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Are these symptoms of Menopause?
What should I expect from HRT?
Am I experiencing Perimenopause?

Doctor, Are these symptoms of Menopause?  

Question: How do you treat menopause and hepatitis C? Are there any recorded adverse reactions to interferon or combo treatments for HCV, or are there any adverse reactions to HRT in HCV patients?

Answer: No research is done in this field. The general rule is not to prescribe estrogens in serious acute liver disease. The reason is that the liver has to metabolize the estrogen load and in acute hepatitis  every extra workload has to be omitted. In chronic liver disease no contraindication to estrogen therapy exists. The interaction of estrogens and the immunologic system is very complicated and has no clinical meaning on this moment.  

Question:  I began puberty early, with hair developing at age 9 and menstruating at 10. This was not consistent with anyone in my family or my mother's family. Is there any medical evidence of any effect this may have on menopause, such as the timing?

Answer: No relation exists between time of menarche (first menstruation) and menopause (last menstruation). Early menarche has some meaning with breast cancer risk. The risk of breast cancer may have something to do with the total number of years a woman is exposed to estrogens (endogenous or exogenous).

Question: I am a 46 yr. old women and I think I'm suffering from pre-menopause.  I have been getting some night sweats, insomnia and mood swings, but that is the least of my worries.  Recently I feel pms all the time and am extremely irritable and impatient.  I went to see an endocrinologist and she referred me to a Psychiatrist!  She thinks I'm depressed.  She said she felt I had an enlarged thyroid and I am going to have a blood test done to see if anything shows up for that.  She said she didn't feel anything would show up regarding changes in my estrogen levels because I'm only 46?

Answer: The cause of PMS is unknown. The current hypothesis is that PMS has something to do with serotonin. That is because antidepressants with SSRI activity will help and other antidepressants will not. SSRI is the selective serotonin reuptake inhibition. Modulation of estrogens or progesterone will usually not help in PMS.

Doctor, am I experiencing Perimenopause?  

Question: Is light-headiness, which I believe to be cyclical, a symptom of the menopause? I am 45 and have been going through perimenopause since the age of 41.

Answer: This is not a typical symptom of perimenopause.

Question: I am 40 years old and have been experiencing night sweats for several years now.  My uterus was removed 3 years ago but I still have my ovaries. I experience pain during ovulation in my pelvic area, is that normal?  My libido is GONE, I feel as though I am to young to be going through this. Not to mention my emotional state.  Am I going through perimenopause?

Answer: Sometimes, ovarian function diminishes after hysterectomy. It is very rare but it happens. Ask your doctor to measure FSH and estradiol levels. Normal estradiol levels makes perimenopause unlikely.  

QuestionI am a 49 year old women who started having slightly irregular periods about a year ago.  I skipped two periods and was having severe insomnia.  No night sweats or hot flashes.  My FSH was 67 estradiol 29 and doctor  prescribed prempro, which made me bleed, and I still was not sleeping. I have read that fsh fluctuates greatly in perimenopause, and since I had just gone without a period for 2 months, I think that it would be high. I just couldn't believe I was already menopausal, with barely any symptoms. I realize that this is the start of menopause, but I think that since my period has not stopped completely that I am perimenopausal. I feel that I need estrogen replacement for my health, but I seem to be worse emotionally when I take the progestin part of the premphase, and the insomnia returns when I use the progestin.  Is Promentrium better?  Could Birth control pills work for me?

Answer: Some women will never experience hot flashes or night sweats. Sleeping problems can be induced by a lack of estrogens but also other causes have to be considered. You have used HRT for several months. Did you sleep better during this time? Then it is worth to continue the HRT. If not, look for other causes. On the age of 49, with irregular cycle and hormone levels as described, you are definitely perimenopausal. During this early perimenopausal stage continuous combined estrogens like prempro will cause unexpected bleeding very often and sequentially combined HRT as premphase is much better. Premphase is a combination of Premarin and Provera. You can also use Premarin and in the second half of the cycle Prometrium. This can be an advantage especially when prometrium (200-300 mg) is taken in the evening, because sleepiness is a side effect of prometrium.

