Questions and Answers

Q: I had a partial hysterectomy four years ago due to fibroids. I was 48 years old and weighed 116 pounds. (I'm five-foot-one.) Now I weigh 137 pounds. I have not changed my diet or exercise routine. I still have my ovaries. Do you think it was just the hysterectomy that caused my weight gain? What can I do to lose weight?

Wulf H. Utian, MD, PhD

A: I hear your question so often from my patients. And the answer isn't simple. There is some evidence showing that women tend to gain more weight after hysterectomy than after natural menopause. Why that is, especially since these women still have their ovaries, just isn't clear.

However, although your uterus was removed when you were 48, in the four years since you've probably reached menopause (you may not know it since you weren't menstruating). And it is clear that women often gain weight after menopause.

This weight gain doesn't appear to be due to any effects from low estrogen/progesterone levels, but, rather, from changes in lifestyle (primarily becoming more sedentary) and because postmenopausal women tend to lose muscle and gain fat. That, in turn, leads to a slowing of your metabolism. Put more simply: Your calorie-burning furnace is operating on medium instead of high. That means that even if you're eating and exercising the same as four years ago, you either have to eat less or exercise more to maintain your weight.

But you're five steps ahead of many women: You already have a regular exercise routine and, from what it sounds like, a healthy diet. Now it's time to jump-start things a bit. One of the best ways to increase your metabolic rate is to build muscle. Pound for pound, muscle burns more calories than fat.

One of the best ways to build muscle is with some form of weight training. I recommend you check out your local YMCA, recreation center or private health club. If possible, hire a personal trainer for at least one session to show you how to work the weights and to design a routine that fits your current fitness level. Then, every two to three months, meet with the trainer to fine tune your routine as you get stronger.

Don't forget to keep some cardiovascular exercise in your routine, i.e., anything that increases your heart rate. It could be a brisk walk, a bike ride, swimming or using the treadmill, elliptical trainer or other equipment at the gym. It could be digging new garden beds, raking leaves or washing the car. But make movement a regular part of your life.

Now let's talk about your diet. One easy way to reduce calories without reducing the amount of food you eat is to up your fruit and vegetable intake. Add a large salad with low-fat dressing before lunch and dinner. You'll find you're not as hungry for the main meal. Add two pieces of fruit to your cereal bowl and make your midday snack some raw broccoli dipped in plain yogurt or low-fat ranch dressing. You get the idea.

Good luck and remember, good health, which you'll get from eating well and exercising regularly, is the most important thing—not some number on the scale
Posted 1/24/2007

A: Good for you for taking steps to prevent an unwanted pregnancy! I see too many women your age who think they're "too old" to get pregnant and just give up on birth control. But until you have gone 12 consecutive months without a period (the true definition of menopause), you could still become pregnant.

There's no age limit on any contraceptive option. Having said that, however, it's clear that some options are more appropriate than others based on a woman's individual circumstances and health profile.

For instance, you don't mention if you're married, in a monogamous relationship or dating, or how sexually active you are. All are issues you should discuss with your health care professional when determining contraceptive options. For instance, if you're having sex infrequently, you might want to consider a barrier method, such as a condom or diaphragm.

The most common birth control method used by perimenopausal women is sterilization, either tubal ligation, i.e., "having your tubes tied," or hysterectomy. Either is a pretty drastic option, however, since both involve surgery. Plus, research shows that other options can be just as effective when used appropriately.

If you're experiencing the heavy menstrual bleeding common to perimenopausal women, talk to your health care provider about the levonorgestrel IUD, which not only provides effective birth control, but may also help with the heavy bleeding. And, of course, another good option is the one you're already using—oral contraceptives.

Decades ago — in the 1970s—women over 35 were told to stop taking oral contraceptives because of the potential risk of heart disease. Since then, however, we've learned that risk exists primarily for women who smoke, making birth control pills a good option for nonsmoking premenopausal women of any age. Plus, given the drop in the amount of estrogen used in oral contraceptives in recent years, the risks of other health conditions, including blood clots, stroke and heart disease, have also dropped.

