Menopause · for Health and Care Excellenceʼs proposal to publish its first clinical guideline on...

MenopauseMatters

TM

Issue 36

My MenopauseBarbara

Eat like a womanSSttaanneessss JJoonneekkooss

Dr Currie’s clinic

Winner - Scottish Magazine Awards

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2 MENOPAUSE MATTERS 2014

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MENOPAUSE MATTERS 2014 3

contentsMy Menopause - In one of the most disturbing accountsof a menopause experience we have published, BarbaraJackson tells her story and how she nearly took her life 6

Eat Like a Woman - Staness Jonekos reckons most dietplans are derived from the biology and physiology of aman, not an ideal situation for a woman ........................ 8

Diabetes - when the menopause comes with a drop inhormones and a bundle of symptoms the fluctuations inblood sugar level must be carefully monitored ............. 12

NICE - Dr Heather Currie welcomes the National Institutefor Health and Care Excellenceʼs proposal to publish itsfirst clinical guideline on the diagnosis and managementof menopause ...............................................................14

My Menopause - Armrget Kaur could sense there wassomething not quite right about her health but it tooksome time before her flushes, erratic periods and fatiguewere properly diagnosed ............................................. 16

You Matter - we examine the usefulness of exfoliatingand the role of collagen; visit Liverpool on a girlsʼ guide;welcome our guest chef from Estepona and look at someof the latest beachwear, while Kathleen Stewart takes usthrough a series of Pilates exercises ...................... 18-25

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12

16

The future is

NICE14

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welcomeLadies, I have a confession to make. A fewissues ago I introduced you to "porridger-cise" my two-minute blast of activity whilecooking porridge in the microwave. I wasdoing really well, starting each day withsome exercise and a healthy breakfast butwhat happened? I went on holiday, whichwas fabulous, but my routine was upset. Onreturn, I just didn't manage to get back intothe habit that I had so proudly described.How could this be? I know how importantweight control and exercise is, yet it is soeasy to afford something else the prioritythat exercise deserves.

Becoming menopausal can have manyconsequences, not least a detrimental effecton our weight, metabolism, glucose and insulin control and subsequently our hearthealth. As I have said, written, tweeted and

blogged many times, the menopause is notjust about flushes and sweats. At this periodin our lives it is hugely important to focusand invest time and effort in ourselves andour health, take control, increase exercise,eat healthily, stop smoking (at least I don'tsmoke), take alcohol in small amounts andbe moderate with caffeine. All these simplemeasures can help reduce symptoms andimprove heart, bone and breast health.

Whether or not we choose to take HRT oralternative therapies or techniques forsymptom control, let's not forget the simplestuff. Healthy eating and an exercise assimple as walking can make a huge differ-ence. Having given myself a good talking to,I am back on track with regular walking anda smattering of zumba, I have even reintro-duced "porridgercise". Any exercise is good,let's just not sit!

Menopause,let's not pause,keep active!


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ADVERTISEIf you would like to tell us about yourmenopause or if you have any

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Contact Menopause Matters

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The 14th world congressof the InternationalMenopause Society was

held on May 1-4 in Cancun,Mexico. Delegates heard aboutthe latest research and find-ings on a variety of topics fromspeakers representing manycountries from around theworld. Menopause clearly doesnot take a holiday or is selec-tive and women everywhereare affected. Throughout thisissue of Menopause Matterswe give a brief summary ofsome of the main subjects thatwere discussed.

Does low-dose HRT work?Doses of estrogen used inHRT have gradually reducedand statistics were presentedon the effect on menopausalsymptoms of a preparationcontaining only 0.5mg estradiolalong with progestogen. Results showed a rapid re-

duction in symptoms of flushesand sweats by week three oftreatment. Further improve-ment continued. The reductionin symptoms was statisticallysignificantly greater in women taking the ultra low-dose HRTcompared with those takingplacebo. The treatment had excellent

tolerability with little or neutraleffect on breast density. Thus,when treating any condition,there should be no need totake a higher dose of treatmentthan necessary and startingwith ultra low-dose HRT shouldbe encouraged.

Study on diabetic drugA common anti-diabetic drugcould hold the key to prevent-ing the disease in obesewomen. Menopause is knownto be linked with increases inbody fat, body mass index(BMI), resistance to insulin,glucose intolerance and risk ofdeveloping Type 2 diabetes. More than 380 million people

world-wide have been diag-nosed with the disease, buthealth experts fear the numberaffected is set to dramaticallyincrease with rising obesityrates.Metformin has been used for

many years to treat Type 2 dia-betes and acts by increasingthe sensitivity to insulin. A trialthat compared the use of Met-formin and placebo in 120

days per week and by 60%from 30 minutes six days perweek.

Is HRT good for the brain?New data from the KEEPScognitive study were presentedand showed that HRT startedwithin a few years of themenopause provided no effect,good or bad, on aspects suchas verbal learning and mem-ory, auditory attention, workingmemory, visual attention ortests of cognition compared towomen taking placebo. A trend for benefit for estro-

gen-only therapy was seen formemory function tests, thoughthis was not statistically signifi-cant. While it is reassuring thatno adverse effect was shownfor use of HRT, these resultswould indicate that HRT shouldnot be relied upon for improv-ing these aspects of brainfunction.A beneficial effect was seen

on mood that was sustainedover four years.

requires oxidation of the fattymolecules LDL (Low DensityLipoproteins). It appears that estrogen pre-

vents this process at the vessel wall and so may indeedbe important in preventing car-diovascular disease, as hasbeen predicted for many years.

Walking is bestWhile debate continues aroundthe effects on cardiovascularrisk for differing types androutes of HRT, exercise assimple as walking can make abig difference. Cardiovascularrisk in women can be reducedby 30% to 40% with as little as30 minutes of exercise three

women aged 35 to 65 whowere obese with a BMI greaterthan 30 showed a significantdecrease in insulin resistance,weight and BMI in the womentaking metformin. The participants were given

the drug or a placebo twicedaily for 26 weeks. Womenwho had 1700mg/day of Met-formin had improved insulin resistance and weight loss andit had the preventive effect onwomen with excess abdominalweight, but not those who weremorbidly obese.The research was conducted

in Melbourne by Monash Uni-versity's Professor SusanDavis who said: “These prom-ising findings could have animpact on the treatment ofpeople at risk of diabetes andultimately, reduce the numberof new cases of this deadlydisease.”

Can ovaries be reawakened?Encouraging research hasshown that ovarian failure maynot be irreversible after all.Ovarian stem cells (oocyte pro-ducing oogonial stem cells) inmouse models have been re-activated so that new egg cellscan be produced. And with thisongoing ovarian function, micehave aged much better. Much work is still to be done

in researching this potential inhumans, but this exciting find-ing may completely change theway we view ovarian functionand may offer hope to womenwith premature ovarian insuffi-ciency.

Effect of HRT on the arterialwallInterest continues to surroundthe effect of estrogen in theform of HRT on blood vesselwalls and the role it plays inthe potential prevention of ath-erosclerosis (narrowing of theblood vessels by fatty plaquesleading to cardiovascular dis-ease). Part of the process ofdeveloping the fatty plaque

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My name is BarbaraJackson and I am 51years of age. I held the

opinion that menopause wouldfind me feeling hot, I would getHRT and I would be zoomingaround better than I was be-fore. I should have realisedthings would be different aftermy mother had a hysterectomywhen I was a teenager andhad a breakdown some timeafter with much anxiety andlack of sleep.My periods have always been

difficult, I have three childrenall born early due to pre-eclampsia (a condition that af-fects some pregnant women)and I had one stillbirth in 2002due to a placental abruption. Iwas lucky to have two morechildren soon after this, whichhas me the proud mother of a25-year-old daughter, a nine-year-old daughter and aneight-year-old son. My life has been interfered

with by troublesome periods. Ittook me many years to con-ceive again after my firstdaughter but I never gave uphope even after the stillbirth. Ieven moved house to down-size and pay for IVF, whichwasn't needed as I got preg-nant naturally but it left me in aless than perfect home for awhile. I had anxiety in the 1990s

and connected it to hormonesafter a miscarriage but no-onelistened to me, it left me and Inever looked back apart fromsaying I would never let it hap-pen again and would fight ittooth and nail. I always suf-fered with my periods, usuallya day or so before, having verybad nausea, anxiety and pain.You can cover that up thoughfor a couple of days eachmonth, no-one notices youhaving an early night or notdoing much on those two days. One thing that sticks in my

mind was when in my thirties Iworked for a company that washaving financial difficulties,they actively encouraged us totake holiday days off, evenringing in the morning to ask ifwe would consider not comingin. I complied with their wishesbut when I looked back at myʻholiday dates taken listʼ oneDecember and seeing the

ing a glass of wine with myfood but it soon got that ittasted like poison or paint strip-per. I decided to go for morningruns to get my endorphinsgoing but I could not evenenjoy that, I really tried but Iwas in a bad place. I went to see a woman doctor

and she sent a stool test off forhelicobacter pylori (a bac-terium that is the major causeof peptic ulcers) and gave mesome anti-acid tablets. It madesense, I could have this so Iput all my efforts into thinking itwas that. She also arrangedfor a blood test to check myhormones, finally. I then hadone of my worst weekendsever and I felt so sick I had tospend the day in bed, my eld-est daughter convinced me tovisit A&E. By early evening when I got

up to get ready, I felt a gush,my period had started. I went

Barbara Jackson had appalling menopausal symptoms thatmade her life such a misery that it pushed her to the brink.