QuestionI am 38 and have "regular" periods.  I have vaginal dryness, slight urinary stress incontinence, increasing urinary frequency, some "foggy brain" stuff, etc.  My dr. says I'm perimenopausal and has ordered a hormone panel.  He says to increase my low estrogen the pill would be indicated.  I read however that perimenopause involves a lower progesterone level?

Answer: Your doctor will probably have some reasons for saying that you are perimenopausal.  But estrogen levels during the menstrual cycle are fluctuating and a low estrogen level measured once in a normal cycle is no reason to diagnose perimenopause and to prescribe estrogens. Urinary complaints are not caused by a lack of estrogens in menstruating women.

Question: Could you please list the possible reasons for a high estrogen level in a 46 year old female?

Answer: It is nearly always a persistent follicle: an unruptured Graafian follicle can produce very high levels of estrogens. It is a self limiting process. Often followed by a heavy period with long duration.

QuestionI am 52 years old and I am still having my menstrual cycle.  My doctor prescribed Prefest for me but my periods have actually gotten worse.  My period last for about 3 wks with heavy bleeding and clots.  My blood then turns to almost mud/or dark chocolate color and is very thick in texture.  If I'm lucky I may have 3 or 4 days w/o bleeding. My doctor did a laparoscopy about 3 yrs ago and said he didn't see anything.  However, I can always tell when I am going to start by the pain I have in my groin area it gets very painful. I'm not sure if bleeding and groin pain is associated with menopause or if there is something else going on.  I would appreciate your thoughts on this matter.  My doctor is now suggesting that I take Depo shots to stop the bleeding.

Answer: It is not unusual to have a menstrual cycle on the age of 52. About 45% of all women have menstruations at that age. It is not clear to me why your doctor has prescribed Prefest. Did you have hot flashes or other complaints and did the symptoms disappear with the HRT? Prefest is a new cyclic combination of 3 days estradiol and 3 days estradiol with norgestimate. This combination will cause bleeding problems in many women when used before menopause. It is only tested in postmenopausal women (at least one year of amenorrhea). Before menopause a cyclic combination of estrogens for 2 weeks and estrogens+progestagens for the other 2 weeks will result in good cycle control. Do not start with Depot shots, because they will induce bleeding problems also in many women.

Please check-out these great articles about your question.  Perimenopausal Bleeding - What's Normal? by Paul D. Indman, MD, Painful Periods by D. Ashley Hill, MD,  and Pain in Endometriosis by Mark Perloe, MD with Dr. Ray Garry.

QuestionI am 42 years old and believe I have begun perimenopause (10 months of irregular cycles).  I began noticing more facial hair a few months ago and began experiencing a tremendous amount of hair loss, especially at the front of my scalp.  I began taking B12 and Iron in addition to my multiple vitamin, thinking stress or anemia was the cause.  While I understand that hair loss and changes in texture are common in post menopause, I am deeply concerned with this sudden change. Is there help?

Answer: Hair loss is not a perimenopausal symptom. It is usually a symptom of poor health. Your idea that stress or anemia is the cause sounds very probable. It will stop when the general health improves. Baldness because of this kind of hair loss is very, very rare. When hair loss occurs in an androgenic way, especially on the forehead, further medical investigation for hyperandrogenism is necessary.

Please check-out this article from the Advanced Fertility Center of Chicago called Hirsutism and hyperandrogenism in women.

Question: I am 43 yrs of age and have been having night sweats for 4 years on an irregular basis. My periods do fluctuate but are slightly heavier than usual on day 2. I have noticed my skin under my chin has increased hair (fair colored), my skin and hair is much drier and I wondered if this is due to lack of oestrogen. PMT symptoms seem to have lessened though abdominal bloating and headaches are common. I have noticed I want to urinate more frequently and I do have some tendency to be more emotional and irritated. Otherwise, I am healthy and take no medications.  Am I in perimenopause?

