The only constant in life, it is said, is change. When we are young change occurs rapidly. One day a baby is crawling and the next he or she is a toddler. It seems as soon as the child is talking and walking he or she is starting school. Soon puberty arrives with all of its challenges. The emotional roller coaster of the teen years gives way to marriage, career development and parenthood. After a period of stability we face a phase of life so dramatic that it is often referred to as the “change of life.”

What that change is depends upon whether we are male or female. A woman enters menopause, a man mental pause, or so I have been told. It is often as much an emotional challenge as a physical one. The end of menses signifies the end of a woman’s reproductive life and is an inescapable warning that life will one day draw to a close.

We live in an age of “cookbook” medicine. A standard protocol is recommended for nearly every condition. The art of medicine has been lost. The complexity of human nature with its body, mind & spirit does not lend itself to uniform standards of treatment, however. Nowhere is this more evident than in the management of menopause.

The menopause experience varies widely. Some note that menses have ceased, but life continues on without any other transformation. Others experience a few mild “hot flashes” that are transient and non disruptive. Many are subjected to a wide variety of symptoms including disabling hot flashes, mood swings, night sweats, vaginal dryness, and insomnia. This being the case, to suggest that every menopausal female should be placed on the same regimen is illogical.

Medical regimens for menopause have changed repeatedly. In medical school I was taught that every woman going through menopause should be placed on estrogen and kept on it for the rest of her life. Then, in the early 1970s a statistician reported that women taking estrogen were more likely to develop uterine cancer than women who were not receiving supplemental estrogen. Suddenly, no woman was to be placed on estrogen, and if menopausal symptoms were so severe that estrogen therapy was deemed necessary it was to be discontinued as quickly as possible.

Subsequent research demonstrated that uterine cancer could be prevented by administering progesterone in combination with the estrogen. This, along with the observation that osteoporosis was developing more quickly in women who did not receive estrogen, caused a shift to the use of estrogen/progesterone combination regimens. These are still widely prescribed today. Most women are advised that they must take estrogen and progesterone to avoid osteoporosis and decrease their chances of developing heart disease and Alzheimer’s dementia.

Controversy is again entering the realm of hormonal replacement therapy, however, with new studies suggesting a link between progesterone and breast cancer. How this will affect management protocols remains to be seen, but regardless of the outcome some important facts about the substances in common use should be understood.

In the years since this article was written a great deal has been learned about true progesterone.  The breast cancer link appears to be limited to chemicals with progesterone-like characteristics, rather than to actual progesterone.  For details see Will the Real Progesterone Please Stand Up.

For many years the most commonly prescribed estrogen replacement therapy has been conjugated estrogens, the most popular brand being Premarin. Conjugated estrogens are horse estrogens. They are extracted from the urine of pregnant mares. Many consider this a disgusting source, but it is the make-up of Premarin and other conjugated estrogens which is most concerning. Human ovaries produce three types of estrogen: estrone, estradiol, & estriol. While horses manufacture estrone they also manufacture other estrogens, the predominant being equilin. The effect of foreign estrogens on the body is uncertain and many feel that they may increase the risk of developing cancer, particularly breast cancer over time.

In an attempt to eliminate the potentially harmful effects of horse estrogens synthetic estradiol was introduced. This is sold under a number of brand names, Estrace being the most popular. Estradiol was chosen because it is the most effective in relieving hot flashes, but it causes more stimulation of breast tissue than other estrogens and may itself increase breast cancer risk.

Knowing that many women dislike the idea of taking pills derived from horse urine a manufacturer introduced Cenestin, conjugated estrogens synthesized from plant substances, in 1999. Cenestin consists of a blend of nine estrogenic substances based on those found in horses. Shortly after it was introduced I received a call from a drug salesman. He was excited about his new plant-based product. “What’s in it?” I asked.

“We’ve successfully duplicated 9 of the 10 estrogens found in horses,” he boasted.

“Why would you do that?” I responded.

“Because Premarin is the Gold Standard!” he replied.

“Wouldn’t it have been nice to have followed the human standard?” I countered. He quickly ended the conversation, realizing that I would not be a major promoter of his product.

Prescription progesterones also have drawbacks. The most commonly prescribed compound is Provera, which is not progesterone as found in the body, but medroxyprogesterone acetate, a synthetic compound with progesterone like effects. Unfortunately, medroxyprogesterone acetate has a number of unpleasant side effects including headache, nausea, depression, insomnia & weight gain.

