
  * Dry, papery skin
  * Hair loss
  * PMS-like bloating
  * Sore/swollen breasts
  * Increased chin whiskers
  * Pimples/acne
  * Deepening voice
  * Migraines
  * Heart palpitations
  * Weight gain
  * Stiffness/aches, pains
  * Bladder issues
  * Vaginal discharge
  * Vaginal dryness
  * Painful sex
  * Loss of libido

**Mental and Emotional Symptoms**

  * Memory loss

  * Mood swings

  * Depression

  * Withdrawn/antisocial

  * Anxiety

  * Feelings of being overwhelmed

  * Weeping/Crying/Sobbing

  * Grumpiness

  * Bursts of anger/violence

  * Loss of libido (no, the inclusion of this in both categories  is not a typo)

Sounds fun, right? If any of these sound familiar, read on. And before you protest that you're too young, keep in mind, you don't have to have an AARP card to begin the long and arduous process of perimenopause and menopause. Now don't bolt and stop reading. This is all for your information, not to make you fearful. You will be able to deal with all of these issues, just read on!

# PART TWO

## Are We Having Fun Yet?

### Symptoms of Perimenopause and Menopause

# Chapter 3

## Memory Loss and Brain Fog

You're in the middle of a conversation with a colleague, and lose your thought halfway through a sentence. You call your children by the dog's name. (If you name your dog after your first born, you might save yourself some embarrassment!). Your desk is plastered with sticky note reminders. You find yourself asking your significant other, "Honey, can you call my phone? I can't find it." You wish you could do the same with your keys and wallet.

It's not in your head: Menopausal memory loss is real.

As hormones fluctuate in your body during menopause, cognitive functions are affected. Doctors say self-reported memory problems are common in women 33-55. Many menopausal women have trouble with working memory, as well as keeping themselves focused, says a study from the University of Rochester Medical Center and the University of Illinois at Chicago. Additionally, the Study of Women's Health Across the Nation (SWAN) showed that cognitive decline is common, and that it can be more difficult to learn new things as you go through menopause. That translates to problems with even some of the most basic real-life tasks, like calculating a tip after a restaurant meal or adjusting an itinerary after unexpected flight changes. (Take a look at this clip of a Menopause Monday event on the TODAY Show discussing the research!)

FYI, the study says hormone therapy works better when you begin early on, say before your last period or by 53 years of age. There might be a detrimental effect if you begin hormones much later in the game—three or four years after your last period.

"If a woman approaching menopause feels she is having memory problems, no one should brush it off or attribute it to a jam-packed schedule. She can find comfort in knowing that there are new research findings that support her experience. She can view her experience as normal," lead researcher Miriam Weber, Ph.D., said in a statement. Between one-third and two-thirds of women report forgetfulness and other memory difficulties during perimenopause and menopause, according to Weber.

Still, "normal" doesn't always mean "good." And it definitely doesn't mean you have to accept it.

**Here are five natural ways to help overcome some of these issues and keep a sharp** **mind during menopause:**

**1. Get to Know Your Memory**

Ruth Curran, creator of Cranium Crunches brain-training games, recommends examining your memory and embracing your strengths and weaknesses. "Sometimes 'thinking inside the box'—seeing and recognizing our 'failings'—helps us embrace the way we function right now and make something great out of what we might otherwise see as 'deficits.' We need to give ourselves permission to embrace the way we are and maximize our potential."

Is your problem not being able to focus, or perhaps picking out the most important part of someone's story? Pay attention to what mental tasks are challenging for you. "Once you know them, you can work by yourself or with a cognitive therapist so that you can best use your unique brain," Curran says.

**2. Play Games**

Memory games aren't just for kids! "There is growing evidence (based on functional MRI studies) that mental exercise helps rebalance and rewire the brain," says Curran. Cranium Crunches uses cognitive puzzles that mimic everyday life to hone your day-to-day attention and processing skills, make new brain connections, and generally up your brainpower. Other websites, including Luminosity, Posit Science, Happy Neuron, and CogniFit, also offer fun brainteasers for cognitive health.

**3. Break a Sweat**

"Physical exercise influences the delivery of neurochemicals throughout the brain that regulate memory (and are directly affected by hormone levels)," Curran says. In fact, a study in _Neuroscience_ found that running increases levels of a protein called brain-derived neurotrophic factor (BDNF), which supports neurological health and encourages the growth of new brain cells. Meanwhile, weight training increases levels of insulin-like growth factor, another protein in the brain that promotes cell division, growth, and health. Don't sweat it, just get moving! Exercise feeds your brain, contributes to your overall health, and helps fight that muffin top.

**4. Eat Right**

Speaking of muffins, I love to eat. Pie. Cake. Ice Cream. Wait, what was I saying? Oh right.

Your brain runs on food, so if you want your brain to work right, you have to feed it properly. Research from Oregon Health and Science University shows that people with diets high in vitamins B, C, D, and E and in omega-3 fatty acids are less likely to suffer from brain shrinkage and other abnormalities associated with Alzheimer's disease, while people who consume diets high in trans fats—often found in fast, frozen, and processed foods—are more likely to have low scores on thinking and memory tests. So skip the cake (sigh) and have a meal your brain will thank you for.

**5. Meditate**

Menopause stress can contribute to memory loss, weight gain, osteoporosis, and even sagging skin. Basically, it can make us old!

A study from the University of California, Santa Barbara, found that meditation, a.k.a. mindfulness training, improves working memory and diminishes mind wandering—the two biggest brain problems women experience during perimenopause and menopause. In the study, subjects completed a two-week mindfulness course that involved daily meditation exercises. "Meditation can help restore a healthy chemical and electrical balance in the brain," Curran says.

You don't need to have candles or incense or a Yanni recording playing to meditate; all you need is a few minutes in a quiet room where you can practice mindfulness such as focusing on sensory experiences like your breathing, the taste of a piece of fruit, or the sound of an audio recording. Meditation is extremely helpful in lowering blood pressure and minimizing the effects of depression.

Here are some other great tips to help you remember:

  * Drink red wine and eat dark chocolate! The active ingredient resveratrol helps improve memory. If you've put on a few pounds during menopause, take heart. The study claims it works better on overweight adults. (Consider this one in moderation!)
  * Learn to speak another language.
  * Play the piano or guitar: musical arts training and cognition are inter-related.

The good news in the SWAN study is that menopausal cognitive decline might be time-limited, so as you near the later stages of menopause, you do feel more clarity. And for me personally, once I started HT, my brain fog lifted and I was fully functioning again!

True self care is about more than your body. It's about your mind, which is the control center for everything you think, do, and are. Clear cognitive health allows you to be your healthiest, happiest self. Sure, it's easy to dismiss brain fog with late nights, busy schedules, and to-do lists as long as your arm, but you owe it to yourself to stop making excuses and to get to the real cause.

Remember, just because your challenges are "normal" doesn't mean you can't ease them. Be your own best friend—take good care of yourself!

# Chapter 4

## Night Sweats and Hot Flashes

Are you experiencing your own internal heat wave? Do you wake up at least once during the night in a sweat? Do you have to get out of bed, towel off, change clothes and then try to get back to sleep, only to experience a repeat performance? Do you have to prod your partner to move over a bit to avoid sleeping in the "wet spot." (No, not the fun one.) Do your nights of interrupted sleep seem endless? If so, you're not alone, and this is not being caused by global warming.

According to the North American Menopause Society, about 75 percent of women report perimenopausal symptoms such as night sweats and hot flashes. If you're one of them, you know it's more than a seasonal heat wave. And you know that the symptoms — a flushed face, drenching sweat and rapid heart rate—will only be compounded as the numbers on the thermostat continue to climb. Before you move to the North Pole, let's examine this common symptom a bit further.

What exactly is a hot flash?

During perimenopause and menopause, the body's levels of estrogen, progesterone and testosterone begin to fluctuate. When estrogen levels go down, they can trigger your body's thermostat to send a signal that you are overheated. This causes your body to send out an _all hands on deck_ alert: your heart pumps faster, the blood vessels in your skin dilate to circulate more blood to radiate heat, and your sweat glands release sweat to cool you even more. Like so much about the process of menopause, there is no "one size fits all" for the timing, duration, frequency or pattern of menopausal hot flashes.

**So what does this hormonal meltdown feel like? You may experience one or more of these:**

  * flashes of heat spreading over your skin

  * skin flushed red or blotchy

  * racing heartbeat like you've just run a 100-yard dash

  * sweating a lot

  * dizziness

These episodes:

  * last from 30 seconds to 5 minutes

  * occurring in upper or lower body

  * occur during the day and/or night (night sweats)

  * are infrequent (several per month) to frequent (several per hour)

  * are followed by a feeling of being cold and clammy once the hot flash has passed

Fortunately, there are lots of options for treating hot flashes beyond wearing easy-to-strip-off layers, or attaching a small fan to your forehead. Since every woman is different, you will have to explore which options work best for you with your menopause specialist.

**Options needing prescriptions:**

  * Hormone therapy Advances in hormones and a wide variety of delivery systems, from pills to patches to gels, have made HT a viable and effective treatment for many symptoms of perimenopause and menopause.

  * Selective serotonin and serotonin norepinephrine reuptake inhibitors (SSRIs and SNRIs) These drugs are often prescript for the treatment of depression and anxiety, but they also can work in alleviating hot flashes and night sweats.

**Non prescription options:**

It's helpful to be aware of some of the typical hot flash instigators. You can try eliminating these triggers one at a time to see if that helps alleviate your symptoms. For example, reduce your alcohol intake and caffeine (especially before bed), and cut back on spicy foods. All of these things may increase or worsen hot flashes.

Try a Mediterranean Diet. According to a study in the _American Journal of Clinical Nutrition, m_ enopausal women who most closely follow a Mediterranean-style diet were about **20 percent less likely to suffer hot flashes and night sweats** **.** (This isn't an excuse to rush out and eat a huge plate of spaghetti! I don't know about you, but fusilli doesn't look so good on my hips.)

Acupuncture, yoga, and meditation may also help.

Soy, anyone? There is lots of conflicting information about soy. I spoke to **Dr. Gordon Saxe, M.D., Ph.D.,** Research Director and Preventive Medicine Physician **at the UCSD Center for Integrative Medicine and co-developer and Medical Director of the UCSD Natural Healing & Cooking Program, and got the skinny on soy! If you are interested in integrating soy into your diet, take the time to read my two interviews with him:** Part I **and** Part II **.**

Some women find help with black cohosh. You can find this ingredient in Remifemin, an over-the-counter product available at many pharmacies. Dr. Elena Ratner, Assistant Professor of Obstetrics, Gynecology, and Reproductive Sciences at the Yale Cancer Center, recommended it to her breast cancer patient Vicki, whose treatment threw her into menopause. "Hot flashes started full on for me... and I immediately went on Remifemin," Vicki said. "The hot flashes are about 98 percent gone."

As of 2014, we have a new product that has come to the U.S. called Relizen, which is made in Sweden from pollen extract and has been used successfully in Europe for more than 15 years.

Exercising increases your endorphin levels, usually adding to a feeling of well-being; it also helps reduce stress levels and supports general wellness. Any of the typical remedies for de-stressing your life, like biofeedback and even massage, might help keep those temperature spikes under control.

"All exercise, ranging from housework to running marathons, impacts menopause in a positive way," says Dr. Diana Bitner, M.D., a North American Menopause Society Certified Menopause Practitioner & Physician and board-certified OB/GYN. "My patients who exercise on a regular basis have fewer menopause symptoms as well as improved body chemistry—lower cholesterol, better sugar control, less weight gain, and stronger bones. Women who exercise have better sleep, better mood, and better quality of life."

The reason: "A higher body mass index (BMI) as well as a higher body fat percentage both increase hot flashes and night sweats in menopause, lead to poor sleep, low energy, bad moods, and can cause a poor self-image," Dr. Bitner says. "I talk to my patients about belly fat as a furnace that makes them hot and tired." So get rid of it!

Remember, when you find yourself going from 0 to 90 (degrees) in 30 seconds, keep a cool head, call your menopause specialist, and don't sweat it! Relief is on the way!

# Chapter 5

## Irregular Periods (Abnormal Uterine Bleeding)

"Say hello to my little friend!"

\---Al Pacino in _Scarface_ not talking about his period

Do you remember what a nightmare puberty was? Along with the emotional roller coaster ride that made _everything_ seem devastating and urgent or, like, totally boring and lame, you also had to deal with an erratic period. How many times did you end up wearing your sweater around your waist because you were caught off-guard when your period showed up?

It was a relief when the menstrual cycle finally settled down to a regular schedule; at least you knew in advance when to keep the Midol and tampons handy.

Flash forward 35 or 40 years (on average), and it's like you're going through puberty all over again. Your moods get a little crazy, and your period comes whenever it darn well feels like it. You might even keep an extra sweater in your office, just in case.

It's a common misperception about menopause that one day you have a period, and then next you don't. Your monthly visitor doesn't just stop dropping by. You may find your flow starting to get heavier and more frequent than normal before it starts to get lighter and less frequent. This irregular schedule can begin years before full menopause, which is defined as when you've been without a period for 12 consecutive months.

For most women, this change in the menstrual cycle begins in their 40s. However, it can start in the 30s, or even in the 20s for women who go through premature or early menopause, or as late as your 50s. The timing can be based on any number of factors, including genetics.

If you experience any change in your normal cycle, see your doctor. Before you make your appointment, it might be helpful to have a clear idea of what your cycle is up to—is it very different from what you consider normal, or just a little out of whack? I created a section in my Menopause Symptoms Chart where you can track the duration and nature of your flow, noting whether it's heavy, light, or normal.

You may be one of the lucky women whose periods don't change all that much before they disappear for good, or you might find that your formerly dependable three-week-off/one-week-on schedule completely flips to three-weeks-on/one-week-off. It's annoying, but it's not unusual.

And remember, if you have been without a period for, say, three months, and then it reappears (unannounced, of course), then the 12-month menopause clock starts over.

### What is abnormal bleeding?

Although menstrual irregularity is normal during perimenopause, unusual bleeding could be a sign of a problem. Unusual bleeding can be attributed to a variety of factors, including: thyroid problems, hormonal imbalance, thinning (atrophy) of the endometrial or vaginal tissues, uterine polyps, fibroids and cancer – just to name a few.

When I was having random bleeding, my gynecologist recommended I have an ultra sound of my uterus. Although the pictures were stunning, you will not see them on the cover of Vogue. However, they did spot a growth known as a polyp. My gynecologist recommended that he go in and take a good look at my uterus (Hysteroscopy), then do a little housecleaning/scraping of the lining of the uterus (Dilation and Curettage), and cut that polyp (polypectomy). All these goodies were then checked to be sure that they were cancer free (they were, phew!).

It was a little different for my friend Molly. On the drive home from a family vacation, when Molly took a bathroom break and noticed a small spot of red on her toilet paper, she tried to shrug it off. Sure, at 63 years old, she hadn't had a menstrual cycle in five years, but maybe she wiped too hard. Maybe she was dry "down there." Maybe she had a bladder infection. Excuses to just forget about it abounded, but an hour later she found another drop of blood.

While vaginal bleeding can be caused by a lot of things, especially in perimenopause and menopause, it's also a common sign of uterine cancer, which Molly was about to find out she had. More than 40,000 women are diagnosed with uterine cancer each year, according to the Foundation for Women's Cancer (FWC).

Luckily, Molly called her gynecologist right then and there and made an appointment for the next day. He performed a Pap, spotted a small polyp, and removed it to have it screened. He also scheduled Molly for an immediate ultrasound. A week later, she received the results: "You do have cancer," her gynecologist said. "You are going to have to have a hysterectomy."

Molly learned hers was an estrogen-related cancer, meaning that a surplus of unopposed estrogen in her body helped to coax along the cancer's growth.

Now, post-recovery, Molly is confident her cancer—or as she calls it, her "bad dream"—is behind her. Of course, she still has follow-up appointments with her gynecologist, but as her gynecologist told her, "You have a greater chance of falling out of bed in the hospital and breaking your leg than you do of having this cancer be a life-threatening event." Thanks to early detection, she didn't need radiation or chemo to combat the disease. While women don't typically get routine screening tests for uterine cancer, abnormal vaginal bleeding typically spurs early, life-saving detection in women like Molly, according to the FWC.

According to the American College of Obstetricians and Gynecologists (ACOG), the three most common causes of irregular bleeding are:

  * Polyps – Polyps are growths of tissue that are usually noncancerous. On the uterine wall or endometrial surface, they can cause irregular or heavy bleeding. On the cervix, they can cause bleeding after sex.

  * Endometrial atrophy – Due to low estrogen levels after menopause, the endometrium may thin out, causing abnormal bleeding.

  * Endometrial hyperplasia – This is the opposite of atrophy, as the uterine lining thickens due to excess estrogen (without enough progesterone). If the cells of the uterine lining become abnormal (atypical hyperplasia), this can lead to uterine cancer. However, endometrial cancer can be prevented with early diagnosis and treatment. ACOG notes that bleeding is the most common sign of endometrial cancer in postmenopausal women.

### What should you do if you experience abnormal bleeding?

If you suddenly experience **out-of-the-ordinary bleeding** **,** it's very important to be evaluated by your gynecologist.

So how can you tell if your bleeding is abnormal? According to ACOG, _any_ bleeding after menopause is abnormal. During perimenopause and menopause, alert your doctor if you experience any of the following:

  * very heavy bleeding

  * bleeding that lasts longer than normal

  * bleeding that occurs more often than every 3 weeks

  * bleeding that occurs after sex or between periods

In addition to a physical examination, ultrasound and endometrial biopsy are two ways your doctor can examine endometrial bleeding.

Other diagnostic tools include:

  * Dilation and curettage (D&C) – The cervix opening is enlarged and tissue is scraped or suctioned off the uterus then sent to a lab for testing. When I experienced that episode of abnormal bleeding I mentioned earlier, I took my uterus for an ultrasound. The photo shoot revealed a polyp and some fibroids, so we had to go for a D&C, but at least I remembered to buy my uterus some flowers after the procedure.

  * Endometrial biopsy – A thin tube is used to extract a small amount of tissue from the uterine lining; the sample is then sent to a lab for testing. Not the most fun a girl can have lying on her back, but less invasive than a D&C.

  * Hysteroscopy – No, a hysteroscope is not a raving, crying piece of equipment for looking at stars. It's actually a thin, lighted tube with a camera at the end that is inserted into the cervix, providing a view of the inside of the uterus. Say cheese!

Treatment depends on your diagnosis. ACOG outlines several options:

  * Polyps may require surgery.

  * Endometrial atrophy can be treated with medication.

  * Endometrial hyperplasia can be treated with progestin therapy, which causes shedding of the endometrium. However, you'll need regular endometrial biopsies as this condition puts you at increased risk for endometrial cancer.

  * Endometrial cancer usually requires a hysterectomy (removal of the uterus) and removal of nearby lymph nodes.

The upshot is, if something doesn't feel right, don't pretend it's not happening. If you find you are having weird random bleeding, get yourself to a doctor. It may well be part of the normal process of menopause, or it may be something more serious. While cancer is scary and hysterectomies are anything but fun, surviving both is about more than living to see another day—it's about loving each and every day for the gift it is.

# Chapter 6

## Stress, Anxiety, Irritability, Depression, and Mood Swings

One minute you're screaming at a colleague to get that project done now! The next you're in tears over a cat food commercial. WTF is going on? Women often hear the word "emotional" used interchangeably with "hormonal," and it's not usually a compliment. But there are legitimate reasons why your emotions are in upheaval during the process of menopause.

**Stress**

"Menopause, itself, is a stressful life event because of the various types of change that occur," says Dr. Jeff Brown, a professor of psychology at Harvard Medical School.

Hot flashes are tightly linked with stress and anxiety, according to a six-year study published in _Menopause_. Researchers found that anxiety and stress preceded hot flashes among perimenopausal and post-menopausal women.

Stress is your body's reaction to any kind of demand—good or bad. Acute, or brief stress can make us more efficient and effective (think: deadlines), too much stress or chronic stress, on the other hand, can be harmful to your mental and physical health.

What's more, chronic stress can compromise our immune systems, making us more prone to illness. Between 50 and 60 percent of all medical issues originate from stress or stress-related events, he says.

So how can you tell the difference between a stressful situation and a real stress rut? Signs that you've hit your acute-to-chronic tipping point include changes in appetite and sleeping patterns, headaches, crying, irritability, and even panic attacks, according to Brown.

"When it comes to stress and menopause, it's crucial to keep your finger on the pulse of physiological, psychological, and relationship aspects of your life. Change is occurring and knowing yourself well is vital," he says.

Of course, you likely won't feel the exact same way pre-menopause as you do post-menopause, and some of that is natural. But there's no need to feel like a totally different woman, especially if that woman is stressed all of that time. You can slash your stress levels. Remember, though, that while your old stress-busting tactics like bubble baths, exercise, and meditating still work, you might have to go above and beyond them to beat stress during menopause, especially when menopause is the actual stressor.

"Each woman who deals with menopause may find that her typical stress-coping strategies need to be adjusted because of the high levels of stress that may be occurring as a result of physical changes during menopause," Brown says.

**Here are three tips for fighting menopause-induced stress:**

**1. Take charge.** Don't let menopause and its symptoms take control of your day-to-day life, says Brown. Commit to an open and close relationship with a perimenopause and menopause specialist, healthcare provider, or therapist who can help you manage your symptoms and find hormone happiness. "The alliance you have with a physician or therapist can mean the world to you during tough times," Brown says.

**2. Invest in friends.** Misery loves company—but so does happiness. Recognize the people in your life who are healthy for you and invest in those relationships. Healthy people are the ones you want to hang out with, and who make you feel better about yourself, Brown says. It is especially helpful spending time with the women in your life who have already traveled the menopausal road you're currently on. The support, understanding, and even learning opportunities can help make this time in your life a little less stressful, he says.

**3. Say no**. This is a hard one. While women are famed for multitasking, it takes a huge amount of time and cognitive energy, and adds unneeded stress to an already stress-filled time of our lives, Brown says. And during menopause you may not have the same amount of energy you did in your twenties. For your health's sake, scale back a bit. Say no from time to time, and don't feel guilty about it afterward.

**Depression**

According to Dr. Julia Frank, women are in states of "hormonal flux" at puberty, premenstrually, postpartum, and during perimenopause.

Dr. Frank says that "hormonal flux, loss, and change" are "part of normal experience," but when you're living for weeks on end at a 2 instead of a 10 or can't find the joy in living, there are options that are best evaluated and treated in partnership with a knowledgeable doctor that you trust.

"Hormones are also neuromodulators, so rapid changes can trigger mood symptoms," says Dr. Frank. "In addition, women who are in the later stages of mid-life face many changes that can lead to depression–loss of the members of the older generation, dealing either with not ever having children or having children leave home, reaching a plateau at work or other workplace stresses, and the sexual changes that may occur in intimate relationships all may trigger depression. All of these factors–hormonal flux, loss and change–are part of normal experience, so the association with depression usually involves either prior personal depression, experiencing more than one stressor or factor, or having one stressor that is unduly severe.

