Midlife Issues A to Z

The information given below is not intended to give specific medical advice but only to provide basic medical information about these topics. Its purpose is for education only and it should not be used for diagnosis or treatment. This information is not intended to replace the need for discussing these issues with your health care professional.

- Menstrual periods frequently become irregular during perimenopause due to infrequent ovulation. Other causes include pregnancy, uterine fibroids or polyps, hormone imbalance, changes in weight, excessive exercise, stress, illness, or certain medications. Cancer of the cervix, uterus, or vagina may present as abnormal bleeding. Treatment of abnormal bleeding depends upon the underlying cause. Abnormal bleeding should be evaluated by a health care provider right away.

- Natural healing therapies can play a role in overall health promotion and maintenance. These therapies include the use of diet, vitamins, herbs, yoga, meditation, essential oils, acupuncture, spinal manipulation, homeopathy, exercise, massage, and biofeedback.

Are alternatives safe? Most botanical products such as herbs and phytomedicinals can be sold as dietary supplements as long as they make no health claims and are not proven unsafe. There is no safety or efficacy data on most botanical products. It is important to recognize that herbal remedies may lack uniform quantities of active ingredients or contain contaminants which may be dangerous. Claims may be unsubstantiated. There are known harmful herbs. Some contain carcinogens (borage, calamus, coltsfoot, comfrey, liferoot). Some have potential for liver toxicity which can lead to liver failure (chapparal, germander) and some Chinese herbs have been associated with kidney damage leading to kidney failure and requiring kidney transplant.

How can I use alternatives safely?

  • To be safe, buy products that detail all the ingredients, "standardized extracts."
  • Let your physician know what you are taking and consult about drug interactions and potential toxic side effects. Rely on medical research, not packaging claims.
  • Don't take any herb every day -- effects could be cumulative.
  • Don't take a large amount of any one preparation -- no idea how much is toxic.
  • Don't use if you are pregnant, nursing or planning pregnancy.
  • Don't give herbs to infants or children under 2 -- their livers are immature and can't detoxify toxins as well as adults.

Handout Available on-line from Alternative/Complementary Therapy for Midlife Seminars given at Midlife Health Center

brea2.jpg (6477 bytes) - Most breast problems, especially in younger women, are benign. These problems may include breast pain (known as mastalgia), fibrocystic breast changes, fibroadenomas, and microcalcifications. Cyclic breast pain is most often due to hormonal changes. Noncyclic pain is probably not hormonal and should be evaluated [self breast exam, mammogram, & breast cancer]. Fibrocystic changes are most common between the ages of 25 - 50. These changes include cysts, thickened and tender areas, and tender lumps that may vary in size from month to month. Fibroadenomas are solid, benign lumps that occur most often in young women. Microcalcifications are tiny deposits of calcium which may be indicative of cancer, but not always. Breast calcifications are not well understood and may be a result of inflammation or injury of the breast.

- Breast cancer is the most common cancer in women. Over 182,000 women will develop breast cancer this year. One woman in nine will develop breast cancer during her lifetime. Breast cancer is the leading cause of cancer death in women aged 34 - 50. Monthly self breast exams, annual breast exams by the health care provider, and regular mammograms are the best way to detect a lump early. When diagnosed early, breast cancer is nearly 100% curable. Known risk factors include: previous breast cancer, close female relatives with breast cancer, such as a sister, mother, or daughter, abnormal cell buildup diagnosed on a breast biopsy, early menstruation (before age 12), late menopause (after age 50), childlessness or late first-time motherhood (after age 35), certain ethnic groups, such as European Jews and Northern Europeans. Although there is no way to prevent breast cancer, the risks can be reduced by: regular exercise, diet low in fat and high in vitamins A & C, eating lots of fiber from grains, fruits, and vegetables, and eliminating alcohol. [ More Resources]

- A thorough medical exam should include a review of your social, family, and medical history, psychosocial-sexual issues, a physical examination, any necessary laboratory evaluations, immunizations, and nutrition, exercise, and safety issues.