She wanted to end it all but fortunately she received medication that brought her back from those dark places

periods. He gave me anti-sick-ness tablets as by then mysymptoms where like feelingpregnant and I felt nauseous24/7. I was not sure if it wasanxiety, it seemed like anxiety.One day I woke up feeling sooverwhelmed I did not knowwhere to start, I am a hard-working able-to-cope personand it was such a strange sen-sation. Luckily it passedquickly but I could not deny Iwas withdrawing from familyand friends. I really did notwant to hold a civil conversa-

same two days taken off every28 days or so for the entireyear it told its own story.I probably started perimeno-

pause long before I realised.The years leading up to thisawareness had been great,busy and full of life. I startedhaving bouts of frequent diar-rhoea a few months after Ireached 50. Then about onemonth later I had my first earlyperiod, up to that point I hadbeen every 28 days. My firstthought was cancer, not peri-menopause, I even went on a

gluten-free diet thinking thatwas causing the stomachupset. A few months later I wassuffering from palpitations, Iput them down to anxiety. Then I had a panic attack in

the drive-through queue of Mc-Donaldʼs. I went to the GP toask for diazepam but he wasextremely unsupportive. Whenmy periods continued to be er-ratic and my anxiety got reallybad I dreaded going too farfrom home, it was then I firstthought menopause. I went to another GP, he said

menopause was not possibleuntil I had one year clear of

tion with anyone, I felt sick andjust wanted to get home tosafety. By the end of the sum-mer, when I had been feelinghotter than normal, I realisedthat I had barely taken my chil-dren out anywhere over theholidays, I was feeling reallypoorly. September came and Ithought with school being backI would have a rest and getmyself sorted. I could not havebeen more wrong, I started tostruggle to eat. I am naturallythin and have a good appetiteand I know not eating cancause nausea too so I forcedmyself. At first I did this by hav-

Barbarabegins a new

chapter in her life

One day I woke up feeling so overwhelmedI did not know where to start

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my whole life I have alwaysbeen opinionated on suicide,where people were either at-tention-seeking or selfish. Itwas not something I could doto my family. In the past had Ibeen found to have a terminalillness, I would probably haveleft my house immaculate,videos would be made andspecial boxes for my children. There would be lists of in-

structions on how to do thingsand a huge legacy left. I nolonger cared that my husbandwould not know how to sort outschool uniforms or make aplait. I just thought everyonewould be better off without me. On a drive one night I looked

for a motorway bridge, the fol-lowing night I put my plan intoaction. I climbed over the bar-rier and sat there waiting tojump. I couldn't do it, I keptwaiting for the right moment asI did not want to be injured, justdead. That moment nevercame, I just crouched forhours. I had no plan B it wasgoing to happen to the point Ieven had a wee up therethrough my clothes as it nolonger mattered. Daylight came and I was still

trying to jump when the trafficseemed to lessen, then itstopped. I thought there musthave been an accident fartherdown the carriageway andlooked up to see policemencoming towards me. I felt reliefthat someone would inject meto put me to sleep and I wouldno longer feel nauseous. Thatnever came. After a brief conversation I

was put into a police car,someone drove my car homeand I was told I would be goingto the local station as it wasshift changeover time. I sat forages while they argued what todo with me as no-one wantedto work extra hours. I felt adeep sense of shame at wast-ing their time. Eventually I wasdriven to a hospital far away asmy local one does not dealwith mental health. I have never had anything to

do with the police before apartfrom watching The Bill manyyears ago. Suddenly, I was aprisoner not even allowed togo to the toilet alone being

was 51 years old not 30 yearsold trying to convince them sixweeks later I was feelingslightly better. I still knew I didnot have depression per seand it was hormonally induced. I knew I was taking a sticking

plaster for a broken leg. I dothink I had got depressedthough but due to hormonesand circumstances. Christmaswas looming and all the stresswith that but I somehow gotthrough. In the New Year therewas an article on This Morningon the menopause. I rang inand got to speak to someone. Iwas not on the programme via

driven to a hospital wheresome other policemen wouldbe standing guard until I wasassessed. I had the thought Iwould be put in a hospital roomand they would throw away thekey. The policeman standingguard told me that I was one oftheir more rational cases andseemed quite normal. I was later informed that

when my family arrived theywould discharge their care andleave me to the mental healthteam. I tried to appear normaland by lunchtime I was on myway home, deeply ashamed. Iforced the GP to see me,which took quite a lot of effort. I was prescribed an anti-de-

pressant called sertraline,sleeping tablets and diazepam.I still felt terrible when I gothome. The next few weekswhere dreadful, the anti-de-pressants made me feel evenmore depressed and the sideeffects where dreadful, my carkeys where no longer availableand I felt so lonely. I struggled to eat but made

myself, I could not even eat inthe presence of my family. Icould not take phone calls. Ispent lots of time in bed. Mynormally extremely hands-onmothering skills had me barelyeven able to clean my kidsteeth. My husband took overmost of my duties. Even doinghomework with them was im-possible. I could not cook, justmaking mashed potatoseemed like an overwhelmingtask. I joined Menopause Matters

and felt like I had found myway again, I read how symp-toms should be used to decideif menopause was happeningnot blood tests. Letʼs face it, I

phone but someone else waswho was identical to me inevery way. I made an appoint-ment to see another womandoctor at that moment. Iemailed Dr Currie throughMenopause Matters and askedher which HRT she would rec-ommend for me. Four weeks later I finally saw

the GP I should have seen ayear ago. She confirmedeverything I had read abouthormone results not being con-clusive and symptoms shouldbe used. She even recom-mended Menopause Matters.She said I would have got HRThad I gone to her a year ago. Ifelt like I had won the lotterytwice over. It would be threeweeks before I could take myHRT patches (same ones DrCurrie recommended). I justkept looking at the packet andfelt wonderful.I am now two months in on

HRT and getting better by theday. I have had side effects butnothing I cannot handle. I amsure in a few months things willeven out and every day will bewonderful again. I can feel myconfidence returning.My conclusion is to trust your

instincts, never give up and tryas many GPs as needed. Iwrote a journal, which servedto remind me on bad days thatthere were good days. It alsohelped me see my symptomsand how they related to mycycle. I wrote everything I didin it even if all I did that daywas change the bedding. It makes me sad to read

pages from this again for thefirst time in months and makesme realise how far I have pro-gressed from the person whowanted to take her sleeping pill

at 7pm so I could have oblivionfor a couple of hours, to theperson who gets up and doesnot stop until late, never com-promising my standards againand doing everything. There isa gap in the market about themenopause, there should bemore help and awareness. Itwas a total shock to me and atotal shock that help was noteasy to get. However, life doesseem better for having gonethrough a bad time. It doesmake you appreciate thingsand my hope is that writingabout my experience will helpother women.

to the GP to get my resultshoping for a diagnosis butsadly it was negative on allcounts. I went away thinkingthat is good but once home Istill felt dreadful.By now I was only getting

about one hourʼs sleep a night,I used to waken with a hugeadrenalin rush. I was dizzy andhad lots of palpitations, Ineeded the toilet several timesa night, my hair was falling out,I cried at sad things and feltlike I had a continual kidney in-fection. I had taken to drivingabout at 2-3am and comingback once the sun was up. Ittook my mind off things. Things then progressed down-hill rapidly and by the end ofSeptember I was a mess. Athought came into my head,what was the point in living, Iwas no good to anyone plus if Iwere dead I would be asleepand not feel the nausea. For

My MenopauseBARBARA

My hair was falling out and I cried at sadthings, I was dizzy with palpitations

ONCE UPON A TIME: therewas a woman called Barbara who was havinghorrbile symptoms thatwere not being diagnosed.