In fact, long-term use of birth control pills has numerous health benefits, including reducing the risk of ovarian cancer, probably by preventing ovulation. Studies also suggest that birth control pills reduce the risk of endometrial cancer, colorectal cancer, pelvic inflammatory disease, fibroids and even endometriosis, as well as helping alleviate some of the heavy bleeding related to fibroids and endometriosis.

One of the main reasons perimenopausal women choose oral contraceptives as their contraception of choice is to help reduce the heavy bleeding and irregular periods often a part of this time of life. There's also some evidence they can help maintain bone density and reduce the risk of osteoporosis, as well as reduce the incidence of hot flashes, both of which concern perimenopausal women. An added bonus—they can help clear up middle-aged acne.

So, to summarize, it's fine to continue taking birth control pills up to age 50 or even 51 (keep in mind that the average age of menopause in this country is 51) as long as you don't have any risk factors for heart disease or other potential complications, including smoking, obesity, diabetes, high cholesterol, high blood sugar or migraines.

One reason your doctor suggested you stop taking birth control pills when you turn 50 is so you'll know if you've reached menopause. If you continue taking them as directed—with a week's break between active pills—you'll continue to menstruate and won't know.

Although the decision is between you and your doctor, you may want to consider at least taking a break for a few months and using a non-hormonal contraception to see if your periods continue, or if you have reached menopause and no longer need contraception.
Posted 11/08/2006

Q: I did not have a period for 11 months. Then I had a period. Does this mean I have to wait another 12 months to be sure it is menopause?

A: This is an excellent question, and one that is often quite confusing to women and even many health care professionals. The North American Menopause Society (NAMS) defines menopause as the final menstrual period. Of course, you can't know if your last period really was your last until 12 consecutive months without a period (in the absence of other causes, like removal of the ovaries or chemotherapy) have passed. Since you got your period on the 12th month, you have to start counting all over again!

You don't say how old you are, but it is not unusual for women in the months or even years before menopause (called perimenopause) to have irregular periods. You may find your periods come more frequently (every 24 days, for instance), less frequently (skipping months), are heavier or lighter. They may be shorter than normal or longer than normal. In fact, it's probably safe to say that when it comes to menstruation during perimenopause, there is no "normal" anymore!

One thing to keep in mind: Since you're still menstruating, you can still become pregnant. Thus, if you're sexually active, still have your uterus and don't want to get pregnant, make sure you use some form of birth control.
Posted 10/24/2006

Q: Is it true that one of the side effects of uterine fibroid embolization is early menopause? If I had this procedure (UFE) done and my periods were regular for seven month afterward and then suddenly stopped in March, should I be concerned?

A: As you probably know, about 25 percent of premenopausal women and 40 percent of women 40 or older have uterine fibroids. They are the most common form of reproductive tract tumor, although they are benign, or noncancerous. The fibroids can cause heavy menstrual bleeding, pain and bloating, and are one of the most common reasons women have hysterectomies.

Today, however, there are alternatives to hysterectomy, including uterine fibroid embolization (UFE), one of the newest treatments available. The goal is to shrink the fibroid and treat heavy uterine bleeding. Studies find 89 percent of women report improved menstrual bleeding after UFE.

The procedure destroys the blood supply to the fibroid. It's performed on an outpatient basis, typically by a specially trained interventional radiologist or gynecologist. The doctor passes a catheter, or very small tube, through a small incision in your groin into the blood supply to the fibroid. Then the doctor injects tiny plastic or gelatin sponge particles, about the size of a grain of sand, through the catheter into the artery. The particles stop blood flow to the fibroid and over time, the fibroid shrinks.

About five to 10 percent of women find their periods temporarily stop after the procedure, and about three percent of those under 45, and seven to 14 percent of those older, find they permanently stop. This is thought to occur if the artery leading to the ovaries is mistakenly embolized, but may also be related in some way to the procedure itself.

You don't say how old you are, so it's difficult to know if your period may stop permanently. You should talk to your health care professional about the fact that your period has stopped, have a complete medical examination and work together to figure out if it's related to the UFE or to some other issue.
Posted 9/30/2006

Q: I am a perimenopausal woman who has been experiencing rash-like symptoms prior to my periods for several months now. This month the rash was not only around my groin/pelvic/rectum area it also covered my neck and was red, blotchy and itchy. Are these rashes common to perimenopause?