- According to the American Cancer Society, an estimated 131,200 new cases of colon and rectum cancer will be diagnosed in 1997. Screening tests for colorectal cancer include tests that identify blood in the stool, flexible sigmoidoscopy, and colonoscopy. Signs & symptoms of colorectal cancer include rectal bleeding, blood in the stool, or a change in bowel habits. Risk for colorectal cancer can be minimized with regular exercise, high fiber diet, and adequate intake of fruits and vegetables. Recent studies suggest that estrogen replacement therapy may be beneficial in reducing the risk of colorectal cancer.

- Depressed feelings during midlife are common. These feelings may result from lack of sleep, hot flashes, and other signs of menopause. Mood swings may be caused to changes in the estrogen and / or progesterone levels. Any major life change, such as menopause, can also cause emotional distress. Declining estrogen does play a role with wider emotional reactions. It is important to have a complete physical as well as psychological evaluation to determine if your are suffering from clinical depression. Once clinical depression begins, it can last for weeks, months, or even years if untreated. However, 80% of individuals who are depressed will recover with appropriate treatment. [ More Resources]

- Exciting new research has discovered synthetic estrogenic compounds which have both estrogenic and anti-estrogenic effects. Raloxifene, trade name Evista, is a second generation of tamoxifen. Tamoxifen is currently used in many breast cancer survivors to decrease the risk of recurrent breast cancer and is now being studied for prevention of breast cancer. However, tamoxifen has been shown to increase the risk of uterine stimulation with polyp formation and a slightly increased risk in uterine cancer. The new SERMs (selective estrogen receptor modulators) or designer anti-estrogens like raloxifene have estrogen-like activity on the cholesterol profile (lowering the risk of heart disease). They also increase bone mineral density (lowering the risk of osteoporosis) and appear to potentially decrease the risk of breast cancer and uterine cancer. Evista is FDA approved for the prevention of osteoporosis and has been available since January 1998. New compounds are in research.

- Good nutritional practices play a key role in maintaining a healthy body weight and promoting general good health and vitality. After menopause, many women gain weight; the weight gained tends to be distributed above the waist which is a risk factor for many chronic diseases such as heart disease and diabetes. Additionally, the decreased amount of estrogen during the perimenopausal and postmenopausal years alters a woman’s blood lipid profile and bone status negatively. Therefore, it is important during this phase of your life to maintain a healthy body weight and eat healthy foods. [ Nutrition Services available at Midlife Health]

- A procedure where a small portion of the uterine lining is removed for laboratory evaluation using a microscope.

- Endometriosis is a condition where tissue that looks and acts like the lining of the uterus is found outside of the uterus elsewhere in the body. Since this tissue thickens and breaks down like the uterine lining, inflammation and scarring results at the site of these implantations. Symptoms of endometriosis include: painful menstrual cramps, infertility, and painful intercourse. Treatment may include hormonal therapy and surgery.

- Estrogen is secreted primarily by the ovary (and placenta during pregnancy). Estrogen stimulates growth of the ovary and egg follicles, growth of the muscle & lining of the reproductive tract, growth of external genitalia, breasts, female body shape (narrow shoulders, broad hips, female fat distribution), thins sebaceous gland secretions, growth of female body hair pattern, bone growth, stimulates retention of fluid, and protects against atherosclerosis (build-up of plaque in the blood vessels).

- For women in whom estrogen is contraindicated or who choose not to take estrogen, strategies are available to provide many of the benefits of estrogen. These include statins or cholesterol-lowering agents which prevent heart disease. FDA-approved options for osteoporosis treatment includes alendronate (trade name Fosamax) and nasal calcitonin (trade name Miacalcitonin). For prevention of osteoporosis, Fosamax and the new raloxifene (trade name Evista) [designer estrogens] are available. For mood changes or depression, antidepressants such as serotonin uptake inhibitors are available. For control of hot flashes, Vitamin D, clonidine and progesterone have been shown to be more effective than placebo. Vaginal moisturizers and lubricants are available to help with vaginal dryness.