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previous years in nearly half ofthe nationʼs counties – many ofthem rural and in the south andwest United States.Obesity, smoking and less

education are suspected con-tributors to these new alarmingstatistics. That said, todaymany women spend moreyears postmenopausal then intheir reproductive years. If awoman goes through meno-pause at 51 and lives to 85 –she will enjoy 34 years withoutmonthly cycles. According to the US Census

Bureau by the year 2020 halfof the female population in thewill be over 45. Perimeno-pause typically begins in awomanʼs mid-forties and canlast for four to six years. Menopause can be a frustrat-

ing transition for many womenbecause the ovaries stop pro-ducing the hormones estrogenand progesterone that leads tomany body changes: irregularperiods, hot flushes, nightsweats, weight gain, loss of libido, anxiety, depression, hairloss, and skin changes. Com-bine fluctuating hormones withageing and add them to a busylife and this period can be diffi-cult.

we do know for each life stageis important and can make thedifference between a healthytransition or not. We live much longer than our

ancestors. Today a womanturning 65 today can expect tolive, on average, until 85. Per-haps, we can thank our two “X”chromosomes for longevity. When cells go through ageing

they have a choice in terms ofgenes — either on one X chro-mosome or the other. Awomanʼs cells can perhaps beprotected by a slightly bettervariation of a gene on the sec-ond X chromosome. Men whohave one “X” and one “Y” don'thave this option. Unfortunately, a recent study

released by the journal HealthAffairs using data from theCenters for Disease Controland Prevention has shownwomenʼs longevity is not grow-ing at the same pace as menʼs. This latest research found thatwomen age 75 and youngerare dying at higher rates than

again as it was during our girl-hood years before our first period, but now we addressageing concerns.Going through these life tran-

sitions can be challenging withweight changes causing healthissues, embarrassment and formany frustration.I have gone through each life

transition, surviving the teenyears going from a skinny girlto a curvy C-cup before myfirst period, a rocky reproduc-tive stage with monthly 5 to 10-pound weight changes, and amiserable 30-pound weightgain during menopause. Now Iam celebrating an unchangingmonthly chemistry at a healthystable weight and no longerstruggling with PMS or hotflushes in my postmenopausalyears. As I survived the roller

coaster of life changes, I wishthese transitions were em-braced culturally in our society. As research and science con-tinues to grow for women, what

Awomanʼs life stages aredramatically differentthan a manʼs. Once a

male teenager goes throughpuberty he will not experienceanother major life transition ofchemical proportions. Hisbiggest life transition is ageing.Until recently, science has

treated females as smallermales with our only differencebeing reproductive. In the lasttwo decades a femaleʼs nutri-tional needs for each life stagehas been researched otherthan previous science that focused only on pregnancyand breastfeeding. It is no sur-prise weight gain is one of themost frustrating challengesduring the menopause.As I assembled the different

nutritional needs for each lifestage I am amazed at the re-markable changes unseen tothe naked eye. Our sophisti-cated biology changes shouldbe celebrated at each transi-tion. We survive enormousshifts from our hormones toour brain chemistry not oncebut four times in one life! During our first transition from

girlhood to adolescence wemature as a sexual being withmonthly periods. Then we slideinto our reproductive years,giving birth and being able tonourish our child by breast-feeding. Next our reproductivehormones turn off during peri-menopause creating years ofphysical and emotional chaosfor many. Finally our bodyʼschemistry becomes stable

Are you eating like awoman or like a man?After years of frustratingweight changes fromPMS to menopause withno relief, I created myown eating plan. Myfood program workedbecause women are verydifferent than men—from our brains to ourguts to our hormones.Sounds logical, right?Here is the shockingpart. Incredibly, many ofour medical treatmentsand dietary solutionshave been derived fromthe biology and physiol-

Girls, itʼs time to quit that man-size appetiteogy of a man. Yes, itʼstrue. For decades, re-search was conductedusing only men. Whatwe know about womenʼsnutrition has been basedon the typical 70kg man,long used in medical science as a referencestandard. Research hasfocused on a womanʼsbiology and physiology,with the results slowlytrickling into the main-stream. Many currentbest-selling diet bookscontinue to present pro-grams for men andwomen that are based

on the research resultsthat used men only ignoring the critical factthat men and women aredifferent, making the as-sumption that men andwomen will benefit fromthe same plan. Bewil-dering, isnʼt it? Itʼs nosurprise that womencomplain about theirmen losing more weighton the same diet. So ifyouʼve struggled onother diets and nutritionprograms and wonderedwhy, the answer may bea simple one: youʼre nota man!

Women are differentfrom men and what

they eat and how theymaintain their healthand fitness should

reflect those differences, writesStaness Jonekos

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If you are not yet perimeno-pausal I hope you read this en-tire section so you witness howimportant it is to live a healthylifestyle before menopause.The good news today is thereare many options available forwomen going through themenopause transition. Formany women supporting hernutritional needs at this stageand including exercise canoften minimise menopausalsymptoms. For some including alterna-

tive practices can help. And forwomen who still donʼt find relief, hormone and non-hormone therapy may be anoption to discuss with yourhealthcare provider. Today there is solid research

on hormone therapy and thegeneral consensus from theNorth American MenopauseSociety and the Endocrine Society is a lose-dose startedaround the menopause yearsfor a short duration is consid-ered safe for the relief ofmenopause symptoms. Have a thorough conversa-

tion with your practitionerabout the benefits verses therisks.Are you at risk from breast

cancer? If so, hormone ther-apy may not be your best option, but there are othermedical choices available –there is no need to suffer in silence. For the past decade there

has been much confusion overhormone therapy. Today hor-mone therapy products havedifferent routes of administra-tion from transdermal, oral andvaginal to different choices inthe actual hormone ingredi-ents. Your comfort level andpersonal choice is an importantfactor in deciding if hormonetherapy is a good fit for you. I still hear Dr Klein as I write

this, “We are all different.”What works for me may not bea good fit for you. Health risks increase with age

and declining estrogen levels,such as cardiovascular dis-ease, breast cancer and osteo-porosis making the necessarynutritional changes during peri-menopause important. Duringpregnancy and lactation youwere caring for two, now youmust care for YOU. Me-No-Pause!

Girls, itʼs time to quit that man-size appetite

EAT LIKE A WOMAN byStaness Jonekos is onsale now. You can orderit from Amazon, £9.76.

Mirena providesmany benefitsThe progestogenreleasing intra-uterine system,Mirena has beenin use since 1990and continues tobe successful for re-ducing heavy menstrualbleeding in premenopausalwomen and those in the peri-menopause. With advancingage, periods often increasein heaviness and irregularity. The evidence presented

confirmed that following in-sertion of Mirena there isoften an initial increase inthe number of days of bleed-ing, particularly spotting, butthis returns to baseline bytwo months in most womenand then gradually de-creases thereafter. Studies have shown that

Mirena is more effective thanthe standard treatments ofTranexamic acid, Mefenamicacid, combined hormonalcontraceptives and oralprogestogens in reducingheavy menstrual bleeding,with 83% of women becom-ing bleed-free after 12months of use of Mirena inthe perimenopause. Forhealth-related quality of life,Mirena is as good as the useof endometrial ablation orhysterectomy, as well asbeing cost effective.Use of Mirena for the pro-

gestogenic protection of thewomb lining (endometrium)while taking estrogen HRT,provides a good combinationof continuing contraception,bleeding control and en-dometrial protection whileestrogen controls meno-pausal symptoms. Adverse effects of Mirena

and estrogen are reported asminor with no detrimental ef-fects on cardiovascular riskfactors and no conclusiveevidence of any increasedbreast cancer risk from alarge case control study.

Life after breast cancercan be difficultWomen can experiencemany symptoms and have tocope with many distressingissues after a diagnosis ofbreast cancer. These includefatigue, anxiety, fertility is-sues, fear of recurrence,side effects of treatment, relationship issues and hor-monal effects.

The challenge contin-ues to be around

what support andtreatments areavailable. Formenopausalsymptoms,

whether themenopause occurs

naturally or as a resultof treatment for breast can-cer, diet and lifestyle issuesshould be discussed firstsince reducing weight andreducing alcohol if applicablemay help menopausal symp-toms but can also reducerisk of breast cancer recur-rence. Specific prescribed non-

hormonal treatments can beconsidered for symptomssuch as flushes and sweatsand moisturisers and lubri-cants can be used for vagi-nal dryness. Low-doseantidepressants have beenshown to reduce flushes andsweats, but care must betaken in the choice of typesince some can reduce theeffect of Tamoxifen. For some women, vaginal

estrogen and even HRT canbe considered when simplemeasures do not controlsymptoms, after full discus-sion. Psychological supportmay be required and consid-eration should be given tooptimising later heart andbone health due to possibleeffect from early menopauseand effect of certain breastcancer treatments. No newdata was presented but thediscussion raised awarenessof the challenges faced.

Call for more detail in assessing ovarian cystsMany postmenopausalwomen are referred to gy-naecology clinics becausean ovarian cyst is found on ascan, which may have beenarranged for a non-relatedreason. While it is knownthat ovarian cancer affects1.4% of women, most post-menopausal women withcysts measuring less than5cm are unlikely to havecancer, especially if the cystis described as simple. Measurement of blood level

of CA125 is not always help-ful but a new tumour markeris under investigation. A de-tailed examination of the cystby scan would help in deter-mining which women shouldbe offered surgery.