A: Actually, there is no evidence that rashes like what you're describing are linked to menopause or hormones. However, estrogen does play a major role in the overall condition of your skin, and it wouldn't be unusual to notice changes as your body's production of the hormone fluctuates.

For instance, we know that postmenopausal women using estrogen therapy tend to have skin that is thicker and moister than postmenopausal women who don't supplement with estrogen, and that loss of estrogen leads to drier skin. This dryness could make your skin more susceptible to irritation from your clothing, particularly your underwear.

Women's skin also becomes thinner after menopause, leading to an increased risk of skin tearing and bruising, and some of this thinning may be related to estrogen loss. Plus, as any woman knows, your skin begins to loosen and wrinkle as you age. Much of this, however, results from earlier sun exposure and other environmental damage rather than loss of estrogen.

Estrogen also plays a role in wound healing, so lower levels could contribute to excessive irritation. Finally, women are more likely to develop rosacea, a common skin disorder characterized by a bright red rash and scaliness on your face, in their thirties and forties, although rosacea is not related to estrogen.

Obviously, there is no way to diagnose your condition without a thorough medical exam. Your rash could be related to many things, ranging from an allergic reaction to the laundry detergent or bath soap you're using, to hives from stress, to a medical condition. Thus, I strongly recommend that you make an appointment with your primary health care provider or a dermatologist for a thorough medical history and evaluation.
Posted 8/18/2006

Q: What preventive tests should middle-aged women receive to prevent serious illness?

A: I'm glad you've asked this question. Midlife is a particularly important time for screening tests—tests that can identify warning signs of serious health conditions such as diabetes, heart disease and cancer early, when they're most easily treated. Various health organizations recommend the following at the noted ages, but you should also talk to your health care professional about screening guidelines with your personal health history in mind. There may be a reason to be screened earlier than the recommendations below suggest.

Q: I guess I'm now in menopause, because I'm having symptoms. I am going to start bioidentical hormone therapy with a doctor who specializes in this type of hormone therapy. Once I start on this hormone therapy, will it remain the same or will the amount of supplemental hormones have to change as I grow older? (I am 49, and the longest I have gone without a period is four to five months.)

A: First, let's talk about what "menopause" really means. Menopause is diagnosed after you have not had a menstrual period for 12 consecutive months. It is not reliably diagnosed from testing hormone levels. In fact, hormone levels fluctuate so much during this time of life that it's nearly impossible to get a consistently accurate report.

So if you're still having periods, albeit infrequently, you have not reached menopause. Instead, you are considered perimenopausal—a time of life when your hormone levels fluctuate and you may experience symptoms. This phase can last several years before menopause occurs.

Nonetheless, some women do begin to feel the need for relief from menopausal symptoms before they officially reach menopause, and hormone therapy is a treatment option frequently used. There's nothing wrong with this if you've discussed all the possible risks and benefits of hormone therapy with your health care provider. For instance, there's some evidence that hormone therapy that combines estrogen and progestin may slightly increase your risk of breast cancer, heart disease, stroke and blood clots. On the other hand, supplemental estrogen has been shown to protect against bone loss and reduce the risk of colon cancer. Thus, the decision to use or not use hormone therapy is an individual one for each woman to make in conjunction with her health care provider.

It's also important that you consider the best kind of hormone therapy for you. As you probably know, you have several options today, including the form of the therapy (pill, patch, vaginal ring, cream, lotion, etc.), the type of estrogen used and the strength of the dose.

As I hope your doctor has explained to you, "bioidentical hormone therapy" refers to a type of hormone therapy that uses hormones that are structurally identical to the substances as they naturally occur in your body. Both estrogen and progesterone are available in several bioidentical hormone therapy products—estradiol (estrogen) in Estrace (a vaginal cream) and progesterone in Prometrium (an oral capsule) and Prochieve (a vaginal gel). Other hormone therapies, like Premarin and Prempro, contain a conjugated estrogen produced from the urine of pregnant mares.

