Questions. Answers.
Diana Bitner, M.D., always wanted to be a doctor, and loved being an obstetrics and gynecology physician for twenty years. As her patients aged with her, Dr. Bitner began getting more questions about the symptoms of midlife and menopause—questions she couldn't answer. She went into the world to be educated, became a certified menopause practitioner, and brought information to West Michigan. As she taught herself to use that information, a process to organize and individualize medical information and options for treatment of perimenopause and menopause evolved. She didn't plan to write a book, yet I Want to Age Like That: Healthy Aging Through Midlife and Menopause was born out of her desire to affect women's health more than she could do in an office setting.
Here, Dr. Bitner answers questions from several West Michigan women, on midlife, menopause, and aging.
Q: I've never had trouble sleeping, yet now I'm tossing and turning at night. What causes it? What can I do?
A: There are many causes of sleep difficulties, but most commonly as women transition into menopause, night sweats can make staying asleep difficult. Many women fall asleep and by 3.5 hours, they are awoken because their body does not tolerate the extra ½-degree warmth caused by being cozy under the blankets. And then many women just never get back into a good deep sleep again because of a sweaty T-shirt, being worried about the next day's events, having to go to the bathroom, et cetera. Of course, more serious causes can be the culprit, like sleep apnea, narcolepsy, or significant depression or anxiety. Always check in with your doctor for an evaluation.
Q: How many hours of sleep do you recommend?
A: Approximately seven every night, or 49 per week. If one night is too short, many experts agree that you can make up sleep hours.
Q: I often feel anxious at night. What can I do about this?
A: For many women, unresolved issues are the culprit to feeling anxious. I recommend you make a list in the day hours, when it is light and you are feeling more clear, and at least possible steps to resolve these issues. Anxiety can also come when you are worried about whether or not you will get a good night sleep because you have not been sleeping well recently. I recommend a consistent bedtime regimen, like you might have had as a child or made for your children. After teeth are brushed, et cetera, I recommend you go out of the bedroom to a spot like a chair in the kitchen, and do your metered breathing. This means sit comfortably, open you eyes, close your mouth, and stare at a spot. Just be and breathe. If you think of a thought that won't go away, focus on it for a second, without attaching a story to the thought, and then go back to the sound of your breath. The pesky thought or worry will float away. then be there at least five minutes, and then go to bed. If you lay there and toss and turn, then get back up, go to your spot, and do your metered breathing all over again. It really works!
Q: Does every woman get hot flashes and night sweats? If not, what percentage of women do?
A: 80% of women get hot flashes and night sweats. Some women are just lucky. I do see that women are more likely to not have these symptoms if they have kept extra weight off, are hydrated drinking an extra serving of water for every caffeine and alcohol serving, and stay away from triggers like sugar and stress.
Q: How long does menopause last? Does menopause—specifically hot flashes—go away and come back?
A: Menopause is a phase of aging; once it starts with 12 months of no spontaneous period, it is what you are in for the rest of your life. For many women, even without estrogen, hot flashes will fade away and become rare over 3 – 5 years from the last menstrual period. Women who get menopause symptoms later, for example 7 – 10 years after menopause, are more likely to have risk factors for heart disease such as inactivity, obesity, high blood pressure, high blood sugars, or pre-diabetes. This is because hot flashes are caused by more than low estrogen.
Q: What is the percentage of women who get through menopause without estrogen?
A: Many women choose to not take estrogen or are not able to take estrogen because they have breast cancer or medical conditions such as prior blood clots in the legs or lungs or heart disease, and they get through! A healthy lifestyle is where it all begins with the SEEDS, and there are other medical therapies, including serotonin medications, and alternative therapies, including acupuncture.
Q: Natural hormones versus synthetic: How do you know what's best? How long do you stay on hormones? How do you feel about compound hormones?
