Menopause

Midlife Muddle — Own the Power of Naming

Hormones, Language, Menopause, Menstruation, New Research

Guest Post by Jerilynn Prior, M.D. — Centre for Menstrual Cycle and Ovulation Research

By “midlife muddle” I don’t mean the trouble concentrating or remembering names that sometimes occurs for all of us (but more frequently if we’ve wakened with night sweats and not gotten back to sleep). I mean the condoned and official confusion about naming of women’s reproductive aging. Let me show you why I am upset.

 

STRAW+10 staging system for reproductive aging in women

Stages of Reproductive Aging Workshop (STRAW) held a 10-year anniversary last summer. (As someone frustrated by not being “heard” at the original conference, I still think that the “W” in STRAW should stand for Women!) Despite that, STRAW+10 has made progress because at least some of the classification is now supported by population-based prospective data rather than based on what experts believe. The names that are now politically correct are summarized in the STRAW+10 Executive Summary1 and the diagram1 at right.

 

We in the Society for Menstrual Cycle Research have also had our say about nomenclature: “Naming Women’s Midlife Reproductive Transition”.  I wrote this (with revision and refinement by collective effort of SMCR members) because women keep getting left out of this naming business. For example:

  • a regularly menstruating woman with night sweats, heavy flow, and increased cramps could learn to call herself perimenopausal2 (not STRAW+10 Late Reproductive Phase -3b?!).
  • a woman who just finished her period can say, I’m in late perimenopause and have at least a year without further flow before I’ll be menopausal. Based on STRAW+10 she could be told that specific menstruation was her final menstrual period (nickname “FMP”) and the next day, according to STRAW+10 be told that she is now “postmenopausal”!!
  • a woman with sore breasts, irregular periods, and heavy flow could say, I’m in perimenopause. However, she may instead be told she is in the “Early Menopausal Transition.” Because she has heavy flow she is also likely to be prescribed the birth control pill (as is currently and commonly recommended). Usually she will not be told that The Pill will make her perimenopausal irregular flow worse—she may well start spotting in the middle of her cycle.3

This new and improved STRAW+10 still centers all of women’s reproduction on that mythical FMP. But to call the FMP “menopause”, as many women’s health experts do, is just unscientific. It takes at least a year without another menstruation in those of us over age 45 before nine out of ten of us will not get another period4. But one (out of ten) of us will get a further, normal period even though we’ve been that whole year without any4. We can tell that new flow is normal (in other words, does not need investigation for endometrial cancer) if we had cramps or bloating or sore breasts or moodiness—or all of these—that told us our period was coming.

 

So our new Naming position statement says don’t call it “menopause” until you’ve not had a period for a year. And do call it “perimenopause” if things are variable and changing even if you are still having regular flow2.  Three of nine changes can confirm for you that you are perimenopausal even if your flow is still regular:2

  1. Shorter cycles (25 days or less);
  2. Increased cramps;
  3. Heavier flow;
  4. Increased trouble sleeping—especially waking up in the middle of sleep;
  5. New or increased migraine headaches;
  6. Night sweats—especially if they tend to occur before or during flow;
  7. An increase in or new premenstrual mood swings;
  8. New sore, enlarging or nodular breasts; and
  9. Weight gain without changes in what you eat or the exercise you do.

If women can learn to call themselves perimenopausal, they will be saying they know that perimenopause is not the same as menopause—perimenopause is a midlife transition with higher and erratic estrogen levels. Menopause is a fairly stable life phase with normally low estrogen and progesterone levels that begins one year after their last menstrual flow.

 

Furthermore, by naming themselves accurately they will be able to tell whether a medication that is proposed for them has been tested and proven effective in perimenopausal women. Usually symptomatic women are treated with oral contraceptives (that are proven reasonably safe and useful for premenopausal contraception), or offered hormone therapy that has only been tested and shown effective for hot flushes/flashes in menopausal women.

 

So. . . I like the word, perimenopause and think if women understand and own it they will be on their way out of a midlife muddle.