- Scientific data continues to accumulate. Studies continue to show that estrogen therapy decreases the risk of heart disease, both through its effect on cholesterol and its effect on heart vessels. Bone density is maintained with a decreased risk of fracture. New studies suggest that estrogen may decrease the risk or severity of macular degeneration of the eyes, tooth loss, Alzheimer's disease and colon cancer. Most of these studies are epidemiological, thus suggestive but not proof. Major concerns about estrogen continue to be the need for progesterone to protect against cancer of the uterus and whether long-term use, defined as anywhere from 5 to 15 years, increases the risk of breast cancer.

- Heart disease is the leading cause of death for U.S. women over 55. Heart & blood vessel disease kills twice as many women each year as all cancers combined. Women usually develop heart disease after menopause, around 10 years later than men. Women who take estrogen replacement [HRT] have 40% fewer heart attacks and less chance of dying from heart disease than those not on estrogen replacement. Risk factors include: age, family history, race, diabetes, early menopause, cholesterol levels, estrogen levels, blood pressure, cigarette smoking, social isolation, excessive weight, excess alcohol, and inadequate exercise. Estrogen appears to reduce the risk of heart disease by: reducing total cholesterol, decreasing LDL (bad) cholesterol, increasing HDL (good cholesterol), decreasing plaque formation inside the blood vessels, increasing blood flow to the heart & brain, and improving flexibility and elasticity of arteries and blood vessels. [ More Resources]

- Hormone replacement therapy is available to women during perimenopause and menopause. Each woman should discuss this decision with her care provider. Short term (<5 years) therapy is helpful in dealing with the signs of menopause. Long term (>10 years) therapy can help prevent osteoporosis, cardiovascular disease, and possibly Alzheimer’s disease and colon cancer. Risks of hormone replacement therapy may include endometrial cancer and breast cancer. Endometrial cancer risk [endometrial biopsy] can be minimized by using estrogen and progesterone in combination for women who have their uterus. Women who have had a hysterectomy are not at risk for endometrial cancer and therefore do not need progesterone. Concern about the risk of breast cancer in women who take hormone replacement persists. Higher doses of estrogen (1.25mg) or use over long periods of time (>10 years) may be associated with a slight increased risk of breast cancer. Low doses, such as 0.625 mg, have not been associated with any increased risk.

Long term HRT, usually 10 years or more, is felt to provide major health benefits including a reduction in heart disease even with documented heart disease and a reduction in osteoporosis and osteoporotic related fractures. Possible benefits include a delay or decrease in the severity of Alzheimer's (even if Alzheimer's is already diagnosed), preservation of tooth enamel and less tooth loss, decrease in risk and death from colon cancer and prevention or less severity of macular degeneration of the eye. Concerns or risks include ongoing risk of uterine cancer if adequate progesterone is not given and possible increased risk of breast cancer. There are over 30 studies evaluating the risk of breast cancer with estrogen use and the results are conflicting. This means that if there is an effect, it is small. Breast cancer survival appears better if a woman is on estrogen when her breast cancer is diagnosed.

- Hysterectomy is a surgical removal of the uterus. Sometimes, the ovaries are also removed. This surgery may be done through the vagina or it may involve an abdominal incision. Hysterectomy may be necessary due to cancer, rapidly enlarging fibroids, uncontrolled vaginal bleeding, or for other reasons.

- Insomnia may be: transient (last a few days), short-term (last a few weeks), or long term (last indefinitely). Transient insomnia may be due to stress, mild pain, or jet-lag. Short-term insomnia, common in menopausal women, may result from anxiety, nervousness, or physical and mental tension. Long-term insomnia may be due to environmental factors (living on a busy street), health factors (heart disease, arthritis, ulcers), sleep apnea, or due to chronic alcohol or drug use. There may be difficulty falling asleep or staying asleep. Relief options include: avoidance of stimulants, regular bedtime routines, regular exercise, herbal teas, maintaining a dark, quiet sleep environment. Hormone replacement therapy may also be helpful.