DATELINE: Cancun, May 1-4, 2014, IMS conference

IMS2014

COMING UPIn the September

issue of Menopause Matters,

Staness gives tips on how to manage the

menopause transition

Meno June 2014:Layout 1 13/6/14 09:05


CasebookDr Currie answers your questions on the menopause

I was 53 in January and untilOctober/November 2013, havehad regular, heavy periods. MyOctober period did not arrive,which coincided with my feel-ing anxious and in a bad wayemotionally. In mid-December Istarted Femoston 1/10mg andfelt better.In mid-February, I changed to

Evorel 25 and Utrogestan200mg because I wanted todecrease the risks of HRT. Myperiod has been arriving at 28-day intervals, after takingprogesterone for about fivedays (as it did with Femoston).It is heavy, a little heavier thanbefore and lasts seven days.Since it happens before the

end of the progesteronephase, I have only been takingthe progesterone for aboutnine days, figuring I didn't needit because the womb lining hadbeen shed.I don't know whether this is

OK and I am also concernedabout the ratio of estrogen toprogesterone. It seems ratherheavy on the progesterone, al-though it hasn't been adverselyaffecting me. I did wonder if myown body is still producing hor-

mones and would it be OK touse the low-dose patch withoutprogesterone, until I stop hav-ing periods or try a lower doseUtrogestan?Jessica Collings

Often bleeding at this stagecan be a little irregular due to amixture of effects of HRT andinfluence of your own ovaries,which may still be producingfluctuating hormone levels. This stage of changing ovar-ian function is often tricky, it

becomes easier when it isclear that your own ovarieshave stopped working, by hav-ing a year of no periods. Goingon to a monthly bleed typeHRT means you won't knowwhen your periods havestopped since the HRT leadsto bleeds. At the age of 54, we can befairly sure that your periods willhave stopped. Then, you cantry a "period-free" type in whichyou take estrogen and proges-togen every day, keeping the

The age to consider'period-free' therapy

womb lining thin rather thanbeing stimulated and thenshed as happens with themonthly bleed types. It may be worthwhile havinga short spell off the currentHRT, perhaps even just for acouple of months, then restartat the beginning of a period.Of course, if after two to threemonths you haven't had aspontaneous period, then justrestart anyway. Waiting for aperiod, if they are still occur-ring, will allow you to fit in theHRT with the cycle, whichmay be a little out of synchro-nisation at the moment. If youhave increased bleeding evenwhen not taking HRT thenplease see your doctor.The current view aboutwhich HRT to take is thatthere are very little risks withany type. If you are happywith the low-dose patch andcyclical Utrogestan, then con-tinue, but there is no real reason to think that there isincreased risk using Femo-ston 1/10. The main point isthat progestogen in someform should be taken for theinstructed duration.

Meno June 2014:Layout 1 13/6/14 09:05


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Patch or gel safest routeI am 52 and of slim build. I hada hysterectomy in June 2008and still had my ovaries, I didnot have any symptoms untiljust over one year ago when Iwas referred to a menopauseclinic where I was prescribedTibolone, which made mysymptoms worse. I was thenprescribed Elleste Solo 2mg,which improved symptomswithin a few weeks, it wasgreat for a whole year.In the past month all my

symptoms have returned. Istarted with anxiety, low moodespecially when I wake and in-terrupted sleep, although hotflushes are not my main prob-lem. I haven't had joint pains(as I did before) but my legsache and become shaky, I amfeeling tired and unmotivated. Ihave tried to exercise, whichtemporarily helps, but strug-gling to even do that now.My GP was concerned about

my BP (while on HRT), whichhas been around 140/80 butlower with regular exercise andhigher when stressed. I usedto be able to manage it well. Ilive alone, which does not help

In time, while the amount ofestrogen from Elleste Solo re-mains the same, your ovariesgradually produce less and sothe total amount in your sys-tem reduces, which may nowbe the reason for the return ofsymptoms. The dose of tabletcan be increased but it isknown that with increaseddose by tablet, there is a smallincreased risk of a blood clot(e.g. deep vein thrombosis)and possibly even stroke. Therefore a safer optionwould be to take estrogenthrough the skin by patch orgel, through which better andmore direct absorption can beachieved. This usually pro-vides much better control ofsymptoms when the symptomsare not controlled by tablets. There are various types anddoses of patches and twotypes of gels. You should beable to discuss this at themenopause clinic but if there isa wait, I wonder if it would beworthwhile discussing this withyour own doctor in the first in-stance and then go ahead andtry a patch or gel.

and find it hard to ask for help;most of my family live far away.I am taking omega 3, magne-

sium and vitamin D supple-ments, which I am quitedeficient in as being from anAsian background. I am beingreferred again to a menopauseclinic but there is a waiting list.The menopause nurse saidthey may consider increasingthe dose I am on. I have readsome views on the MenopauseMatters forum and some ladieshave said Elleste Solo 3mgmay be too high a dose. Why have my symptoms re-

turned and what would you advise I do about the dosageor other methods, are somesafer than others? Quality oflife is my main priority.Aadita Banerjee

If estrogen is started when theovaries may still be producingsome estrogen, the amounttaken simply tops up your estrogen levels. Tibolone con-tains a weak estrogen and soprobably was not enough,whereas the Elleste Solo wasstronger and so helped more.

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Regelle is a class IIb Medical Device, CE Mark 0120.References: 1 Nachtigall LE. (1994) Comparative study: Replens versus local oestrogen in menopausal women. Fertil Steril.;61, 178 – 80. 2 Loprinzi CL., Abu-Ghazaleh S., Sloan J., van Haelst-Pisani C., Hammer A., Rowland K., Law M., Windschitl H., Kaur J. and Ellison N. (1997) Phase III randomized double blind study to evaluate the efficacy of a polycarbophil- based vaginal moisturizer in women with breast cancer. J Clin Oncol., 15, 969 - 73. 3 Bachmann GA, Notelovitz M, Gonzalez SJ, Thompson C, Morecraft BA. (1991) Vaginal dryness in the menopausal woman: clinical characteristics and non hormonal treatment. Clin Pract Sex, 7, 1-8.7. 4 M. Gelfand and E. Wendman (1994) Treating vaginal dryness in breast cancer patients: results of applying a polycarbophil moisturizing gel. Journal of Women’s Health, 3 (6), 427-433.

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DDrraaggoonnss tthhiinnkk iitt’’ss ccoooollDid you know that three in fourwomen suffer from hot flushesbefore and during the meno-pause, with flushes and sweatsplaguing women for around adecade on average?Ironically, one solution has

emerged from the heat of theDragonʼs Den. EntrepreneurKay Russell managed to secure investment from theDragons for her patented rapidevaporation technology (Physi-cool), which she has cunninglyadapted into a spray to easethe hot flushes and nightsweats of the menopause. Once the formulation makes

contact with the skin, it beginsto evaporate rapidly, drawingthe heat away with it, reducingskin temperature and calmingredness.A consumer study revealed

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gynaecologist at LondonBridge Hospital, reports that:"Whilst the golden standard fortreatment of the menopause isHRT (hormone replacementtherapy), not all women re-spond well to estrogen and forthem hot flushes can be hugelydisruptive to every aspect oftheir lives. “Very few products can tackle

hot flushes effectively, but Ihave to say that the PhysicoolCooling Mist really works and Irecommend it to my patients.As soon as the mist hits theirskin it begins to evaporate,drawing out the heat immedi-ately and evaporating it away. “This results in an instant

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Women with diabeteshave since diagnosislived with the aware-

ness of being careful aboutwhat they eat, drink, exerciseand how they administer in-sulin injections. They are alsofully alert to the side effectsand complications of this seri-ous condition that increasesrisk of stroke, heart disease,blindness, kidney and nerve

disease. Consequently, theyhave lived a regime wheremanagement of the diabeteshas been paramount. Now, in the menopause,

women with diabetes must beeven more vigilant as the lev-els of hormones estrogen andprogesterone decline andcause blood sugar levels tofluctuate. Their lifetime obser-vance and control of their

blood sugar level will be helpfulin preparing them to deal withthis new variable and less predictable situation.What to look out for includes

common issues such as weightgain that some women experi-ence during the menopausaltransition, which in turn willhave an impact on your doseof insulin.The slowness of the healing

process will be well-known tothe diabetic but for womenextra care must be taken toavoid high sugar levels as theywill contribute to urinary andvaginal infections. The fall inestrogen at this time promotesthe opportunities for yeast andbacteria to thrive in the urinarytract and vagina.Sleep problems, a common

symptom to many menopausal

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women, can also have an ef-fect on sugar levels requiringthe need for further caution. Di-abetes alters nerves and thosein the cells that line the vaginamay become damaged. Theloss of sensitivity will impedearousal and orgasm and if ac-companied by vaginal dryness,another familiar situation, willcause pain during sex.A drop in blood sugar coupled

with hormonal imbalances cancause intense hot flushes fordiabetic women and the dailystress of diabetes control canaggravate the symptoms of depression.Now that you know what to

expect, steps can be taken toreduce or eliminate yourchances of being affected. Thedecline of estrogen and prog-esterone has made life andyour blood sugar level muchless predictable. ConsiderHRT, which will replace themissing hormones and helpstabilise your blood sugar andgive you a better quality of life.If HRT is not the balancing

act you wish it is vital that youcheck sugar levels frequentlywhen you are going throughthe menopause. Keep a dailydiary and if your level is toohigh or even too low for a period, adjust your dose.Heart disease is reckoned to

be four times more likely in diabetic women. These risksincrease with high blood pres-sure, high cholesterol andmore body fat.It is not all doom and gloom

as women with diabetes havelived with and managed thecondition but by taking certainprecautions and advice abouttreatments, the combination ofdiabetes and the menopausecan be held in check.