Answer: I can not tell you if this is perimenopause or not. By definition perimenopause starts when the periods become irregular. But in most women there become some changes in menstrual flow, or length of periods before irregularity. Night sweats can also occur because of other mechanisms than perimenopause, especially in anxiety disorders and depression.

Question: My mother is perimenopausal.  She is 56 years old, and weighs 230 pounds. Does not smoke or drink alcohol with a sedentary lifestyle. She recently had a full physical examination, during which she found out that her uterine lining is 8 mm thick.  She was told 4 mm is normal. What is this condition called?  What causes the lining to thicken? Treatment procedures?

Answer: Endometrial thickness of less than 5 mm is normal after menopause (women who did not have any period in at least 12 months). In perimenopause the thickness is changing with the hormonal stimulation and 8 mm means that there is some kind of proliferation (by endogenous estrogens). No treatment is necessary. Treatment is indicated with irregular bleeding. Then one has to perform a diagnostic endometrial biopsy, especially in heavy overweight women with a high risk of endometrial cancer.

Question: I am 46 yrs. old, and in search of relief for my nerves.  My mother went through her change at the same age. I have hot flashes, night sweats and can't seem to control my mood swings. I can't even stand my self! What can I do?

Answer: The best way to treat these symptoms is the use of estrogens. When you still have periods, you can use low dose birth control pills. Within three months a remarkable improvement could be seen.

Question: I haven't had a period since July. I have had one ovary removed since 1971. With one ovary do you go through menopause earlier then normal? Since not having a period I've experienced a fullness in the lower abdomen and still no period. I do experience dizziness throughout the day and heart palpitations, and very tired.. with going through my change is it possible to be pregnant with the fullness and feeling like weight in the lower abdomen?

Answer: There is evidence that menopause comes earlier when ovarian tissue is surgically removed. But there is a large range. This is only applicable for the mean of many women together. Maybe with 2 ovaries menopause would be at the same time in your case. Because 47 is not early. It is good to use contraceptives until one complete year without a menstrual cycle.

Question: I am 43 years old and had a hysterectomy approximately 10 years ago. I do still have a tube and ovary on the left side. My question is, am I considered postmenopausal now? Recently a small cyst was found on my ovary during a CT SCAN. My doctor says it is nothing to be concerned about, however I am still having the pain. IVP was done and showed no problems. Colonoscopy was done and that also was normal. This pain is extreme at times. Is it possible it could be from the cyst?

Answer: After hysterectomy no definition describes the situation. Menopause is the last menstrual period but not actually the last menstrual period before hysterectomy. After hysterectomy the diagnosis can be made with high FSH and low estradiol in two settings two weeks apart. Small cysts (<3 cm) are often seen during perimenopause, but also after menopause sometimes small cysts arise and disappear again. Cysts can be the cause of pain.

Question: I am 40 years old, and have been having hot flashes, mood swings, and periods that come irregularly, sometimes 2 weeks apart, lasting 3-4 days, then spotting for another 4-7.  This has been going on for a full year.  I am not on any medication, just a daily vitamin.  My doctor had 2 blood tests done and said I am not perimenopausal, that my hormone levels are fine, my testosterone was fine, etc.  What do you make of this?  What is your opinion of natural herb creams for hormone replacement.  I have heard of a prescription for natural yam cream that absorbs only the amount of estrogen needed?

Answer:  All claims on natural hormone replacement are fragmentary and not well studied. I do not know of any prescription that is absorbed only the amount needed. Those products are not studied and the stories are only for profit of the manufacturer. With normal blood tests you can exclude perimenopause. But how is prolactin and thyroid? There are more reasons for cycle disturbances.