A: Define "natural." To me, natural means identical to the hormones the ovary makes. It would be nice if we could smear sweet potato on our skin and have human ovarian estrogen absorb into our bloodstream, but humans and sweet potato estrogen is very different. To get the estrogen from a plant source to be identical to human estrogen, it needs to be altered in the lab. Once it is altered, it needs to be put in a form that will absorb into the blood stream, such as a pill, a patch, a spray, or a cream. Estrogen is a very powerful hormone. At low even doses, we know it is safe for many women and can have very positive effects. At doses that are too high, estrogen increases the risk of serious and life-threatening conditions such as heart attack, blood clot in the leg or lungs, stroke, and uterine cancer. Also, we know that bio-identical progesterone does not adequately absorb through the skin to protect the uterus from cancer, and therefore to take bio-identical progesterone, it has to be put into peanut oil, in a capsule, and swallowed. The cream form sold by many compounded pharmacies is not adequate protection. FDA-approved medications provide the measured doses and constant delivery that allows us to prescribe the lowest effective dose. The goal is to use the lowest dose that works, under a certain safety limit. It is not necessary to know blood and saliva levels, only that there is a reduction of hot flashes and night sweats. If the symptoms are not improved at the top dose, which is safe, then there are other reasons that are causing the symptoms other than low estrogen.
Q: If a woman has had an endometrial ablation, how does she know when she goes through menopause?
A: By symptoms—and sometimes it is necessary to check a blood level of FSH (follicle stimulating hormone). My question would be, why do you want to know? Your symptoms will tell us if anything needs to be done. Also, you are most likely to go through menopause when your mother did.
Q: For heavy bleeding, do you recommend an ablation? An IUD? What do you do when you don't want to opt for a hysterectomy in any form?
A: Heavy bleeding in perimenopause is very common, and the most important first step is to figure out why the bleeding is occurring. An ultrasound and endometrial biopsy are the first necessary steps. If there are anatomical reasons like uterine fibroids, then an ablation will not likely be effective. If the reason is pure hormone fluctuations near menopause, then an ablation will likely be effective. I frequently recommend a Mirena IUD because it contains progesterone and it keeps the lining of the uterus thin and treats heavy bleeding for most women with heavy bleeding from hormone changes, does not require surgery, and is reversible. Even women who are very sensitive to progesterone do not notice the hormone, because the amount that gets out of the uterus is very low.
Q: I've had a full hysterectomy. How long could I safely be on estrogen?
A: The length of time that estrogen will be safe depends on your overall health. I tell my patients that if they keep a healthy weight, stay active, avoid pre-diabetes or diabetes, and if they have high blood pressure, make sure it is well treated with a healthy lifestyle and medications. Women who are at risk for heart attacks on hormones are women who have metabolic syndrome, or a combination of high blood pressure, pre-diabetes, high cholesterol, and central obesity. Stay healthy and you can have it longer. Some studies show that women who take estrogen and synthetic progesterone have an increased risk of breast cancer. The risk appears to be small (3/10,000 women), and therefore the discussion needs to be individualized and had every year with you and your doctor/NP/PA.
Q: I had a hysterectomy at age 43, and my weight keeps fluctuating. I don't have any signs of menopause. Do I need estrogen and/or testosterone to help keep my weight down?
A: A recent study did show that women entering perimenopause who took patch estrogen had a lower risk for insulin resistance, or a change in sugar metabolism that makes it easier to gain weight and hard to lose. I would start by an overall assessment of your risk factors for weight gain such as having a family history of diabetes, diabetes in pregnancy, inactivity, or a diet high in simple carbohydrates. Along with a healthy lifestyle, estrogen can be helpful to helping keep a healthy steady weight.
Q: Is ovarian cyst proliferation related to menopause, hydration, or calorie intake?
A: Ovarian cysts develop as a result of a follicle or baby egg developing in your ovary. Most women make a cyst every month as a result of ovulation.
Q: How do you treat polycystic ovarian syndrome (PCOS)?
A: PCOS is best treated with regular exercise including strength training and a diet low in simple carbohydrates. Birth control pills or the Mirena IUD protect from heavy bleeding and pre-cancer of the uterus. Sometimes the use of the medicine glucophage or Metformin(R) can be helpful. the reason this combination works is that most PCOS is caused by high insulin levels and an ovary more sensitive to high insulin.
