When menopause symptoms are controlled, you can smile as if you just had your first period.

Do you think of hot flashes when you think of menopause? Many women in or approaching menopause experience hot flashes occasionally. Many others go through misery because of hot flashes.

But there is much more going on, affecting more than your body temperature and your tendency to sweat.

Emotionally, menopause can be a confusing time as the sense of relief in knowing that an unplanned pregnancy will never happen may collide with a sense of loss, knowing you'll never bear another child, or if you've never had children, you will remain childless.

Do you want to start caring for a baby at age 55? For most of us the answer is no. But the sense of loss can still be very real and pervasive.

For some women, there may be unsettling questions. If they are no longer fertile are they also somehow less feminine? Is sexiness and desirability now relegated to other, younger women?

Weight gain, even for many women who never battled their weight before, can become an ongoing issue. This can make a woman who's well aware that she's getting older, feel older still.

If a woman has for most of her adult life seen herself in terms of her appearance, menopause is a trying time. Disturbing questions may arise. Has her value as a woman dropped? Has her currency as a human being diminished?

If she's focusing on new wrinkles and reduced muscle tone, she may wonder what she has to offer. Will anyone will want it?

While men don't undergo an exact parallel to menopause, middle age can take a toll on the male sex as well. Men get worn out too, and may go through their own crisis of confidence, as energy and erections are perhaps not quite what they used to be.

Put a man and woman together who are weathering these storms and you may have a prescription for a depressed sex life. Frequency, pleasure and confidence can take a nose dive that, if not handled in a straightforward manner, may never get turned around.

If both partners need reassurance and neither can offer it, sexual encounters can become less frequent, their sexual relationship muted, and relegated to nostalgic memories of the good old days long past.

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Sex is one of the basic human needs which unfortunately does affect women undergoing menopause.

It's important, even though good sex may be only five per cent of a relationship. But I stress to patients that it's the first five per cent! Besides, it can also affect physical health.

Dr. Leonard DeRogatis, Director of Sexual Medicine at Johns Hopkins University, emphasizes a major difference between men and women.

He says that men have the desire, but as they age can't be aroused. Still, they're the lucky sex. Erectile dysfunction drugs solve their problem in most cases by increasing blood flow to the "you know what". (If I use the anatomical word, many newspapers block this column).

Women are less fortunate. Some suffer from what's called the "Hypoactive sexual desire disorder." In effect, sex may never have been high on their list of priorities. So would ED drugs help to start sexual desire for women too?

In one study 202 women were given Viagra. As expected it increased blood flow to the genitals, improved sexual satisfaction for some women who had arousal problems, and provided the stimulus to engage in sex. But it had no effect on those who suffered from HSDD.

So, as has been pointed out many times, there's a major difference between men and women. For males all that's needed is an engorged organ for a happy bedroom. Their brains are always primed for sex. But for women, ED drugs will not turn those who have HSDD into raving sexual maniacs.

Is there anything that will do it? Many experts believe that the male hormone testosterone will also govern a woman's sexual desire. At 50 years of age women produce 50 per cent less testosterone than those in their 20s. That's one reason why sexual desire gradually diminishes. Boosting testosterone levels, they say, will also boost their libido.

Does it work? The International Journal of Impotence Research analyzed 12 studies and concluded it does help. The North American Menopausal Society reached the same conclusion and endorsed its use.

But getting testosterone is easier said than done in this country. Like the controversy surrounding the use of estrogen for menopause, there is an underlying worry that testosterone might increase the risk of breast cancer.

But according to Dr. Jerald Bain, a prominent Toronto endocrinologist, some doctors are using small amounts of testosterone to treat sexual problems in women.

Dr. DeRogatis believes it unlikely testosterone increases the risk of breast cancer and that the greater possibility is growth of facial hair and transient acne.

This can occur if too much testosterone is prescribed. Non-hormonal treatments are also available.

For instance, Wellbutrin has been available for many years to treat depressed patients.

But it has also been shown to increase sexual desire in women who are not depressed.

But for women there's more to sex than hormones. They don't enjoy a happy bedroom if there's discontent in a marriage, financial problems, lack of communication or no love.