- Pelvic floor muscle exercises, commonly called "Kegel exercises" are intended to strengthen these muscles. The mechanics of Kegel exercises is accomplished by contracting these muscles to stop the flow of urine. By constricting these muscles and holding for a short time (commonly to the slow count of 10), on a repetitive basis (10 to 15 times in a row at least 4 times / day), the pelvic floor muscle tone can be improved.

- While mammograms do not detect 100% of breast cancer, on the average a mammogram can detect a lump 2 years before it can be identified on a breast exam. Mammograms become more effective as women grow older because the breast becomes less dense, making it easier to detect an abnormality. A mammogram is simply an X-ray with the breasts pressed between two plastic plates. The radiation exposure is extremely low and is not felt to contribute to breast cancer risk. [American Cancer Society Mammogram schedule]

- By definition, menopause is the absence of menstrual cycles for one year. Commonly, menopause is used to refer to the series of changes that occur as the body produces less estrogen. The average age of menopause for American women is 51 years, with the range typically 45 to 55 years.

- Signs of menopause may include: hot flashes (warm feeling the may include redness around the face, neck, back, & chest), hot flashes at night (called night sweats), insomnia, headaches, vaginal dryness, depression or emotional turmoil, fatigue, nervousness or anxiety, short-term memory loss, decrease or lack of sexual desire, joint or muscular aches, frequency or urgency of urination.

- Often occur on only one side of the head and can last several hours to 3 or more days. Symptoms include: nausea & vomiting, pulsing or throbbing pain, sensitivity to light or sound, seeing spots or shimmering lights with eyes closed, numbness of lips, tongue, fingers, or legs before headache, blind spots, tunnel vision, or double vision. Most likely due to temporary enlargement in blood vessels in the brain. Sudden decreases in estrogen is associated with migraines in 60% of women who have migraines. Other triggers may include: alcohol, certain cheeses, citrus fruits, processed meats, food additives, peanut produces, chocolate; fatigue, stress; excessive light, heat, or noise; and certain smells. To help prevent migraines: avoid triggers, exercise regularly, talk with your health care provider about hormone replacement.

- Osteoporosis is an exaggerated loss of bone tissue, which makes the bones more susceptible to fracture. Half of all women over the age of 50 will have a fracture as a result of osteoporosis. Risk factors for osteoporosis include: thin or small bone structure, heavy tobacco or alcohol use, Caucasian or Asian, inadequate exercise, family history of osteoporosis, low dietary calcium intake, certain medications (steroids, heparin, thyroid, methotrexate, progesterone injections). There is no cure for osteoporosis, however, there are ways to prevent or slow its process. By maintaining estrogen [HRT] levels, the rate of mineral loss can be slowed. Calcium, vitamin D, and certain medications are helpful in preventing or slowing the progression of osteoporosis. [ More Resources]

- Ovarian cysts are growths that occur on the ovaries. These cysts may be fluid-filled and may occur before or after ovulation. Ovarian cysts may be benign or malignant (cancerous). They may have no symptoms or be associated with disturbances in the menstrual cycle, and pelvic pressure or dull pain. [ Ovarian Cancer]

- A Pap smear or test involves examining cells from the cervix under a microscope to identify any abnormalities. These cells are obtained during a pelvic exam by using a spatula and soft brush. The cervical cells are then placed on a microscope slide for examination under a microscope by a pathologist. Pap smears are only a screening test for abnormalities, not a diagnostic test for cancer. Most women over the age of 18 should receive a Pap smear once a year, but certain women may require testing more or less frequently. [ More information on Pap tests]

- Two primary muscle groups form the bottom of the pelvic diaphragm. Certain factors, such as aging and childbirth trauma, may weaken these muscles. Pelvic relaxation may result in poor support of the bladder, uterus, rectum, and small intestines. Symptoms include intense pelvic pressure, difficulty passing stools, and leaking of urine. Although pelvic relaxation is not life threatening, most women benefit from prevention of relaxation or desire treatment should it occur. Kegel exercises can strengthen pelvic muscles and play a role in treatment and prevention. Estrogen therapy helps thicken the lining of the vagina, bladder, and urethra and is helpful with mild relaxation. A pessary (device designed to help support the pelvic organs) may be used in the vagina for support. Severe pelvic relaxation can only be corrected with surgery.