Q: If you've improved your health choices—lost belly fat, exercising, drinking more water—can you continue to be insulin-resistant, or does this improve?
A: Sometimes it is necessary to add a medication called glucophage to reduce insulin resistance. Even taken for a short time, it can help make your efforts more effective. And some women will always be at risk for rapidly becoming insulin resistant again, but it can be controlled-including the bad effects of the medical condition including obesity, diabetes, heart disease, and stroke.
Q: What will help prevent recurring yeast infections caused by hormonal imbalance? Are bladder infections related to menopause? They're new to me.
A: Yes, because of low estrogen in the vagina, the acid level changes and makes the vagina more susceptible to infection leading to more bacteria being close to go up into the bladder. If you are sexually active, you are more likely to have a bladder infection after sex. Also, low estrogen can change the anatomy, making the opening of the bladder (urethra) almost look shrink wrapped, more tipped downward, and more open to bacteria. Taking vaginal estrogen can reduce the occurrence.
Q: My handwriting has changed considerably in the past few years, through perimenopause, and has not gotten better. Is there any correlation?
A: As women age, especially if also becoming less active and losing muscle mass, the grip strength can be reduced, perhaps changing handwriting.
Q: Hypothyroidism. Depression. Stress. Total hysterectomy. Vaginal dryness. Poor body image. Do I need hormone therapy? How could I feel better?
A: This is a lot! And, unfortunately, all too common! Hormones might help, but not without assessing your total picture and having clear expectations for hormone therapy. We prescribe hormones for specific symptoms like hot flashes, night sweats, vaginal dryness, and to prevent osteoporosis. You have at least one of those symptoms, so hormone therapy could be the right thing. If the result of the hormone therapy is better sleeping and therefore improved motivation to improve your lifestyle starting with the SEEDS, then we have a success. The next step would be determining if hormones are safe for you; for example, has it been less than 10 years since your last period, have you had a blood clot in your legs or lungs, do you have migraine headaches with loss of vision, or have you had breast cancer? These are factors that would determine if—and how—you would be able to take hormones.
Q: Why is one of my breasts much bigger now—since menopause?
A: I am not sure. Usually women will have one breast larger than another, but I would imagine the changes after menopause would be symmetrical. If you have not yet had a screening mammogram, I would recommend to determine whether you have a breast cyst or other changes making the size difference, as well as a physical breast exam.
Q: I have trouble with concentration. Is this related to being 47?
A: Midlife is a time where many women have a lot going on. If we get stuck in flight-or-fight—as in overwhelmed or overstressed with just too many things on our plate—the brain has a hard time storing memories or retrieving memories, therefore making it difficult to concentrate. Also, if you are not sleeping well, your brain does not have time to process all the day's events and replenish brain chemicals. I think of brain chemicals like money in the bank. On the positive side of your brain chemical balance sheet, we make brain chemicals when we sleep, and genetically some women make more than others. (Yes, therefore anxiety and depression can run in families.) On the spend side of the balance sheet, we spend brain chemicals on life events—picking out clothes to wear takes only a little brain chemical, but a kid having a hard time in school, relationship issues, or a sick parent costs lots of brain chemicals. When there is a deficit, we start to not feel like ourselves—with anxiety, depressed mood, not feeling like doing the things we normally like to do, over-reacting to stupid things, et cetera. Treatment is sleep, at least moderate small amounts of exercise, metered breathing, writing in a gratitude journal, et cetera. Having a plan is crucial, and my book I Want to Age like That! could help you find that plan. If you already have it, I hope the book helps.
Q: What can I tell my husband or partner about all of this?
A: Like I say in the book, it is not about them. It is not their fault, and they cannot fix it. The changes are normal, and with a good partnership and support, it can be a phase that adds to the relationship, not takes away. This can be an opportunity to learn more, go over issues that maybe have been pushed under the rug for too long, and focus together on a healthy simple lifestyle. Also, it will happen to them 10 years or so after it happens to women, so what comes around goes around! If your partner is a woman, especially so. I have patients who are in same-sex relationships, and it helps if menopause does not happen at the same time—that can be trouble!