A woman recently said to me, "I'm bored with my husband and wish I'd never married him." It would take the coming of a Messiah to solve this problem.

And not all sexual problems confronting women are in the head. All too often the reason post-menopausal women shy away from sex is medical. But the diagnosis is missed by doctors who neglect the pelvic examination.

Lack of estrogen in menopausal women results in thinning of the vaginal lining.

This may cause pain and inability to have sex or an orgasm.

Some women with this condition have been unable to have sex for years. It's tragic when they could have been cured within a few weeks by Premarin cream or Vagifem pills.

I remind these patients that if Engelbert Humperdinck is unable to sing with a sore throat, neither can they be expected to enjoy sex with an inflamed vagina.

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eating excessive amounts of chili peppers can trigger hot flashes!

Studies suggest that eating carbs can increase the release of tryptophan, an amino acid that helps the brain manufacture serotonin, which helps people fall asleep.

SAY YES TO:

• Eating a piece of toasted whole grain bread or a small portion of another carbohydrate before going to bed.
• Other foods that contain tryptophan are turkey, soy, cod, egg whites and warm milk.
• Also, omega-3 fatty acids, found in fish such as salmon, trout and tuna, play a role in sleep induction.
• And don’t forget cherries. They contain melatonin, a substance found in the body, which helps regulate sleep.

SAY NO TO:

• Large meals. When you eat a large meal, digestion brings blood into the abdomen, raises body temperature and tells the hypothalamus in the brain to send a signal that causes hot flashes. Eating smaller meals can help reduce the number of hot flashes.
• Caffeine. Coffee, tea, colas and dark chocolate contain caffeine. They may trigger hot flashes and affect your sleep. So drink water and avoid caffeine, especially in the late afternoon and at night.
• Alcohol. Alcohol can increase the hot flashes and affect sleep, mood and weight. Heavy use can lead to osteoporosis because alcohol prevents cells from building new bone. Limit yourself to no more than one drink a day.

BLOATING

During the menopause transition, another common midlife symptom is bloating, which may be due to hormone fluctuations, overproduction of estradiol and conversion of androgen (a so-called “male” hormone) to estrogen through a process called aromatization, which increases with age and body weight.

SAY YES TO:

• Foods and herbs that have diuretic properties, such as celery seeds, parsley, dandelion, juniper berries, asparagus, artichokes, melon and watercress. And drink plenty of water and herbal teas.

SAY NO TO:

• Sugary and high-sodium foods such as frozen dinners and canned soups. Read the sugar and sodium content on food labels, and reduce the amount of sugar and salt you add to foods and beverages.

MOOD SWINGS

Many women during the menopause transition report a decreased sense of well-being due to irritability and mood swings. Good nutrition plays a major role in moods. So it is important to understand which foods stabilize our moods and which ones to avoid.

SAY YES TO:

• Omega-3 fatty acids in foods such as tuna, salmon and mackerel.
• Eating vegetables such as asparagus, Brussels sprouts and beets, which are rich in B vitamins. Green vegetables such as spinach and peas are high in folic acid, a member of the B-complex group that may also help stabilize mood because it’s needed to make serotonin. Don’t forget that spinach and other dark, leafy greens can be used raw in salads and sandwiches as well.
• Chicken and turkey, which are rich in vitamin B, a player in the production of serotonin in the body.

SAY NO TO:

•     Sugary foods, which cause a rise in blood sugar and may increase mood disturbances.

DECREASED SEX DRIVE

For some women, menopause and its associated decline in “sex” hormones can lead to a decline in sex. A lower level of estrogen is the main culprit and that can lower libido and cause vaginal dryness. Recent information suggests that food can spice up your love life.

SAY YES TO:

•  Granola, oatmeal, nuts, dairy, green vegetables, garlic, soybeans and chickpeas. These foods contain L-arginine, which is thought to be helpful in improving sexual function.
• Avocados contain potassium, which regulates thyroid hormones and may enhance female libido.
• Chocolate intake releases serotonin in the brain, producing feelings of pleasure similar to having sex. But indulge in moderation for its benefit, and try eating it as a prelude to lovemaking.
• Asparagus is a vegetable to consider due to its vitamin E content.
• Fresh fruits. Feast on fresh fruits such as strawberries, pomegranates and grapes, which are delicious and rich in antioxidants.