Now as to your specific question. Yes, it is likely that over time your hormone therapy dose will change. In fact, initially you may need to try several doses to find the one that works best for you. Overall, the goal is to use the smallest dosage possible for the least amount of time possible to provide you with symptom relief. You should not be taking hormone therapy to protect your heart.

So make sure you see your health care provider on a regular basis for checkups and screenings and to discuss the role hormone therapy should play in your health as you get older.
Posted 6/30/2006

Q: I have just been diagnosed with osteopenia. What is this? I am about to begin post-breast cancer treatment with the aromatase inhibitor Arimidex, which I understand will increase my chance of bone loss. Any information would be appreciated.

A: Osteopenia refers to low bone density, a condition that affects about 34 million Americans. It puts you at a higher risk for osteoporosis. Osteoporosis is a condition of weak and fragile bones, leading to fractures. Both are related to the way bone is broken down and built back up, a process called "remodeling." Certain cells break down bone to release calcium and other minerals; other cells build it back up. The hormone estrogen plays a major role in this rebuilding process. After age 30, however, bone breaks down faster than it builds up. And once you reach menopause and for several years afterward, the rate of breakdown increases.

As a breast cancer survivor, you have a higher risk of osteoporosis, because many hormonal treatments used to prevent the cancer's return reduce the amount of estrogen in your body, which serves as a kind of "fuel" for cancer cells in some cancers. Reducing the amount of available estrogen can slow or even prevent the cancer's growth.

Two primary classes of drugs are used for estrogen-positive cancers: an anti-estrogen like tamoxifen, or an aromatase inhibitor like Arimidex (anastrozole), which your doctor prescribed. Aromatase inhibitors work by preventing the action of the aromatase enzyme, which is required for estrogen production. Unfortunately, since estrogen is also important in maintaining bone density, inhibiting its production can negatively affect your bones. Your existing osteopenia, coupled with the effects Arimidex will likely have on your bones, could put you in serious danger of developing osteoporosis.

The good news is that we have several treatments available today to help maintain and even improve bone density. Bisphosphonates, a class of drugs including Fosamax (alendronate) and Actonel (risedronate) that is used in the treatment of osteoporosis, have proven at least as effective as hormone therapy for this purpose. So talk to your doctor about the possibility of starting on one of these medications along with the Arimidex.
Posted 6/7/2006

Q: Can you tell me about vaginal atrophy?

A: You're talking about changes that occur in the vagina as women age. These changes become more pronounced after menopause, when estrogen levels significantly drop. That's because estrogen plays an important role in this part of your body, helping maintain moistness and elasticity.

So when the estrogen dries up, so, too, can your vagina. Unlike hot flashes, however, which tend to begin before women actually reach menopause, urogenital symptoms may not begin until several years after menopause and may continue (and get worse) as you age. It's estimated that such problems affect about 20 million women in the United States, most of them over age 50. By age 75, it's estimated that two out of every three women are affected.

The loss of estrogen and its effect on the lining of the vagina can lead to itching, burning, pain and discomfort during intercourse. If the lining of the vagina becomes thin enough, it can even result in some vaginal bleeding. This thinning also makes you more susceptible to infections, which could result in a foul odor and discharge.

In addition to or instead of vaginal symptoms, you may also notice problems with bladder control and an increased incidence of incontinence, or urine leakage. Again, it's related to the loss of estrogen. This loss of estrogen may result in an atrophying, or thinning, of the lining of the urethra and other parts of the urinary tract. Thus, you may find you have to urinate more often, particularly at night, and that these urges come on more suddenly. You may also find you're experiencing more urinary tract infections.

The best treatment for vaginal symptoms is estrogen therapy. In many instances, vaginal treatment with a pill or cream inserted into the vagina, or with an estrogen ring, can provide relief. In other instances, you may require estrogen via an oral pill, patch, cream or gel. Certain lifestyle approaches may also help. For instance, the more sexually active you are, the fewer vaginal problems you're likely to have.

Estrogen therapy doesn't seem to work as well in alleviating urinary symptoms, however. Instead, talk to your health care professional about other options, including retraining the bladder and urethra muscles through various exercises, surgery and new medications designed to address incontinence.
Posted 5/17/2006

Q: I am 49. Until recently, I've been having a very heavy, extended period. But lately, I haven't had much of a period at all--until this month. This month it's been very heavy and has lasted for three weeks. What should I do?