I asked Dr. Frank to weigh in on the top three questions women ask on the subject. Here's what she had to say:

**Do antidepressants help for menopause symptoms? Can you take antidepressants at the same time as hormone therapy?**

**"** Yes. In particular the serotonin reuptake inhibiting antidepressants work as well for depression in menopause as at other times—they also may relieve hot flashes, even in the absence of depression. In some women, the combination of hormones (estradiol in particular) and antidepressants seems to be more effective than antidepressants alone."

**Are some antidepressants more effective and/or safer than others?**

**"** The selective serotonin reuptake inhibitors (SSRIS, such as fluoxetine (Prozac) and its cousins), and the dual-acting antidepressants that inhibit the reuptake of both serotonin and norepinephrine **(SNRIs, such as** venlafaxine (Effexor) and duloxetine (Cymbalta)) and desvenlafaxine (Pristiq) are all safer than the older classes of antidepressants (the tricylics, such as amitriptyline (Elavil)) and monoamine oxidase inhibitors (tranylcypromine (Parnate)).

"Very few studies directly compare antidepressants to each other, so it is not really possible to say that one group clearly works better than another. However, the SSRIS and dual acting agents both clearly help with depression in menopause. Some women will respond better to one than another, but that has to be determined on an individual basis; it isn't predictable from large studies."

**What are some natural ways women can fight depression?**

"EXERCISE, EXERCISE, EXERCISE is the best proven "natural method" for fighting depression. Thirty minutes of vigorous aerobic exercise three to four times a week is necessary to experience this effect, but you don't need to sign up for a marathon or a boot camp; walking, biking, swimming all work fine if you do enough of them. Exercise also helps with sleep, bone health, and even hot flashes.

"Exposure to very bright light in the winter (not tanning, just bright light in the visible spectrum) helps many women, especially those with what's called Seasonal Affective Disorder, or 'winter blues.' The equipment for this is not terribly expensive and does not require a prescription, but you do need to use it correctly for 30-40 minutes every day.

"Psychotherapies of many kinds also help with depression; often just a few sessions are enough to get people back on track. Interpersonal therapy, which involves focusing on important relationships, or cognitive behavioral therapy, which involves changing patterns of thinking and activity, are both well proven methods of relieving depression without medication.

"Attending to spiritual concerns—resolving conflicts with others, looking for meaningful activities and a supportive community—is another important aspect of self-care for depression. Various herbal remedies are much less clearly effective than these methods."

Dr. Frank's advice makes perimenopause and menopause sound like an opportunity to learn more about ourselves, improve our relationships, and stay healthy. She may be on to something.

**Anxiety**

"Calgon, take me away!"

¾1970s bubble bath commercial

First and foremost, it's not your imagination that life is rockier than it used to be. We're at that time in our lives when caring for ailing parents, raising children, and working full-time are on a collision course. We're long past those idyllic pre-internet, pre-cell phone, pre-email, pre-everyone has to be available 24/7 days, when a simple bubble bath was enough to soothe our frayed nerves. Even the various stages of menopause can affect your mental wellbeing.

Psychiatrist Dr. Harry Croft, principal researcher at Clinical Trials of Texas, says putting yourself first is critical in restoring a healthy mind-body balance.

A study cited by the National Institute of Health uncovered significant differences between peri- and post-menopausal women in terms of vitality and quality of life. Two control groups of each age range were scored on anxiety, depression, and quality of life and the differences between the two groups was dramatic. Considering you spend one-third of your life in the peri- and post-menopausal years, it's a good time to sit up and take notice.

"Stress and menopause can make for an endless anxiety-riddled loop, requiring women to examine whether their current approach to managing their health is really working. For example, low estrogen can make you feel crummy and you won't function as well. Throw in lack of sleep due to insomnia or waking in the middle of the night and boom—you're super stressed. Because of that stress women may recognize depression, anxiety, and turn to self-medicating through alcohol consumption. There is a huge rise of alcohol abuse in older folks because they don't have to get a prescription to drink. Many women closet drink and tell themselves it helps them relax, but might not recognize that they're drinking because of stress. Also, women build up a tolerance to the effects of liquor and then have to drink more to feel good. Now, if they go to their doctor complaining they can't sleep and doc writes a script for a sleeping pill, then that can be a troubling mix," explained Dr. Croft.

Dr. Croft says a much smarter approach is to have a menopause specialist run a hormonal panel. Balancing menopausal hormones is an important first step to feeling better. Often, women find that hormone therapy as recommended by their specialist is enough to get them in top shape. If there is a need for further evaluation by a psychiatrist who might prescribe antidepressants, those meds work more effectively once hormonal levels are closer to normal, especially estrogen.

While a bubble bath and a little peace and quiet away from the demands of your oversubscribed life would probably help, it's a great relief to know you've got a lot of options to quiet the storms brewing inside your head.

# Chapter 7

## Weight Gain

Welcome to the Sisterhood of the Shrinking Pants!

If you're anything like me, you woke up one morning and suddenly nothing in your closet fit. Has an alien mysteriously entered your closet during the night and shrunk all your clothes?

Maybe you try to cut back on the M&Ms and ramp up your exercise routine, but still the pudge keeps on coming.

Regardless of what number she sees on the scale, a woman's weight through menopause and perimenopause is largely determined by five factors: hormones, diet, exercise, stress, and genetics. Though you may not be able to control all of these factors on your own, a healthy weight is certainly within reach.

**Here are five steps to help you shed those extra menopausal pounds (a.k.a. the menopot belly):**

**1.** **Don't let your hormones get the best of you.** Research shows that estrogen receptors located in the hypothalamus of the brain control food intake, energy expenditure, and body fat distribution. When estrogen levels in the brain dip during menopause, this control panel increases hunger, slows metabolism, and encourages fat gain around the waist. Hormone therapy could potentially be used to keep the brain's estrogen receptors from promoting hunger, a sluggish metabolism, and a growing waistline during menopause. HT may prevent abdominal fat gain, according to research from Gunma University School of Medicine in Japan.

**2. Quit dieting! Seriously, diets don't help.** Deprivation diets cause weight gain, not loss. Since they don't provide your body with the energy (a.k.a. calories) it needs, they can cause your body to slow the metabolism to conserve resources, according to the Mayo Clinic.

On the flip side, in one study of 465 overweight and obese postmenopausal women by the University of Pittsburgh, women who simply ate more fruits and vegetables while reducing their consumption of desserts, meat, and cheese, not only dropped pounds, but maintained that weight loss for four years.

If you are looking for an actual program to help you eat healthier, Weight Watchers is frequently recommended by physicians and has topped _US and World News Report_ 's "Best Diets" list for weight loss. (My husband and I tried it with great success. At first I was reticent, as I would rather have a Pap smear than have to add up points, but if you use the Weight Watchers app, all the adding is done for you. WW taught us a new way of eating that was both size shrinking _and_ life changing.)

**3.** **Exercise.** Physical activity not only wards off saddle bags and thunder thighs, it also keeps the body young. Exercising during and after menopause can help maintain the muscle and bone mass that we tend to lose rapidly after menopause, according to the American Council on Exercise.

If you're unsure of where to start, try taking a walk. While all exercise raises your fitness and feel-good endorphin levels, breaking a sweat outside has been shown to increase energy and positive thinking while slashing tension, anger, and depression even better than indoor exercising, according to a review published in the _Environmental Science and Technology_. Wearing a pedometer or one of those activity trackers like Fitbit could give you incentive to move more. There are also plenty of apps for your smartphone like MyFitnessPal that can help you stay on track.

**4. Slash stress.** It's hard to relax, especially when you're going through the trials of menopause, but it's important for your mind and body to decompress. Stress not only tends to add weight around your belly but can also boost your appetite, creating a vicious cycle. High stress is a predictor of weight gain and can break your will to stick with a diet, according to research from King's College London.

Find some form of exercise that makes you smile. Grab your lover or friend and take a walk, ride your bike or go to the gym. Take the time to read a book, watch a favorite TV show, meditate, or simply enjoy your family and friends. Do whatever helps you decompress.

**5. Control your genes.** Researchers now say genetics plays a huge role in weight at any age. If your female relatives developed curves in their later years, you probably will too—unless you do something about it. Maybe you can't change your genes, but you can change the degree to which they impact your health. Walking briskly for an hour a day can cut the genetic influence toward obesity in half, according to a study from the Department of Nutrition at Harvard School of Public Health. However, a sedentary lifestyle (a.k.a. watching TV for four hours a day) increases the influence of your genes on weight gain by 50 percent, according to the study.

A positive attitude is the first step to feeling good and looking good. It's never too late to start living a healthier life. Your brain and body will thank you and so will those clothes collecting dust in your closet. Take the first step! Go ahead—you can do it!

# Chapter 8

## Insomnia and Fatigue

Are you Sleepless in Seattle? Does Disney's Sleeping Beauty make you hostile? Does the sight of a blissfully snoozing infant make you weep? Do memories of teenage sleepathons that last 12 hours make you misty with nostalgia? Take heart, you've got a lot of company.

Insomnia is a problem many women encounter when they enter perimenopause. I have always been a very busy, multitasking kind of person, who worked hard in the daytime and slept hard at night (including falling asleep mid-conversation, but we don't need to get into that). All of a sudden in my forties, not only was I having trouble sleeping, but multitasking became more difficult, too. My focus and memory kept failing me. I felt like an alien had taken over my body and I was no longer in control. My insomnia was getting the best of my... what was I just about to say?

If you're suffering through insomnia, you are not alone. Only 45% of peri-menopausal women report getting a good night's sleep almost every night, says the National Sleep Foundation (NSF). Hormones connect your brain and body. When they change, the way your brain and body function does, too. Progesterone is a very important hormone for sleep, but progesterone levels drop when you enter perimenopause, making your body chemically less capable of sleeping well.

The North American Menopause Society (NAMS) lists trouble falling asleep as one of their main five symptoms of menopause. According to the NSF, most women complain of sleeplessness during perimenopause to post-menopause, with about 61% of post-menopausal women having issues with insomnia.

A study conducted in 2013 by scientists at the University of California San Francisco found a lack of sleep can put adults at risk for a variety of chronic health issues. A report published in Harvard University's Harvard Women's Health Watch in 2006 says adults who sleep less than six hours a night can suffer from such issues as memory loss, poor cardiovascular health, irritability, and problems with their metabolism and weight.

**Here are four tips to help you get back in touch with Mr. Sandman:**

### 1. Get Moving

To get a good night's sleep, you may have to move your body more during the day. Menopausal women who had more leisure physical activity during the day reported rating their sleep as good. Those same women who did household physical activity during the day—like vacuuming and mopping—found they were sleeping through the night more.

### 2. Just Relax

While you are lathering yourself in your latest and greatest wrinkle reducing moisturizer, think about preparing yourself for sleep, too. Before you hit the sack, try some tricks to help relax your body and get you in the sleeping mode. For example, do something calming like reading a book while sipping some chamomile tea, enjoying a candlelight bath, or just closing your eyes and listening to some soft music. As it gets closer to sleep time, prepare your bedroom so there are no distractions—eliminate as much light and sound as possible, and definitely keep your bedroom a smart phone free zone (phone sex is permitted). In fact, experts suggest you turn off all the electronics at least an hour before bedtime.

### 3. Stay Cool

Hot flashes can be another reason why women in menopause have a hard time staying asleep. To help combat the heat, the Cleveland Clinic suggests women subject to hot flashes be prepared by wearing loose-fitting clothing to bed and by making sure their sleeping area is well ventilated.

### 4. Consider Hormone Therapy

An article published in _Menopausal Medicine_ —the journal of the American Society for Reproductive Medicine—says that studies have found HT helped menopausal women with sleeping issues, and helped them get more productive sleep. If sleeplessness is a major issue for you, this is an option you may want to discuss with your menopause specialist.

There's no need to stumble through your day like an extra on _The Walking Dead._ Ditch your inner zombie and get your snooze back!

# Chapter 9

## Vaginal Dryness and Pain During Sex

Let's face it, love can hurt. And I'm not talking about the he-left-me-for-a-younger-model-and-broke-my-heart kind of hurt. I'm talking about the _physical_ pain that can be associated with intercourse during menopause.

There's actually a medical term for painful intercourse: dyspareunia (really??) If you're experiencing pain during sex, you could be suffering from vaginal atrophy or VA (I used to think VA stood for Virginia, which ironically, is for lovers.). VA is also known as vulvovaginal atrophy or VVA. The latest appellation, courtesy of the North American Menopause Society (NAMS), is genitourinary syndrome of menopause (GSM), a blanket term to describe menopausal symptoms that occur to the vulva, vagina, and lower urinary tract as a result of estrogen deficiency. Who makes up these words? Once again, the vagina gets the short end of the stick! I can't even pronounce "genitourinary"! Perhaps NAMS should call in the Opi Nail Color Labeling Committee?

Anyway, vaginal atrophy is just that: a thinning of the vaginal wall thanks to a drop in levels of estrogen, whose job it is to maintain the structure and function of the vaginal wall, elasticity of the tissues around the vagina, and production of vaginal fluid.

We seem to hear more about hot flashes, insomnia, and memory loss, but vaginal discomfort is every bit as difficult—and critical—to deal with as other menopausal symptoms. Vaginal symptoms can negatively impact not only on your relationships and sexuality, but your quality of life and self-image.

In my experience, most women don't even know what VA is, nor understand that **it is a chronic problem that requires ongoing treatment and IS treatable**.

**What are the symptoms of VA?**

  * Vaginal dryness

  * Vaginal burning

  * Vaginal discharge

  * Genital itching

  * Burning with urination

  * Urgency with urination

  * More urinary tract infections

  * Urinary incontinence

  * Light bleeding after intercourse

  * Discomfort with intercourse

  * Decreased vaginal lubrication during sexual activity

  * Shortening and tightening of the vaginal canal

Vaginal dryness affects as many as 75 percent of postmenopausal women. Between 17 and 45 percent of postmenopausal women say they find sex painful, according to The North American Menopause Society (NAMS). According to the Women's Health Concern, only 25 percent of these women seek treatment. What may be even more disconcerting is that, according to the International Menopause Society, 70 percent of women say their healthcare providers rarely or never raise the subject with them.

The Closer survey found that vaginal discomfort caused 58 percent of the women surveyed to avoid intimacy and 64 percent to experience a loss of libido.

The NAMS notes that pain during sex (or simply the fear of pain during sex) can trigger performance anxiety or arousal problems in some women. This also can diminish lubrication or cause involuntary—and painful—tightening of the vaginal muscles, called vaginismus. (Another one of these ridiculous words! Where is Merriam Webster when we need her?) It's a vicious vaginal cycle.

**Here are some solutions:**

**P** **elvic Floor Therapy**

According to Harvard Medical School, this is a safe and effective technique. A physical therapist uses massage and gentle pressure to relax and stretch tightened tissues in the pelvic area. You also learn exercises to help strengthen your pelvic floor muscles, which may have been weakened by aging, childbirth or hormonal changes. Now _that's_ a massage with a happy ending!

**Personal Lubricant or Moisturizer**

Both can go a long way in the bedroom. However, your vagina may need more. Non-hormonal vaginal _lubricants_ can help decrease friction and discomfort during intercourse. Be sure that they are water-based and designed for vaginal use. Petroleum-based lubricants can harbor bacteria in the vagina and lead to infection, as well damage latex condoms. Vaginal _moisturizers, similar to facial moisturizers_ can help relieve dryness and rebalance the acidity of the vagina, and _most women find these helpful to use every day_. Both lubricants and moisturizers provide temporary relief of symptoms but often do not treat the underlying condition of vaginal atrophy.

**Time for a lube job? Here are the three basic categories of lube** :

**1. Water Based** lubes can contain a number of plant based ingredients (in addition to water), such as aloe (aloe barbadensis), guar gum (Cyamopsis tetragonolobus), flax seed extract (Linum usitatissimum), and locust bean gum (Ceratonia siliqua). They are often combined with preservatives—some natural, such as tocopherols (vitamin E) and citric acid, and in other cases synthetic preservatives, such as potassium sorbate, parabens and propylene glycol. They can also contain glycerin, xylitol and phenoxyethanol. They tend to dry out much faster than oil or silicone based lubes and can become tacky (heaven knows, we don't want to wear anything tacky) and sticky. However, they clean up easily, do not stain the bed sheets, and get along just fine with latex condoms and toys. Some newer lubricants contain carrageenan (a seaweed product), which minimizes the tackiness or stickiness associated with water based lubes.

**2. Oil Based** lubricants, which _cannot be used with latex condoms or latex toys_ , can be either pure natural oils, a mix of natural and petrochemical oil, or pure petrochemical oil. If condoms are required, either Polyurethane or Polyisprene condoms can be used. As natural oils, some people use Organic 100% Sweet Almond Oil (this contains oleic and linoleic essential fatty acids, which helps your muscles relax) or Organic 100% Virgin Coconut Oil (this can help prevent yeast and bladder infections) as a lubricant. These oils will not burn or inflame the vagina or the penis.

**3. Silicone Based** lubricants are, you guessed it, silicone based. Dimethicone (Polydimethysiloxane or PDMS) is the form of silicone used in the better silicone lubricants. It does not dry out as some water based lubricants do, has a thick lush feeling, and is generally considered to be non-toxic and non-irritating (this, of course, can depend on the individual user). It does cause damage to silicone toys, is difficult to wash off, and can stain bed sheets.

Test all the lubricants on your skin first for potential irritation. Try the inside of your elbow or another spot where the skin is delicate.

I conducted an informal survey among my readers to see which lubes/moisturizers are most popular. Here are their top choices:

  * Albolene Face Cream (I know, this one is a bit of a curveball, but hey if it's safe and it works for you, go for it!)

  * Astroglide

  * Gun Oil—comes water based and silicone based

  * Replens

  * Sylk

  * Surgilube

  * Vaginal Renewal Complex

If you are all lubed up and still have no relief, see your menopause specialist to see about medical interventions that can help. You do not need to suffer. **Talk to your specialist about the various hormone treatment options available.**

**There are two types of HT:**

**1.** **Local Estrogen Therapy** (LET) is estrogen applied directly to vaginal tissues, so it goes directly to the affected area with minimal absorption of estrogen into the bloodstream. LET is available in creams, a ring (def not jeweled) and a tablet.

**2. Systemic Hormone Therapy** allows estrogen to circulate throughout the bloodstream to all parts of the body. It's available in many forms: a pill, injection, patch, gel and spray. Systemic HT is most often prescribed for multiple whole-body symptoms of menopause, including night sweats, hot flashes, and others. Some women need a combination of treatments.

Above all, communicate with your partner. Honesty is definitely the best policy. If you're avoiding sex due to pain, your partner could misinterpret it as your dissatisfaction with the relationship (or the sex). Remember the guy who called in to the radio show about the collapse of his marriage over this very issue? Ask your partner to join you at the doctor visit so he or she can be part of the solution. If sex is a vital part of your relationship—it takes two, as they say—then make this part of your journey a partnership, too.

# Chapter 10

## Loss of Libido

Do you find yourself suddenly needing to mop the kitchen floor or organize the recycling when your spouse suggests it's time for bed, hoping he or she will have fallen asleep before you get there? Do you find yourself wondering whatever happened to that wildcat who couldn't wait to get her partner alone? And more importantly, do you find lack of intimacy time is creating an emotional chasm with your partner? Thanks to the changing levels of hormones women experience during menopause, your libido may be taking a nosedive.

You may have noticed the countless television and print ads for pills and creams and power drinks that support a man's virility—there's that "little blue pill" and that couple who inexplicably watch a sunset in separate bathtubs (last time I checked, you need to be in the same tub if you want to get busy).

So where's the help for women? Research shows that sexual dysfunction occurs in about 30% to 50% of women (and that's just those who report it). Common complaints include low sexual desire, difficulty attaining or maintaining sexual arousal, and inability to achieve an orgasm.

Are we meant to resign ourselves to live out the second half of our lives as though we're holed up in a convent? No! Just because you've reached a certain age, it doesn't mean you no longer have a need for good sex in your life. In fact, some people find mid-life sex far better than the sex they had when they were young. "As we age, most of us become more aware of what we need in the bedroom and how to get there. We feel more deserving of sexual pleasure and are more willing to ask for what we want from our partners," says Hilda Hutcherson, M.D., Clinical Professor of Obstetrics and Gynecology at Columbia University Medical Center. "In our 50s we are more likely to focus on our pleasure than in our 20s, when we tend to focus almost exclusively on his experience."

Women have the right to toe-curling, earth shattering orgasms, just like men. But due to this double standard, having a fulfilling sex life after menopause may not be a reality for all women.

However, all is not lost. Read on.

If your sex drive seems to be firmly stuck in park—or worse, reverse—and you're worried that it may never come back, there are several things to consider. Is low estrogen to blame or could something else be going on? Dr. Hutcherson suggests for many women it's just boredom, although "Medical problems and medications certainly can wreak havoc on desire." Whatever you do, don't fake it! "Faking orgasms will guarantee that your sex life with your partner never improves," she says.

For women who experience what the experts call hypoactive sexual desire disorder (HSDD)—again with the crazy terminology!—doctors and researchers are currently working on pharmaceutical solutions. As Katie Couric described on Yahoo News, Sprout Pharmaceuticals has developed the drug Flibanserin, otherwise known as the "little pink pill," which is awaiting FDA for approval. "Flibanserin is a novel, non-hormonal pill to treat hypoactive sexual desire disorder in premenopausal women," says Sprout CEO Cindy Whitehead. If approved, it would be the first of its kind to treat women with HSDD.

Dr. Michael Krychman, Executive Director of the Southern California Center for Sexual Health and Survivorship Medicine in Newport Beach, California, explains, "While estrogen is critical, it is my belief that there is interplay between lowered estrogen and lowered testosterone levels in women as they age."

**Here is a testosterone 101, courtesy of Dr. Krychman:**

**Testosterone is part of our hormonal makeup.**

Testosterone is a steroid hormone primarily found in men, but smaller amounts are also produced in women's body: one specific place is the ovaries. Testosterone is necessary for muscle tone, a healthy libido, and strong bones. Women begin experiencing low "T" during their menopausal journey, which may begin a decade earlier than when menstrual periods stop.

Testosterone isn't just for guys. Women with low testosterone levels can experience depression, fatigue, weight gain, bone and muscle loss, and cognitive dysfunction. Then there is the whole "loss of libido" issue, which can be dramatically decreased. As for orgasms, if we have them, they can be more "ho-hum" than "woo hoo!" if your "T" level is down, according to a report from the North American Menopause Society.

**There are many benefits of testosterone supplementation.**

Supplementing with testosterone can benefit your heart, mood, energy, and bone and muscle health. Additionally, testosterone can sustain skin elasticity and tone, encourage heart health, boost libido, help prevent osteoporosis risks, decrease body fat and increase muscle strength.

**Here are some tips to help you find that lost libido:**

  * Schedule a visit with your menopause specialist to rule out any other medical problem. Underactive or overactive thyroid, for example, can also affect your energy level, libido and general physical health or well being.