SAY NO TO:

• Chile peppers. Eating chili peppers in excessive amounts can lead to hot flashes. This will not help you set the mood. However, when enjoyed in a flavorful recipe, these feisty peppers can also help trigger the release of natural endorphins, creating a high that is not unlike lovemaking.

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Menopausal Hormone Therapy Questions & Options

• Are in their 50s or younger.
• Had their last menstrual period within the last 3 years.
• Have moderate to severe symptoms.

Estrogen therapy can protect against bone loss. However, you might have side effects like breast tenderness, spotting or bleeding, nausea, bloating, water retention, headache, or mood changes. If you have not had a hysterectomy, you will need to also take a second hormone, a progestogen, to protect your uterus from the risk of cancer.

Systemic hormone therapy at low doses does not always improve your vaginal symptoms (dryness, uncomfortable sex, urinary tract infections). If your vaginal symptoms do not improve, consider adding vaginal hormone therapy.

ESTROGEN ONLY OPTIONS

    Pills - Relieve hot flashes and vaginal thinning with one daily dose.

    Skin Patches, Gels or Sprays that Absrob through Skin - Relieve symptoms and are easy to use. Might be safer because they bypass the liver.

    Vaginal Estrogen Ring – Can relieve hot flashes as well as vaginal dryness.

1/ Questions to Ask Your Doctor About Your Menopausal Symptoms

• Could the symptoms I have come from something other than menopause?
• Should I get checked for diabetes, thyroid disease, and colon cancer?
• How does my health history affect my risks and my decision about menopausal hormone therapy?
• What if I don't want to take hormone therapy? Are there non-hormonal options to relieve my symptoms?
• What non-hormonal prescription drugs interact with my current medications, and how? What about over-the-counter drugs?
• Are there any lifestyle changes I should make?
• What advice do you have to help me eat right, be more active, stop smoking, sleep better, or manage stress?

2/ Questions to Ask Your Health Care Provider if You Decide to Start Hormone Therapy

• Before I start menopausal hormone therapy, should I:
  • Have my blood pressure, cholesterol, and triglycerides checked?
  • Get a breast exam and mammogram?
  • Get a Pap smear and pelvic exam?
  • Review my family history of heart disease, blood clots, or breast cancer?
• What is the lowest dose that will work for me?
• In light of my medical history, what is the safest form of therapy to take?
• How long should I take menopausal hormone therapy?
• What are the possible side effects of hormone therapy, and how can I deal with them?
• If I want to stop menopausal hormone therapy, should I stop cold turkey or taper off?

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Common Myths about Menopause Busted!

Popular culture tends to send a “dread-it” message about menopause, which can begin for women in their early 40s but, on average, strikes at 51.

Menopause’s bad rap might have been born centuries ago, when a woman’s life expectancy coincided with the age of menopause, leading observers to equate the “change of life” with “the end of life.” And even in the land of Google, girl power and WebMD, myths about the “change of life” persist.

But two local health experts — Dr. Carol Gnatuk, OB-GYN at Penn State Milton S. Hershey Medical Center, and senior nurse educator Sharon Veet of PinnacleHealth — say there isn’t much to fear. We asked them to help bust common myths about menopause.

Myth 1: Menopausal symptoms don’t start until you are no longer having periods. Not true. “You get symptoms long before menopause,” Gnatuk said. Menopause is confirmed after a woman has missed 12 consecutive menstrual periods. Women can be most symptomatic during the perimenopausal transition — about two to eight years before the actual age when your periods stop — because of the instability of hormone levels. “It is like entering puberty, but in reverse,” she said. The most predictive factor of your age at menopause is not when you hit puberty, but when your mom hit menopause, Gnatuk said.