TThhee ttiimmeebboommbb

tthhaatt iiss TTyyppee 22

The United States hassent people into space

and landed them on themoon. Contributions to theworld include hairspray,bubble gum and nylon. Un-fortunately it is less smartwhen it comes to diet andas a nation nourished onfast-food outlets whereburgers, hot-dogs, pizzasand high-calorie subswashed down by litres ofsweet sugary drinks pre-vail it is now as they wouldsay, wake-up time.Being overweight and the

lack of physical activity isthe most common causeof people developing Type2 diabetes. Last year onein eight Americans (29 mil-lion) were diagnosed withthe disease that happenswith the bodyʼs ineffectiveuse of insulin.Pills, diet and exercise

can control it, however, itcan damage the heart,blood vessels, eyes, kid-neys and nerves.In the UK 6% or around

3.2 million people havebeen registered as dia-betic. The NHS spends10% of its budget on dia-betes with most treatingkidney failure and heartdisease.

Meno June 2014:Layout 1 13/6/14 09:05


The effects of themenopause canbring demands at work. More

support is needed for women says

Dr Heather Currie

It is more than likely that awoman will serve you in adepartment store. The type

of work and the flexibility ofhours can be helpful for thewoman with ageing parents tolook after or indeed childrenthat are not yet loose of her

apron strings. Departmentstores across the UK employ alarge number of women. Other areas too are largely

populated by the distaff side ofthe family. Women account forlarge numbers in our healthservice and in schools, col-leges, local authorities they areemployed in a considerablerange of posts.Alas, women are not like

men. Men go through pubertyand thatʼs them until afavourite son-in-law escortsthem down to the Bull ʻnʼ Bushfor a pint of bitter. Women onthe other hand have a muchmore complicated plumbing

Why menopausal women need a better deal in the workplace

In 2015 the National Institutefor Health and Care Excel-lence (NICE) is to publish itsfirst clinical guideline on the

diagnosis and management ofmenopause. For all of us in-volved in caring for women experiencing consequences ofthe menopause and for all uswomen who experience themenopause, this should bewelcomed. We have now lived through

more than a decade of confu-sion and controversy aroundthe risks and benefits of thetreatment options for womensuffering from menopausalsymptoms and later conse-quences of the menopause. In this time, the focus has

been around perceived risksand benefits of Hormone Re-placement Therapy (HRT) andwhat seems to have been for-gotten is that women havecontinued to suffer from theconsequences of estrogen de-ficiency and that understandingand managing the menopauseis not just about HRT. The NICE guidelines are ex-

pected to provide us with anup-to-date, evidence-based directive that will be trustedworld-wide, but also with anopportunity to use the sur-rounding publicity to raiseawareness of the importanceof the effects of the meno-pause and to instil confidencein both women and healthcareprofessionals in how to man-age the menopause. For many years, public per-

ception has often focused onthe menopause as simplybeing the time around periodsstopping and on the earlyonset symptoms such as hot

of the association of estrogendeficiency on these importantaspects of health.Menopausal, or estrogen defi-

ciency symptoms have oftenbeen regarded as insignificant,something that is inevitable,part of the ageing process andnot worthy of treatment. I amstill often saddened to hear ofwomen who have been told inthe past that this is “just yourage” and should be tolerated. Within the development of the

guideline, there is welcomedrecognition of the impact of es-trogen deficiency. It is statedthat 84% of women experienceone or more of the classicalmenopausal symptoms withvasomotor symptoms affecting70% of women. The early onset of symptoms

are often short-lived due toadaptation of the body to theeffect of estrogen lack on theestrogen receptors and indeedmay not need treatment, butthey are thought to cause

Estrogen deficiency also com-monly affects the vagina andbladder (the urogenital tract),causing vaginal dryness, dis-comfort, irritation as well asbladder symptoms of passingurine more often, passing urineat night and an urgency topass urine with the possibilityof incontinence if the toilet isnot reached in time. Vaginaland bladder symptoms areoften referred to as “intermedi-ate” symptoms, since theycommonly occur a few yearsafter the last period (the time ofthe menopause) or a few yearsafter stopping HRT, thoughearly onset urogenital symp-toms can occur. Finally, estrogen deficiency

has an important impact onlater health, particularly onbone and the cardiovascularsystem. With the later onset ofurogenital symptoms, and thelater health effects on boneand cardiovascular health,there is often poor awareness

flushes, night sweats andmood changes. Many womenstill assume that they will “getthrough” the menopause withina few months or a few years atthe most. Thankfully, the guideline

group has a great understand-ing of the concept that manyparts and systems of the bodycontain estrogen receptorsthrough which estrogen exertsits effects. Hence, that the es-trogen deficient state followingthe decline of ovarian function,whether that be spontaneousor due to surgery or othertreatment, has widespread effects, which last forever. Symptoms of estrogen defi-

ciency that are often noticedearly in the stage of ovariandecline include hot flushes andnight sweats, (known as vaso-motor symptoms), muscu-loskeletal symptoms of jointaches and psychologicalsymptoms of low mood, moodswings, anxiety and irritability.

The future is

NICE

Meno June 2014:Layout 1 13/6/14 09:05


Why menopausal women need a better deal in the workplacesystem and when it comes tothat time in and around themenopause the fall in estrogencan bring horrible symptoms.These symptoms do not makeit easy to function effectively. They bring stress, anxiety,

mood swings, fatigue throughlack of sleep, hot flushes andnight sweats. Women did notask for this and many employ-ers would appear keen not towant to know about, whisper it,“womenʼs problems”.At its recent conference in

Brighton, the National Union ofTeachers voted to recogniseand seek better support forolder women teachers. The

motion argued: “employershave a responsibility to takeinto account the difficulties thatwomen experience during themenopause and they shouldbe able to expect support andassistance during what is, formany, a difficult time”.Recent changes in appraisal

and capability procedures haveadded pressure to women as itallows the targeting of individu-als. The injustice for teachersin and around the menopauseis that it can be difficult to copewith some aspects of their jobbut rather than being subjectedto a cross-examination theyshould be receiving sympathy

and a genuine offer of support.As a doctor working in the fieldof menopause, I wish that allwomen could receive good ad-vice and information about theeffects of estrogen deficiency,what simple changes womencan make to reduce symptomsand improve long-term healthand available treatments. Sadly this vision is a long way

off but if symptoms are affect-ing you and your work, do seekhelp; ask your GP or practicenurse, make an appointmentwith occupational health, butdo not battle alone.See more information at

www.menopausematters.co.uk

that for most women under theage of 60 who have meno-pausal symptoms or are at riskof osteoporosis, the benefitsoutweigh the risks. However,the long-term benefits andrisks of HRT are still not fullyagreed and both women andhealthcare professionals stillfind it difficult to make an in-formed decision. In summary, estrogen defi-

ciency affects ALL women andNICE has accepted that manywomen in the UK experiencemany effects of estrogen defi-ciency, which can significantlyaffect their quality of life, yetsupport and provision of infor-mation is variable and can beinadequate. What areas will the guideline

cover? The NICE “Diagnosisand Management of theMenopause” guideline will en-compass menopausal women(covering perimenopause andpostmenopause) and womenwith premature ovarian insuffi-ciency, whatever the cause. For these women, clinical is-

sues will include diagnosis andclassification of the stages ofmenopause, best clinical man-agement of related symptoms,the contribution of HRT in pre-venting long-term associatedconditions and diagnosis andmanagement of prematureovarian insufficiency. What treatments will be re-

viewed? Hormonal pharma-ceutical treatments such asoral, transdermal and vaginalestrogen, oral and transdermalestrogen combined withprogestogen, tibolone, testos-terone, bio-identical hormonesand selective estrogen recep-tor modulators; non-hormonal

pharmaceutical treatments inthe form of certain types of an-tidepressants, gabapentin andclonidine; non-pharmaceuticaltreatments in the form of phytoestrogen-containing pro-ducts, herbal preparations,acupuncture and lifestyle advice; and psychological ther-apies in the form of cognitivebehavioural therapy. All will be reviewed in terms

of risks and benefits, timing oftreatments, monitoring of treat-ment, duration of treatmentand how best treatment shouldbe stopped.While the guideline will offer

evidence-based guidance onaspects of the management ofthe menopause, it will take ac-count of clinical and cost alongwith the patient perspective.The highly respected NICEguidelines are applicable to allNHS healthcare settings and itis very likely that publication ofthis guideline will influencepractice, leading to improvedunderstanding of the conse-quences and impact of themenopause by healthcare pro-fessionals. The future is therefore indeed

NICE and hopeful but mean-while, healthcare professionalsshould ensure that they con-tinue to support and informwomen from currently availableevidence and I urge women tocontinue to seek informationand support from reliablesources, such as MenopauseMatters.We should not put meno-

pause education and supporton hold until publication, butwe should do the best that wecan from what is currentlyavailable.