A: As you may know, you are perimenopausal. This refers to the time before menopause when hormone levels, particularly estrogen, begin fluctuating. Perimenopause occurs, on average, about four years before actual menopause. Menopause is timed as the date of the final period, confirmed after periods have been missed for 12 months.

In the meantime, however, your hormones are all over the place. Some months, levels of estrogen and/or progesterone are up, and some months they're down. All of which affects your periods. You may go months with a normal period, or months with one that's so heavy you can't leave the house. Your period may last four days or two weeks. You may skip a month or have spotting between periods. You may find your period comes every 28 days or every 45 days. There just doesn't seem to be any rhyme or reason to it.

Perhaps the most bothersome part of all this is the heavy bleeding. It's not just a slight inconvenience. Heavy bleeding makes it difficult for women to leave their homes, sit in meetings, shop or exercise, because they fear having an "accident." Additionally, the fatigue that often accompanies heavy bleeding can interfere with your daily activities.

Plus, heavy bleeding can lead to iron-deficient anemia, the most common health-related threat of heavy bleeding. While most cases of anemia are easily treated with oral iron supplements, sometimes the bleeding is so severe a woman's entire volume of blood drops, leading to shortness of breath, severe fatigue and heart palpitations that require hospitalization.

While abnormally heavy menstrual cycles can occur at various stages of a woman's life, they occur most often during puberty and perimenopause. Both of these times involve wildly fluctuating hormone levels and months in which you may not ovulate. This, in turn, can lead to a thicker uterine lining, which has to be shed at some point. The result: heavy bleeding. Overall, studies find, most women diagnosed with heavy bleeding, called menorrhagia, are over 30.

While your abnormal uterine bleeding (AUB) is likely related to fluctuating hormonal levels, you should still talk to your health care professional to rule out other causes. These include fibroids, uterine cancer, endometriosis (in which the lining of the uterus grows outside the uterus, invading the uterine cavity), a pelvic infection, clotting disorders and hyper- or hypothyroidism (the first related to high levels of thyroid hormones; the second to low levels).

Once a firm diagnosis is reached, there are numerous options available to help regulate your periods, particularly to relieve the heavy bleeding. These include medications such as oral contraceptives, a hormone-releasing IUD, a surgical procedure called endometrial ablation, in which the lining of the uterus is destroyed, or, in severe cases, a hysterectomy.
Posted 4/6/2006

Q: Is it common to experience mood swings and depression during the years leading into menopause and immediately after?

A: Yes, particularly before you actually reach menopause (which is, recall, the day at which you've gone twelve consecutive months without having a period). In fact, one study found perimenopausal women (those in the menopause transition) had more psychological symptoms than postmenopausal women. Overall, studies find that about 10 percent of perimenopausal women have some mood swings, and that you're more likely to experience them if you have a lot of hot flashes and problems sleeping, a history of premenstrual symptoms and other health problems.

You may find you're more irritable and tearful, and that you just feel "down," or "blue" more often than you used to. But there's no evidence linking depression to perimenopause itself. Having said that, studies find you are more likely to become depressed during this time of your life if you have a history of depression and are having a lot of menopausal symptoms.

However, just because these mood swings intensify during perimenopause, doesn't necessarily mean they're related to dropping estrogen levels. For some women, this time of life is fraught with new stresses -- aging parents, children leaving home, facing one's own mortality, stresses that can certainly result in mood swings. But the symptoms of the menopausal transition itself, particularly hot flashes and insomnia, can also trigger mood swings, as can the sense that you're losing control over your own body.

Nonetheless, it's important to know that the majority of women say this is a time of their life in which they feel happier and more fulfilled than at any other time. In other words, sadness and irritability don't have to be a part of this time of life.

If you find that your mood swings affect your ability to function in your every day life, or are affecting your relationships with family, friends, coworkers, you should seek help. Talk with your health care professional or a mental health therapist. Numerous other factors can be at work here, and with the proper diagnosis and treatment, you can return to your "old" self.
Posted 2/3/2006