Question: I'm 40 years old and over the past 9 months have been experiencing mood swings, anxiety, irregular periods, forgetfulness, hot flashes and many nights can't sleep.  But most disturbing is, I have no sexual desire and often can't stand having my husband around.  My children are suffering as well due to my moodiness. Could this be perimenopause.  My mother was in her late 40's early 50's when she experienced menopause.

Answer: Lack of sexual desire is not a manifestation of perimenopause. Maybe it has something to do with tiredness and depression because of hot flashes and bad sleep. Try to regulate your cycle with birth control pills or otherwise. When vasomotor symptoms disappear, the other symptoms will fade away to. When they persist, especially depression and anxiety, consult a psychiatrist. When only lack of sexual desire persists, consult a sexuologist.

QuestionI am a 30-year-old mother of three.  I started to have hot flashes just after I turned 29.  My period was skipping around between every five weeks and every three weeks and then going back to four weeks for a month.  I have almost every symptom of perimenopause, (hot-flashes, moodiness, hair falling out, skin itching, lack of sex drive, can't sleep, irregular periods, no memory, headaches etc.). I talked to my doctor and she did a thyroid test which was normal.  She tells me it is stress.  I know how my body reacts to stress, I used to work 12 hour nights and have to go home to take care of a 14-month-old and a newborn!  Should I get a new doctor, one that will check for things rather than to tell me it is just in my head?  Could it be premature ovarian failure?  I don't want to go on hrt and taking birth-control pills is out of the question?

Answer: This is not a perimenopausal question. There are lot of reasons for menstrual irregularity and POF on the age of 30 is very rare. Why check as you refuse hormonal therapy? What options are left?

Doctor, What should I expect from HRT?  

Question: My question concerns the difference between taking hrt as pills or patches.  I just don't understand the relative differences in patches and pills and why and when one is indicated over another.  Could you help me understand how, when, and why each kind of hrt works?

Answer: What matters is the amount of available estradiol for the cell. With oral pills the first-pass metabolism through gut and liver makes most of the oral gift unavailable. A large amount is circulating as the not active estronsulphate. With patches less estradiol is administrated but the first-pass effect through the skin is essentially different. The result is that with pills and patches the same amount of available estradiol is reached. The same biological activity is reached. The extra benefit for patches is a lower workload for the liver, but a healthy liver can handle oral pills easily. Only for diseased livers is the difference meaningful.

Question: I had a total hysterectomy 4 months ago. I've  been unable to find an estrogen that works well for me. I react oddly, soon after taking oral Estrace I develop a feeling in my though I've just finished a strenuous run. My lungs ache. At first I thought I was having a panic attack but nothing else happens. My pulse does not quicken. I oxygenate well. And my mind remains clear. I eventually tried  quartering the pill and took small doses throughout the day--that helped some.  I then switched to an Estraderm patch-- it worked great!   However, they come off. ( I'm a runner.)   So, I'm  wondering if you can explain the aching lungs and if you have any suggestion for what may work better?  I've tried Premarin and Estratest. The estrone based  med seemed to cause minimal distress. I've read so much about the benefits of estradiol, I'd like to take it if possible.

Answer: Try another brand of the patch. Or use estradiol gel for percutaneous estrogen administration. Or intranasal application. There are a lot of ways of administration but not always everywhere available.

Question: I am 54 and have been on HRT for 5 years using the patch and prometrium.  6 months ago a gynecogolist advised taking the prometrium once a day (instead of 2) for the last 2 weeks of the cycle, as I was having sporadic spotting.  I still have monthly spotting and have had a biopsy (no results yet). I have had spotting every day since then.  What do I do and is this abnormal?  Also, should I still have spotting when taking the prometrium every day?

Answer:  Prometrium contains 100 mg progesterone per capsule. There is no need for dividing the dose in 2 portions. Once a day is good. But the dose of at least 200 mg per day is important. Take it in the evening because progesterone in sufficient dose will cause sleepiness. For some women 200 mg is not enough because of resorption problems. They need sometimes 300 mg. But an endometrium biopsy done at the right moment in the cycle will reveal that. Spotting after a biopsy is not unusual. When spotting does not disappear with an adequate dose of progesterone further diagnostic measures are advised (Saline infused sonography, hysteroscopy). Another regimen of HRT is the continuous combination of estrogens and progestagens. You can take the patch continuously and every day one capsule of 100 mg prometrium. But first of all diagnose the cause of spotting.