  * Talk to your specialist about testosterone testing. Total testosterone and "free" testosterone are typically measured and calculated. Free testosterone, measures your levels of bioavailable testosterone that is not bound by the blood proteins. It is the active portion. Ranges vary between post-menopausal and premenopausal women, with a gradual decline as we age, says Dr. Krychman. However, he adds, "I advise treating symptoms, not lab values. A comprehensive assessment with a good differential is the rule. Testosterone supplementation is not the panacea. It is important to remember that this there is also approximately 40% placebo effect."

  * Discuss the various treatment options with your menopause specialist. If your testosterone levels are below norm and you have the symptoms, your health care professional may suggest an "off-label use" of testosterone, with or without estrogen. Why "off-label? Because the FDA has yet to approve any testosterone drug for women. According to WebMD, when you take it orally (by mouth), it gets processed by the liver—which can result in a change of cholesterol levels. But that same effect doesn't occur when testosterone is administered by skin patch, gel or cream (a.k.a. transdermal) or in pellet form (the size of a grain of rice) inserted under the skin. "What form to use depends on many facets including patient tolerability, patient price, side effects and clinician preference," says Dr. Krychman.

  * Weigh the risks vs. benefits with your menopause specialist. Dr. Krychman has a frank and candid conversation with his patients about the benefit versus the risk – safety and efficacy are always balanced, he states. He further recommends that before starting therapy you are aware of the benefits and risks and that once you start therapy, you need to have regular blood work to keep track of your levels. It is important to monitor your blood count and lipid panel, coupled with testosterone levels.

For some women, the sex drive is fine, but the ability to cross the finish line is a problem.

If you're having trouble achieving orgasm, or your orgasms aren't as powerful as they once where, there are several ways you can strengthen your Big O:

  * Strengthen and tone the pelvic floor muscles with Intensity, an intimate health and stimulation device that improves a woman's sexual experience by exercising the pelvic floor muscles and providing targeted stimulation to specific areas of the anatomy. Intensity is scientifically designed to restore intimacy and pleasure.

  * To strengthen pelvic floors to prevent unexpected bladder leakage, turn to Apex, an automatic pelvic floor exerciser. It's a medical device that will strengthen and tone the pelvic floor muscles to eliminate accidental bladder leakage. You've been told to "do your kegels," but actually doing them correctly is tricky. This is the first in-home device that exercises your muscles correctly every time.

Recurring vaginal dryness can make everyday comfort and sex painful and can put unnecessary strain on your relationship. As baby boomers reach menopause, they are saying no to "sandpaper sex." Get the info you need to take charge of dealing with your faltering sex drive.

Remember, sex is more than just fun. It's integral to most intimate relationships, and it's also great for your overall health (but, yeah, it's also really fun). Check out these benefits you probably weren't even thinking about when you started reading this chapter!

  * Stress relief. When you have an orgasm, the hormone, oxytocin, is released from the hypothalamus of the brain into the bloodstream. This creates an instant feeling of release and relaxation. And what better way to start off a good night's sleep than with an orgasm?

  * Pain relief. Research shows that endorphins can help women increase their pain tolerance by as much as 75%. So rather than popping pain-relieving pills for your headache, try a little self-pleasure instead.

  * Improved creativity. Increased blood flow to the brain helps it to receive the nutrients and oxygen it needs to function at a high level. So if you're in need of some fresh ideas, want to rejuvenate your artistic goals, or want to be able to express yourself more freely, try getting it on more often.

The old motto "use it or lose it" is still true, so you might as well enjoy every second.

# Chapter 11

## Migraine Headaches

There are headaches that gnaw at the base of your spine or throb in your forehead, but pop a couple of aspirin or ibuprofen and you can go about your usual routine. Then there are the monster headaches that derail your whole day, or maybe several days, and no over-the-counter pain relievers make a dent on them. These are migraines, and they can be a real pain for women going through perimenopause and menopause. In fact, some people get them so bad, they become extremely sensitive to light and become sick to their stomach.

Research confirms what women with migraine headaches have told their doctors for years; migraine attacks seem to get worse in the years before and during menopause, and women entering perimenopause and menopause experienced the most headaches.

According to Dr. Susan Hutchinson, director of the Orange County Migraine & Headache Center in Irvine, California, about 13 percent of adults in the United States suffer from migraines annually. That's 35 million people, and 27 million of those migraine sufferers are women.

Migraines, unlike other headaches, are often hormonal in nature. Intense fluctuations of hormones, especially estrogen, in women can egg on and worsen migraines. The silver lining is that two-thirds of female migraine sufferers notice marked improvement when they enter menopause, a time in which hormones finally stop fluctuating. In fact, after age 60, only 5 percent of women suffer migraines, according to the Migraine Research Foundation.

Here are some helpful tips for managing your migraines:

**Find a Specialist**

As with most things medical, visiting a trained specialist is a solid first step. Your Menopause Specialist can evaluate your migraines in relation to your hormonal status. You may find that you need hormone therapy or if you are already on HT, you may need to have it adjusted. If you find that your HT is not doing the trick, it is time to find a good headache and migraine specialist who is versed in how fluctuating hormone levels affect migraines. Ask your menopause specialist for a referral or look for local doctors at the National Headache Foundation or American Headache Society.

**Consider HT**

Whether you are on hormone therapy or are just thinking about taking the plunge, talk to your perimenopause and menopause specialist about how HT can influence perimenopausal migraines—both for good and for bad.

"All forms of HT are not created equal. If HT is used, the general consensus in the 'headache world' is to use a non-oral delivery system such as the estradiol transdermal patch. It would be expected to help prevent migraines, as it provides an even level of estradiol and is the same chemical structure as the estrogen/estradiol that a woman's ovaries produce prior to menopause," Hutchinson says.

Dr. Hutchinson further explains that if you use an estradiol patch, you should work with your healthcare provider so that they understand when your headaches are occurring, relative to when you change the patch. Sometimes the patch will need to be changed more often than what the package insert indicates.

On a synthetic, oral hormone pill? It might actually be _worsening_ your migraines.

"Oral preparations such as conjugated equine estrogen have more variability in absorption and blood levels, and therefore would be predicted to not be as helpful in treating/preventing menopausal migraine. Synthetic and oral preparations are more likely to cause or aggravate headaches," Dr. Hutchinson says.

"For perimenopausal women who are put on oral birth control pills, take note that there is a difference in monophasic, biphasic, and triphasic birth control pills. Monophasic are the best, as the estrogen and progesterone remain the same dose in all active pills. In biphasic and triphasic the estrogen and/or progesterone are changing and this can wreak havoc on migraine control. I recommend monophasic for migraineurs if oral birth control is needed and/or desired. Another option is a low dose birth control ring (15mcg. ethinyl estradiol) which is inserted intravaginally and taken out after three weeks; then a new once placed one week later. Many patients change every three weeks and use them continuously. This can provide very even blood levels of estradiol," Dr. Hutchinson further explained.

Dr. Hutchinson reminds us that birth control may be needed for some perimenopausal women, as they are still vulnerable to getting pregnant (if they have not had a tubal or their partner has not had a vasectomy). Remember, hormonal therapy such as the estradiol patch used for menopausal symptoms, does not protect against pregnancy as it is a lower does estrogen than what is available in birth control preparations.

**Fight Your Triggers**

According to the North American Menopause Society, hormone fluctuations, bright or flashing lights, a lack of food or sleep, and stress can all contribute to migraines. Your best defense is good self-care.

Dr. Hutchinson advises; eating small, frequent meals throughout the day that pack both complex carbohydrates (think: whole grains, legumes, and starchy vegetables) and protein to regulate blood sugar levels. Dietary supplements including butterbur, B-2 (riboflavin), co-enzyme Q-10, and magnesium can also be helpful in migraine prevention.

Make sure to drink plenty of water, as dehydration can cause headaches.

Getting a full night's sleep and exercising regularly (which can help you sleep better!), can also help.

Last but not least, don't smoke!

So, if it's the middle of the day and you're on your back with the blinds closed, a wet washcloth over your eyes, and a nauseated feeling in the pit of your stomach—do not suffer in silence. Find the solution that works for you.

# Chapter 12

## Incontinence and Other Urinary Symptoms

Everybody loves springtime, but no one likes the allergies all those new blooming flowers bring, right? It's even worse if you find you have to cross your legs every time you sneeze to keep from having an accident. And who doesn't love a good joke? Well, if your bladder doesn't hold up to the laughter, a joke can become an embarrassing nightmare.

According the North American Menopause Society (NAMS), there are two kinds of urinary incontinence.

The first is stress incontinence, which comes from weakened pelvic floor muscles, which can happen because of childbirth or plain old aging. This is the one that makes laughing and sneezing risky.

The other is urge incontinence, which is also known as overactive bladder (OAB). According to Mayo Clinic, one in 3 adults over the age of 40 report having an OAB. They list the following symptoms:

  * A sudden urge to urinate that's difficult to control;

  * Involuntary loss of urine immediately following an urgent need to urinate;

  * Frequent urination, usually eight or more times in 24 hours;

  * Awakening two or more times in the night to urinate.

To make matters worse, says NAMS, up to a quarter of women with urinary incontinence experience it during sex. Talk about ruining the mood!

In addition to menopause, several other conditions may contribute to signs and symptoms of overactive bladder, including:

  * Neurological disorders, such as Parkinson's disease, strokes and multiple sclerosis;

  * High urine production as might occur with high fluid intake, poor kidney function or diabetes;

  * Medications that cause a rapid increase in urine production or require that they be taken with lots of fluids;

  * Acute urinary tract infections that can cause symptoms similar to an overactive bladder;

  * Abnormalities in the bladder, such as tumors or bladder stones;

  * Factors that obstruct bladder outflow—enlarged prostate (in men, of course), constipation or previous operations to treat other forms of incontinence;

  * Excess consumption of caffeine or alcohol.

This is why it is very important to determine the cause of _your_ specific issues so that your specialist can find a treatment plan for you.

The evidence-based clinical guidelines from the American College of Physicians state that half of women with urinary incontinence never report it to their doctor. Doctors recommend using Kegel exercises to strengthen pelvic floor muscles, bladder training, and weight loss as an effective, non-surgical treatment for women with urinary incontinence. One study found that locally applied estrogen in the form of a cream or ring or pill that you insert directly into the vagina may help. You may have to try several options before you find the one that works for you.

Don't suffer in silence!! Talk to your menopause specialist or a urologist to discuss medical or surgical options.

# PART THREE

## Get Me Out of Here!

### Help for Menopause Symptoms

# Chapter 13

## Finding a Menopause Specialist

Finding a perimenopause and menopause specialist can be a daunting task. How do you know you'll be satisfied? Where do you even begin to look for one?

Finding a medical practitioner who specializes in perimenopause and menopause symptoms is critical for your well-being. This might not be the same person who delivered your babies or has been giving you your annual Pap smear. A specialist will have the unique knowledge and skill set necessary to offer you the perimenopause and menopause help you need. They should be able to:

  * Recognize and diagnose your symptoms.

  * Run the proper blood work and tests.

  * Partner with you to determine the treatment approaches that are right for you.

  * Make the necessary adjustments to your treatments on an ongoing basis.

Think of your menopause specialist as a business partner, and don't be afraid to be picky! I went through several before I found one who was right for me. Many women spend more time researching hotels, hairdressers, and restaurants than researching menopause specialists. Don't skimp! You have to do your research. First, check out my Menopause Specialist Directory and _then_ get a blow-out. These specialists have been recommended by women who have found hormone happiness!

Another great place to start is with a great specialist in another field, if you happen to know one. Great specialists often know other great specialists! You may love the doctor who delivered your babies, but that doctor may not be a menopause specialist. However, your current gynecologist may also be a good resource, as many private practices contain a variety of different specialists within the group—it doesn't hurt to ask.

You might try talking to family and friends for a recommendation of someone who has provided them good perimenopause and menopause help. Med students often know great healthcare professionals as well. You can check out the North American Menopause Society (NAMS) for some assistance in finding healthcare professionals who specialize in this area.

Additionally, you might want to consider an Institute for Functional Medicine (IFM) certified practitioner. These practitioners are experienced in functional medicine, which utilizes each patient's environment, lifestyle and genetic information to address health issues including chronic disease. This approach, recommended by Deb Hubers of La Vita Compounding Pharmacy, takes into account your diet, how you live your life, what diseases you suffered from in early childhood and current stressors in your life. Based on that information, the practitioner orders tests that might uncover things you hadn't considered, such as leaky gut syndrome or sensitivities to certain foods. The IFM certified practitioner then pulls all of this 'new' information together, along with any genetic mutations and how they affect your metabolic pathways, especially during menopause, to determine a very specific course of treatment. Researchers now understand that those pathways provide critical information as to what is going on in your body at the cellular level and that is instrumental in treating disease, fighting obesity and even determining what nutrition your body requires, so that you remain healthy throughout menopause.

Once you have a list of menopause specialists, do Google them! We Google celebrities all the time—why not check out your healthcare professional, too? Then visit your state medical licensing board's Web site to verify that the specialist is currently licensed. (You might want to check your health insurer's website to see if the specialist is covered under your plan.)

Here are some other useful sites:

  * American Board of Medical Specialties

  * American Medical Association

  * Health Grades

  * RateMDs

Many women, tired of their regular doctors not taking them seriously, are seeking out anti-aging specialists (or what I like to call "healthy aging specialists") for hormonal therapy, one study says.

It's critical for you to do your homework and investigate which type of menopause specialist will work the best for you.

The great thing about specialists is that if you're unsatisfied, no divorce papers are needed to go on to the next one. (If you have a specialist you'd like to recommend who _isn't_ in the directory already, email his/her information to me at ellendolgen@ellendolgen.com.)

Because every woman's experiences in perimenopause and menopause vary, the approaches to treatment are as different as ice cream flavors. Depending on your menopause symptoms, specialists will recommend different treatments or therapies. The most important thing to remember when entering this stage in your life is that _you_ know your body best and _you_ have the final say. Trust how you feel!

Don't forget to track your symptoms on the Menopause Symptoms Chart so you can detect patterns in your body. Take the information with you when you visit your specialist to more accurately communicate your needs.

The intensity and duration of symptoms vary from person to person. For some women, these symptoms go away over time without treatment, and other women need to take a more proactive approach. There are several options available to women and with the help of a menopause specialist; you can find the right one.

Unfortunately, there won't be any billboards telling you which exit to take, but once you program your personal GPS, you'll be living the menopausal dream in no time!

# Chapter 14

## Getting Tested for Menopause (and Fertility)

As you move through the menopausal transition, remember that your personal health screenings should still include annual mammograms and Pap smears. However, even the experts disagree as to when and how often you should take pictures of your "breast friends." The American Cancer Society still advocates screening every year, but the U.S. Preventive Service Task Force recommends against routine mammograms for woman in their 40s and screening only every other year for women over 50.

I sought clarification from Dr. Anees Chagpar, Associate Professor of Surgery (Oncology) and Director of The Breast Center at Smilow Cancer Hospital at Yale-New Haven, to help us understand the new mammogram guidelines. She advocates for annual screening after your 40th birthday, but says that women under 40 need not get a mammogram— _unless_ they have a strong family history of breast cancer being diagnosed at an early age; in which case, she recommends that women should have a baseline mammogram 10 years before the earliest diagnosis of breast cancer in their family.

Also, be sure to take note that not all mammography machines are created equal. There is a new kid on the block: the breast tomosynthesis mammography. This mammogram machine finds 41% more invasive cancers according to two large, retrospective studies published in The Journal of Roentgenology (AJR) and The Journal of the American Medical Association (JAMA). "This is simply a means for mammography to take serial thin slices through the breast tissue rather than a cumulative picture... kind of like slicing a loaf of bread into thin slices and looking at each slice rather than trying to see through the whole loaf. This technique has been shown to reduce the number of call-backs for abnormal screening mammograms and may be helpful in women with dense breast tissue," explains Dr. Chagpar.

The Pap test has long been a part of your annual pelvic exam, serving as the gold standard for diagnosing cervical cancer for the past 60 years. However, there are some new thoughts and recommendations regarding this test. Before you decide to forgo those stirrups read: The New Pelvic Exam Guidelines¾Changes for the Change.

Now let's talk about those out-of-whack hormones. Fortunately for us, when it comes to testing for hormone levels, no pencil is needed, and you really can't fail. For those of you squeamish about needles, rest assured you can get most of these done with a single blood draw. You might find that you don't need all these or that you need a test or two that I haven't listed. More is not necessarily merrier when it comes to medical testing, so you'll want to discuss all of the options with your menopause specialist.

It is not unheard of that a women's hormone numbers will appear normal while her menopause symptoms are through the roof, because every woman lives differently and at different hormone levels. What is normal for one woman may not be functional for another. Be sure to bring your Menopause Symptoms Chart in with you to help you explain how you feel to your specialist, because this helps determine what the test results mean for your body and how best to approach your individual situation.

Please note: If a woman is using certain hormone therapies (such as birth control pills), your hormone tests will not be valid. A doctor may ask you to stop taking birth control pills for several months before conducting tests. If you're still menstruating, have your hormone testing done during the first three days of your period.

**Here are the tests that I found helpful in my own menopause journey:**

###

  * Follicle-Stimulating hormone (FSH) Test Follicle-stimulating hormone (FSH) levels are sometimes measured to confirm menopause. This test is also used to determine a woman's likelihood of conceiving a child. The test is generally repeated over several months to account for fluctuations in hormone levels that may be occurring. After several tests, if a woman's FSH blood level is consistently elevated to 30 mIU/mL or higher, and she has not had a menstrual period for a year, it is generally accepted that she has reached menopause. Some doctors prefer to test the anti-mullerian hormone (AMH) levels instead. The AMH levels are decreased in perimenopause. Fertility doctors have been using this test for years as they find that the levels are not affected by taking birth control pills.
  * DHEAS DHEA sulfate is a hormone that easily converts into other hormones, including estrogen and testosterone.
  * Estradiol This is the main type of estrogen produced in the body, secreted by the ovaries. Low levels can cause memory lapses, anxiety, depression, uncontrollable bursts of anger, sleeplessness, night sweats and more.
  * Free and Total Testosterone Free testosterone is unbound and metabolically active, and total testosterone includes both free and bound testosterone. (No, this has nothing to do with 50 Shades of Grey.) In women, the ovaries' production of testosterone maintains a healthy libido, strong bones, muscle mass and mental stability.
  * Progesterone Low levels of progesterone can cause irritability, breast swelling and tenderness, mood swings, "fuzzy thinking," sleeplessness, water retention, PMS and free membership to the sisterhood of the shrinking pants (weight gain).
  * TSH (thyroid-stimulating hormone) According to the North American Menopause Society, menopause symptoms are similar to those of other conditions, such as thyroid disease. For some women, it may make sense to undergo medical tests to rule out such conditions as well. If there is an irregularity with your TSH, you may need to get your Total T3 and Free T4 checked as well.

Once you've determined that you actually are in the midst of perimenopause or menopause, here are other important tests to consider:

  * Bone Density Test Also called a bone scan or DEXA scan, this test can determine whether you have osteopenia (low bone density) or osteoporosis (very low bone density). When you enter perimenopause and menopause, the decline in estrogen can trigger a rapid loss of bone mass. The scan takes only minutes and exposes you to very little radiation. If you do have low bone density, your doctor may recommend you increase your intake of dietary calcium (found in food) or to take calcium supplements to avoid fractures.

  * CA-125 Cancer antigen 125 is a protein best known as a blood marker for ovarian cancer. It may be elevated with other malignant cancers, including those originating in the endometrium, fallopian tubes, lungs, breasts and gastrointestinal tract. Note that this test can result in false positives.

  * Cholesterol Panel Cholesterol levels change in perimenopause and menopause. Too much cholesterol can build up artery plaque, narrowing blood vessels and potentially causing a heart attack. A cholesterol panel usually includes checking your HDL (high-density lipoprotein or the good cholesterol), LDL (low-density lipoprotein or bad cholesterol) and triglycerides (molecules of fatty acids). You'll need to fast for 12 hours before this test.

  * Vitamin D3 This vitamin helps maintain normal blood levels of calcium and phosphorus, keeping your bones nice and strong. Women taking a combination of hormone therapy and calcium and vitamin D tablets after menopause were less likely to fracture their hip than those not taking hormones or supplements, according to one study.

However, a study from the Women's Health Initiative (WHI) shows no significant connection between vitamin D levels and menopause symptoms.

**Testing for Fertility**

Perimenopause may start earlier than you think, so too does your fertility begin to wane earlier than is commonly known. In order to take charge of your fertility and family planning, here are some tips for you:

About 95 percent of 30-year-old women have only 12 percent of their original number of ovarian follicular cells, which can develop into eggs. And at 40, only 3 percent of the cells remain, according to research from the University of Edinburgh.

Now, the good news: The research says that before birth, females have roughly 600,000 ovarian follicular cells. That means that even if you lose 88 percent of them by the time you blow out 30 candles, you can still celebrate having 72,000 cells left. While it's easiest for women to become pregnant before age 35, all egg-laying ovaries are not created equal, says David B. Smotrich, M.D., a Diplomate of the American Board of Obstetrics and Gynecology specializing in Reproductive Endocrinology and Fertility. During your early 30s, your eggs can decline in quality and you might begin ovulating less frequently, even if you are having regular periods, Smotrich says. A 30-year-old woman has a 20 percent chance of getting pregnant per cycle, but by the time she's 40, her odds drop to 5 percent per cycle, according to the American Society for Reproductive Medicine. That's where some newfangled fertility tests come in.

If you plan to have a baby in the great "someday," Smotrich recommends treating yourself to a baseline exam or two for your 30th birthday. Follow up with yearly tests until age 35, semi-annual tests (I suggest you time them with the Victoria's Secret semi-annual sales!) until 39, and quarterly tests thereafter to monitor your fertility.

**Here are some of your fertility-testing options, some of which overlap the tests for menopause:**

  * Follicle-Stimulating Hormone (FSH) Test (See above for details.)

  * 25-Hydroxy Vitamin D Test A blood test that determines if your body is deficient in calcidiol, your body's main form of stored vitamin D. Calcidiol levels generally decline with age, and deficiencies can predispose your baby to health complications, according to Smotrich.

  * Estradiol Test (See above for details.)

  * Anti-Mullerian Hormone (AMH) Test A blood test that estimates the number of the eggs in the ovaries.

If the ticking of your biological clock has become deafening and time is running out, medical interventions can help women older than 35 conceive. During in vitro fertilization, for instance, eggs are harvested from your ovaries, frozen unfertilized, and stored for later use. Your eggs can then be thawed, combined with sperm in a lab, and implanted in your uterus. In women ages 35 and younger who undergo up to six cycles of in vitro fertilization therapy, the live-birth rate ranges from 65 to 86 percent. Women ages 40 and older have half the chance of giving birth from in vitro therapy, with their rate ranging from 23 to 42 percent, according to an analysis of more than 6,000 patients published in _The New England Journal of Medicine._ The procedure typically costs about $10,000 per cycle, according to Smotrich.

During perimenopause, it is possible to conceive a healthy baby, while at the same transitioning to menopause, he says. However, since the risk of chromosomal complications increases with the mother's age, Smotrich recommends women older than age 35 talk to their doctor about having their developing baby monitored for chromosomal conditions including Down syndrome. Tests include a nuchal scan, a type of ultrasound, and amniocentesis, also referred to as an amniotic fluid test or AFT, in which a small amount of amniotic fluid, which contains fetal tissues, is sampled.