Myth 2: Menopause makes you fat. Yes, many women gain about 10 pounds after menopause, but it’s not a sure thing. Menopause might also not be the primary cause of those extra pounds. Often, weight gain is caused by other changes in your life, such as a slower metabolism, stress eating and reduced activity levels. Hormone pills don’t make you fat either, Gnatuk said. But she concedes, most women do see weight gain in midlife, and it is mostly in the midsection. At this age, many women “turn into an apple instead of a pear,” Gnatuk said. But “weight gain is not everyone’s destiny,” Veet said. “All symptoms of menopause can be as unique as the women who experience them.”

Myth 3: Menopause kills your libido. Some women might lose their sex drive, but again, this might be linked to factors other than menopause, such as relationship issues spawned by an empty nest and adolescent children, pain at intercourse and embarrassment over weight gain. But libido loss has a scientific basis: Gnatuk said testosterone is the biggest predictor of sex drive, and testosterone production does decline at menopause. But sex drive is not totally hormonally driven. Many women experience vaginal itchiness, burning and discomfort, even without having sex. But for some women, Veet said, no longer having to worry about getting pregnant can actually increase sex drive and induce “a kind of freedom.”

Myth 4: Because you can’t get pregnant anymore, you can skip that annual appointment with the OB-GYN. Don’t, Gnatuk said. At this age, the risk of ovarian and uterine cancer rises, and cardiovascular disease and osteoporosis are real dangers. Gnatuk points out that a hip fracture can be fatal. Women need to be thinking about ways to prevent a heart attack, stroke and bone loss. After menopause, men and women have the same risk for cardiovascular disease, since estrogen can be an artery-protector and bone-builder for women earlier in life. Post-menopausal women need ample amounts of calcium and vitamin D, along with weight-bearing exercise, to ward off serious health issues.

Myth 5: Menopause always causes hot flashes. According to Veet, 15 percent of women experience no hot flashes at all, another 15 percent have severe hot flashes, and the other 70 percent fall somewhere along a bell curve. Gnatuk reminds women that hot flashes may be triggered by summer temperatures, cigarette smoking, the heat of cooking, flannel nightgowns, stress, hot foods (both in spice and temperature) and alcohol. Gnatuk advises women to dress in layers so they can shed the top layers when they are flashing and to drink cool liquids instead of hot. Some anti-depressants and anti-seizure medication work on the hypothalamus, which controls temperature, and can be effective for those with embarrassing hot flashes.

Myth 6: Menopause makes you depressed. Does every woman get depressed during menopause? “Absolutely not,” Veet said. While acknowledging that emotional changes can be triggered by changes in hormone levels, a feeling of sadness might be linked more to life changes, such as an empty nest or retirement. Those who suffered from premenstrual syndrome, or PMS, earlier in life might experience more intense symptoms, Veet said, such as crying jags and “a short fuse.”

Gnatuk points out that, in general, women are more susceptible to depression than men. And those who suffered from depression earlier in life might be more prone to a relapse at menopause or perimenopause. Any woman with symptoms of depression, such as changes in sleep or appetite and difficulty getting along with others and concentrating, should be screened by their primary care doctor or OB-GYN, Gnatuk advised.

Myth 7: Menopause requires hormone therapy. Women who take hormones at menopause are “in the minority,” but hormone pills or patches can be helpful for relief of hot flashes, night sweats, mood and concentration issues and vaginal dryness. Despite a controversial 2002 study that had many women throwing out their hormone pills, hormones are “safe to use for symptoms if you need them,” Gnatuk said. The risks of having a heart attack or stroke or getting breast cancer are very low, she said. Risks exist for any medication, even ibuprofen, she said, but the risks are well-defined and should be discussed with your doctor. Veet said doctors recommend “the smallest dose, for the shortest period of time, for symptom control only.”

If you don’t want to take hormones, other medical options are available, such as anti-depressants and anti-seizure medications, which help with night sweats and hot flashes. Symptoms can also be treated individually, such as a cream for vaginal dryness. While you cannot absorb estrogen through the vagina, tissues that line the vagina are estrogen-dependent, and prescription-only creams can help, Gnatuk said.

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