QuestionWhat is the difference between taking estrogen with testosterone and estrogen with progesterone?  I had a tah/bso in 1977 and am having a hard time finding a replacement for the estradiol valerate.  The delestrogen does not work the same for me.  I am having hot flashes, anxiety, insomnia and weight gain.

Answer For women after hysterectomy no need exists for progestagens (or progesterone). Only estrogens is enough, because progestagens are necessary only for protection of the uterus. Some women especially after BSO (bilateral oophorectomie= removal of both ovaries) experience problems in libido and wellbeing because of a lack in androgens. The ovaries produce androgens also after menopause. For women with problems because of androgen deficiency tablets with estrogen and testosterone are available.

QuestionI am 50 years old and have been on HRT since April of this year.  I am currently taking premarin and progesterone.  Things were going along fairly smoothly with the expected break through bleeding, and then ended up bleeding 20 days in August and also spotted 6 days on top of that.  Then in September I bled 16 days and spotted an additional 11, and went to my gynecologist and had a biopsy which came back normal.  The last week in September I started taking a double dosage of progesterone which I am still taking.  I bled the entire month except for two days... prior to getting my biopsy done.  I am so tired of bleeding I could just scream.  All of my paps have come back normal as well.

AnswerBleeding problems with continuous combined HRT is seen very often especially in women who start combinations like this before menopause. When taken for the first time 12 months ore more after the last menstrual period, about 40-50% of women will experience breakthrough bleeding during the first 6 months. Before you are really postmenopausal a sequential combined regimen such as Premphase or other brands are much more appropriate and will regulate your cycle.

Question:  I am 45 years and still having menses every 3 to 4 months and experiencing very mild hot flushes. When should I start HRT? Should I wait until menopause as I am afraid to develop osteoporosis (I have no high risk) but also afraid of increasing risk of cancer breast?

Answer: Start with HRT when you have complaints of hot flushes. And complaints is somewhat different than the existence of hot flushes. For preventing osteoporosis there has to be a certain risk. Only for women with low bone mass long term estrogens are indicated. Ask your doctor for a bone mass assessment, especially because you are rather young for menopause.

Question: How important are the hormone pills after a hysterectomy? I had one several years ago and still can not get my normal feelings back. I have been on several different pills and the patch.  I have the awful mood swings, hot flashes, and night sweats?

Answer: When hormones are not diminishing your symptoms, you have to search for other causes. Usually, after hysterectomy, the ovaries remain functioning as before. And with normal hormone production by your ovaries, you cannot expect any cure from HRT.

Question:  I want to know if there is any risk of cancer for a woman using vaginal estrace cream who has had a total abdominal hysterectomy?

Answer: It depends on the dose. Estrogens are absorbed very well from the vagina. You can expect that with sufficient dose the same effects on the breast, and a small increased risk of breast cancer can occur. With the low-dose usually advised, the risk is extremely low, if you have no other risk factors for cancer.

Question I am 45 years old and was experiencing numerous hot flashes and absence of menstruation. My doctor ordered a blood test and said that my FSH was 96 which indicates that I am definitely in menopause. I have taken Prozac for 10 years and it has been wonderful, in terms of anxiety and mood regulation. My doctor prescribed FemHRT for my menopausal symptoms. I have only taken FemHRT for about 2-3 weeks and it has helped with the hot flashes. However, I'm feeling as if it is diminishing the effectiveness of Prozac?

Answer: Prozac inhibits the reuptake of serotonin in the neuronal synaps in the brain. Estrogens interfere with the serotonergic system. It is a very difficult and not very well studied subject. Recently a hypothesis was formulated about the role of serotonin in hot flushes. According to this data one can expect that Prozac and HRT can augment each other. But no studies are done.