While men experience a drop in fertility after age 50, mom's age is the most important one in terms of conceiving, according to Smotrich. Still, older men have increased levels of sperm DNA instability, which is linked with a higher risk of autism and schizophrenia in children, according to Eric J. Topol, M.D., _Professor of Genomics at the Scripps Research Institute_ _._

Our baby makers don't work forever. Thank goodness. Can you imagine if they did? But if we keep an eye on our fertility clock, we can help make sure that when our lives are ready for pregnancy, childproofing, and dirty little handprints all over our walls (and our hearts), so are our bodies. If you are more in the grandma stage of life than the mom stage, share this information with the young women in your life who are in their childbearing years.

BTW, no matter what kind of tests your having, always ask for a copy of the lab results and keep them in a notebook or folder at home.

Do not be shy about asking for the tests you need. You're worth it! Your test results, together with an evaluation of how you feel and a discussion of your medical history will enable your specialist to successfully help you find hormone happiness and regain your quality of life back.

# Chapter 15

## Hormone Therapy

Okay, so now we come to the $64,000 question: to HT or not to HT? In order to answer this, let's take a look at what HT actually is.

Basically, the way it works is that when you go through perimenopause and menopause, your body begins to produce different amounts (usually smaller) of estrogen, progesterone, and/or testosterone hormones. These fluctuations often result in the symptoms that many perimenopausal and menopausal women experience. HT is intended to supplement or moderate these hormone fluctuations and ultimately provide an umbrella for a woman caught in a perimenopause and menopause storm.

Simple, right? Not so fast. See, not all HT options are created equal.

The first distinction you will want to make is whether an HT supplement is bioidentical or not. A bioidentical hormone is identical to the hormone produced in your body. It may not have originated in your body, but it has the same chemical structure and even goes by the same name. Most important, it has the same biological function.

**The most common bioidentical hormones prescribed for menopausal women are:**

  * estradiol

  * estrone

  * estriol

  * progesterone

  * testosterone

**Here are some helpful definitions:**

**Progesterone** gets the uterus ready for pregnancy and the breasts ready for milk production. (Seems like we are always getting ready for something.) After ovulation, progesterone helps make the uterus ready for implantation of a fertilized egg. Not sleeping? Low progesterone may be the cause.

**Estradiol** is the most important form of estrogen produced in the body.

**Estrone** is one of the three most common types of estrogen secreted by the ovaries.

**Estriol** is the weakest of the three main types of estrogen.

**Estrogen dominance** refers to the situation in which there is too much estrogen relative to the amount of progesterone in a woman's body. When estrogen dominates, there is a greater risk of heavy menstrual bleeding and other symptoms.

**Testosterone** is a steroid hormone primarily found in men, but smaller amounts are also produced in women's body: one specific place is the ovaries. No, this doesn't mean we're all harboring an inner Schwarzenegger. Testosterone is necessary for muscle tone, a healthy libido, and strong bones.

**Hormone Therapy Menu**

  * **Oral or tablet form** : This is the most common type of hormone therapy. When swallowed, the medication immediately travels to the liver (via the gastrointestinal tract), where the majority of the hormone is metabolized (deactivated); and then a small fraction of active hormone goes into the bloodstream.

  * **Patches** : These are applied to your skin on your stomach, thigh, bottom, or hip (swab the area with alcohol first and the patch will stick better). Patches need to be changed once or twice a week depending on your prescription and your needs. It is best to place them in a different location each time to prevent skin irritation. This patch looks like a piece of scotch tape—no, I am not kidding!

  * **Implants** : These are small pellets that are inserted into the fat under the skin. This process is carried out with a local anesthetic in your doctor's office. These implants last about four to six months. It is difficult to tweak the dose once they are inserted.

  * **Transdermal creams, gels, and sprays** : These can be applied to the skin, usually once or twice daily. After application, the medication is absorbed into the bloodstream.

  * **Vaginal treatments** : Generally referred to as local estrogen therapy (LET), these come as tablets or creams that are inserted into the vagina, similar to a suppository. They can help ease the symptoms of dry vagina, such as vaginal discomfort and painful sex. There is also a vaginal ring (no diamonds on this one!) available, which can be left in the vagina for three months. It slowly releases estradiol (the most potent form of the three natural estrogens) into the vaginal tissues. Estriol, the weakest form of estrogen, can also be applied into the vagina in the form of vaginal creams.

  * **Sublingual** : These are liquids or tablets. At present, these are only available from compounding pharmacies.

Patches, implants, gels, creams, sprays, and sublingual methods all transmit hormones to your body first through your bloodstream, making a first pass to their sites of action and then ultimately degrading in the liver. Because these methods do not go directly through the gastrointestinal tract, you can keep the dose much lower than with the oral or tablet form.

On the other hand, there are HT options available that are NOT identical to the hormones in your body. They might be similar, they might even have a similar name, but they are not exactly the same as the hormones produced in your body. Don't be fooled by a hormone with two names. Even if one of those names is the name of your body's hormone, the presence of another name should tip you off that you are NOT dealing with a bioidentical hormone. For example, estradiol is bioidentical, but ethinyl estradiol is not.

The other important characteristic to understand is whether or not the HT option is natural and/or synthetic. I say "and/or" here because the natural and synthetic labels are NOT mutually exclusive. Here's how that works. Technically speaking, if a hormone is called natural, that means it is originally derived from a plant or animal source. A hormone is considered synthetic if the chemical structure was altered in a laboratory. Sometimes hormones are extracted from yams and then chemically altered. In this instance, the hormone is both natural and synthetic.

**If you're given a prescription for HT and want to know what you're getting, ask the following questions:**

  * Is this HT option bioidentical? In other words: Is this HT option chemically identical to the hormone I produce in my body?

  * Was this HT chemically altered in a lab? (If the answer is yes, then the HT option is a synthetic hormone.)

  * Did this hormone originate in a plant or animal? (If yes, then that hormone is technically considered natural.)

If the answer to all three questions is yes, then you have a plant- or animal-derived hormone that was chemically altered to become identical to a hormone found in your body, which means it is natural, synthetic, and bioidentical.

I know it's confusing, because natural and synthetic seem like opposites, but with regard to HT, they are actually referring to two different distinctions. Whoever came up with these terms needs a talking to. If this doesn't make total sense the first time around, don't feel bad. It took me years to fully understand what all this stuff means. Try reading the information again, maybe a bit slower and without grinding your teeth!

These distinctions are important, because just as your body reacts differently to a tablet of Advil than it does to a tablet of Aleve, different hormone therapy options have different potentially positive and negative results. When you take bioidentical hormone therapy, your body may react the same way it would if it produced the hormone itself, because, chemically speaking, it is the same as the hormone your body actually does produce. When you take hormone therapy that is not bio identical, your body may react differently. The choice to be on a bioidentical HT vs. a non-bioidentical HT is up to you and your specialist.

As for me, with a family history of heart disease, I went on bioidentical HT early in my menopausal journey. It relieved my brain fog, sleeplessness, hot flashes, vaginal dryness and crashing libido! All the numbers in my Lipid Panel remain in the normal range, my calcium deposit score remains at 0, and my bone mineral density is all in the normal range. HT gave me my quality of life back and put a smile on my face. In my heart, I know this was the correct course of action for me!

Keep in mind that there are many schools of thought on HT and there is no one-size fits all solution. It is up to you to educate yourself and together with your menopause specialist, work out an individualized program to fit your personal health needs.

Now that you have the HT lingo down, there have been a number of studies about HT which I'll address in the next chapter. Rather than react to headlines in the media, which often sensationalize and exaggerate the findings of these studies, I reached out to experts to help us navigate the murky waters of HT (leave your scuba gear at home). Let's dive in!

# Chapter 16

## The Hormone Therapy Controversy Debunked

You may have heard that there's been a lot of controversy surrounding HT, and a lot of confusing information about whether or not it causes more harm—such as heart disease and breast cancer—than benefits. I want you to base your healthcare decisions on fact instead of fear. So let me set the record straight.

Back in 2002, a study called the Women's Health Initiative (WHI), which examined the effects of both estrogen and combination estrogen and progestin hormone therapy on menopausal women, created headlines when it was cut short because participants were found to have an increased risk of heart disease, stroke, and breast cancer. Immediately, people panicked. Women stopped taking their hormones, and doctors stopped prescribing them. Within 18 months of the findings' publication, half of the women who had been using menopausal hormone therapy stopped, according to Dr. David L. Katz, Founding Director of the Yale University Prevention Research Center _._ Currently, less than one-third of hysterectomized women are using estrogen to manage their symptoms.

Continuing research shows that there were holes in the WHI's findings—potentially life-threatening holes. The biggest two problems were 1) the women in the study were all well past menopause—nearly ¾ were over 60—and 2) they only tested on one kind of HT—made from the urine of pregnant horses (seriously, you can't make this up).

Luckily, we now understand that _if hormone therapy is started at the onset of menopause, the risks involved are much lower_. The results of hormone therapy varies widely between newly menopausal women and those who start treatment a decade or more after the onset of menopause, says Dr. Katz.

There have been several useful studies since then. If you'd like to educate yourself about them, here's what you should read:

  * A 2011 follow-up review of the WHI

  * The North American Menopause Society 2013 Convention "Global Consensus Statement on Menopausal Hormone Therapy"

  * Estrogen and Thromboembolism Risk Study (ESTHER)

  * The Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial

  * Kronos Early Estrogen Prevention Study (KEEPS). Notably, after the study, Dr. S. Mitchell Harman, director of the Kronos Longevity Research Institute and lead investigator for it, said, "Four years of estrogen treatment in healthy recently menopausal women is unlikely to worsen risk of cardiovascular events and is therefore a relatively safe strategy for relief of menopausal symptoms."

  *  The Danish Osteoporosis Prevention Study, which showed that there was a decreased incidence in breast cancer for the women who used estrogen-only HT.

###

### The upshot of all these studies? I spoke to Dr. Josh Trutt and asked him to simplify all this information for us. Here's what he had to say:

  * Earlier is better. Starting HT within ten years of menopause gives much greater benefit than starting later. In women who are younger than age 60, oral estrogens decrease the risk of both heart attack and stroke! In addition, starting HT within eight years of menopause cuts your risk of Alzheimer's disease in half.

  * Using oral non-bioidentical estrogen (such as ethinyl estradiol), at any age, will increase the risk of blood clots. When you swallow it, it gets metabolized in the liver, and increases the formation of clotting proteins. And using it together with fake, altered progestins increases the risk of clots even more. Using it in women with other risk factors for blood clots, such as obesity or smoking, raises the risk even further.

  * Transdermal estrogen (meaning through a cream or a patch) does not increase the risk of blood clots, in either older or younger women.

  * Oral estrogen that is started more than ten years after menopause is more likely to cause a stroke or heart attack in that first year after starting HT. The reason is, estrogen protects women from building up plaque in their arteries. After menopause, estrogen is not being produced—so unless she goes on HT, she will start building up plaque. Therefore, if a woman has had ten years without any estrogen, she will have built up significant plaque in her arteries. If she then starts oral estrogen, the plaque that has formed over starts to reorganize, and can become unstable in that first year, causing a heart attack or stroke.

On the subject of HT and breast cancer, Dr. Trutt had this to say:

Synthetic, altered progestins like medroxyprogesterone, norethindrone, and norethisterone all increase the risk of breast cancer _slightly_. Estrogen with natural, bioidentical progesterone does not increase the risk of breast cancer. Estrogen given alone for HT actually _decreases_ the risk of breast cancer.

The Endocrine Society did a review of HT in 2010 and concluded that not all types of HT are appropriate for all women. But very importantly, they also pointed out that _HT was associated with a 40% reduction in mortality_ in women in trials in which participants had a mean age below 60 years or were within 10 years of menopause onset, and that is exactly what they found in the Danish Osteoporosis study. Imagine finding a medication that lowers your risk of death by 40% for as long as you take it! That is what HT offers when taken appropriately.

So, despite all of the misleading information out there regarding HT, the conclusion that I have come to with Dr. Trutt is this: hormone therapy is not a necessary evil; it is necessary and _not_ evil. It is extremely important, however, to discuss with your specialist exactly what type of HT is right for you.

# Chapter 17

## Breast Cancer and Menopause

You know all those pink ribbons you see every October during Breast Cancer Awareness Month? Cute as they are, there's a very serious reason for them. According to the American Cancer Society, each year in the U.S., approximately 50,000 women younger than 50 are diagnosed with invasive breast cancer. More than 10,000 of them are younger than 40.

As scary as that diagnosis can be, for a lot of women, depending on treatment, it can also mean sudden or early menopause. During chemotherapy, women may have irregular menstrual cycles, amenorrhea (disappearance of menstrual periods), menopausal symptoms or be thrown into actual menopause. Menopause may be immediate or delayed, permanent or temporary when triggered by chemotherapy.

I reached out to the Yale Cancer Center and spoke to Dr. Erin W. Hofstatter, Assistant Professor of Medicine (Medical Oncology); Co-Director, Genetic Counseling Program, and Dr. Elena Ratner, Assistant Professor of Obstetrics, Gynecology, and Reproductive Sciences, to shed some light on issues of concern to my readers.

**Tomosynthesis Mammography**

Dr. Hofstatter said, "I am a huge fan." More and more data shows that this 3-D mammography cuts false-positives and call-back rates, and is picking up a few extra cancers per 1,000 women screened. It is a small amount of extra radiation compared to the usual 2-D mammogram, but is well worth it since it reduces call-backs and need for diagnostic mammograms (which are a lot more radiation than a screening 2-D mammo).

**Genetic Testing For BRCA1 and BRCA2**

Dr. Hofstatter noted that about 5 percent of breast cancer patients test positive for the BRCA1 and BRCA2 genes associated with the disease. However, the likelihood of testing positive for a woman with breast cancer depends on how old she is, if she is of Ashkenazi Jewish heritage, and what type of breast cancer she has. All these women have a slightly higher chance of testing positive. Here are some stats on the chances of women with breast cancer testing positive:

  * Non-Ashkenazi Jewish woman with breast cancer at any age: 1 in 50 -2 percent

  * Non-Ashkenazi Jewish woman with breast cancer <age 40: Less than 10 percent

  * Ashkenazi Jewish woman with breast cancer at any age: 10 percent

  * Ashkenazi Jewish woman with breast cancer <40: 30-35 percent

  * Woman of any descent any age with triple negative breast cancer: roughly 10-20 percent

One study recommends routine screening for the BRCA1 and BRCA2 genes for all women of Ashkenazi Jewish descent—even without a family history. Knowing your genetic mutations and what predisposes us to cancers is beneficial so that we can actually be proactive about it.

Dr. Ratner explained that the standard care options for women who carry the gene vary depending on the medical history of each patient. However, it is recommended that you add an MRI and sonogram—alternating at six-month intervals for breast cancer screening. For ovarian cancer screening, usually it is a pelvic (vaginal) ultrasound done every 12 months and a blood test CA-125 done every 6-12 months.

**Breast Cancer Treatment Options**

Research is also continuing on surgical treatment of breast cancer. Dr. Hofstatter shared her analysis of a JAMA study on the survival benefit of a double mastectomy in treating unilateral breast cancer: "Many women diagnosed with a breast cancer believe that getting a bilateral mastectomy will help them to improve their chances of curing the cancer and will make them live longer," she said. "The truth is, once the cancer has developed, the long-term risk of the cancer to someone's health is the same no matter what surgery they choose. In other words, the chances that their cancer will recur at a later time are the same regardless of the surgery they choose. If a woman chooses bilateral mastectomy, she should understand that the purpose of that type of surgery is to prevent a second, new breast cancer in the future. For most women, the chances of developing another new breast cancer is .5 – 1 percent per year.

"I completely understand why a woman might want to be aggressive about her surgical options, and I always think it should be a patient's choice. However, I fear women are 'going under the knife' without truly understanding the risks and benefits of the procedure. If anything, this JAMA study supports the idea that breast conservation is a safe option both in the short term and long term for most women."

**Breast Cancer After-Care Protocol**

According to Dr. Hofstatter, just how long women must be on drugs like Aromasin/Exemestane is up for debate. She said the new standard will likely be 10 years. For pre-menopausal women, she said, 10 years of Tamoxifen has been proven to be better than five years. No data yet definitively says that 10 years of an aromatase inhibitor is best, but the guidelines are saying to "consider it" in all patients who have completed five years.

"The BCI Index is designed to help doctors and patients decide the length of treatment. This test takes the original tissue from the cancer and sends it to the company, which studies gene expression of several different genes in the particular woman's tumor. Based on these results, a statistical report is produced that estimates the possible benefit from extended therapy."

Dr. Hofstatter predicts that the clinical use of the BCI will likely become a new standard.

**Treatment for DCIS**

What are the recommended protocols are for women with ductal carcinoma in situ (DCIS)? Dr. Hofstatter said DCIS is still officially considered a breast cancer, but is non-invasive, which means it cannot spread outside the breast and therefore cannot be life-threatening.

Women are typically treated for DCIS-type cancer with radiation and surgery, and oftentimes anti-hormonal agents that carry side effects. But some people are suggesting that this is "overkill" and that the treatment is worse than the disease. Some suggest that we should leave DCIS alone, not call it a cancer, and instead consider it a "high-risk lesion." This debate will no doubt continue.

While many DCIS lesions lie dormant and harmless for many years, there are others that do invade and become dangerous, Dr. Hofstatter said. We do not fully understand which DCIS lesions are which, so it becomes hard to pick and choose which patients need everything and which don't.

The bottom line is that women should talk with their doctors about their particular DCIS lesion, and decide which therapies are best for them. Sometimes, surgery with either radiation or anti-hormone pills is acceptable.

**Treatment of Menopausal Symptoms**

Some women find estrogen-free black cohosh helps keep their hot flashes at bay. You can find this ingredient in Remifemin, an over-the-counter product available at many pharmacies. In addition, Dr. Hofstatter is studying the use of Remifemin in early-stage breast cancer, specifically DCIS, to see if a few weeks of Remifemin taken before surgery can reduce cell proliferation in areas of DCIS.

Dr. Elena Ratner said that women whose menopause was triggered by treatment for breast cancer are the hardest to help. Their tumors have hormonal receptors, and even a minuscule amount of estrogen could grow their tumors.

Ironically, estrogen therapy is often prescribed to relieve menopausal symptoms in _non_ -breastcancer patients. For example, local estrogen therapy (LET) is often used to treat vaginal atrophy (dry vagina). While Dr. Ratner acknowledges that LET has a very low systemic absorption, she said many oncologists discourage its use in breast cancer patients. She further recommends vaginal moisturizers as a viable option for these women. She noted that even testosterone can convert to estrogen in the body, so this is not an option for women with breast cancer.

**Osteoporosis Prevention**

While estrogen protects bone health, for breast cancer patients Dr. Ratner prescribes two 600mg doses of calcium twice a day with vitamin D, plus cardio and low weight-bearing exercise.

**Fertility Preservation**

Many of these young breast cancer patients also hope to start a family, but toxic treatments such as chemo can adversely affect their fertility. Dr. Ratner stresses the importance for women and their providers to discuss fertility _prior to_ their treatment. Some chemotherapy will not affect fertility in the long run, but others may.

The takeaway for breast cancer patients is to talk to your doctor about treatments and side effects to find out what will work best for you.

# 

# Chapter 18

## Ease Menopausal Symptoms with Food

An apple a day keeps the hot flashes away... if only that were true. The good news is that the food we eat can make a big difference in how we experience the symptoms of perimenopause and menopause.

According to Susan Wysocki, WHNP, FAANP, president at iWoman's Health, diet is a huge factor in how perimenopausal and menopausal women feel and behave. Research shows that what women eat can either quell or exacerbate just about every menopausal symptom from hot flashes and night sweats to mood swings and weight gain.

Unfortunately, most of us are filling up with the wrong foods. During perimenopause and menopause, many women gain weight as reduced estrogen levels trigger cells to store more fat, according to research from the Mayo Clinic. No more!

Here are three tips for eating your way to a healthier, happier menopause:

**Eat Your Veggies**

"Certain fruits and vegetables have mineral called boron that may increase estrogen levels in certain women," says Wysocki. These include cabbage, dandelion, parsley, says Project Aware. Even produce that doesn't boost your estrogen production can still do a menopausal body good. One large-scale study published in _Menopause_ found that menopausal women who lost weight eating a low-fat diet rich in fruits and vegetables reduced or eliminated their hot flashes and night sweats.

Talk about a two-in-one benefit! Fruits and vegetables can reduce your hot flashes _and_ help you avoid menopausal weight gain.

**Find the Right Fats**

Research published in the _American Journal of Clinical Nutrition_ found that menopausal women who most closely follow a Mediterranean diet rich in produce, whole grain pasta, and healthy fats cut their risk of hot flashes and night sweats by about 20 percent. Meanwhile, menopausal women who eat diets high in sugar as well as saturated and trans fats increase their risk by 23 percent.

"Research has also shown that trans fats increase bad cholesterol in the body and decrease good cholesterol, and too much in the diet could result in memory loss and an inability to concentrate, both of which some women experience as symptoms of menopause," Wysocki adds.

Your move: Avoid foods such as butter, fast food, and baked goods that are rich in saturated and trans fats and opt for foods such as fish, olive oil, and canola oil that are rich in unsaturated, good-for-you fats.

**Pass on Processed Foods**

Packaged foods are breeding grounds for sugar and salt.

"Refined carbs such as white bread, rice, pasta and potatoes release glucose into the bloodstream quickly, which can lead to high-low mood swings and weight gain, not to mention making you feel tired. Opt for low-glycemic carbs that will provide energy without causing moodiness and fatigue," Wysocki says.

Likewise, opt for sugar-free drinks such as water and tea. Contrary to what most women think, even diet sodas aren't safe. Artificial sweeteners can cause glucose intolerance and change our healthy gut bacteria, which can lead to weight gain.

The simple way to find your grocery's whole foods: Stick to the perimeter of the store. Many grocery stores are designed with whole foods like produce and lean meats around the perimeter. "Be careful in the aisles," Wysocki warns. "That is where a lot of the 'non-food' food is." If it comes in a box, can, jar, or bottle, read the ingredients and nutritional facts on the back rather than falling for the advertising on the front.

This doesn't mean we can't indulge in the occasional pint of ice cream or candy bar from the checkout aisle, but "occasional" is the operative word!

Food is fuel. So when we start eating to live, rather than living to eat, it's nearly impossible not to feel better in our bodies—especially when those bodies are going through all the changes of perimenopause and menopause.

# Chapter 19

## The ABCs of Vitamins and Supplements

I don't know about you, but the thought of visiting my drugstore's vitamin and supplement aisle is enough to send me into a stress-induced hot flash. There are so many brands and types to choose from! Which do I need, which are merely the ingredients for really expensive and strangely colored pee, and why on Earth are there seven dozen different kinds of calcium?