current practice is addressingthese issues. It appears not. The information and support

given to women is variable andcan be inadequate. A surveycarried out by Menopause Mat-ters published in 2007 showedthat 73% of women did notknow enough about HRT tomake informed choices, 85%said they did not know enoughabout alternative therapies, yet95% would try alternative ther-apies before HRT in the beliefthat they were “more natural”. The women who experienced

vaginal dryness or bladdersymptoms as well, only 20%had discussed their symptomswith a doctor and even fewerhad received treatment. To address this lack of infor-

mation, the British MenopauseSociety recommended that allwomen be invited for a healthand lifestyle consultationaround their 50th birthday todiscuss menopausal symp-toms, treatment options, dietand lifestyle and what changescould be made and treatmentsconsidered to improve currentand later health. Despite widespread support

for the theoretical benefits ofthis visit, there is little evidencethat this practice is takingplace or that it is possible withcurrent resources.Regarding current licensed

treatments for management ofestrogen deficiency, HRT pre-scription rate by GPs hasdropped significantly since2002 following publication ofthe Womenʼs Health Initiativetrial. Since then reanalysis oftrial data has disputed the risksof HRT and has reconfirmedthe benefits; understanding is

significant distress in 25% andcan last for up to 15 years in10%. Most important is thatrecognition is given to theawareness of postmenopausalwomen being at increased riskof osteoporosis, cardiovasculardisease and changes in thevagina and bladder. It is acknowledged that pre-

mature ovarian insufficiency(menopause before the age of40) and early perimenopause(changing ovarian function before the age of 45) are asso-ciated with increased risk ofmortality, cardiovascular dis-ease, neurological disease,psychiatric disorders and os-teoporosis. With an estimated 13 million

women over the age of 45 inthe UK and the number rising,it is clear that the magnitude ofpeople affected by the conse-quences of estrogen deficiencymerits such a detailed assess-ment of treatments.It seems clear: ovaries stop

functioning in all women due todepletion in egg cells, surgeryor other treatments. The result-ant estrogen decline and thendeficiency, which lasts forever,has many consequences,early, intermediate and longterm. Symptoms are varied inseverity and duration and ef-fect of later consequences hasvaried impact. All women should be provided

with information about recom-mended diet and lifestylechanges, treatment options,and later effects so that theycan truly make an informedchoice about how they managetheir menopause. This informa-tion has been known for sometime and one might wonder if

Meno June 2014:Layout 1 13/6/14 09:05


Iam 52 years of age and I docontract work, which involvesdriving around eight to 10

hours each week, then cominghome for a day-and-a-half andgoing back through the ritual ofthe work contract. I also studyand workout daily, combininggym exercise with doing yogaand meditation. This helps meremain sane while keeping mealert and focused. I am aware that this work

model needs reviewing as it isnot sustainable and may havebeen the link that led to myhealth triggers. Who knows? Ido have perks in my life and itis those benefits that make mehappy. The way I see it is I aman adult making choices thatgive me some sense of control. During 2005, I noticed I was

progressively getting sluggishand irritable and sleep patternswere a struggle, the aches inmy body were also exhausting.I chose to go to the gym as Ireckoned the more I exercisedthe sooner I would be able toreboot myself. My first hot flushes started in

2007 but I ignored them. Myfeet and hands were constantlyhot but as the years moved onI found myself heating up andsweating. So I would wear lightcotton clothing, thinking itwould pass by but it made nosense to me. I may have beena bit grumpy and my emotionalregulation off kilter but I wastired and working long hours.The years slipped away, then

in 2011 my periods started tochange. It was so erratic that Ibegan to carry a variety of san-

All I really wanted was to havesome advice about how to stopthe bleeding and make senseof what was actually happen-ing to me. But for some reasonI had a blind spot with this situ-ation, I knew something waswrong but I had not wanted tosee a GP or talk about “it”.I spent the weekend thinking

about what had happened withthe GP and what I had done tomyself. I went to work on theMonday, leaving the house for5.30am to drive four hours.Through that journey I thoughtabout what she had said andallowed myself to think aboutwhat is important so on thatday I ended my work contractand drove home. I felt like Ihad taken the traction off thesituation and said to myself, Imatter. Eventually, in September

2013, I was fast-tracked to seea consultant who was gentle,concerned and told me whatwas occurring. But I had amental block with what wasbeing said so I tried to min-imise the circumstances andsay letʼs just crack on and getthis over and done with. On reflection this was not an emo-

going from size 12 to 16 andstill growing. I managed tocomplete my work contract andwent from rural Scotland toLondon. At this point I was bleeding so

heavily that I was fainting andchanging sanitary wear on thehour, there is only so manytimes one can go to the ladiesbefore noticing something isterribly wrong. And so I calledmy doctorsʼ surgery andbooked the last appointmenton a Friday, I saw a female GP.

When I went to the practiceI had driven four hours

from a contract. I was unsure ifI wanted to see her and wastrying to justify in my mind whyI was sitting in this surgery at4.30pm on a Friday for a 10-minute slot. Eventually I wascalled from the waiting area, Isat and was very avoidant. In due course, I opened up to

her and she tried to examineme. I was at the point of painand rather ashamed by howfoolish I had been. She calmlyexplained that I needed to seea consultant as I had large fibroids and may require sur-gery. She suggested that I taketime off as I was not well.

itary wear. This continued until2013 and during this time I didnot go for smear test invites. I did not think that the past

year would have been so over-whelming for me but I was determined to keep working asmy job is important and peoplerelied on me so I could not letthem down. Consequently, Iburied my head in the sand. To improve my health I took

high-strength iron tablets andhigh-dose calcium each day sothat I could deal with the flood-ing periods. I had reachedfever pitch from April throughto September and it was I finally decided to see my GP.My job was busy and I had

key events to attend, nothingwould stop me from being focused as I was committed tothe task but it put my health insecond place. I was puttingweight on and this made nosense as I was not eating agreat deal and I was workingout; I became angry at mybodyʼs inability to keep on topof things. A forthcoming family gather-

ing meant I needed to lookgood but I was so unhealthy,breathless and sweating and

SSoorrrryy,, bbuutt II aamm rreeaallllyy ttoooo bbuussyyttoo hhaavvee aannyytthhiinngg wwrroonngg wwiitthh mmee

Flushes, erratic periods and fatigue were symptoms for

Armrget Kaur but she sensedsomething was not quite rightwith her health. Armrget tells

us her story

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Meno June 2014:Layout 1 13/6/14 09:05


lected me and took me home.My view in the hospital was ofthe cemetery, I did not enjoyeither hospital experiences andwas glad to go home.During the coming months a

sudden menopause tookplace, it was surgically inducedbut no-one had told me what toexpect. I was given a leafletabout exercises to do. Thenight sweats were unlike any-thing I had ever experienced; Ithought I was in the Bahamas.This did not stop and I had notslept since the surgery, it wasthree months of physical andemotional turbulence. I first thought this must be the

effects of surgery. On the thirdmonth, I was given HRT and Iwas calmer and could sleep.My temperature was good andI was doing my gym workout. I thank Dr McVicar at Cairn

Medical Practice and my con-sultant at Raigmore Hospital,Dr Wareham. Also, a completestranger in consultant Dr Cur-rie who was my post-operativecomforter and my family whowere my rock. They all showedme care and taught me differ-ent things about health andpartnership working.

tionally intelligent action to takeand I would laugh it off to ap-pear brave. I was scared but Idid not say to the consultanthow I was feeling as she wasbusy and I could not see thepoint in revealing my emotionalside to her. I thought that sheprobably did not want to knowme and was also somehow un-able to say my name. I wasmore put out that she could notsay my name and never didsay my name. Itʼs strange whatyou hook on to. I could not hear her voice

when she spoke. All I remem-ber is signing a consent formand saying ʻyes let`s get It overand done with if it stops thebleeding let`s move forwardʼ.

The consultant was smartenough to see I may benefit

from seeing her again. Butwhen we did meet I was dis-missive of what was takingplace because I wanted to bebrave and show I can deal withthis but what I really wanted todo was cry and be held.In December 2013, I had a

hysterectomy also having myovaries and cervix removed. Iwas eight when I was last inhospital, a family member col-

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My MenopauseARMRGET

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The effect of estrogen lossduring the menopausehas a major impact on

our skin. Some women haveinherited good skin and theageing process for them isslower but for the majority acombination of ageing, fall inestrogen, general exposure tothe sun, pollutants and dehy-dration leaves its mark.During our lives estrogen has

stimulated collagen productionto keep our skin wrinkle-free. Ithas balanced oil secretions,promoted cell renewal andslowed the rate of unwantedhair growth. But its loss hastaken the shine off our skintone and made it less elastic. Itlooks and feels dry and therecan be lots of pigmentation dis-orders and an increase in visible capillaries.