 

References

  1. Harlow, S. Executive Summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging [pdf]. Fertility Sterility, 2012   doi: 10.1016/j.fertnstert.20012.01.128
  2. Prior JC. Clearing confusion about perimenopause. BC Med J 2005; 47(10):534-538.
  3. Casper RF, Dodin S, Reid RL, Study Investigators. The effect of 20 ug ethinyl estradiol/1 mg norethindrone acetate (MinestrinTM), a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause 1997; 4:139-147.
  4. Wallace RB, Sherman BM, Bean JA, Treloar AE, Schlabaugh L. Probability of menopause with increasing duration of amenorrhea in middle-aged women. Am J Obstet Gynecol 1979; 135(8):1021-1024.

Menopause Isn’t for Dummies

Celebrities, Media, Menopause, Television

Roseanne’s Nuts was one of the delights of summer 2011, especially for those of us who have missed the comedic talents of Roseanne Barr. If you don’t watch television (or are outside the US), Roseanne’s Nuts is Roseanne Barr’s return to episodic television, this time in the form of a reality show set on the star’s 40-acre macadamia nut farm in Hawaii. When her eponymous sitcom ended in 1997, she made a couple of attempts at talk show hosting, then left L.A. and the limelight to raise her youngest son and macadamias in Hawaii. He’s now a teenager, and the nuts are ready to harvest.

An ongoing thread of the show is Roseanne’s plan to harvest and distribute her nuts as a low-cost protein source for impoverished people. Each episode also has its own self-contained, seemingly unscripted plotline. Unlike many of today’s popular reality shows, however, there are no manipulated showdowns or drunken feuds. Much of the time, Roseanne and her family seem like everyone else’s family — if only the rest of us could live off sitcom residuals and were followed around by a camera crew. There is laughter and teasing, and some conflict underpinned with genuine affection, but everything isn’t always tidily resolved in 22 minutes.

In the Episode #15 (original air date September 10), 58-year-old Roseanne copes with continuing symptoms of menopause. It’s handled so honestly (for the most part) that I’m going to overlook the fact that the episode was titled “Menopause for Dummies”.* The episode opens with Johnny Argent, Roseanne’s manpanion**, sharing a list of menopause symptoms he has found on the internet. Roseanne acknowledges having them all, except for tingling in her extremities, and decides to visit her friend, Dr. Allen, and to investigate whether she should receive hormone treatments. (The full episode can be watched online at Lifetime.com until Oct. 11; preview a short clip at right.)

-+-+-+- SPOILERS AHEAD -+-+-+-

Roseanne visits Dr. Allen — on camera, of course — this is a reality show — and explains her concerns. He asks about her libido and her sex life, and she replies, “It’s like an old person’s”. She responds forthrightly to his suggestion that dryness may be the cause of her ‘feminine itching’: “that’s all dried up like a sonofabitch”. Dr. Allen wants to measure Roseanne’s hormone levels with a 24-hour urine test, as he believes that will provide more precise information than any blood test. Roseanne is horrified by his description of her contribution to the procedure (“You pee in a bucket for 24 hours”), but even more horrified by his other recommendation: she needs to exercise.

Roseanne tells the camera — the proxy for us, the audience at home — that she doesn’t know if she’ll go on hormones or not. Her women friends recommend red wine, saying it’s bad for menopause (“because it makes you sweat”) but good for the libido. Her eldest son Jake is delighted to hear that his mom is considering hormones, telling the camera, “After eight years of being batshit crazy, I think she’s finally ready. I’m so happy — once she gets hormones, my life’s gonna be a lot easier.”

Some of my SMCR colleagues who study menopause may cringe at these scenes, but I think they’re representative of the kind of communication many women experience around menopause; that is, well-meaning, if ill-informed, advice from friends and family. It feels like the kinds of conversations lots of us have in our own living rooms and front porches. It is this feeling of unscripted authenticity that draws viewers to Roseanne’s Nuts. I also note the special irony of menopause; after 20 or 30 years of our hormones being blamed for erratic and irritable behavior, we’re now advised to consume hormones to rein in our erratic and irritable “batshit crazy” behavior.

This sense of authenticity and realism continues in the scenes where Roseanne works out with the trainer recommended by Dr. Allen. The trainer eases Roseanne into aerobic activity, but Roseanne is reluctant and uncomfortable, especially when the trainer starts to show enthusiasm and high-fives Roseanne. She tells the trainer, “I hate the fact that I’m supposed to act like I like it. That’s not gonna work for me. I don’t like it. I can’t lie through it.”