"That's no excuse to go running, arms waving, into the parking lot," says menopause specialist Dr. Josh Trutt, M.D., a healthy aging expert in New York City. Trutt says virtually everyone should take supplements to boost their health—especially women during perimenopause and menopause.

"Getting all of your nutrients from your diet is a nice ideal to strive for, but there are some supplements that aren't part of the diet in our culture," Dr. Trutt says. "For example, some Asian cultures drink green tea all day long. Studies have shown that if you ingest the amount of green tea contained in ten small cups (which is what some Asian cultures consume in a day), you can lower your risk of prostate and colon cancer. I think drinking ten cups of green tea over the course of the day is in fact the best way to get the antioxidants it offers—but that's just not part of my lifestyle, so I take it as a capsule instead."

What's more, during menopause, fluctuating hormone levels (compounded with ever-increasing age!) can up your body's need for certain vitamins. Supplements can help you make up the difference. But since those same hormones can also slash your body's need for other nutrients, you shouldn't just pop any vitamin you can get your hands on. "All medications essentially cause some alteration in our physiology. Supplements are no different," Trutt says. "The question is, 'Is that alteration helpful or harmful, and at what dose?'"

Never head into the vitamin supplements aisle without first finding the right info, Dr. Trutt advises. "I've spent years reading about vitamins and other supplements, and if I have learned one thing, it's that Google-searching for supplement info is a terrible way to learn what you need to know. I suggest finding accredited medical doctors who blog and have a good reputation on this topic," he says, citing mercola.com and ChrisKresser.com. "Talk to your doctor about receiving a standard blood test, which evaluates levels of vitamins and nutrients including vitamin D, CoQ10, B12, zinc, and copper."

Please note: tests were conducted on top selling store brands of herbal supplements at GNC, Target, Walgreen and Walmart, and found that 4 out of 5 of the products did not contain any of the herbs on their labels! Dr. Trutt also suggests checking out Emerson Ecologics to find the best brands. "All of the companies listed there have very good reputations and allow independent analytical testing of their products and audits of their facilities," he says. Remember that all brands have different specialties.

If that sounds like a lot of homework, don't worry. Here is Dr. Trutt's need-to-know intel on some of the most popular vitamins and supplements out there. **_Be sure to consult your doctor and have proper testing before taking any supplements._**

**Iron**

As far as iron goes, a burger probably has all you need. "Once a woman stops menstruating, she is much less likely to need extra iron," Dr. Trutt says. "The Iowa Women's Health Study showed that taking supplemental iron is linked to decreased life expectancy." Why? Iron is a pro-oxidant, meaning it induces oxidative stress and the accumulation of free radicals in the body, which can contribute to disease. Dr. Trutt's advice: Only take iron if you need it for iron deficiency. Ask your doctor to run a simple blood test to determine your levels.

**Multi-Vitamins**

"The truth is that there are very few multis on the market that are worth taking. When you have that many ingredients mixed in, there are a lot of opportunities to get it wrong. Many blends have too much of certain vitamins and too little of others for optimal health, especially when it comes to helping women ease menopausal symptoms. Rather than cramming dozens of vitamins in one capsule, focus on getting the specific vitamins you need," Trutt says.

**Vitamin K**

Not all K vitamins are created equal. Trutt recommends MK-7, as it helps prevent osteoporosis. Since plummeting estrogen levels during perimenopause and menopause can cause loss of bone mass, women over the age of 50 are at the greatest risk for developing osteoporosis, according to the Cleveland Clinic. Dr. Trutt advises taking at least 100mcg of MK-7 a day. If you are taking Coumadin (warfarin), a medication that's typically prescribed to help prevent blood clotting, **be sure to _speak with your doctor_** **_before_** _you start taking the big K_. You may need to adjust the dosage of your medications.

**Calcium**

After menopause, bone breakdown outpaces the building of new bone. Calcium can help—in moderation.

"Taking extra calcium can be harmful because it will deposit in your blood vessels instead of your bones—unless you take plenty of MK-7 (that last vitamin we talked about!), which keeps it out of your blood vessel walls," says Dr. Trutt.

Women older than 50 need to consume 1,200 milligrams of calcium every day to keep their bones strong, according to Dr. Diane L. Schneider, M.D., M.Sc., author of _The Complete Book of Bone Health_ and co-founder of 4BoneHealth.org.

The best sources of calcium include dairy, almonds, broccoli, kale, salmon, and soy products, such as fortified tofu. If you focus on a healthy diet filled with these foods, you can hit your daily bone-fortification quota, making calcium supplements and all of their controversy a moot point. But before resorting to supplements, take a look at your diet to see how you can increase your calcium intake with the food you eat.

**Vitamin D**

"Your ability to convert sunlight to vitamin D decreases as you age, and so you may need more supplemental vitamin D to keep your blood levels in that sweet spot of 35-40ng/mL. We know that having a vitamin D level below 25ng/mL is bad, but in one study after another, people with vitamin D levels above 45 actually die more often than people with lower levels," Dr. Trutt says.

Dr. Schneider recommends women older than 50 get 600 IU of the vitamin a day and women older than 70 get 800 IU to maintain those levels. Adequate vitamin D, along with calcium levels, are helpful in preserving your bone health.

Have your vitamin D level checked to know what you need. While the top sources of vitamin D include oily fish, egg yolks, and fortified milk, according to the National Institutes of Health, the recommended amount of vitamin D is hard to achieve with diet alone, especially in winter months when there is less sunlight or even when sun is plentiful since sunscreen blocks vitamin D production. In any event, count your food first and only use supplements to _supplement_ your diet. Don't take the entire recommended amount in supplements.

**Curcumin**

Curcumin has been used for centuries, is very safe, has documented anti-cancer benefits, and we think it helps prevent Alzheimer's disease. Your mainstream doctor has nothing to offer you to prevent or slow the progression of Alzheimer's. In that light, Curcumin seems a very reasonable supplement for nearly everyone." Still, "Curcumin is very hard to absorb, making most brands useless," says Dr. Trutt, who recommends taking one capsule a day of Longvida brand Curcumin.

**CoQ10**

As your estrogen supplies dry up, so can your thyroid function, especially if your estrogen drop is sudden or dramatic. That explains why subclinical thyroid disease strikes 23.2 percent of postmenopausal women. Of those women, 73.8 percent suffer from hypothyroidism, according to German research published in _Gynecological Endocrinology_. "If you use significant amounts of thyroid hormone, you should take CoQ10 with it. Thyroid hormone can cause you to deplete your CoQ10 levels," says Dr. Trutt, who suggests taking 100mg a day.

**Omega 3**

Estrogen is good for your heart: It helps keep blood vessels flexible so that they can relax and expand to accommodate blood flow. So when estrogen levels drop, the risk of heart disease can increase. Omega-3 fatty acids, however, can help. A type of unsaturated fatty acid, it reduces the effects of inflammation on blood vessels and the heart, according to Mayo Clinic. "In patients who have high triglycerides and are taking fish oil to lower it, 2 grams a day is of documented benefit," says Dr. Trutt. "For the rest of us, this may be an area where eating two servings of fish per week is the way to go."

Ladies, it's time to say goodbye to supplement anxiety... and hello to better health! Vitamins and minerals are integral to everything our bodies do and everything we can be. Before you supplement, check with your doctor to be sure that you are giving your body what it truly needs!

# Chapter 20

## The Impact of Smoking on Menopause

#

#

It might have been cool to suck on a ciggy when you were in high school, and maybe a few drags and a mega cup of coffee got you through all-night study sessions in college, but let's be honest—smoking is just plain bad for you. Aside from the significantly increased risk of stroke, heart attack, and all kinds of cancer including lung and disfiguring head and neck cancers, it also makes your breath and clothes stinky and causes wrinkles. Who wants more wrinkles?? And last but not at all least, smoking has a serious impact on menopause!

In a study published online in the journal _Menopause_, researchers from the Perelman School of Medicine at the University of Pennsylvania reported the first evidence showing that smoking causes earlier signs of menopause. In an announcement of the study's findings, it was noted that, although previous studies have shown smoking hastens menopause by approximately one to two years regardless of race or genetic background, this study is the first of its kind to demonstrate that genetic background is significantly associated with a further increased risk of menopause in some white women who smoke. In the case of heavy smokers, this can be up to nine years earlier than average in white women with certain genetic variations. Genetic variation refers to diversity in gene frequencies, and can refer to differences between individuals or to differences between populations. In this case, we're talking about differences between individual women in the study. The genetic variants were present in 62 percent of white women in the study population.

"We already know that smoking causes early menopause in women of all races, but these new results show that if you are a white smoker with these specific genetic variants, your risk of entering menopause at any given time increases dramatically," said the study's lead author, assistant professor of Obstetrics and Gynecology at Penn Medicine Samantha F. Butts, M.D., MSCE (her last name suggests she was born to do this work).

Smoking can also make menopausal symptoms more severe. No if ands or butts—smoking is not cool, especially if it is bringing on hot flashes that rival global warming.

Now let's go back to the non-menopause smoking risks, since we're here. Dr. Sarah Nyante of the U.S. National Cancer Institute released a study that found that women smokers are 19% more susceptible to developing breast cancer after menopause than women who don't smoke after menopause.

Have you put down that cigarette yet? **Smokefree.gov **has four more reasons to consider living your life smoke-free:

### 1. Aging Skin

In addition to its effects on menopause, smoking can do a number on your skin. Smoking can cause skin to be dry and lose elasticity, leading to wrinkles and stretch marks. A smoker's skin tone may become dull and grayish. Let's face it (pun intended), it's simply not fashionably chic; a grayish skin tone, brownish fingers from tobacco stains, and yellowish teeth clash horribly. Eww.

### 2. Belly Fat

Most women find that they suddenly become members of the sisterhood of the shrinking pants during menopause. As if that is not frustrating enough, many smokers find that those menopausal muffin tops (the belly fat dripping over your pants) are getting bigger and they have less muscle tone than non-smokers. In addition, smokers have a much more difficult time controlling diabetes.

### 3. Lower Estrogen Levels

If you or someone you love is interested in getting pregnant, definitely put down that cigarette. Women who smoke have a harder time getting pregnant and having a healthy baby.

### 4. Other Smoke-related Health Problems

The average age for onset of menopause (when you have been without a period for 12 consecutive months) is 51. According to the North American Menopause Society (NAMS), during and after menopause your risk of other health conditions rises, and smoking increases that risk even more, including: heart disease, stroke, breast cancer and diabetes, decreased bone density, rheumatoid arthritis, gum disease, ulcers, post-surgical complications, and depression.

### **The good news**

Are you ready to quit? Margery L.S. Gass, M.D., NCMP, executive director of NAMS, has some good news to share with us. She notes that women who quit smoking before age 40 erase most of the risk of early death. The risk of stroke and heart disease drops quickly after you stop smoking. (The risk of cancers drops more slowly.) Women who quit by age 50 buy back about six years, and those who quit by age 60 gain about four years of the decade they'd lose if they didn't quit.

If you're a smoker, this might just give you the incentive to kick the habit for good.

# Chapter 21

## Surgically Induced Menopause (Hysterectomy and Oophorectomy) and Premature Menopause

While it is true that perimenopause and menopause are completely natural, they can be annoying and disruptive parts of the normal life cycle. For some women they come abnormally early (premature menopause), or as a result of surgical or medical interventions (hysterectomy or as a result of some cancer treatments like radiation and chemotherapy).

In some cases, you may be able to treat your menopause symptoms under these circumstances with HT.

In the meantime, let's take a look at what we're talking about.

**Hysterectomy**

We women love to change things up: our hairstyle, our hemlines, our wardrobes. And if we don't like something—that couch, that old dress—we toss it and get a new one. Well, let me stop you right there, because if your doctor tells you that you should have a hysterectomy, make sure you get a second opinion, and maybe a third. After all, a hysterectomy is forever.

How are these for some startling stats? The CDC reports that 600,000 women have their uterus removed every year. More than one-third of women will have had a hysterectomy by the time they turn 60, the National Women's Health Network reports.

As Peg Rosen wrote in _More_ magazine, just because you're done having babies, don't throw the uterus out with the bathwater. Not only will the procedure cost you six weeks in pain and out of work, it could leave you incontinent, put the kibosh on your sex life, and maybe shorten your life. If that's not enough, a landmark study showed that removing ovaries along with the uterus ups the likelihood of heart disease and bone loss, according to study coauthor William Parker, M.D., of the UCLA School of Medicine.

Only 10% of hysterectomies are performed to treat cancer. Most of them are done to treat bothersome but benign bleeding from fibroid tumors—even though there may be other ways to treat them, such as uterine fibroid embolization, a non-surgical technique that introduces microbeads via a small catheter to block the blood supply to the tumor, thereby reducing its size and alleviating symptoms. Other less invasive treatments include hysteroscopic myomectomy (removing the fibroid through the cervix rather than slicing you open) and endometrial ablation.

**If you do indeed need a hysterectomy, due to cancer or prolapse, say, ask your doctor about laparoscopic surgery, which is completed through small incisions rather than one large incision. Be sure to talk to your doctor _before surgery,_ so that you can have a plan in place to deal with the hormonal and other physical and emotional effects of the procedure.**

**Physical effects of hysterectomy.**

After the procedure, a woman may no longer become pregnant. If she has not yet entered menopause at the time of surgery and her ovaries are left in place, they will continue to produce estrogen. However, she may enter menopause at an earlier age.

If her ovaries are removed during the hysterectomy, she will enter menopause and encounter symptoms caused by a lack of estrogen, such as hot flashes, vaginal dryness, and sleep problems. She may also be at risk of developing osteoporosis at an earlier age, according to The American College of Obstetrics and Gynecologists (ACOG).

A woman still needs regular Pap tests to screen for cervical cancer if she has a partial hysterectomy and does not have her cervix removed, or if her hysterectomy was performed as a treatment for cancer, says Lauren Streicher, M.D., Assistant Clinical Professor of Obstetrics and Gynecology at Northwestern University's Feinberg School of Medicine in Chicago. Any woman who has had a hysterectomy should still have regular pelvic exams and mammograms.

Dr. Anees Chagpar, Associate Professor of Surgery (Oncology) and Director of The Breast Center at Smilow Cancer Hospital at Yale-New Haven, suggests "annual screening starting at age 40, but tailor this recommendation to individual patients." Women under 40 need not bother sticking their girls in the mammo waffle iron unless there's a strong family history of breast cancer diagnosed at an early age.

Dr. Rebecca C. Brightman, assistant clinical professor OBGYN and Reproductive Science at the Mount Sinai School of Medicine in New York City, points out that for many women, the OBGYN is the one and only healthcare provider. "We frequently screen for and diagnose other medical conditions. Women confide in their OBGYNs and seek advice in many areas from mental health concerns to social problems. So it's way more than just a Pap smear!" Anyway, who would want to miss putting on that gorgeous gown and saddling up in those stirrups?

**There can be emotional affects from a hysterectomy as well.**

"Very few women are thrilled about having to have a hysterectomy. Even though intellectually you know it's the right thing to do and will benefit you in the long run, it's a complex decision that is often psychologically difficult," says Dr. Streicher. Some women feel depressed because they can no longer have children, and, if they have entered menopause after the surgery, hormonal changes can cause emotionally difficult symptoms. Still, she may feel relieved because the symptoms she was having are no longer present.

What does hysterectomy mean for your love life? Some women experience more sexual pleasure post-surgery because of the loss of symptoms, as they no longer are having discomfort or heavy bleeding during sexual intercourse, according to a study by Jan-Paul W. R. Roovers, M.D., an obstetrics-gynecology professor at the University Medical Center in Utrecht, the Netherlands.

However, because the uterus has been removed, the uterine contractions that the woman may have felt during orgasm will no longer occur and can decrease sexual satisfaction for some women, says Dr. Streicher. A minority of women report developing sexual dysfunctions following a hysterectomy. Reduced estrogen levels are the main cause of vaginal dryness, says the Mayo Clinic. I know that when my estrogen levels began plummeting, my vagina took a trip to the desert and I am not talking about Las Vegas. It was dry and parched!

**Premature Menopause**

Perimenopause arrives unscheduled and uninvited. Most women first begin to experience perimenopause in their early to mid-forties, but some women begin to have symptoms in their thirties, or even in their twenties, and achieve full menopause (no period for 12 consecutive months) before the age of 40. I wish I could tell you that you will receive a "Hold the Date" notice so that you'll know exactly when your menopausal journey will begin—sorry, no dice.

The loss of ovarian function at an early age is often referred to as premature menopause, early menopause, premature ovarian failure, or premature ovarian insufficiency (POI). Where are the naming police?

There are many factors that contribute to menopausal timing, including autoimmune and genetic disorders, chemotherapy, radiation therapy, and surgical history. However, sometimes the cause is unknown. Women who undergo an oophorectomy or radical hysterectomy in which the ovaries are removed jump right over perimenopause into full menopause, as the actress and filmmaker Angelina Jolie thoughtfully described about her own journey.

According to an article published in _JAMA Internal Medicine,_ which looked at a group of nearly 1,500 women with frequent symptoms of the onset of menopause, women who began to experience hot flashes and night sweats at a younger age tended to have them over a greater period of time. That means women who experience early or premature menopause symptoms may experience these symptoms longer than average.

But it's not all bad news.

When I first met Christine Eads, she was co-host of the popular radio show "Broadminded" on Sirius XM Radio 107. Now Christine is the co-host of the digital radio program, "The Mom Squad Show." Christine opened up and shared her powerful story about her own struggle to find hormone happiness. When she was 24, her period stopped. For the next five years, she saw doctor after doctor, looking for a solution. They told her the problem was caused by everything from depression to weight gain to weight loss to sexually transmitted disease! All the while, she was experiencing terrible mood swings and waking up in pools of sweat—both typical menopausal symptoms.

Ultimately, she went to a specialist at the National Institutes of Health, who discovered that she suffered from primary ovarian insufficiency (POI). Christine was devastated! She wasn't ready to have kids at that point in her life, but she had always dreamed of having a huge family with tons of children. She was really angry at the doctors who didn't diagnose her properly. After five years of suffering needlessly, Christine was put on hormone therapy. The therapy curtailed her symptoms and ultimately she was able to conceive!

What saved Christine in the end was her determination to find an answer. "You have to be your own advocate. No one cares about your health more than you. Don't blow it off and say that it's normal or it will go away. If you don't feel right in any way, get to a specialist and ask a million questions until you are satisfied. Don't be embarrassed to talk to family and friends about what is happening with you. You may not know that POI, or other disorders, run in your family, for instance, and you might find strength sharing your experience with another person who is feeling the same way. It is worth taking the time and doing the research to feel better," she says.

I couldn't have said it better myself!

# Chapter 22

## Compounding Pharmacies

As if all these symptoms and treatments weren't enough to think about, here's one more ingredient to throw into the mix—what kind of pharmacy to go to! That's right, you'll also want to consider whether a traditional pharmacy or a compounding pharmacy is the best place to get those meds that keep you feeling like your new and improved self.

For starters, let's talk about the difference between a compounding pharmacy and your local or chain pharmacy. Christine Givant, RPH, and Deb Hubers, co-founders of the La Vita Compounding Pharmacy in San Diego, explain how compounding pharmacies differ from traditional pharmacies.

**"** Compounding pharmacies specialize in the preparation of medications by mixing raw ingredients to formulate a medication that is custom made exclusively for a patient based on a prescription from a physician. Traditional pharmacies dispense commercial medications manufactured by a pharmaceutical company. Compounding pharmacies can dispense commercial medications as well as compound medications. All pharmacies (compounding and traditional) are regulated by the State Board of Pharmacies in their respective states. No pharmacy is regulated by the FDA. Reputable compounding pharmacies use ingredients that are sourced from an FDA-approved chemical house."

**So why would you use a compounding pharmacy vs. a national chain pharmacy?**

**"** A woman's treatment must be personalized to address her individual health requirements. Physicians use compounding pharmacies to customize a woman's prescription to meet her unique health needs. Although there are commercially available bioidentical hormones, they are only available in limited dosages and forms. If your physician's protocol requires a different dosage form, she/he will prescribe a compounded medication formulated exclusively for you. There are other ingredients that may need to be included and/or combined in a treatment regime that are only available from a compounding pharmacy. For example, Estriol is a bioidentical hormone that is not available commercially."

**So what does it mean if a pharmacy is PCAB accredited?**

**"** PCAB stands for The Pharmacy Compounding Accreditation Board. If a pharmacy has its PCAB accreditation, that means it is legitimate. It adheres to the 'Principles of Compounding,' its product's potency is ensured through formal testing, its operating procedures are regulated and approved, its facilities exceed inspection standards, its lab design and equipment is of highest quality and safety, its personnel is trained properly, it buys from FDA-approved chemical houses, and its physicians prescribe the highest-quality compounds with confidence. (For more information, visit pcab.info).

**Givant and Hubers suggest the** following **questions to ask your pharmacy** :

  * Do they have a sterile clean room?

  * Do they send out formulations to a third party for potency and stability testing?

  * What training does their staff have in compounding?

  * How many years have they been compounding medications?

  * What equipment do they use to compound your medication?

  * Do they mill their creams?

  * Are they certified or accredited by their national organization?

  * Ask them if you can make a site visit or ask them to show you where they compound the medications. Patients can learn a significant amount about how their medication is prepared by visiting the pharmacy. If you can't make a site visit, ask for pictures of the lab.

Remember, check with your insurance carrier to find out about coverage for compounded prescriptions.

In the fog of menopause, it's difficult to wade through all of the information associated with HT and the pharmacies that dispense the meds. But you'll be glad you did, because if given just the right medication and dosage, the difference between how you feel now and you will feel is the difference between night and day.

# Chapter 23

## A Word About Menopause in the Workplace

Unfortunately, you can't leave your hot flashes on the kitchen counter when you go to work in the morning. When I experienced my first one, I was in a room full of men who, of course, had never experienced a hot flash. I was totally mortified. I quickly learned Hot Flash wanted to be my new best friend, showing up at the most inopportune times, like when I was getting ready for work. As soon as I finished my hair and makeup, whoosh! Sometimes I'd have to change my clothes and redo my makeup! I was always hot flashing in the supermarket checkout or, my personal fave, the dentist chair. I have one friend who gets 'em every time she gets her nails done and has to apologize to the manicurist for her sweaty palms. The fabulous award-winning actress Kim Cattrall told me her own hot flash story—can you imagine being in the middle of a scene or a photo shoot and have that dreaded flash leave you red in the face and totally drenched when everyone is looking at you?

My friend Paul told me about a business trip he took with a female colleague. On the plane to Switzerland, his colleague was sitting next to him when beads of sweat started pouring down her face. Without a word, she peeled off a few layers of clothing until she was down to a sleeveless t-shirt. Later, during a highly sophisticated presentation, the dreaded flash reappeared. For a moment, Paul worried his colleague would start to strip again! She did not, and no one said a word about what was obviously happening to her. It wasn't until their return plane trip that Paul turned to her and said, "You know you're in perimenopause, right?"

Let's face it, women in the workplace is a fact of life, and therefore so is menopause. Maybe your grandmother could take to her bed for a few years and only her family noticed, but not so anymore. A 2010 report by the U.S. Congress Joint Economic Committee says that "the number of women in the workforce has grown by 44.2 percent over the last 25 years, from 46 million in 1984 to 66 million in 2009." It's a pretty good bet some of those women are going to be working into middle-age, and therefore going through menopause while they're at it.