- Refers to the period of time "around menopause." Menopause does not occur suddenly; the entire process takes years. Estrogen levels begin to decline during the mid-30s. During perimenopause, menstrual cycles may become irregular, and the amount of menstrual flow may vary. PMS may develop or worsen.

- Premenstrual Syndrome (PMS) is a collection of symptoms some women experience just prior to the menses. To identify PMS, cyclical timing is more important than the actual symptoms. Each pattern of PMS symptoms must be followed by a symptom-free phase. Symptoms usually begin at or near ovulation and reappear at about the same time each month. Symptoms may include: Headaches, irritability, mood swings, anxiety, weeping, tension, frustration, change in sex drive, acne, water retention, weight gain, breast tenderness, and fatigue. The cause of PMS has not been determined. However, it is believed to be related to changes in the hormone levels. Tips to relieve PMS include lowering alcohol and caffeine intake, eating a well balanced diet, and exercise.

- Progesterone is secreted by the corpus luteum - the ruptured egg follicle on the ovary (and placenta during pregnancy). It stimulates the endometrial glands (inside the uterus) to secrete the menstrual period, induces thick, sticky cervical (mouth of the uterus) mucus, decreases contractions of the uterus muscle and fallopian tubes, and stimulates breast growth.

- Most breast lumps (90%) are discovered by women while checking their own breasts. A woman who is familiar with her own breast anatomy may notice a new lump or changing area before her health care provider can feel it. The breasts should be examined on the same day each month (2 to 3 days after the menstrual period for women still menstruating regularly). During this exam, the woman looks for new lumps, thickening, or hardening in the breast or under the arms, changes in breast size or shape, nipple discharge, dimpling or scaling in the skin or nipple, changes in color or texture of the breast skin, retraction (pulling in) of the nipple, or any other unusual appearance of the skin or nipple.

- Physical & mental health, cultural expectations, hormonal changes, medication, and relationship issues all play a role in each person’s sexuality. During menopause, all of these factors may be changing at once. Vaginal dryness can usually be alleviated with a vaginal moisturizer, a water-based lubricant, extended foreplay, and regular sexual activity. Other treatments include estrogen given locally in creams or in a new estrogen ring. Systemic estrogen therapy, either by mouth or by patch, may improve both vaginal dryness and sex drive. Supplemental testosterone may be at least partially effective in improving sexual response for women who have had their ovaries surgically removed or have low testosterone after menopause. Slower arousal time and decreased orgasm intensity are normal aspects of aging and do not necessarily indicate rejection or lack of interest in sex.

Do men have changes in their sexual function also? Yes, men often have changes during this time, including less firmness, slower response and increased risk of impotence (inability to achieve erection or orgasm). There are new treatments now available for men with impotence including testosterone shots and patches and a new prostaglandin gel inserted into the urethra. Men who desire help should consult with the physician or a specialist in urology. [ More Resources]

- The thyroid is a gland in the neck that secretes hormones necessary for normal development and function of the central nervous system, regulation of body heat and temperature regulation, and body growth. This gland may produce excessive or insufficient hormones. Signs & symptoms of hypothyroidism (insufficient hormones) include fatigue, cold intolerance, weight gain, depression, hair loss, and decreased memory. Signs & symptoms of hyperthyroidism (excessive hormones) include nervousness, tremors, weight loss, anxiety, sweating, heat intolerance, heart palpitations, and warm, moist skin. Blood tests are used to measure the level of thyroid hormones in the body. Symptoms of thyroid disease are similar to perimenopausal symptoms. Therefore, screening to rule out thyroid disease during the perimenopausal period is helpful.