I couldn’t help but think what a great, if implicit, endorsement this is for Health At Every Size. Roseanne gives up on the trainer and exercise after one workout, because exercise for its own sake is seldom enjoyable to those who haven’t been active. HAES encourages people to find pleasure in moving one’s body — whether walking the dog, doing yoga, swimming, bicycling, or whatever — and doing the activity for the joy it provides rather than for an external goal. HAES also affirms Roseanne’s belief that “if you’re fat, it’s probably because you had fat parents and no amount of dieting will change that”.

In the final scenes, Roseanne and Johnny try to follow Dr. Allen’s last bit of advice, apparently delivered off-camera, to be “more romantic” to jump-start her stalled libido. The camera follows them to dinner, where they alternate between trying to enact cultural expectations of a romantic dinner and discussing their own relationship, concluding that “sex isn’t what it’s all about”.

As the final credits begin, Roseanne faces the camera and announces her final decision about hormone treatments:

I just decided, F it, I’m not gonna get anything going on some libido level. I’m not gonna pee in a bucket, I’m not gonna exercise, everything’s fine. I don’t care. I’ve got a really thick beard, and I don’t give a fuck.

Some re:Cycling readers may be uncomfortable with Roseanne’s diction, but it was this monologue that won me over. Once again, Roseanne comes across as sincere, relatable, honest, and comfortable with herself — and comfortable with getting older and with menopause. Roseanne’s Nuts just may be to the 2010s what Roseanne was to the 1980s.

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*The whole “For Dummies” book series is a personal pet peeve. I’ve never bought any of those books, as I refuse to contribute to the profits of a publisher and author whose first assumption is that I am stupid.

**I just can’t call a 62-year-old man her boyfriend, although that is the title that runs beneath his name during the interview segments.

Breaking News: Pfizer ordered to pay millions in PremPro cases

Law/Legal, Menopause, Pharmaceutical

Pfizer, which now owns Wyeth’s PremPro synthetic progestin-estrogen combination that was widely taken for relief of discomforts that sometimes accompany menopause, has been ordered to pay damages in two separate cases this week. The company must pay more than $10 million in damages to an Arkansas woman after an appeals court reinstated a jury verdict. And yesterday in Pennsylvania, an appeals court overturned a previous ruling that Pfizer’s Wyeth unit deserved a new trial in the case of a Philadelphia woman who had been awarded $1.5 million in compensatory damages and $8.6 million in punitive damages on her claim.


Menopause in the funny pages

Humor, Menopause, Newspapers

Widely distributed U.S. comic strip “Zits” — the ongoing story of the life and times of 16-year-old Jeremy Duncan — began a storyline about menopause this week. Apparently, Jeremy’s mom has begun experiencing signs of perimenopause. So far, it’s not awful. The humor is based on the unpredictability of hot flashes and Jeremy’s apparent embarrassment at seeing his mother spontaneously remove her blouse.

© 2011 ZITS Partnership

© 2011 ZITS Partnership

It’s open to interpretation, of course, but so far (see yesterday’s strip), it seems to me that we’re invited to laugh at how easily the teenage boy is embarrassed, and to sympathize with the menopausal woman.

Hormone Therapy and the Brain

Menopause, New Research

Medical-Anatomical-Superior-half-of-diseased-brainSo there’s a surge today in news stories about how hormone treatment for menopause (popularly known as ‘hormone replacement therapy’ or HRT) benefits the brain, apparently based on publicity over this study published in Hormones and Behavior. In media interviews, the researchers suggest that HT enhances the communication between left and right sides of the brain, making the older women’s brains more similar to those of younger women. The researchers had the women perform tasks designed to demonstrate fine motor coordination, such as tapping buttons with different fingers. Of the 62 women in the study, the 36 on hormone treatments showed higher levels of motor coordination, leading the researchers to conclude that hormone treatments, especially estrogen, “exert positive effects on the motor system thereby counteracting an age-related reorganization.”

Admittedly, I have not read the entire study, just the abstract and press summaries, but would you consider me too cynical if I suggested that the publicity this research report is receiving is more about promoting the use the hormones among menopausal women than the significance of the research findings?