The University of Nottingham did a study called Women's Experience of Working Through Menopause. In it, women were asked which menopause symptoms were affecting their work performance. The top three were: poor concentration, tiredness, and poor memory. More than ¾ of the respondents said their job performance had been negatively affected by their menopausal symptoms, or that their performance would have been affected had they not put in additional effort to overcome those symptoms. Perhaps not surprisingly, 70% of women had not told their managers that they were experiencing menopause.

Women have been busting through the glass ceiling for decades now. Women are CEOs of some of the biggest companies in the world. Yet that shame and secrecy that we've inherited from our grandmothers and mothers about perimenopause and menopause has followed 21st Century women right into the boardroom.

Until I was able to get my symptoms under control with HT, I faced hot flashes at work the same way I deal with everything I find difficult—head on and with humor. If I was in a meeting, I would simply say, "Yes, people, I am experiencing a hot flash. No worries, it will pass in a flash, and it is not contagious!" Everyone would laugh and the meeting would continue while I peeled off a couple of layers until the episode passed. (Layers, especially breathable cotton ones, can be a hot-flashing lady's best friend.)

That's right, don't hide your hot flash under a bush. (Sorry, ladies, I just couldn't resist saying this... some of us still have these.) Be open about it. There may be others in the sisterhood quietly suffering in the next office or cubicle who would appreciate the support, and it may well go a long way toward enlightening the brotherhood about why some of their female colleagues are struggling at work.

# PART FOUR

## Keep the Party Going

### Preventing Long-Term Health Problems

# Chapter 24

## Osteoporosis

Snap! Crackle! Pop! are sounds best left to breakfast cereal and not your bones, but for many women as they get older, especially as estrogen levels diminish with perimenopause and menopause, bone loss is a unpleasant reality. When it comes to your bones, being dense is a _good_ thing. The disheartening truth is that, according to the National Osteoporosis Foundation (NOF), more than 50 million Americans have osteoporosis and low bone mass, aka osteopenia. Furthermore, studies suggest that approximately half of all women and up to a quarter of men age 50 and older will break a bone due to osteoporosis.

As women enter perimenopause and menopause, we need to be especially aware of our bone health. After menopause, bone breakdown outpaces the building of new bone in women, making women over the age of 50 at the greatest risk for developing osteoporosis, according to the Cleveland Clinic.

Time to bone up on our bone health.

Dr. Diane Schneider, author of _The Complete Book of Bone Health,_ warns, "Unless you break a bone, you may not be paying attention to your bone health. Bone loss is a silent process. The transition to menopause is the time when bone loss accelerates due to the loss of estrogen. By optimizing your bone health you may lessen the impact of menopause on the bone."

She says, "Few Americans are meeting the daily recommendations for calcium, vitamin D, and exercise."

Schneider tells us to focus on the basics, which she calls the ABCs of bone health:

**A – ACTIVITY**

_Engage in regular physical activity._ Bone requires physical activity to stay in shape. Mechanical strain on the bone provided by activity helps to maintain bone. A total of 30 to 60 minutes of moderate-intensity exercises on most days of the week is recommended. If you are already active, turn it up a notch by increasing the time and intensity.

_Do something you like_. But impact and resistance exercises are the best to promote bone building. Incorporate weight-bearing and weight-resistive exercises in your exercise routine.

_Vary your routine._ Do a combination of cardiovascular exercises, stretching, weight training, and resistance work. Alternate days of cardio and muscle strengthening or focus on separate muscle groups, such as upper body one day, lower body the next.

_Spend more time on your feet_. Maintaining good bone requires more time than just time in the gym. During the day stay active and avoid long periods of sitting. Everything you do while in motion counts as physical activity including household work, gardening, and walking.

**B – BALANCE**

_Build and maintain core strength_. The goal is to prevent falls and make you more stable on your feet. In later life, 90 percent of broken hips are a result of falling. Keep engaging your core muscles to work on improving your balance.

_Start with simple balance exercises_. Walk heel-to-toe. Balance on one leg. Then close your eyes while balancing on one leg.

**C – CALCIUM**

_Know your target daily calcium intake_. Recommendations are based on your age and gender. (Refer to chart.)

_Track your daily calcium_. Add up your calcium from your foods. Dairy products are the highest in calcium. Learn about other foods that are rich in calcium such as broccoli, kale, turnip greens, bok choy, black beans, and almonds.

_Check "Nutrition Facts."_ Calcium on food labels is given as % Daily Value or DV. Since the daily value for calcium is 1000 milligrams, just add a zero to the percent for the amount in milligrams. For example, a one-cup serving of whole milk is 30%, which would be 300 milligrams.

**Calcium Recommended Daily Intakes** _2010 Institute of Medicine_

C _ount food first_. Supplements mean just that, you are supplementing your diet. If you don't reach your goal with food, fill the deficit with a calcium supplement. Don't exceed the upper level of calcium intake. (Refer to chart.)

**D – VITAMIN D**

_Don't count on the sun._ Although sunshine is the main source of vitamin D, you can't expect sun to be your primary source in all seasons of the year. Sunscreen also blocks the production of vitamin D.

_Eat vitamin D-rich foods_. Unfortunately, few foods contain vitamin D. The highest natural sources are fatty fish like wild salmon, herring, and sardines. Other foods may be fortified with vitamin D. All milk is fortified but not all milk products are fortified with vitamin D.

_Check "Nutrition Facts."_ Vitamin D on food labels is given as % Daily Value or DV. The daily value for vitamin D is 400 IU (International Units). Multiply the percent by 4 for the amount in IUs. For example, a one-cup serving of milk is 25%, which would be 100 IUs.

_Ensure adequate vitamin D status with supplements._ The amount of vitamin D needed is hotly debated. Refer to the chart for the latest general recommendations. However, your individual needs may vary. In general, taking 1000 to 2000 IUs a day provides adequate vitamin D status. Talk with your menopause specialist about checking a vitamin D level to be sure.

**Vitamin D Recommended Daily Intakes** _2010 Institute of Medicine_

**E – ESTROGEN**

_Consider restoring the estrogen support of bone that is lost with the transition to menopause_. Estrogens are approved by the Food and Drug Administration (FDA) for prevention of postmenopausal osteoporosis.

_If you are at higher risk for breaking a bone, estrogen decreases the risk of fractures._ In research studies, use of estrogen in women with low bone density lowers the risk of having a spine or hip fracture.

_Use the lowest dose required to control your menopausal symptoms_. Changes in bone density may be related to the dosage of estrogen. Low dose estrogen maintains bone density and lowers your risk of breaking a bone.

Osteoporosis is often called a silent disease because you can't feel your bones getting weaker. Dr. Schneider says, "Awareness and education about simple measures can make a difference."

**To scan or not to scan? That is the question. Are you a candidate for abone scan?**

The NOF suggests that you should consider it if you can answer "yes" to these two questions.

1. Are you a postmenopausal woman or man age 50 or older?

2. Have you recently broken a bone?

The most common—and most accurate—test is a dual-energy X-ray absorptiometry (DXA) scan. This test uses X-rays to measure how many grams of calcium and other bone minerals are packed into a segment of bone. The bones most commonly tested are those in the spine and hip and sometimes the forearm is added. If you're worried about radiation, have no fears. A DXA scan uses low-dose X-rays. According to the National Institutes of Health, you receive more radiation from a chest x-ray.

The test itself only takes about 10 minutes, so you can't use "I've got no time" as an excuse. However, not all insurance plans cover bone scans, especially if you're under 50, so be sure to check with your carrier first.

After your test, you'll be given a T-score (and we're not talking golf). The Mayo Clinic explains that your T-score compares your bone density with that of a healthy young adult of your sex. According to the criteria established by the World Health Organization, here's what your T-score means:

-1 & above | Normal  
---|---  
Between -1 to -2.5 | Osteopenia or low bone density  
-2.5 & lower | Osteoporosis

If you have a T-score of -1, you have twice the risk for bone fracture as someone with a normal BMD. If your T-score is -2, you have four times the risk.

A study published in the _Journal of the American Medical Association_ in 2001 reported that a 50-year-old white woman with a T-score of -1 has a 16 percent chance of fracturing a hip, a 27 percent chance with a -2 score, and a 33 percent chance with a -2.5 score.

"Over the past decade, we have learned to use bone density scan results in the context of assessing one's overall risk of fracture," Dr. Schneidersaid. "The result of osteopenia must be evaluated along with other risk factors. For instance, if you compare a 55-year old woman with a 75-year old woman who both have the same T-score of -2.0, the 75-year old woman will have a higher risk of fracture based on her age alone. Various tools are being used to quantify fracture risk like the FRAX calculator. As a result, fewer early postmenopausal women are being treated with osteoporosis medicines."

The National Osteoporosis Foundation recommends drug treatment for osteopenia in postmenopausal women and men age 50 and older who have at least a 20 percent risk of any major fracture (spine, forearm, hip, or shoulder) in the next decade or at least a 3 percent risk of a hip fracture.

Johns Hopkins Medicine warns that taking bisphosphonates or other bone-building medications for osteopenia means you may be treating a condition that might never develop. These medications also can be costly, which may be a determining factor on when—or if—you begin taking them. You will want to make sure your risk is high enough to warrant starting on medicines.

Medications used to treat osteopenia/osteoporosis include alendronate (Fosamax and Binosto), risedronate (Actonel and Atelvia), ibandronate (Boniva), and raloxifene (Evista). Other medical options include denosumab (Prolia) as twice a year injections, zoledronic acid (Reclast), given intravenously once a year or every two years, and teriparatide (Forteo), daily injections for a total of two years only. Estrogen is FDA-approved for prevention of osteoporosis if other options are not viable.

Some doctors recommend taking medication for five years, taking a break, and then going back on medication. This may mitigate any potential rare negative side effects, such as femur fractures, jawbone decay and more.

Harvard experts suggest if your T-score is closer to -1, you're better off getting more weight-bearing exercise, calcium (1000 mg/day), and vitamin D (800 mg/day). The NOF suggests such weight-bearing exercises—usually those where your feet touch the ground—might include running, walking, dancing, tennis, and aerobics. Strive for at least 30 minutes a day. I ride my bike every morning and do weight bearing exercises three times a week... it helps my mood and my bones!

Heavy drinking can increase your risk of osteoporosis. So before you pour that second glass of wine, take note: One alcoholic drink a day for women and two a day for men is considered moderate. (Hey, I am just the messenger.)

Don't smoke. Period. No butts about it.

Now that fracture risk is assessed, those with low fracture risk do not benefit from medicine, but those with high risk, as defined by the NOF, do. If you've been diagnosed with osteopenia, consult with your physician to determine the best course of action. Make no bones about it, healthy bones are key to a healthy you.

# Chapter 25

## Heart Disease

While women are constantly hearing how important it is to do breast self-exams and have annual mammograms, heart attack—not breast cancer—is the number one killer of women. Right now as you read this, more than one in three women have some form of cardiovascular disease, according to the American Heart Association, and every 90 seconds one of them suffers a heart attack, according to the Centers for Disease Control and Prevention. That's 435,000 every year, according to the Women's Heart Foundation.

Why is heart disease such a problem for women? Well, menopause doesn't help. Estrogen promotes cardiovascular health by keeping blood vessels flexible so that they can relax and expand to accommodate blood flow. During menopause, however, estrogen levels drop, raising women's risk of heart disease (and giving us oh-so-joyful hot flashes!). The level of fats in the bloodstream increases while the walls of the blood vessels collect an increased level of plaque. What's more, the evil weight gain that goes hand-in-hand with menopause also increases the risk of heart disease, according to the Mayo Clinic.

So how do we protect ourselves?

I had my first brush with heart disease at the young age of 11, when my loving father, who was 42 at the time, suffered his first heart attack. From there, my family watched him go through one open-heart surgery, countless diets and lifestyle changes, and, ultimately, his passing at just 58 years young.

The doctor who performed my father's open-heart surgery suggested that all of us kids get our cholesterol checked. So when I learned at the age of 17 that I too had alarmingly high cholesterol levels (honestly, at first I thought the doctor had mistakenly switched my results with my dad's!), I knew I had to make a change. I learned that the best defense against heart disease is a good offense.

Today, I am living proof that a healthy lifestyle is as important as hereditary predispositions in determining your heart health. Healthy living has not just saved my heart—it has saved my life! It can save yours, too!

The first step to waging war on heart disease is to know thy enemy. To arm yourself with the right weapons, you first need to understand your own personal risks factors and what you can do to reduce them. Talk to your physician or menopause specialist about the tests out there that are available to you: A lipid panel, a blood test that measures your triglyceride as well as overall cholesterol, HDL, and LDL levels; a blood glucose test, which helps determine your levels of insulin sensitivity; C-reactive protein tests, which evaluates your body's inflammation levels; a stress test, which determines how much stress your heart can handle; and an electrocardiogram, which assesses your heart's electrical signals. You can also get a general idea of your cardiovascular risk by taking the American Heart Association's Go Red Heart CheckUp. If your numbers are out of sorts, take it seriously, but try not to panic.

There's a lot of conflicting information about how menopause and its treatments affect heart disease for good or ill. But studies are showing estrogens in particular to be beneficial, causing not just reduction in hot flashes, but "reduction in coronary events, breast cancer, and mortality," Columbia University endocrinologist Rogerio Lobo, M.D., told Bioscience Technology.

Of "immense importance," Howard Hodis, chief of the University of Southern California Atherosclerosis Research Unit, reported in 2013, was heart data from the 2012 Danish Osteoporosis Prevention Study (DOPS). Mortality, myocardial infarction, and heart failure combined were "significantly" lower—49 percent lower—among HT users even 16 years later. Mortality was 34 percent lower.

Of course, there are non-HT ways to prevent heart disease, too. The big question is: Does an aspirin a day keep the heart attack away?

There are many schools of thought on aspirin. The FDA has said there is no evidence to support the use of aspirin a day to prevent primary heart attacks and strokes. However, the American Heart Association recommends using aspirin for people _with elevated risk for heart disease_ : "The use of aspirin for cardiovascular (including but not specific to stroke) prophylaxis is recommended for persons whose risk is sufficiently high for the benefits to outweigh the risks associated with treatment." While the U.S. Preventive Services Task Force recommends aspirin use for primary prevention in women ages 55 to 79, when the expected reduction in the risk of stroke outweighs the potential harm of GI bleeding. It is not recommended in younger patients, and the task force found insufficient evidence to make a recommendation in those 80 and older.

Bottom line, before you pop an aspirin a day into your daily routine, check with your healthcare professional to be sure that it is the right course of action for your medical needs.

A friend of mine thought she was having a heart attack. She carried a small bottle of aspirin in her purse. She took one immediately. The ER doctor told her the aspirin she chewed saved her life! You can guess what I carry in my purse now! Just in case.

For emergency purposes, don't take a coated aspirin, because it will act too slowly. And be sure to chew, not swallow, the aspirin for it to be most effective. A side effect, however, is that aspirin increased by 40 percent the risk of bleeding within the stomach and intestines.

Perhaps the best preventive "medicine" you can practice for heart health is exercising regularly. A sedentary lifestyle is one of the risk factors of heart disease, so get moving! Luckily, even if menopause lands you in the sisterhood of the shrinking pants, going down a size to up your heart health doesn't require a complete lifestyle makeover. Practicing five healthy lifestyle habits—consuming moderate amounts of alcohol (sorry alcohol lovers!), eating a healthy diet, exercising daily, maintaining a normal body weight, and not smoking—can cut your heart attack risk by a whopping 92 percent, according to a Swedish study of more than 24,000 postmenopausal women. These activities will also help out with those annoying menopause symptoms in perimenopause and menopause, which is a WIN-WIN! Integrating just the first two into your routine cuts your risk by more than half. What's more, walking may reduce the risk of high cholesterol, high blood pressure, and heart disease as well as running does, according to a study published in _Arteriosclerosis, Thrombosis and Vascular Biology_. You don't have to be an athlete to find heart health!

Obviously, every one of us brings different elements to the heart table—family history, personal history, habits (good and bad). And we women have a habit of putting ourselves last. Women are 52 percent more likely than men to have at least 15-minute delays in treatment for heart-attack-related 911 calls, according to research published in _Circulation: Cardiovascular Quality and Outcomes_. What's more, the most common heart attack symptoms in women can be confused with everything from stress to a backache. That's right, women can be suffering from a heart attack _without_ having chest discomfort. That's why it's so very important to recognize the other symptoms, as outlined by the American Heart Association:

  * An uncomfortable feeling in the center of your chest (pressure, squeezing, fullness, pain) that lasts more than a few minutes, goes away, and returns

  * Pain or discomfort in the jaw, neck, back, one or both arms, or stomach

  * Breaking out in a cold sweat

  * Nausea/vomiting

  * Lightheadedness or fainting

  * Extreme fatigue

It's the last four symptoms listed above that often are confused for something less serious, such as the flu or indigestion.

Keep yourself informed! Remember, you aren't truly able to care for anyone else until you first care for yourself. So listen to your body. It's telling you something!

# Chapter 26

## High Blood Pressure

Why is it that everything with menopause goes up, up, up? Our weight goes up, our temperature soars, and even our blood pressure is prone to spike! What gives?

While it's easy to spot rising body temperatures (red faces and sweat-drenched clothes) and expanding waistlines (busted buttons and zippers and snaps—oh my!), an increase in your blood pressure may not be so apparent.

Take, for example, the recent experience of one of my colleagues. One night, she woke up in the middle of the night with a horrific headache at the base of her skull. So she popped an ibuprofen and managed to go back to sleep. The next night, deja vu. On the third night, she woke up and entered "headache base of skull lying down" in the web search engine.

We all know it's not usually a great idea to self-diagnose based on Internet search findings, and indeed my colleague found everything from migraines (she had these before, but said this headache felt different) to an abundance of spinal fluid to brain cancer to high blood pressure.

Trying not to panic (after all, it could raise her blood pressure), she called her doctor the next morning and managed to get an appointment the same day, citing her concern over elevated blood pressure. Even though she had low blood pressure her whole life, monitored her salt intake and exercised regularly, high blood pressure was the only diagnosis that seemed plausible.

Turns out, her self-diagnosis was spot on.

My colleague is not alone. According to the National Institutes of Health, hypertension is by far the most significant risk factor for women in the early postmenopausal years. About 30 percent to 50 percent of women develop hypertension before the age of 60. And it's not fun: mild to moderate hypertension may cause complaints such as non-specific chest pain, sleep disturbances, headaches, palpitations, hot flushes, anxiety, depression and tiredness. Just reading this can make a woman anxious!

The Mayo Clinic agrees, suggesting that blood pressure increases after menopause could be attributed to the hormonal changes of menopause or an increase in body mass index (BMI). **M** any doctors prescribe transdermal (cream or a patch) estradiol HT for women under 60 early in their menopausal journey to help keep cholesterol levels down since there is no risk of thrombosis (blood clots) with transdermal HT (it is oral estrogen with progestin that increases the risk of thrombosis). According to the National Institutes of Health, in women with severe menopausal complaints and who are at low risk for cardiovascular heart disease, the use of HT in the years proximal to menopause may be very helpful. According to the WHI, women who start HT before age 60 decreased their overall mortality by 35 percent.

To control your blood pressure both before and after menopause, the Mayo Clinic recommends:

  * Maintain a healthy weight.

  * Eat heart-healthy foods, such as whole grains, fruits and vegetables.

  * Reduce the amount of processed foods and salt in your diet.

  * Exercise on most days of the week.

  * Limit or avoid alcohol. (Sorry!)

  * If you smoke, stop.

Your doctor will consider prescribing medicines if your blood pressure is 140/90 or higher—the threshold for high blood pressure. However, you may want to opt for beta blockers instead of calcium-channel blockers, as the latter have been linked to an increased risk of breast cancer. A study reported in the _Journal of the American Medical Association_ noted that in women aged 55 to 74; use of calcium-channel blockers for 10 or more years was associated with higher risks of both ductal and lobular breast cancer. Other medications used to treat hypertension include enzyme inhibitors, receptor blockers and diuretics.

"The risk of developing high blood pressure over a lifetime is extremely high if a person lives long enough," said Dr. Deepak Bhatt, professor of medicine at Harvard Medical School, and director of the Integrated Interventional Cardiovascular Program at Brigham and Women's Hospital. For post-menopausal women, this is particularly true. By the time they reach their 60s and 70s, 70 percent of women have high blood pressure. After age 75, that figure rises to nearly 80 percent, according to the Centers for Disease Control.

If left untreated, high blood pressure can lead to stroke and heart failure. It also can also contribute to dementia, kidney failure, vision problems (especially for those with diabetes), and sexual dysfunction. (That last one got your attention, didn't it?)

Remember, high blood pressure can sneak up on you- sometimes even before you have any symptoms. Ask your medical practitioner to check your blood pressure when you go for your yearly checkup  makes a wonderful wireless blood pressure wrist monitor for easy at-home checking.

Trust how you feel! Like my colleague, you know your body better than anyone else. I encourage you to stay in tune with your body so that when something doesn't feel right you pick up that phone and reach out to your healthcare professional. No pressure!

# Chapter 27

## Thyroid Problems

The key to who you are isn't just between your ears and behind your face. It's also a few inches lower: in your neck. Lodged between your voice box and collarbone, and wrapped around your windpipe, is your thyroid—and it affects everything you do and are.

A small, butterfly-shaped gland, your thyroid pumps out thyroid hormone, a powerful chemical that works with just about every system in your body to keep your brain sharp, your energy levels up, your reproductive system churning, and your skin, nails, and hair beautiful.

So when it goes on the fritz—and it has for roughly 20 million Americans—everything suffers, and most of those victims are women, according to Dr. Daniel Einhorn, M.D., an endocrinologist at Scripps Memorial Hospital La Jolla. Lucky us, right?

The primary cause of thyroid disorders is the immune system attacking the body's thyroid, and since women are more prone than men to developing autoimmune diseases (such as lupus and rheumatoid arthritis), we get the bulk of thyroid conditions. According to the University of Maryland Medical Center, women over 50 are at the greatest risk of thyroid disorders.

Thyroid disease, generally, comes in two flavors: overactive ( _hyper_ thyroidism) and underactive ( _hypo_ thyroidism). The symptoms of _hyper_ thyroidism—include weight loss, rapid heartbeat, insomnia, irritability, heat intolerance and a constantly "wired" feeling—generally catch women's attention pretty quickly. A common cause of _hyper_ thyroidism is Graves' disease, an autoimmune disorder of the thyroid.

_Hypo_ thyroidism is a whole different story. "The symptoms are usually mild and non-specific, so it's easy to attribute them to many other things... like menopause, for instance," Einhorn says. According to the U.S. National Library of Medicine, an underactive thyroid can lead to fatigue, brain fog, irregular menstrual periods, weight gain, depression, constantly feeling cold and even hair loss—all of which also can occur during perimenopause and into menopause. Five to eight times as many women have _hypo_ thyroidism than hyperthyroidism. A common cause of _hypo_ thyroidism is Hashimoto's disease.