Skin is the largest organ ofour body and we are advisedto moisturise it using a heaviercream when it is still damp,perhaps after a shower. It isbelieved to help hydration andit should be used on the face,jawline and neck every day.There is, however, little point

in using expensive moisturis-ers that must first cut throughthe dead skin and before thisstage is contemplated, exfolia-tion is suggested. The toplayer of our skin is made up ofdead skin cells. Our body will

The procedure does require acareful approach and womenwith certain skin types must becareful not to exfoliate toomuch. Irritation and scarringcan occur on sensitive skinand if you shed too much skinit can lead to inflammation anddryness. But no matter whatyour skin type you must mois-turise after exfoliation.Also women with darker com-

plexions must be careful asthey may be prone to post-in-

flammatory pigmentation thatis difficult to reverse. Exfolia-tion can help prevent acnebreakouts but rough excessiverubbing can aggravate the condition.Hands, feet and back can tol-

erate stronger exfoliants whilechest and shoulders may bebest suited to a combinationproduct that has exfoliants andmoisturiser.

naturally shed millions of deadskin cells every day and thishelps reveal the luminous,younger skin underneath.Exfoliation removes the dead

surface skin cells and withoutregular exfoliation an abun-dance of dead surface skincells will clog pores, cause dis-colouration and ageing. Theprocess also stimulates skincells and increases natural oilproduction and blood flowhelping to create a more youth-ful appearance.Itʼs also a nice notion to be-

lieve that by exfoliating the top,dead layers of skin it will senda signal to our skinʼs deeperlayers to become more activeand produce more wrinkle-fighting collagen.When your skin is properly

exfoliated you will have asmooth base on which to puton your make-up. You will notneed heavy foundations ormuch make-up to create the illusion of smooth skin.Exfoliating treatments also

slow the ageing process andpost-menopausal women ben-efit most as the natural courseof shedding dead skin and re-generating new cells becomesslower. In addition, keratin-filled dead cells build upquicker and more unevenlyonce you reach middle age. Exfoliation accelerates the

process, evens out skin toneand makes skin look healthierand younger.

Doesnʼt shescrub up well

Beautymatters

Exfoliation treatments slow

the ageing process and

post-menopausalwomen benefit

most

Removing deadsurface skin cells

can make you lookyears younger

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The role of collagenCollagen is vital for the

skinʼs plumpness,thickness, elasticity andstrength. Its reduction cancause dryness, wrinkling,poor healing and un-wanted facial hair. Thissituation is really not whatwe want to hear, however,if the estrogen were to beboosted would the ageingprocess slow down oreven halt?Studies certainly verify

that HRT can reverse theprocess quite dramati-cally. But there can be areluctance among skinspecialists to use HRT asa skin-only cure. They arehopeful that research onselective estrogen recep-tor modulators known asSerms that focus on theskin will provide a solu-tion.The chances are that you

will see a benefit in yourskin if your doctor deter-mines that HRT is the bestcourse for your overallsituation. There are hun-

University that showed aspecial combination ofpeptides, one of which isMatrixyl, helped stimulatehigher levels of a bodyʼscollagen.This skin care range is

not the least expensivebut it contains a highquality moisturiser thathelps provide deep skinhydration and helps re-place lost nutrients andvitamins. Most important is that

the creams contain ahigher concentration ofthe combination of pep-tides, which is crucial asclinical research showsthat anything below 2% isuseless. High concentra-tion peptides are the onlyclinically proven methodof increasing your skin'scollagen content.There is a case for start-

ing a care regime early.The environment and sunwill have had some signif-icance on your skin by thetime of the menopause.

dreds of treatments fordry skin. Most of themmake promises to returnyour skin to a youthfulglow. The good ones tendto be more expensive butthey usually come withsome scientific support. The secret is to look for

certain ingredients on thelabel. Skin products con-taining vitamins A and C,for example, can improveskin due to their antioxi-dant effects and thesecreams may help keepskin youthful looking. Severely dry facial skin

will benefit from mois-turisers that containhyaluronic acid, glycerin,lanolin and alpha hydroxyacids that are the bestwater biners.Recognising the link

between decreasing colla-gen levels and ageingskin has been Forme Lab-oratories with its StratumC range of products. Thiscompany took the resultsof research from Reading

Meno June 2014:Layout 1 13/6/14 09:06


Travelmatters

Liverpool was the City ofCulture in 2008 and in recent years it has under-

gone massive investment.Thereʼs been a significant re-generation of areas like thedocklands where the decline ofindustry had left a distressingscar. The result is that todayspirits have been lifted andthere is a buzz around the city.It is a good place to visit for ashort break.There is a bonus for most

girls that are now in the meno-pause, as Liverpool possiblyplayed a significant role in theirearly years. Tuned to RadioCaroline and with their Bush orDansette transistor radiostrategically placed to avoidcrackle and hiss the full flow ofthe Mersey sound may havecaused flushes and palpita-tions of a different kind.Those were the days of the

Beatles, Gerry and the Pace-makers, the Searchers, Billy J.Kramer and Cilla Black. At thetime of the menopause thereʼsnothing wrong with a little bit ofnostalgia. Beehives, bouffants,pixies and bobs were all therage in those days. But thenyou had luxuriously thick hairthat didnʼt come out by thehandful when you ran a brushthrough it.Youʼd wear box dresses, mini

skirts, turtle-necks and go-goboots. And there were plenty ofgirls to follow such as JeanShrimpton, Twiggy, Pattie Boydand Jane Fonda.Liverpool, the Liver Birds and

all things Merseyside has

this street and among theshops are restaurants, barsand bistros where weary legscan enjoy a restful moment.The Chinese food is rather

good here too. In fact Liverpoolwas home to the first China-town in Europe and now has a10,000-strong community.Spanning the width of NelsonStreet is the Imperial Arch,which at 15 metres tall is thelargest outside of China.But despite being in the

menopause you should have ayouthful spring in your step bynow and you may even beconsidering changing yourhairstyle and buying trendyclothes. Feeling younger, reju-venated it wonʼt be long nowuntil you take the magical mystical tour.The Beatles Story is the

worldʼs largest permanent ex-hibition and it is at the AlbertDock. Here you will go back intime and be taken on a journeythrough the lives, culture andmusic of the Fab Four. Repli-cas of the Casbah, MathewStreet and The Cavern capturethe sixties. Feeling younger?Yeah, yeah, yeah, yeah.The regeneration of Liverpool

certainly stimulates memoriesto an era where PMT wasmore in focus than HRT. Thereare lots of traditional places ofentertainment such as theRoyal Court and PlayhouseTheatres that combines with afantastic night life and a fun-packed annual programme.Donʼt just be a day tripper thiscity is open eight days a week.

smaller independent storesthat are unique to the city.Cavern Walks is situated on

Mathew Street and it is Liver-poolʼs top fashion locationbeing home to the largest col-lection of independent retailersand designer brands. Hereyouʼll find Vivienne Westwoodand the Cricket designer bou-tique where fashion advice isfreely given.Bold Street is perhaps the

cityʼs most celebrated. It hasgrown to fame due to its hav-ing the most independent smalland large shops. There is agood measure of culture along

come the full circle. Today it isbeing hailed as one of the bestplaces in the UK to visit and forus girls of a certain vintage itmay well be just the place torevisit those early years.With five shopping centres,

two department stores andmore than 400 shops - you'llfind party wear, gifts and good-ies for every occasion andevery budget. Stores range from stylish

boutiques, designer outlets inMetquarter, Cavern Walks andBold Street to all the bignames you'd expect to find onthe High Street, along with

Strawberry Fields Forever

A GIRLSʼ GUIDE TO LIVERPOOL

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Chef’s masterclass

Lutz Bösing of theFinca Cortesin in

Estepona

Women in and around themenopause may very

well benefit from the simpledish prepared specially forMenopause Matters by LutzBösing, the executive chef atthe Finca Cortesin hotel onSpain's Costa del Sol. Alongside him in the kitchen,

Bösing has a team of profes-sionals that have an open andcreative perspective on fineSpanish cuisine. His mainfocus is to harmonise classicaltraditions with modern con-

seeds and celery are known torelieve hot flushes and aspara-gus helps with a decreased libido.Alas, all that is missing is

being in the El Jardín restau-rant at Finca Cortesin where itspicturesque terrace is adornedwith 100-year-old olive treesand panoramic views of theMediterranean. This elegantbackdrop creates the perfectsetting to enjoy the world offlavours that Spanish cuisinehas to offer.

cepts in an ongoing search forthe best products and “flavoursof life”.The ingredients used should

certainly be on every meno-pausal woman's shopping listas they contain essential nutri-ents, vitamins and mineralsneeded for wellbeing. For ex-ample, tomatoes and carrotsmay lower the risk of breastcancer, there is a cooling effectfrom cucumber water, olive oiland garlic for heart health, zuc-chini fights disease, pumpkin

Porra from Antequera, vegetable crudites, Iberian delights and kikos

What you need (serves 8)

1.1kg ripe tomato0.180kg peeled cucumber3gr. garlic 0.25l of Virgin olive oil0.3kg old bread without crustPinch of salt

Crudites8 sticks of zucchini, carrots,pumpkin, red and green peppers, celery, asparagusand avocado8 slices of finely chopped cucumber8 garlic flowers8 slices of celery and endive

Salt dry ham and choppedkikos

What to doChop all ingredients of theporra into small cubes andmarinate in the fridge for 24hours.

Mix in a blender and emulsify.

Marinate the crudités with saltand lime about 10 minutes before serving.

Make eight bouquets with veg-etables and wrap them up withthe cucumber slices.