- There are four types of urinary incontinence:

  • Stress incontinence is the loss of urine during coughing, laughing, straining, stretching, or brisk walking.
  • Urge incontinence occurs when once the urge to void is felt, the bladder must be emptied immediately, or there is leakage.
  • Unstable bladder refers to spontaneous contraction of the bladder that results in voiding.
  • Overflow incontinence occurs when the bladder does not fully empty with voiding and becomes overdistended. The result is a persistently full bladder that dribbles continuously.

Treatment depends upon the type of incontinence. Incontinence may improve with increased fluid consumption to dilute the urine, regular consumption of fluid throughout the day, avoidance of spicy / acidic foods, limitation of alcohol / caffeine / Nutrasweet / chocolate, and establishment of a regular voiding schedule.

- Declining estrogen levels may cause the urinary tract tissues to become thinner and dryer. The bladder may become smaller and less elastic, therefore holding less urine or cause the feeling of urinary urgency at smaller amounts than prior to menopause. These changes may lead to the development of urinary tract infections. Incontinence may develop or worsen. Kegel exercises (exercises of the pelvic floor) will help tone these muscles. Medical treatment is necessary for treatment of urinary tract infections. Hormone therapy may help improve tissue elasticity and integrity.

- There remains an increased risk of uterine cancer with estrogen taken alone. Progesterone given in adequate amounts for an adequate length of time protects against this risk. Types of progesterone which are FDA approved and available include medroxyprogesterone and norethindrone acetate. Typical doses include 10 mg a day for 10 days, 5 mg a day for 12-14 days, 2.5-5 mg a day continuously or every day. Some providers are prescribing the progesterone every 3 months based on a study which showed no increase in hyperplasia, the pre-cancer condition of the uterus, after one year. Progesterone creams are not believed to be effective at protecting against uterine cancer and have not yet been well studied. A natural progesterone, oral micronized progesterone, has been tested and is effective but is not yet FDA approved. It is currently available through compounding pharmacies.

- Uterine fibroids are benign (not cancerous) growths in the uterus. They occur in 25% of all women, but are more common in African-American women.

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Fibroids develop from cells in the uterine muscle and may be located inside the uterus, within the uterine muscle, on its surface, or attached to a stalk outside the uterus. Most fibroids, even large ones, produce no symptoms. Fibroids require treatment only is they are enlarging or prevent conception. Treatment is usually surgical removal, although medications may temporarily shrink them.

- Symptoms include vaginal dryness, pain during intercourse, or increase in vaginal infections. Atrophy of the vagina is caused by low estrogen levels. The vagina may become thinner, paler, smaller, and the walls may lose their elasticity. Water based lubricants, vaginal moisturizers, and creams and vaginal inserts containing estrogen can help.

To prevent or treat vaginal dryness, estrogen can be given either systemically by pill or patch or in the vagina. There are vaginal creams which contain estrogen and are used 2-3 times per week. There is some systemic absorption with estrogen being detected in the blood. If used in larger amounts, levels equivalent with those seen when oral estrogen is taken can be present. There is a new vaginal estrogen ring which delivers a small amount of estrogen over 3 months (trade name Estring). After an initial "burst" effect with low levels detectable in the blood, there is no detectable estrogen in the blood, although there may still be a small amount absorbed. Both the vaginal cream used in small amounts and the vaginal ring deliver primarily local effects of estrogen to the vagina and bladder. In addition to improving vaginal dryness and decreasing pain with sex, the local estrogen may improve bladder function, lessening incontinence or frequency of urinary tract infections.

- Infections, chemical irritations, medical problems, certain medications, foreign objects, or disturbances in the hormone balance may lead to irritation in the vagina. Vaginitis causes redness, swelling, and irritation of the outer genital area, and discharge from the vagina. Common vaginal infections include: yeast vaginitis, bacterial vaginosis, trichomoniasis, herpes, and genital warts.

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JoAnn Pinkerton, MD