Guess who is one of the 20 million that Dr. Einhorn was referring to? For years I complained to my internist that my hands and feet were freezing. I seemed to poop out in the afternoon and was experiencing brain fog, irregular menstrual periods, and weight gain. He told me not to worry, I was a busy Mom and this was normal. He sloughed off the cold hands and feet to just poor circulation. I never questioned the diagnosis. After all, he was the doctor. What did I know??? Lucky for me, we moved to San Diego five years later and I went to a new internist. This new doctor looked at my records and saw that my TSH was over 5. He asked me what thyroid medicine I was taking for my Hashimoto's Disease. I responded that I absolutely didn't have Hashimoto's Disease and frankly I had never heard of it.

After a few other tests, I learned that because my thyroid stimulating hormone (TSH) levels had been way too high for so many years, it had caused me to develop a nodule smack in the middle of one of my thyroid lobes. This necessitated a needle biopsy. The biopsy was inconclusive so surgery was needed to determine if I had thyroid cancer. Fortunately, it was not cancer. They did need to remove the whole lobe as the nodule was too big. I was so lucky. I will remain on thyroid meds for the remainder of my life. I mentioned it to my Mom, and she said, "Oh, yes, I have that, too." I suffered needlessly for so long! This is why this is such an important chapter.

### Is It Menopause or a Thyroid Disorder?

"The symptoms of hypothyroidism and menopause overlap to a great extent," Einhorn says. "Uniquely menopausal symptoms include hot flashes, loss of periods, and vaginal dryness, but even those may be aggravated by thyroid changes. There are no symptoms that could be absolutely _not_ related to thyroid. We are all different and we change as individuals over time."

If your thyroid is out of control, all of your efforts to curb perimenopausal and menopausal symptoms and achieve hormone happiness will be for naught. What's more, your symptoms might not be perimenopausal or menopausal at all.

Be sure to ask your healthcare provider to check your thyroid! Before your appointment, make sure to chart your symptoms to keep track of what you're experiencing. The blood work is half of the story, the other half is _how you feel_. This chart will help you communicate this to your doctor. After all, in the end, the only surefire way to tell if your symptoms come from a lack of thyroid hormone or a lack of estrogen is to get your hormones tested, Einhorn says.

According to Dr. Einhorn, the most common test to ID a thyroid gland gone haywire is a TSH test, which measures your blood's levels of thyroid stimulating hormone, a hormone that tells your thyroid to get to work. In the case of an underactive thyroid, TSH levels will be markedly elevated, while low levels can be caused by several conditions, meaning that more testing will be needed to determine if the cause is an overactive thyroid.

A T4 blood test measures your blood's levels of levothyroxine (a major product of the thyroid gland) and is often used to confirm TSH results and to better pinpoint exact thyroid function levels. A T3 test, which measures another thyroid hormone called triiodothyronine, is sometimes performed, but is generally not necessary for diagnosis, he says.

If an underactive thyroid's to blame for your individual set of symptoms and not perimenopause or menopause, your physician will likely prescribe a daily dose of a synthetic thyroid hormone therapy and perform follow-up tests every six to eight weeks and adjust the dosage until the right level is found, usually within three to four months. While the benefit of taking T3 is not proven (and too much T3 can be dangerous), a small number of patients seem to respond better to treatments when they're combined with T3 supplementation, Einhorn explains. For hyperthyroidism, treatment often involves a daily drug to slow down your gland's output.

Luckily, in most cases, simply taking thyroid meds can result in complete symptom resolution. It sure did for me!

There's really not much you can do to prevent hypothyroidism. "For better or for worse, hypothyroidism is largely not under our control," says Einhorn, who notes the disease is primarily genetic. Family history may be the greatest indicator of troubles ahead, but since so many people are undiagnosed, you could have a family history of thyroid disease and have no clue about it—like me. Pregnancy increases the risk of hypothyroidism both through altering iodine requirements and through reproductive hormones altering thyroid hormone levels, according to the University of Maryland Medical Center. What's more, some women develop antibodies to their own thyroid during pregnancy, so if you had postpartum thyroiditis, your chances of developing permanent hypothyroidism are also increased. Polycystic ovary syndrome also increases your risk.

If you have any of these risk factors, or are experiencing symptoms that might or might not be due to menopause, your health can benefit from checking in with your doctor. The signs of a thyroid disorder are easy to dismiss. Don't! Ladies, for the sake of your health and happiness, ask your doctor to take a serious look at what's going on in that second brain of yours: your thyroid. Unlike so many of life's problems in today's crazy world, your thyroid is one thing you can take care of relatively easily.

# Chapter 28

## Share Your Stories

I'm a firm believer in sharing. When we share our stories, we help others who are in the same perimenopause and menopause boat. Now that you've read my story, here are some more stories from the sisterhood (and the men who love them). If you'd like to contribute your story for future editions of this book, please email it to me at ellendolgen@ellendolgen.com.

**Barbara G.,Vaginal Atrophy**

I live on Long Island, New York, and I am fifty-one. Before I stopped getting my period, I had maybe two, three years of irregular periods and a lot of anxiety and heart palpitations. I went to a heart doctor, got myself in this vicious cycle of tests, because I didn't know what was wrong. Every time I went to doctors, all they would do was give me prescriptions for Zoloft, Xanax, or any other kind of anxiety medicine, never mentioning hormones or perimenopause.

They said I wasn't in perimenopause; my hormone levels looked fine. They did do blood work and kept telling me I was in the range. My hormones didn't show that I was going into menopause at all. But I knew something was wrong.

I kept getting stress tests and EKGs and everything else. My doctors wanted to put me on beta blockers. It was very frustrating. I know there is a time and place for prescription medicine, but I didn't want to take something just to mask a symptom. I wanted to know the underlying cause. Why did I feel like this?

All my heart tests came out fine. So I'd ask, "Why would you want to give me this drug if nothing's wrong with my heart?" They never had an answer. _Oh, this will make you feel better, stop the palpitations_.

I kept researching, and I never went on any medicine. My gut was telling me it was definitely hormones. Can you imagine, my doctors actually told me stay off the internet. "Why do you keep looking on the internet?"

By chance, I found a book called _Magnesium Miracle_. I started reading and saw magnesium helped with my symptoms, the anxiety, the heart palpitations. When I started taking magnesium, it was a miracle. I was able to sleep. I felt better. I didn't have palpitations anymore. So I rely on magnesium to this day.

But I still wasn't feeling right. My periods had stopped. I had hot flashes during the day. I bought a progesterone cream, and I started bleeding again, so that was a whole ordeal with my gynecologist making me get a biopsy, yelling at me that this is not normal.

I told her I was using this cream. She told me to stop using it. No medical professional I went to was into any natural or bioidentical hormones at that time. They are more popular now than back then. So I stopped using the progesterone cream, and I've just been suffering ever since.

Recently I found a new gynecologist. When she examined me, she said, "You're a mess." She was pretty cold. That was when I found out I had vaginal atrophy.

I had vaginal dryness for a very long time, but I'd never even heard of atrophy before. Nobody talks about anything like this.

Honestly, I don't know why menopause is so embarrassing for people. It's just something natural that you go through, but nobody wants to talk about it. I have two teenage daughters and I told them I was going to reach out to Ellen Dolgen, a women's health advocate who focuses on helping women in perimenopause and menopause. They said, "Ma, are you kidding me? That's so embarrassing."

Even my own mom never talked about it. To this day, she still claims she doesn't know the age she went through menopause. How could you not know the age of such an important thing?

I've been married for twenty-three years. My husband is aware of my menopausal journey, but he's not the type to want to talk about those things either. Even the mention of something like vaginal atrophy, well, he just doesn't want to hear about it. If I read something about hormones or menopause that relates to me, I tell him things like that, but I don't know how much he really listens. He tries to put up with me as much as he can, I guess.

I did talk to a few friends about the vaginal atrophy. They were surprised, same as me. They'd never heard of it. It's unbelievable that it's just not spoken of. It's like those two words got left out of the dictionary. Even though Erectile Dysfunction is all over the news and in every commercial.

My sister is 43, and we know she's heading towards menopause, because my mother, my aunt, and my mother's sister were all young when they went into menopause. I'm trying to help her, telling her I went through the same thing. But it's a big joke in the family now because all you'll hear us say is, _are you dizzy_? _I'm dizzy_.

I have not yet found a good menopause specialist, but I know I need one. I've waited too long, which is partially my fault because I am nervous about going on any kind of hormone replacement. The gynecologist who told me that I was a mess told me I'm not going to feel better unless I do something about my hormones. I'm not going to lose the weight I've been gaining. I walk, I exercise, I watch what I eat, and I cannot lose a pound. It's frustrating. She said "You will never lose a pound unless you go on bioidentical hormones and balance your hormones."

I know she's right, but I'm so scared to do it.

I think of menopause as a natural progression of life. So to me, you're fooling around with Mother Nature by using hormones. But because we're living longer now, there are so many more years of life after menopause than there used to be, is that why so many people are replacing their hormones? I don't know. I'm uncomfortable with it. And without it.

It's a tough decision for me. I still have a whole drawer full of prescriptions I've never filled. Even at my last checkup, again my doctor said, "I think you should really consider going on Zoloft. It'll help you."

_But help me do what?_

My doctor wanted me to go on Estrace for vaginal atrophy, but I didn't do anything. I use lubrication and it's not that bad yet. I'm more affected in an emotional way: I'm fat, I'm this, I'm that, you know. I just don't feel good.

I recently read that Dr. Christiane Northrup said if you're already an anxious person, menopause will escalate everything. I really think that is what happened to me. It's such a relief when you read stories of other people who have gone through the same thing, because no one will talk about it. Then you don't feel so alone. You don't feel like you're crazy or just imagining things. It really does make a huge difference.

I know that I have to do something because things are getting worse. I'm trying to exercise more, and all of a sudden this hurts, that hurts. I've developed joint pain. It's just so discouraging and frustrating.

I read Suzanne Somers, Rosie O'Donnell, everybody... they all say bioidentical hormones are a miracle. Every day I think, _I have to make the call and go on those hormones. I have to call._

So I've decided I will. I have to listen to my body. I have to help myself.

**Jill V.,Anxiety**

I'm fifty-six, married seventeen years with a sixteen-year-old daughter. I was in my late forties, early fifties, in therapy at the time, when I started crying a lot and feeling a lot of anxiety. I have a very high-pressure career. I couldn't juggle it. I kept saying I hate my life, I hate my life.

It affected my relationship, because I would get angry so easily. I never really had the hot flashes. It was more anxiety and feeling like somebody had taken over my body. And I grew a big gut. And it wasn't a slow thing at all. It all seemed to happen overnight.

I'd have deadlines and cry. I would drive to a client meeting and sit in the garage and cry. I didn't want to meet the client because sometimes, things would come out of my mouth that I didn't mean. I couldn't control it.

I prayed, "Please, God, take this out of my body. Please take this out of my body." And I'm not even someone who prays. I would cry, _I can't take this anymore_.

After a while my therapist said, "I think you need to go see a gynecologist who specializes in menopause." I went to see a noted hormone doctor in Beverly Hills who does his own bioidenticals. He met with me for an hour and a half. He put his hand on my arm and said, "You're at the right place. I will take care of you." He was a thousand dollars for the first visit.

And every time you order creams and vitamins, it was another two hundred fifty dollars every month. I left with a bunch of creams in little bottles where I had to twist the little capsule and the cream squeezes out a little bit. I was so confused how to do it. I just wanted to feel better.

I was so desperate I turned the capsule a whole notch. At a stoplight, I opened up the bag, put the cream on right in the car. I got home and took a bath, and then I thought, _oh my god, I washed it off_. So I put it on again. I put it on like lotion. I was wired like you wouldn't believe. I couldn't sleep all night. I must have put on a tablespoon.

I am a person who thinks more is better. If I use more, maybe I'll feel a little better. I called the doctor, so confused, asking all these questions. Which one's the progesterone? What's the pink color for? Which one is the green? I just kept getting them confused, because I was so confused, and so that was a disaster.

Every visit was seven hundred dollars, plus all the pills and the creams and all that stuff. I spent five thousand dollars before deciding to try something else. I just didn't feel any better.

I went to my acupuncturist, who put pins all over my lower abdomen. After every treatment, I'd leave relaxed, but within an hour the anxiety would rise.

I tried intravenous vitamins. No one had done any blood tests until I finally went to see an endocrinologist. She saw my hormone levels and put me on Premarin, but it just made me really crazy, just cuckoo.

Then I was connected with a menopause specialist in Newport Beach. I felt like I was walking a tight rope. Each time I tried something new, I just thought, _Okay, maybe this'll work_. So it was sort of like slapping wet spaghetti on the wall, hoping maybe it'll stick. For five years, nothing really worked. I didn't feel right in my body. It was really hard.

Someone recommended a naturopath, who put me on all kinds of little tiny pills that you stick under your tongue and let dissolve. I must have spent a thousand dollars on those things and all kinds of other supplements.

I tried estrogen patches, from the lowest to the highest dose, and nothing worked. I went on anti-anxiety medication. I tried everything. I had two drawers filled with all the useless stuff.

After six doctors, I ended up with a nurse practitioner who is great. I'm on bioidentical capsules, and estrogen I and II. I'm still on anti-anxiety medication, and she doesn't want to take me off until I'm out of school. I feel pretty well balanced except for the big gut thing. I don't have the emotional swings. I don't have my period anymore. But my libido is crappy. That's probably the toughest part.

It was a long, expensive journey to find the help I needed.

I used to say, "I just want to jump off a bridge," not to commit suicide but to scare the crap out of myself so it would change my hormones. Crazy, right? I even thought about a lobotomy.

I had an interview recently, and the guy asked, "What is one of the biggest feelings of success you've felt in your life?" I didn't say it, but part of me wanted to say, "Getting through menopause."

I think most women think doctors have all the answers. But I learned that if what they are doing is not working, you need to fire your doctor and try another one. I never gave up on myself. I knew that there were answers, and I finally found them. Everyone's going to have their own process, but the most important thing is that you cannot give up.

**Joel H., Menopause Husband**

The biggest issue for me with my wife's menopausal changes was having a daughter entering adolescence at the same time. It was a hormonal sandwich. It coincided with the downturn of the economy, and our family moving to a new city. And my wife lost her clients because of the economy, which created a lot of stress.

So there was a lot of transition in our lives, especially for her. I was driving the machine that was doing all the change, so I was feeling guilty on some level. When I proposed moving out of Los Angeles and going to Portland to change our lifestyle, she couldn't have a solid discussion about it without having all these other things triggered.

But to give her credit, she still tried to find her gut instinct even during the foggy-mind period. If I would propose something and she couldn't mentally process it, she'd always go to her gut and say, "I know we need to do this, even though I can't feel it or understand it right now."

I kept moving forward and she would say yes, but in her eyes, it didn't look like a yes. It looked like _I don't know_. She couldn't focus.

I felt very alone, because I was doing something that was initially her idea, trying to move forward and keep our family sane, but at the same time I didn't have a partner who was fully engaged in the process. Combined with the adolescent daughter, it felt like the perfect storm.

My wife knew she was in perimenopause pretty much from the very beginning, but I didn't know what that really meant. I went with her to some Beverly Hills specialist, and it just felt kind of surreal. These women have to go in and have all these creams and supplements and things. I thought, _Somebody's making a fortune here from women who are very confused_.

All these difference factors colliding may have been our saving grace though, because it was so bad that any change looked good. Instead of saying, _I want my life back_ , my wife was saying, _I hate my life_.

Fast forward three and a half years, we are in Portland and my wife loves it. She uses the "L" word. _I love Portland_. And after many doctors, she's managed to find the perfect concoction of medications to get her through the whole process. That's not to say there are not ups and downs, but I've never seen her happier.

As for my daughter, I think my wife's menopause crisis exacerbated an already existing problem: a mom who was very busy, who was not always available physically. That turned into a mother who was kind of trapped in her own process, no longer available emotionally either.

Luckily, my wife is not one to take her depression and go to bed. She searches for solutions or better answers. I give her a lot of the credit for continuing to pursue answers, talking to people, trying different types of doctors, a lot of different hormonal regimens, and things like that. I don't even remember all the different things she tried. She was wearing a patch for a while, and there were all these different things.

As for me, I had to fix up our house in L.A. to rent. I had to move us to another state and get us in temporary housing for a year while I tore down another house, rebuilt it, and keep my business afloat at the same time.

I was a part of her process, as much as she would let me in. But at the same time, I had to get this house done and all these other things. It felt very isolating. We were in a new city. My wife didn't have any friends. My daughter didn't have any friends. It was a whole different culture, different climate, different everything.

The hardest thing was being in this unfamiliar place, going through what they both were going through. I have to say it was pretty much the worst year or two of my life. We were both very determined to keep moving forward and find solutions and not dwell in our pool of pity. We may have lost a certain amount of intimacy because of the menopause stuff, but we did get through it. I think we are certainly in a much better place than we were three years ago.

I've been married before, and my first wife had a lot of hormonal imbalance. I lived in Portland with my first wife. So part of my exhaustion came from feeling like, oh, here we go again. I don't know if I can do this twice. And then I have a daughter, so thrice. But we made it.

I feel that I lost a bit of my own life in the process. A person just want to be able to focus on themselves sometimes. That's when I do my building projects, and I have my career of course. But it does feel like I've invested an awful lot of my life into dealing with hormones and trying to find the balance.

I've been fortunate to be with wonderful women. I still love my first wife. I had nothing against that whole process. It's just at some point, I think, _man, I need to go skeet shooting or something_.

I was in my 20s/30s with my first wife, so the recovery was quicker then. I mean, I got divorced and I met my current wife and I got married and had a kid. Built a couple houses, did all this stuff. But I don't have the same amount of energy at 50 anymore. This second time I was much more affected. And of course, I have the day-to-day connection with my daughter that takes a lot of my focus and attention too. I am older, and I can feel it. I still feel like I'm in recovery mode right now.

My wife and I are in a better place today than we have been in years. I don't know if it's all due to going through menopause together, but going through adversity together does create a bond. I think we are strengthened through it and we're closer. We're able to speak more frankly and we don't get as triggered as before.

If I was to offer any advice to husbands in similar situations, I'd say, "Don't take it personally, because you may be the target, more often than not, of reactive hormonal things that have nothing to do with you. Try to be as involved as possible in your wife's process, because when somebody has a foggy mind, it's hard for them to even hear the potential solutions out there."

It's really important for husbands to keep a clear head and not take their wife's struggles or outbursts or symptoms personally. It's hard for some guys to do that, especially when your partner is turning on you for no apparent reason. It's so easy to get defensive. But the husband has to know what the wife is going through. Both of them have to know. We talk about educating 30-year-old women, but 30-year-old men need to know about the upcoming changes, too. Otherwise, by the time the woman catches on to what's going on with her, the guy is already out the door.

**Becky R.,Fertility, CFS, and Menopause**

I always knew I wanted to have kids. When I was thirty-five, I watched a "60 Minutes" segment about women's fertility declining precipitously at age thirty-five. And so I went from thinking that I had ten years to find the love of my life and get married and have children, to thinking I had zero time left.

I was beyond blown away because I kept hearing about all these celebrities having kids much later in life, and I didn't know those celebrities who were having babies at forty-seven didn't have their own eggs. I knew fertility declined a little, but I thought that you could have a baby with fertility treatments if you could afford it. On the show, they basically said _that's not true_. I researched on the internet that night for several hours and this was 2002.

But I believe if I hadn't watched that show, I wouldn't have my daughter today. She's now seven.

I started making decisions differently. At thirty-seven, after I got out of a relationship, I knew it was really important to me to have a child, so I decided to have a baby. I didn't want to wait to try to find another relationship. I didn't have any fertility problems. The artificial insemination worked on the second try. I was 38 when I got pregnant. My daughter was born in August 2005.

I had post-partum euphoria. I felt better than I've ever felt in my entire life emotionally for eighteen months. It was extraordinary, because I felt awful in the pregnancy. I was so sick. I thought it was the pregnancy but now I realize it was chronic fatigue.

All I could think was, _When can I sleep next_? Or, _When can I eat some sugar next?_

I was twenty-eight when I got chronic fatigue syndrome for the first time, and I never had the same energy as other people after that. But it had been kind of in remission until I got pregnant. I now understand that I had chronic fatigue during the pregnancy and after the pregnancy. I was really tired. Even though I was so happy to have a baby, I actually thought, _I can't believe the human race continues because this is too exhausting and it's not possible to do this_.

Since there are a lot of people out there with the symptoms of chronic fatigue, I should actually be more specific. I have something called virus induced central nervous system dysfunction. I still call it chronic fatigue because no one's heard of the other thing. It took me many years to find out what I actually had.

I didn't seek treatment for it during my pregnancy, because I thought the exhaustion was from the pregnancy. After I had the baby, I thought it was because she was up all the time, and that I was an older mother. It was only years later, after first trying to be treated for perimenopause and having it not work, that I found out I had this virus induced central nervous system dysfunction.

About two years later, I started wanting to have another child. By this time I did have fertility problems. I did a Chinese medicine fertility diet where I cut out wheat and dairy and sugar. And I felt phenomenally better. The best I physically felt since I first got chronic fatigue in 1998.

I did the diet for a hundred and twenty days and felt extraordinary. It also included acupuncture, meditation, yoga, herbal teas, and supplements. Now, Chinese medicine doesn't say you can have a baby at fifty, but they seemed pretty clear that if I did all these things, I'd have a good chance at it even in my early forties.

This time, I moved on from insemination and tried IVS. I froze my embryos so they could be tested.

I did seven rounds of IVS and each time I had really low quality embryos. Traditional medicine would say it was because my eggs were old and there's nothing you can do about that.

But after I did this Chinese medicine thing, I had completely different results. I did another round of IVS and I had large amounts of eggs, large amounts of follicles develop, large amounts of eggs retrieved, large amounts of eggs fertilized, super high quality blastocysts. They were genetically tested and the results were normal, meaning the eggs were not too old, the eggs were not genetically abnormal.

It's clear to me that western medicine is wrong in saying that you have no control over those eggs and that age irretrievably changes them. Age is clearly a very large factor, but according to Chinese medicine, the eggs go through a process that begins about a hundred and twenty days before fertilization. And all the things I did in the hundred and twenty days clearly made a difference for those eggs.

But at that point, after that diet, I never tried to actually get pregnant. I was tired by the time I got through that summer and I just didn't feel very well anymore, so to have another child would have been much harder.

I had hormone tests done that showed I was in perimenopause, with decreased levels of hormones. Perimenopause must have hit at the same time I got sick again with chronic fatigue syndrome, more sick than I'd ever been. Each has exacerbated the other, and I'm having more of a problem because I can't just find a chronic fatigue doctor who knows anything about perimenopause.

One of the new hormonal symptoms was the inability to find words. I'm pretty articulate and have done a lot of public speaking. And all of a sudden, I just couldn't find my words. So I'd be searching for a word and I couldn't find it. My daughter, who was probably five at the time, noticed. "Mommy, how come you can never think of the word you want to say? You just go, you know the, the, the, you know, this, uh, you know, the thing, you know, the thing."