Marketing Menopause: Economic Forecast

Advertising, Menopause, New Research, Pharmaceutical

Longtime readers may recall that late last year, the New York Times published an essay about how hard Big Pharma has worked to market menopause as an estrogen deficiency disease. Despite that exposé and others of the well-documented risks and limited benefits of hormone therapy, plus thousands of lawsuits pending over the role of HT in breast cancer,  there’s apparently still quite a large potential market for pharmaceutical treatments for menopause (and other women’s health concerns).

To find out exactly how to mine that market, you can purchase the research report titled Women’s Health Therapeutics Market to 2016 – High Unmet Need will Drive the Uptake of Novel Drugs in Menopause and Osteoporosis from GBI Research. The report promises the following:

  • Analysis of the women’s health market in the leading geographies of the world, which include the US, the UK, Germany, France, Italy, Spain and Japan.
  • Market characterization of the women’s health market, including market size, annual cost of therapy, sales volume and treatment usage patterns.
  • Key drivers and barriers that have a significant impact on the market.

This will better allow you to “align your product portfolio to the markets with high growth potential” and “develop market-entry and market expansion strategies by identifying the leading therapeutic segments and geographic markets poised for strong growth”. Not to mention the ability to “reinforce R&D pipelines by identifying new target mechanisms which can produce first-in-class molecules with more efficiency and better safety”.

It all looks very useful. Too bad I don’t have an extra $3500 in my back pocket.


Hot Flash—Progesterone is an Effective Alternative to Estrogen

Menopause, New Research, Pharmaceutical

Guest post by Jerilynn Prior, Centre for Menstrual Cycle and Ovulation Research

hot flash hellIt’s been two weeks since Chris Hitchcock and I returned from San Diego’s recent Endocrine Society meetings. We are feeling incredibly happy with the success of our protracted, intense commitments to a controlled trial of oral micronized progesterone (marketed in the USA and Canada as Prometrium®) for night sweats and hot flushes/flashes. At the Endocrine Society we presented the first-ever trial showing that the molecularly identical progesterone by mouth is effective treatment for vasomotor symptoms (VMS = hot flushes/flashes and night sweats)(1). We were also invited to present our data at an Endocrine Society-sponsored press conference.

Why did a scientific study require so much from us? First, this trial started in 2003 as the initial scientific venture of the newly founded Centre for Menstrual Cycle and Ovulation Research–thus CeMCOR’s reputation became tied to this trial. Second, despite concerted efforts, we were never able to obtain peer reviewed funding for this study—we successfully supported it with individual private donations. Finally, because of the “estrogen myth” and its corollary negatives about progesterone, I wanted to gain additional accurate information about how Prometrium® works in women’s cardiovascular system from this same study. For that reason we decided to enroll only very healthy women who were within 1-10 years since their final flow—they had to be non-smokers, without obesity, diabetes, or high blood pressure, and further to have normal measured waist circumference, blood pressure, cholesterol, and fasting blood sugar levels. Therefore many women were interested but few were eligible.

Late last fall when we broke to code on this study, we were ecstatic to discover that our trial was highly successful. After only three months’ therapy with Prometrium® (300 mg at bedtime daily) the 127 (of 133 randomized) women’s vasomotor symptoms score (VMS Score, combination of number of flushes times their intensity during the day and during sleep) was decreased by about 60% on progesterone compared to less than 30% decrease on placebo.

In early June we learned the answer to another important question: Does progesterone effectively treat intense VMS? The answer is yes! Although less than half all the treatment-seeking women in our study met the FDA’s criteria for more than 50 moderate-intense VMS/week, the 30 women who did who were randomized to Prometrium® showed significantly more improvement in hot flushes than did women on placebo.

What were the reactions to this news? Some local doctors said they already knew that progesterone was good for VMS! Others people were curious, or skeptical but many realized the importance of providing women with an effective alternative to estrogen for VMS. Other reactions were predictable—many questions about whether this couldn’t really be explained, somehow, by estrogen (Prometrium® is converted into estrogen—not!). And there were several questions about side effects and alleged serious health risks from progesterone (wrongly attributed because of confusion of progesterone with synthetic progestins). Happily I was able to respond that participants had no serious negative effects—more placebo-treated than Prometrium®-treated women dropped out before completion. And it is likely that in estrogen-treated women progesterone decreases breast cancer risk rather than increasing it as medroxyprogesterone does (2). Because of Prometrium®’s significant sleep benefit (3), some women who entered the trial sleep-deprived experienced short-lived morning drowsiness. But the estrogen myth-related mood, bloating, weight gain, migraine headaches, and breast tenderness did not occur.