Kenya beans salad with breasts of quail and vinegar of truffle

What you need200g French beans1 onion1 shallot8 breasts of quail10g truffle

Mix beans, chopped shallot,3g of truffle, oil, vinegar, salt,pepper and a little truffle oil.Place in the centre of a plate.Top with caramelised onionand the breasts of quail.Finish with grated truffle andmixed leaves of mezclum

What to doPoach the beans in saltedwater so they are “al dente”.Saute the onion with salt,sugar and butter untilcaramelised.Sear the quail in a pan withhoney on the skin side.

Virgin olive oilSalt and pepper20g mini mezclumTruffle oilSugar VinegarHoney

Meno June 2014:Layout 1 13/6/14 09:06


LLeett tthhee ssuunn sshhiinneeIf you are post-menopausal thechances are that during the wintermonths your bone density mayhave reduced by as much as 4%.Drinking milk and swallowing cal-cium pills will help boost yourbone strength but another moreenjoyable way is to go to thebeach. There you will soak in vita-min D from the sun, where it isreckoned 15 minutesʼ worth is thesame as swallowing a load oftablets.The curse of the menopause

can be weight gain but rememberthat a plus size body is a curvybody and this is much more femi-nine than a skeletal framework. There are all sorts of ways that

you can cleverly disguise tummybulges such as choosing a one-piece that has monochromatic orsubtle flower prints.A swimsuit with ruching helps

conceal your mid-section anddarker colours create a slimmingeffect. Choose a halter top styleand it will draw eyes upwards towards your collarbone.One tip that is widely recom-

mended is considering a tanningsession or using a self-tanner. Alightly bronzed body has a goodstart and it helps cover up minorimperfections such as celluliteand wrinkles.Donʼt forget to drink lots of water

to keep your body hydrated.

1 - Long Tall Sally,snake print halter-neck, sizes 10-22,£40; 2 - FashionWorld, cherry print,sizes 12-32, £32; 3 - Bonmarche, tie-front tankini top, £12,bikini brief, £8; 4 - Bonmarche,David Emanuel floralprint mock tankini,£18; 5 - Long Tall Sally,full high-waisted pantwith tummy controlpanel, 10-22, £40; 6 - Bonmarche, roseprint swimdress,£22.

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Fitness expert Kathleen Stewart

looks at the benefits of

Pilates to womenaround menopause

Fitnessmatters

Introducing the power of Pilates

and metabolic disorders, thiscan create a confidence crisis,negative body image and diffi-culty in dressing as we desire. By emphasising the correct

recruitment and activation ofour core muscles, Pilates canhelp us achieve a tighter anddefined mid-section, althoughadditional cardiovascular exer-cise and nutritional interventionwill be needed to shift stubbornfat deposits.Total body conditioningFor those who do not like thetraditional resistance training,Pilates can be an exciting al-ternative as body weight isused as resistance. A well-structured RT programme is

Hello and welcome to Fit-ness Matters. I hope youare enjoying my articles

and they are inspiring you tomake physical activity a regu-lar part of your life. This timeIʼm turning to Pilates, whichhas become hugely popular inrecent years. This exercisesystem can be of immensebenefit to peri and postmeno-pausal women and there is anabundance of classes avail-able in gyms, leisure centresand community venues. So how can Pilates help me?

While many of us are drawn toPilates in our quest for im-proved abs, there are manycompelling reasons to makePilates a regular part of yourfitness programmes.Core strength One particularly unwelcome effect of menopause and theageing process is weight gainand the increased depositionof fat around the visceral areawith a shift to an androgynousbody shape. As well as an in-creased risk of cardiovascular

ment during Pilates exercises,flexibility will be enhanced.Balance and posturePilates is a balanced, totalbody workout, which will in-crease postural awarenessand correct muscle imbalancesthat can lead to poor posture.Some exercises will improvebalance and coordination,which can help prevent cata-strophic falls in later life.Psychological benefitsPilates has positive psycholog-ical effects. At this challengingtime in our lives, a loss of men-tal clarity, focus and motivationare common. Unlike some fit-ness programmes, Pilates engages our minds as well asbodies as a great deal of emphasis is placed on correctbody alignment and controlledexecution of the moves. In the words of the creator of

the exercise procedure,Joseph Pilates, he says: "Pilates develops the body uniformly, corrects wrong pos-tures, restores physical vitality,invigorates the mind and ele-

key to maintaining and increas-ing muscle mass and boostingmetabolism, even when ourbodies are resting. And as abonus, it can contribute to de-creases in total and abdominalbody fat. Increased bone den-sity is an important additionalbenefit.Improved flexibilityMenopausal transition formany women is accompaniedby a loss of joint range ofmovement and stiffness. Thishas adverse consequences forour ability to carry out every-day activities and a limiting effect on sports and exerciseperformance. By workingthrough a full range of move-

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Meno June 2014:Layout 1 13/6/14 09:07


NEXT ISSUEIʼll be looking at body

conditioning for women in andaround the menopause.

Meantime, feel free to contactme on

[email protected] ifyou have any questions or visit

www.katsfitness.co.uk.

Introducing the power of Pilatesvates the spirit." Lots of rea-sons for giving this system ago.Here are three body exer-

cises for you to try. Performthem in a controlled, focusedmanner, breathing out on theexertion and in on the returnphase. Repeat each exercise8-16 times.Shoulder bridgeLie on your back in neutralspine (lower back slightly offfloor) with legs shoulder-widthapart, knees bent and arms onthe floor by your sides. Armscan be raised over shoulders.Squeeze glutes and slowly lifthips off floor as shown, simul-taneously raising arms abovehead. Hold for a few secondsand return to start position.Heel slideLift head and shoulders off thefloor, keeping chin tucked in.Donʼt allow your head to fallback. Slowly slide your heelalong floor until your leg isstraight while simultaneouslyextending opposite arm over-head and lowering your head

and shoulders to the floor. Stretch as far as possible and

hold. Slowly slide heel in tostart position while curling offfloor and returning arm to start.Repeat on other side.Torso twistLie on your back with legs intable top position, head andshoulders off the floor. Yourlower back will be in contactwith the floor. Keeping abstight, twist torso aiming headand shoulders towards oppo-site knee, while extendingother leg away from your body.Knees can be straight orslightly bent. Return to startand repeat on other side.

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Professionalbrief

The publication of theWomenʼs Health Initiativereport on HRT in 2002

caused much consternationand confusion among women.It has since been recognisedas a hugely flawed report butnone the less its consequencehas been to maintain uncer-tainty about using HRT amongmany women.Reporting to the World Con-

gress on Menopause, Cancun,researchers have found thatthe type of HRT a womantakes and the way it is admin-istered can have a significantlydifferent effect on genes asso-ciated with breast cancer. The studyʼs purpose was to

find the forms of HRT thatwould have a minimal effect onbreast cancer with the potentialto personalise the therapy ac-cording to the genes a womanhas. This research was conducted

in Sweden at the Karolinska In-stitutet and involved a group of30 healthy women. Using aneedle biopsy, they took twosamples of breast tissue fromeach. The tissue was tested tomeasure the activity of 16genes known to be linked with

then underwent the secondbreast biopsy.The researchers used PCR

analysis to confirm that theCEE/MPA HRT changed theexpression of eight out of 16genes (50%), whereas onlyfour out of 16 genes (25%)were expressed differently inwomen taking the E2/P HRT.This difference was shown tobe statistically significant.Professor Gunnar Soderqvist

said: "Until now, it has notbeen possible to assess breastgene regulation in healthywomen in vivo. This is the firststudy ever describing effects inhealthy women during theseHRT treatments and showsvery important differencesmostly in favour of ʻnaturalʼtreatment with the gel contain-

ing estradiol/oral micronisedprogesterone when comparedwith ʻsyntheticʼ oral CEE/MPA.“The study does not show

that either HRT formulationʻcauses cancerʼ, but it doesshow that the type of HRT andperhaps the route of adminis-tration will cause differences ingenes associated with breastcancer.“We can conclude by saying

that natural treatment with theestrogen gel and oral proges-terone affects gene regulationand surrogate markers forbreast cancer risk (such asmammographic density andbreast cell proliferation) lessthan the conventional synthetictreatment, which stopped theWHI study.”Incoming International Meno-

pause Society president, Professor Rod Baber (Sydney)said: "The science from thisstudy supports the evidencewe have from clinical trialssuch as the French E3N trial,which shows that the choicesof estrogen and progestogenand the mode of delivery is im-portant in reducing any risk ofbreast cancer possibly associ-ated with long-term HRT."

a greater risk of breast cancer.The women were then dividedinto two groups and given HRTfor two cycles of 28 days. Fif-teen women took oral HRT,using the CEE/MPA (this is asynthetic conjugated equineestrogen, plus medroxyproges-terone acetate, which wasused in the WHI trial).The other 15 were given E2/P,which is estradiol gel plus oralmicronised (put into smallpieces) progesterone. Estradiolis a type of estrogen found inthe body, so can be consideredmore natural than the CEE/MPA formulation. The estrogen (E2) was ap-

plied to the skin in a gel. Theprogesterone was micronisedand taken orally. At the end ofthe HRT cycles, the women

HRT: minimisingthe risk of

breast cancer

Meno June 2014:Layout 1 13/6/14 09:07


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