Question:  I am 38 years old and started having perimenopausal symptoms 4 years ago.  My last blood work showed an FSH of 88.  Over the last 2 years, my doctor has tried several different birth control pills, an estrogen patch, Estratest, and Cenestin.  All of these caused leg pain.  The birth control pill also caused headaches.  My question is, if all of these caused leg pain, will all estrogen do the same?  I always stop taking the medicine when the pain gets moderately severe - after about 2 weeks. Is it dangerous for me to keep trying different estrogens?

Answer: Leg cramps are associated with low calcium levels or with occlusion of blood vessels as in thrombosis. It is not known to me as a usual side effect of estrogens. With all kinds of estrogens calcium levels usually improve. Thrombosis is a risk with estrogens especially in families with more thromboembolic incidents. In my opinion there is a need for further investigations especially because you are so young for menopause and because of your symptoms. The best choice is for this kind of problems a specialist in internal medicine.

Question:  I am 46 years old and have not had a period for three months. For the last two years I have been experiencing irregular periods, hot flashes and mood swings. I started Black Cohosh about eight weeks ago. About four weeks after starting Black Cohosh all my symptoms disappeared. This product is great! My question to the doctor. Is this product safe? How long can I stay on it? Where did my period go? I have never gone three months without a period.

Answer: Congratulations with such a success with Black Cohosh. No one knows the safety of the product or if there is a maximum duration of use. It has not been studied, and is not approved by the FDA. But I expect that it will be safe and that you can take it as long as you wish. Periods are missed because of ovarian failure. And ovarian failure occurs because of a lack of follicles or follicles poorly reacting to stimulation.

Question:  I am 49 and I have been on progesterone 100 and testosterone 5 for about a year.  I also take aygestin for 10 days out of the month to regulate my periods.  I have severe bleeding that lasts for at least 7 days.  I have real bad mood swings, and my hands feel like they are on fire is this part of the change or is this something else? The Dr. keeps telling me that the period will stop but they just keep getting worse.

Answer: I cannot imagine for what kind of problem you take this medication. Is it really continuous progesterone 100 and testosterone 5? And monthly aygestin? (in what dose?). It is quit unusual. Please ask your question again and give the reason for starting this medication and precise details on the medication.

Question:  Have had hot flashes, etc., since early forties. Because I had a blood clot in my mid-twenties from the Pill, docs were hesitant to give me HRT - also alcoholic, bulimic, anorexic  - in recovery  for many years. It was suggested that I take natural estrogens, progesterins, - black cohosh and wild yam.  I did this for several years and it alleviated most symptoms.  My mom and aunt have severe osteoporosis - I am Caucasian, small boned with a history of eating disorders.  Now I am on menest - one month - I had breakthrough bleeding for the first few days, off seven days but no period. Doctor did not give me progesterone.  Do I need to start the menest on time or wait for my period?

Answer: It is not clear if medication is necessary for osteoporosis. Is bone mass measured? Maybe you have even a high bone mass (but your history suggests a rather low bone mass). For bone mass, Fosamax is available without thromboembolism risk.

Question:  Is it possible that a drug like Celexa could bring about menopausal symptoms?

Answer: SSRI's do influence the level of serotonin in the synaps between nerve ends. The neurotransmitters serotonin, noradrenaline, beta-endorphine are involved in the mechanism of the hot flash. These links between serotonin and hot flushes are hypothesized. There is a lack of studies in this field. The few observations available result in a diminishing of hot flushes with
SSRI's. It is unlikely that these drugs induce perimenopausal symptoms, but again, this is not well studied.


Opinions expressed here are for educational purposes only and, as such, do not constitute and should not be interpreted as initiation of a physician-patient relationship. This information is not intended to supplant the need for you to consult with your physician prior to choosing therapeutic options and/or interventions.

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