An epic journey for me, Chris, and CeMCOR ends in triumph. Now that the dust has settled, I am so grateful that CeMCOR’s many researchers over the last six years dedicated themselves to a world class trial, that local donors made the trial possible, and that the Prometrium® and placebo were provided by Schering Canada (for the first two years) and subsequently by the world-wide manufacturer, Besins Healthcare of Belgium.

Where from here? First, in the fall we will start a new Canadian Institutes of Health Research-funded trial of Progesterone for Perimenopausal Night Sweats using the same design as in this study. Second, I’m tickled to discover what new we can learn about progesterone from analysis of information we have already collected as part of this trial: how women feel through their Daily Menopause Diary® data, and what happens with hot flushes on stopping progesterone and placebo (in particular, do they soar higher than baseline as occurs when estrogen is stopped?). In addition, we will soon know what changes occur in cholesterol and triglyceride levels, thyroid function, blood clot risks, and quality of life in women treated with progesterone rather than placebo. We already know, from a specialized study of blood flow in the forearm, that progesterone does not have negative effects and tends to increase flow like estrogen does (abstract presented at the 2010 Endocrine Society).  Finally, we have solid scientific evidence with which to counter the smirking negatives directed at “bioidentical progesterone.”

Reference List

  1. Prior JC, Hitchcock CL. Progesterone For Vasomotor Symptoms: A 12-Week Randomized, Masked Placebo-Controlled Trial In Healthy, Normal-Weight Women 1-10 Years Since Final Menstrual Flow. Endocrine Society Abstracts . 2010. Ref Type: Abstract
  2. Fournier A, Berrino F, Clavel-Chapelon F. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat 2008; 107(1):103-111.
  3. Schussler P, Kluge M, Yassouridis A, Dresler M, Held K, Zihl J et al. Progesterone reduces wakefulness in sleep EEG and has no effect on cognition in healthy postmenopausal women. Psychoneuroendocr 2008; 33(8):1124-1131.

Hot Flashes: Now Especially for Fat Ladies

Media, Menopause, New Research, Newspapers
Photo of art by Czarnobyl by Flickr user urbanartcore.eu || CC 2.0

Photo of art by Czarnobyl by Flickr user urbanartcore.eu || CC 2.0

Since yesterday, although it seems longer, my RSS reader has been clogged with links to news reports about a UCSF study in which some women who lost weight found that their hot flashes diminished. Of course, that’s not what the headlines say. Here’s a sample of some of the titles of current stories about this study on Google news:

  • Hot Flash Relief: Weight Loss Works, What Doesn’t? (US News & World Report)
  • Bad hot flashes? Try dropping a few pounds (MSNBC.com)
  • Losing weight may ease menopause symptoms (NBC13.com)
  • Symptoms of Menopause Can Be Relieved by Weight Loss (Health News)
  • Weight Loss Helped Overweight And Obese Women Reduce Hot Flushes (Medical News Today)

OK, that’s enough – see the trend? Suddenly weight loss is the cure for hot flashes. But in the actual study – which was about urinary incontinence, not menopause -141 women provided researchers with data about their hot flash symptoms six months after the study began. Sixty-five of the 141 women said they were less bothered by their hot flashes six months after participating in the weight loss program, 53 reported no change, and 23 women reported a worsening of symptoms.

Look at those numbers again, more slowly this time: 65 of 141 women who participated in a weight loss program were less bothered by hot flashes after six months. That’s 46% of the women – less than half – who found relief. Almost as many reported no change in symptoms, so why is this being touted as a successful intervention?

Because the women lost weight. Most of the news reports of this research stop just short of fat-shaming, but I submit that is exactly why this study is getting so much media attention. Even though it is well-established that diets do not work, even if you call them a “lifestyle change” or “a whole new way of eating”, and that the BMI (Body Mass Index) is useless as a gauge of health. In fact, fat is not a measure of health. But why pass up an opportunity to shame women about their bodies?