That was very scary and upsetting. It's gotten better in the past couple of years; I'm a little calmer but still really frustrated by it. I have odd spatial problems too, but that apparently is the virus induced central nervous system dysfunction thing. I have trouble remembering things, too. That had not been part of my experience in any of the previous times that I was sick, so I attribute it to perimenopause.

I feel that doctors have not been trained in a women's hormonal lifecycle. So it's not just menopause they don't understand. I got a lack of information and advice on my biological clock when I was in my childbearing years. And then I'm finding the same thing now in this next phase. So I think that doctors need to be trained in the cycles of a woman's hormonal life. If they were, I would have gotten better advice fifteen years ago as well as be getting better advice sooner today.

My advice is, whatever your issues, there is help. You cannot give up because you definitely have to find it.

**Anne A., Dueling Hormones**

I live in Kansas with my husband of 17 years and our two children, a 13-year-old girl and a 15-year-old boy. I married at 34, had my son at 36 and my daughter at 39.

I started noticing subtle changes to my menstrual cycle around age 47. I thought, my gosh, my daughter is going to go through puberty while I am going through the change! My poor husband and son, there'll be all these female hormones sliding around with the two women in the house at the same time; maybe we should just send the men out for a while.

So I knew menopause was going to happen, but did not really know what was going on until I got into the thick of things in the fall of 2011. This turned into an intense eight-week period where all sorts of difficult things happened.

At that time, I was taking two graduate classes. I had the two kids. My husband is a successful professional and he kept talking about a woman at work; a woman who was my age, with my hair color, my eye color. His "work wife," it sounded like to me. I felt really threatened and paranoid.

At the same time, I was taking this class on research methods. The teacher was new, a little bit vague, and I couldn't figure out what she wanted. I couldn't seem to deal with it. Then at church, I got a challenging committee assignment change. So there I was, trying to keep on top of my marriage and family and meetings and classes and all of my stress.

I thought, _Okay, let me see what I can do to help myself_ , _to take off the stress_.

First, I dropped the class with the teacher I couldn't understand. Then in my church group, I was conducting a children's meeting and another woman kept calling me out for making mistakes. I asked her not to, but one day, she called me out in front of all the adults. There were ten adults in the room and 50 children.

I picked up my purse and walked out of the meeting, got my car and left my whole family there without a car and just went home. People were shocked. I am in the Mormon Church and you just don't do that.

My cognition was falling apart. I could not concentrate. It took me a while to figure out that perimenopause was playing a big role.

Then I woke up in the middle of the night and I felt like I'd jumped into a swimming pool. No underarm sweat, but my scalp and other parts of my body were soaking wet.

As the adult child of an alcoholic, I've always struggled to manage my emotions. I started going to the gym twice a day for an hour at a time. It helped me burn off the anger, the anxiety. If I was depressed, it would bring my mood up.

With my anxiety and anger management issues, the emotional side of perimenopause has been the hardest thing. I still have no clarity on where my older issues stop and the new hormonal-related ones start.

Nothing about this period was what I thought. I expected a decrease in libido, but I went the other way. I didn't know if it was tied with perimenopause or the state of my marriage. I felt like I was losing my husband. So that might have been the cause of the increased libido. I was like a tiger. I did not know I had that in me.

Because of my husband's professional achievements, he was seen as sexually desirable to women, and because of my growing age, the only men flirting with me were the men at the nursing home where I volunteer. I started dressing up more, wearing more makeup, more _hoochie_ stuff. But no matter what I did, to men in their 30s and 40s, I was invisible. I'm still cute, only weigh 110 pounds, really sparkly, but the only men looking at me were in their 60s, 70s, 80s.

So my husband's sexual charisma was increasing at midlife and mine was going down the toilet, and there wasn't a damn thing I could do about it. I had to redefine my sexuality and my societal role at a time when perimenopause was starting and my hormones were all changing and I felt I couldn't cope with anything.

In January 2012, I went to Utah, where my mother and my two sisters live, for my 50th birthday. But when I got there, they staged a family intervention. They told me I needed a therapist, I needed to get on mood altering medication, and I needed pastoral counseling because I was evil and crazy.

I mentioned my blog, Generation Above Me, where I had been sharing about perimenopause and what was happening to me. My family found it inappropriate that I write about myself. They were embarrassed because I process my emotions publically through conversation and writing. They are more decorous, more introverted. They said I was making a scene, which was unacceptable.

This was my response. "You know what? Teenage girls get emotional and we give them wide berth. Pregnant women get emotional and we give them a wide berth. I am going through menopause. Why can't you give me a wide berth? I am doing the best I can."

I told them I needed to go to the gym two hours a day. One of my sisters said, "That's ridiculous; just take a pill."

That was my family's advice: _go take a pill and stop making a scene_.

At the same time, my daughter was starting to go through puberty. Her nickname in our family is the Princess and the Pea. She gets her feelings hurt really easily, takes criticism very badly, and she will get mad and slam the door. She also has anxiety issues, so with her it was hard to know what was changing hormones and what was anxiety.

We have to give her a lot of space. And then she and I would both be going off about something at the same time. Big drama.

But we learned how to handle it. If you are in menopause and you have teens going through their own hormonal stuff, you need to become more analytical about what's going on. Recognize the emotions are real, they are valid, but because of the hormones, they get over-amplified. We've had to learn to cut the drama and the emotions in half, cut it in half again, and cut it in half again.

Realize some of that emotion is coming from a hormone change and is not 100% tied to the situation. Learn not to get mad at yourself, learn to give yourself a break.

I know that there are a lot more older parents like me, and what I want to say is, we have to be very rational about the whole hormone thing. My daughter just turned 13. I am menopausal. We both have to understand we're probably not fighting about the laundry or whatever it seems like we're fighting about. As the parent, I need to remember what is really going on, be a bigger person, and understand that the upset between us is all colored by hormones.

At this point, I am still menstruating. I have not had night sweats or the cognition trouble since that fall. It all just came on for eight weeks and then went away. But I am always looking over my shoulder, wondering when it's going to happen again. My symptoms caused a total disruption of my marriage, not to mention the family intervention.

**Bonnie F., 10 Years of Suffering Until 2 Weeks ofHT Changed Her Life**

I went through menopause earlier than most, in my forties. I'm 57 today. When I would tell gynecologists or my internist I thought I was going through menopause, they all said, "Oh no, you're too young." But by age 47, I was completely done with menstruation.

It was about the time those health studies came out saying that hormones were terrible, the horse hormones, so that wasn't anything I ever looked into. I just went through menopause with some amount of hot flashes; honestly, they were not too bad. And I thought, _Okay, this is it_.

If anybody asked me about menopausal symptoms, I would say, "No, everything is fine." But I did have symptoms, I just didn't recognize them as relating to menopause. I felt very uneasy all the time. One of my daughters was away at school, then the second one went away also. I thought my anxiety and depression were due to these dramatic changes in my life, so I saw a doctor who started me on antidepressants. Yes, they did help.

I also began struggling to fall asleep, which I attributed to anxiety, not to menopause or hormones or anything like that. I was afraid to go to bed because I was afraid to not fall asleep; I was just so fearful. I was so tired and could not think of doing anything, but then again I could not fall asleep either.

I started taking a sedative antidepressant to help me fall asleep, but still I would be up two, three times a night and have more difficulty falling back asleep. I only managed to get four or five hours of sleep a night, for years.

Throughout this time, even with the anti-depressants, I had a constant feeling something was wrong, a constant feeling of uneasiness. That went on for ten years. I had serious trouble with my concentration as well, but I thought it was age related. I couldn't complete things or get things done because I just couldn't concentrate. I attributed my concentration issues to aging and ongoing lack of sleep.

I also experienced dryness and vaginal atrophy. My gynecologist said I was really dry and red down there, atrophied, so she put me on Vagifem. I was afraid because of what I'd read about hormone replacement, but I tried it for three years and it did help a little.

I still didn't realize how many of my symptoms were menopause-based because the whole thing is such a taboo subject. I went through it years before most of my friends did. I just didn't talk about it. It's like sex, you just don't talk about it.

Finally, after ten years of suffering with so many different symptoms and trying so many different things, I read Ellen Dolgen's book about menopause and went to the specialist the book recommended.

None of my doctors, in all the years before I read Ellen's book, ever took any blood levels for menopause.

I was still afraid of hormones, but I thought, _Maybe there is a little bit of an increased health risk but my quality of life could be so much better_. I was willing to give the bioidentical hormone treatment a year to see what changed for me.

But it didn't take a year. The changes were almost instantaneous! Within two weeks on bioidentical hormones, there was a huge difference in my level of uneasiness and anxiety. The treatment calmed me, it was soothing. I initially started with the patch and now I'm doing the cream, which gets right in your system.

I switched from the patch when I started seeing a new gynecologist who tested my hormone levels and put me on the cream instead. The experience of switching from one to the other was a real eye opener for me.

My new doctor prescribed the cream at a very low dose. I started applying the cream as the directions said to my arms and inner thighs. Within four days, I started to feel like I was going through withdrawal. Again, I was very anxious, that same old anxiety and weepiness I'd suffered so long with that the patch had so quickly alleviated.

I called my doctor, who told me the cream had a much lower level of estrogen than the patch. After only four days, my body had returned to the same symptoms as before. That's what really helped me realize the anxiety and the uneasiness I felt _all those years_ was because of _low estrogen_.

My doctor told me to use the cream vaginally, rather than putting it on my inner thigh, so it would be absorbed more quickly in a higher concentration. Apparently, there is a cream for vaginal atrophy and another that helps with depression, anxiety, all the emotional symptoms that occur from low estrogen. And the doses need to be adjusted, based on tests of my hormone levels.

Throughout that whole ten-year period of time, it was such a struggle just to maintain myself emotionally. I really thought I needed the antidepressants. All that time I thought it was emotional problems but now I realize it was hormonal, not having enough hormones. My body was struggling to function. I was an emotional disaster; now I call it PMS squared. I had over 30 menopause-related symptoms!

Now, I can concentrate. I can do computer programs. I can do much more now and I feel so much happier. I do not take the sleep medication anymore, and will soon get rid of the anti-depressant too.

I believe I suffered in silence so long because the subject of menopause has to do with our sexual organs and taboo areas of our body. And aging, another unpopular subject.

It is up to us as women to make sure we break that taboo. I try to bring up the subject everywhere I go. Frequently, though, if I do bring it up, a lot of women do not like it. They say, "I am too young for that," or "I do not want to talk about that."

If I had a room full of perimenopausal women in front of me today, I would tell them to be open to bioidentical hormones. If you don't feel as good as you used to five years ago, be willing to try hormones for a year. And then weigh any risk to what you feel the benefits are. At this point, unless some study came out showing dangers of bioidenticals (at this time, all studies come up positive for them), there would be no way I would ever stop taking them.

**Miranda R.,Medically Induced Menopause in Her 20s**

In October 2010, when I was 24, the index finger on my left hand started to swell up for two or three days at a time. Then the swelling would go away. I thought maybe I had a pinched nerve.

Then in January, the finger swelled up and kept swelling. It was excruciating. I went to several different specialists trying to figure out what it was. In July 2011, I was diagnosed with Ewing's sarcoma, a rare bone cancer usually occurring in children. I was referred to an oncologist.

I worried about being able to have children after chemotherapy. When I asked if I should have my eggs frozen, I was told not to worry about that. The answers to my questions were always the same: that's the last thing you need to worry about right now . . . We need to get you started on treatment . . . You cannot freeze your eggs . . . You'll receive hormones.

No one told me about the side effects of chemotherapy, they just threw me into it. I felt completely terrified, powerless, like I had no control over anything. Clear information about what to expect would have really helped, but I didn't get any.

The treatment I received was so strong; I can never do any of those drugs again. A cycle of treatment was five full days. Two weeks later I'd have three other chemotherapies for one full day. This was considered another cycle. I did that whole thing 13 times.

After the third time, I stopped getting my period and my eyes started watering like crazy. When I asked about it, they told me it was because of all the fluids they pumped into me. Then the hot flashes started. Horrible. I'd sweat right through my pajamas and wake up drenched.

I had no idea what was happening to me. My doctors said it could be the steroids; they said it was normal. They never mentioned my hormones, not a word. Just, "Oh, that's okay. It could be this, it could be that."

I believe they made a choice to not worry me about anything other than the cancer. They just kept saying the same things to me. "You'll be okay." "We'll figure that out when we get there." I had never heard of medically induced menopause. They said my periods would stop temporarily, and then come back.

I kept telling myself, _just get through this and these awful symptoms will stop_. My eyes stopped watering after the seventh cycle, but the hot flashes were awful.

I slept because I was exhausted from low cell counts, but it was anxious, unrestful sleep. When I stopped chemotherapy, I needed a sleeping pill every night. Even months after chemo, my moods never leveled out. My depression got worse and worse. I've never been a depressed person; it's not in my makeup. I hated how grumpy and short tempered I was. I felt constantly stressed, even though I was cancer free. I should have been celebrating life, but instead I kept asking, _what's the matter with me_?

I finally went to a psychiatrist who put me on antidepressants. I also spoke with my oncologist, who told me my lack of periods was normal and said usually girls get their period back within the year.

Around this point, a friend recommended I read _Shmirshky: The Pursuit of Hormone Happiness_. After reading the book and chatting with the author, I finally started to understand what might be happening to me and where to seek the correct kind of help. Help that made a real difference. I went to three gynecologists before finding one who knew anything about chemotherapy and the effects it has on the reproductive system.

My new gynecologist checked my vaginal pH balance. I was so uncomfortable down there, drier than the desert. I had burning and would get painful little cuts from nothing, from just working out or wearing underwear. I had no sex drive, either.

It turned out I had vaginal atrophy. My gynecologist discussed different options about how to bring my hormones up because I had very low estrogen, very low testosterone, and low progesterone. He put me on the NuvaRing for estrogen and prescribed an amazing topical cream, Estrace, to help with the dryness around and inside my vagina. Estrace was a lifesaver. I felt better one week into using it.

I waited too long to find the kind of help I really needed because I was so overwhelmed. I was hopeful my body would kick into gear, like I'd been told, without adding another doctor to the list. I was terrified to find out I couldn't have children. I just wasn't emotionally ready to hear that.

The estrogen in the NuvaRing kicked in at around three weeks. As soon as I felt better, I got off the anti-depressants. My problems were not emotional, they were hormonal!

I started menstruating again, but my period is still very light. It only lasts about three days, but it starts to happen a couple of days before taking out the NuvaRing. That assures me my body really is getting back to its natural groove.

Eventually, I switched back to my regular gynecologist. He gives me more natural medications and supplements like vitamin D. And I'm still using the NuvaRing and Estrace. Because my sex drive is still kind of low and I'm still very tired at times, he suggested a supplement called Yohimbe. I have been taking it for about two months and it works!

As for the finger that started this whole thing, I finally had it amputated after 13 failed surgeries and prosthetic implants that didn't work. Afterward, I felt like I'd been freed from prison, finally able to move on with my life. I made the decision to do it, instead of the doctors telling me to, which was very empowering.

I feel good. I am dating. My hand doesn't look great but I don't care that much, except when I first meet somebody and I have to tell them my story. That has been a little bit difficult, dating and telling people something so personal. But it's a lesson I am learning.

Before NuvaRing and Estrace, I was scared to try to have sex. At 28 years old, to be so dry and not lubricate was terrifying, like something was very wrong with me. But everything worked great; I was so relieved.

People ask me what the most important thing I learned from this experience is. I learned to listen to my body. If something really feels off, then I _know_ it is. As soon as I feel like something is off, I call a doctor, tell them everything, and don't stop till we figure it out. Now I know things are fixable and I need to listen to my body more before it gets to a point where I am so miserable I can't deal with anything.

I am going back to school for nursing. And you better believe I'll tell all my patients to get their hormones checked.

# CONCLUSION

It's a mystery me why our mothers are so good about sitting us down when we're young to tell us about our periods, but no one does that for menopause. As women, if you go through one, the other one is pretty much inevitable!

I hope I've remedied that. By now, you should have a pretty good grasp of the many symptoms of perimenopause and menopause and the treatments available to help you.

With this book, your Menopause Symptom Chart, and an excellent menopause specialist, you're ready to conquer your symptoms and live your best life every day going forward. You know the symptoms to look for, the tests to request, and the wide variety of possibility treatments that are available.

Being a wise woman isn't about having all the answers, it's about recognizing when you need support and knowing where and how to get the help you need. Trust how you feel in body and spirit. Don't say everything's fine when it isn't. You know when you don't feel well. If you're doctor says you're too young for menopause and sends you home without running tests, speak up! You need to be your own advocate. If you're not happy with your doctor, find a new one who takes your concerns seriously. You don't have to accept second best!

You are not alone. Not only is your menopause specialist your ally, so too are your loved ones. They need to understand what you are going through, and it's your job to let them in, especially your partner. They don't have a clue as to what is going on with us when we hit perimenopause and menopause. They don't know why we are acting distant and irritable. They don't understand the physical and emotional changes we are experiencing. A lack of communication about perimenopause and menopause can in seriously strain our important relationships and even lead to tragic and unnecessary divisions. I believe it's no coincidence that a lot of couples get divorced when a woman is going through perimenopause and menopause.

Do not hide! Instead, go seek out the love and support you deserve from the women and men you love, respect, and trust.

Allow yourself to be vulnerable and admit that you are having a tough time. Practice saying, "I am having problems and need your help." You can do it! Then help them understand what you are going through. Give them this book! Bring them along to your doctor appointments. Most importantly, talk about your experience. When we share, we learn so much from each other. You'll not only be helping yourself, you may be helping another member of the sisterhood or helping someone's partner who is desperate to understand what's happening to the person he or she loves.

Put yourself on your own To-Do List. We women seem to find it more difficult taking care of ourselves than taking care of others. Women are the glue of the family, so when we aren't feeling well, everyone in the household is suffering too. It is amazing how much better I felt when I was open and honest with the people in my life. You too will feel so much better when you get the help and support you need. You deserve it!

Share this book with your friends, your coworkers, and your daughters and nieces. Prepare the next generation so they have the tools and knowledge to meet their own perimenopause and menopause adventure head on.

I would love to hear from you. Email me your story at ellendolgen@ellendolgen.com.

My motto is: Suffering in silence is OUT! Reaching out is IN!
big thank-you hugs to...

my husband, David, for his patience and never ending love

my son, Jack, for co-authoring this book and being my remarkable menopause biz partner

my daughter, Sarah, for being my sounding board and dearest girlfriend

my son-in-law, Sol, for his dedication to healing, science, and his loving wife and daughter

my granddaughter, Aviva, for inspiring me to continue my mission to educate and prepare the next generation of women, and for her sweet innocence and love

the wonderful researchers, specialists, and pharmacists for the "philanthropy of their wisdom and expertise"

the sisterhood of women, and the men who love them, that shared their personal stories

my friends who encourage me on my mission and who at every turn are there for me

This book and my work has been a family affair, but it is part of a larger movement aimed at providing women everywhere the resources and knowledge to take charge of their lives and wellness. Every day I see evidence that women are seeking out and finding the information they need to make quality decisions about their health. This inspires me and pushes me forward.

# About the Authors

**Ellen Dolgen** is the Founder and President of Menopause Mondays. After struggling with her own severe menopause symptoms and doing years of research, Ellen Dolgen resolved to share what she learned from experts and her own trial and error. Her goal was to replace the confusion, embarrassment, and symptoms millions of women go through—before, during, and after menopause—with the medically sound solutions she discovered. Her passion to become a "sister" and confidant to all women fueled Ellen's books.

As a result of the overwhelming response from her burgeoning audiences and followers' requests for empowering information they could trust, _EllenDolgen.com_ was born. _EllenDolgen.com_ is a platform from which Ellen reaches the true needs of her readers through varied and substantive discussions of menopause, women's health, and the modern woman's life today as a menopausal woman. Her readers gain the access and knowledge needed to take charge of their health and happiness.

In addition to Ellen's ever-growing social media presence, _EllenDolgen.com_ has become "the place" on the web for informative and entertaining women's menopause and wellness engagement. Ellen was #1 on Dr. Oz Sharecare.com Top 10 HealthMakers on Menopause. In 2012, 2013, and 2014 _EllenDolgen.com_ was named first on the list of the "Best Menopause Blogs" by Healthline.

Ellen was one of the first regular contributors to debut on the Huffington Post's "Huff/Post50," which targets 116 million Americans over the age of 50. She has been a regular contributor to over a dozen leading women's health blogs. Ellen has founded a women's health and wellness program that provides corporate education events for businesses, healthcare institutions, and other organizations. She produces and facilitates _Menopause Mondays Parties TM_ for organizations across the country. In addition, she works with pharmaceutical companies in helping them to have a new point of view in order to better understand and address women's health needs. Ellen chaired a social media roundtable for Novo Nordisk in 2012. In 2013, Ellen was a key spokesperson for GLAM _TM_ (Great Life After Menopause), a non-branded campaign sponsored by Novo Nordisk. In 2015 she partnered with Pfizer on their "Tune In To Menopause" campaign in a series of menopause videos, with the fabulous award winning Kim Cattrall.

Ellen has appeared on the "TODAY Show," "TODAY Kathie Lee & Hoda," "The Katie Show," "NBC Nightly News," "The Rachael Ray Show," "The Doctors," Oprah Radio, Playboy Radio, NPR's "Tell Me More," Doctor Radio, and dozens of regional and national media outlets. In 2011, she appeared in a production of "The Vagina Monologues."

Ellen has a lifelong commitment to philanthropy through board representation, fundraising, and event organization. She serves on the Community Advisory Board of Scripps Memorial Hospital, La Jolla. She has chaired and served on various boards and committees for Planned Parenthood of the Pacific Southwest, Fresh Start Women's Foundation, San Diego Hospice, Brandeis University, NARAL, the Phoenix Heart Ball, Juvenile Diabetes Research Foundation, Weizmann Institute of Science, Angel Charity for Children, Brewster Auxiliary, and Handmaker Home for the Aging.

Ellen is a principal of Dolgen Ventures **.** She lives in California with her husband, David. Her favorite title is Grandma!

**Jack Dolgen** is a writer with a background in music, comedy, and comedic songwriting and production. After growing up in southern Arizona, Jack moved to New York to attend NYU, where his writing began in earnest. He studied travel writing and comedic non-fiction. All the while, Jack was playing in bands, making records, and touring the country. That's when he started writing a book about menopause.

That's right. If you think YOU have mommy issues, talk to the man who co-wrote, self-published, then formally sold a book—to Hyperion/Voice—about menopause with his mother.

While working with his mom (and seeking therapy for same), Jack began co-writing and producing comedy songs with several comedians, namely his song-writing partner, Rachel Bloom (F**k Me Ray Bradbury, You Can Touch My Boobies). He recently served as Executive Music Producer and co-songwriter for Rachel's CBS/Showtime pilot, Crazy Ex-Girlfriend.

Jack is the co-host of the popular storytelling podcast "Doodie Calls with Doug Mand" and regularly contributes theme songs and original music for film, TV, and commercials.

Jack currently resides in Los Angeles, where he performs in comedic music and story telling shows at the UCB Theater and other venues around town.