Fortunately, many options are available to women as they enter menopause. Each should address her individual condition, using those measures that are indicated.

Menopausal management should first address the diet. Women who eat a predominantly plant based diet experience fewer menopausal symptoms then women who are regularly include meat in their diet. This may, in part, be due to the effects of meat, but it is more likely that estrogen like substances in plants, phytoestrogens, are responsible for the difference.

Most plant-based diets include soy, one of the richest sources of phytoestrogens. Soy contains substances called isoflavones that have been demonstrated to have estrogen like activity in the body. Studies have shown approximately a forty five percent decrease in hot flashes with consumption of 25 grams of soy protein daily. In addition to the reduction in hot flashes soy lowers total cholesterol, LDL cholesterol and triglyceride levels and appears to lower the incidence of breast cancer. It does not increase the risk of uterine cancer and has no known adverse effects.

Soy was once found only as tofu, tempeh, or miso – forms that were rarely found in American meals. Today soy comes in an unlimited number of forms: soy milk, soy nuts, textured vegetable protein (TVP) with meat-like consistency and flavor, cereal, cheese and ice cream. It is even possible to buy chocolate covered soy.

A number of herbal preparations may be used to ease the transition. Some of the most widely used are black cohosh, dong quai, licorice, damiana and vitex. Extracts of black cohosh have been shown to inhibit the growth of breast cancer cells suggesting that it may be helpful in preventing breast cancer. As with other conditions, herbal combinations or blends appear to be more effective than single herbs in managing menopausal symptoms.

Although it is not generally recognized our endocrine (hormonal) system is delicately balanced. When the body is unable to produce adequate amounts of one hormone a stress is placed on the entire system and other glands may be unable to handle the stress. For example, diabetes results when insulin is not being produced in adequate amounts or is not being utilized properly. Diabetics are far more likely to develop thyroid problems than non-diabetics. Therefore, when the ovaries fail during menopause the entire endocrine system is stressed. Using a balanced glandular supplement to support the endocrine system as a whole is often effective in easing the stress of menopause.

While most of the medical community has focused on estrogen replacement, Dr. John Lee has demonstrated that the majority of women continue to produce adequate amounts of estrogen well into their menopausal years. His research has shown that progesterone deficiencies are far more common and are responsible for many problems associated with menopause. Dr. Lee has demonstrated, for example, that while estrogen replacement can slow the rate of bone loss and thus delay the onset of osteoporosis, progesterone supplementation is able to increase bone density over time.

Unlike its synthetic counterpart, medroxyprogesterone acetate, true progesterone is remarkably free of side effects. Rather than triggering headaches, depression and sleep disturbances, progesterone tends to ease these conditions. Progesterone is available as creams or lozenges, often without a prescription. Commonly used dosages are 20 to 40 mg. daily. Studies have demonstrated as much as an 85 percent reduction in hot flashes on this regimen.

While many will do well on non-prescription regimens, some women will find that they require a prescriptive estrogen/progesterone replacement to feel their best. In those cases I advocate the use of a mixture of the three human estrogens commonly referred to as Tri-est. This can be prepared by a compounding pharmacist and is typically administered as a lozenge which is allowed to dissolve in the mouth between cheek and gum. The most commonly prescribed dosage is 2.5 mg., but this may be increased or decreased depending upon response. Progesterone is often combined with the Tri-est in the same lozenge for maximal benefit.

At times, loss of sex drive accompanies menopause. This is often a result of declining testosterone levels. DHEA is a supplement that the body can use to manufacture testosterone along with several other hormones. Up to 25 mg. daily may be taken, often with excellent results. Higher amounts are discouraged as these may cause undesirable hair growth and other masculinizing effects.  An alternative is a Peruvian herb called maca.  Maca has been used for centuries to boost and prolong sexual responsiveness in both men and women.

Menopause should be viewed as a new phase of life rather than as a disease. Each person should approach this phase of life in the manner that is best suited to her individual condition. It should not be approached with dread, nor should a condition in which one will spend up to half of ones total lifespan be treated with neglect. The body should be listened to and symptoms addressed appropriately. Adopting this approach should result in a long, healthy and enjoyable life far beyond the end of the reproductive cycle.