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  • Contraception for Perimenopausal Women

    by JoAnn Pinkerton | Dec 05, 2016

    We're pleased to have a guest post from Dr. Andrew Kaunitz.












    Andrew Kaunitz, MD, NCMP

    NAMS Board Member

    Much confusion surrounds contraception (birth control) for perimenopausal women. Before getting started with specific methods of contraception, let’s start with a few definitions:

    • Menopause refers to the permanent cessation of menstruation; the average age of menopause is approximately 52 years.
    • Perimenopause refers to the years of transition from regular menstrual cycles to menopause. The transition tends to begin sometime between a woman’s mid-40s and her early 50s. For most women, the first sign of perimenopause is that menstrual cycles become less predictable; skipped cycles or more frequent cycles are common. A second common symptom of perimenopause is the occurrence of hot flashes and night sweats that may come and go.

    Although the likelihood that a perimenopausal woman might become pregnant is lower than for younger women, pregnancy can and does occur in women who are in the of this transition phase. Few of my perimenopausal patients wish to become pregnant. Furthermore, pregnancy in women in their late 40s or early 50s is often associated with increased health risks for the mother and the baby. For these reasons, contraception is important for perimenopausal women.

    Although barrier contraceptives such as condoms are notoriously ineffective for younger women, perimenopausal women who are motivated to use condoms consistently may have more success with this over-the-counter contraceptive method compared with their younger counterparts. After all, as we get older, we become more disciplined regarding many activities, and that can include condom use.

    Another factor reducing the failure rate of condoms in perimenopausal women is that women undergoing the transition are less fertile than younger women. In addition to birth control, condoms protect women against sexually transmitted infections. Having acknowledged that perimenopausal women can use condoms effectively, I must also acknowledge that few of my patients in the transition are interested in using this approach to birth control.

    What about birth control pills (which contain estrogen and progestin)? Although many women believe that the pill should not be used for more than 5 to 10 years, in fact, there is no time limit applicable to duration of pill use. Furthermore, use of the pill (along with the birth control patch and vaginal ring) has particular benefits for perimenopausal women. The irregular bleeding and hot flashes that commonly accompany the transition are prevented by using the pill, patch, or ring. In addition, the decline in bone mineral density often associated with perimenopause is prevented by use of the pill. Finally, perimenopausal women who use the pill long term will experience a significantly lower risk of ovarian and uterine (endometrial) cancer.

    It is important to be aware, however, that some perimenopausal women cannot safely use the pill, patch, or ring (each of these methods contain estrogen and progestin). Specifically, older reproductive-aged women who smoke; have hypertension, diabetes, or migraines; or are obese should not use these estrogen-containing methods of birth control.

    Older reproductive-aged women who are doing well on the pill can continue until menopause. Rather than checking hormone levels, a practical approach is to continue until age 55. At that time, the likelihood of menopause is very high, and then a woman can simply stop the pill, or if she prefers, transition to hormone therapy.

    In the last decade, more and more US women who are using contraceptives are using intrauterine devices (IUDs) and the contraceptive implant—these methods are more effective and convenient than condoms or the pill. Furthermore, because IUDs (hormone-releasing models as well as a copper IUD are available) and the implant do not contain estrogen, they can be used by women who are not good candidates for the pill, patch, or ring.


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  • All About Dem Bones and Truth About Calcium

    by JoAnn Pinkerton | Nov 16, 2016

    We're pleased to have a guest post from Dr. Nanette Santoro.


    Nanette Santoro, MD
    NAMS Board Member

    We just celebrated my mother-in-law’s 90th birthday with a big family party. My mother-in-law has Paget disease of the pelvis and had been taking Fosamax for about 10 years when her doctor had her go on a “drug holiday.” That was about 3 years ago, and her bone density has been relatively stable since. Paget disease of the bone affects up to 10% of women older than age 80. It causes excessive bone resorption, but as opposed to the much more common postmenopausal osteoporosis, this process happens only in selected areas of certain bones.

    To understand both of these problems, it’s important to understand how bones are made, and how they are maintained. The processes of bone formation and bone resorption are coupled to each other. When all is well, and growth has ended, bone is formed at a rate exactly equal to the rate at which it is resorbed. These two processes are happening at different areas of the bone, but over time, bone remodeling occurs. When these processes are in perfect alignment, they keep bony tissues healthy throughout the body. I think of it like a highway repair system: work teams do surveillance and fix the potholes and cracks periodically, maintaining the integrity of our roads.

    After menopause, the loss of estrogen may lead to a slight excess of resorption over formation, but both processes are still ongoing. The net effect, over time, is bone loss. If the bones were relatively weak to begin with or resorption is happening rapidly, a woman will develop osteopenia or osteoporosis. These conditions differ only in degree, with osteoporosis being the more serious condition. They are important problems, because thinning bones can lead to a greater risk of fracture. Elderly women are typically terrified of fractures, and rightly so. Hip fractures are a common cause of death in the elderly and a frequent reason for a loss of independent living.

    The bisphosphonates were a breakthrough in the treatment of osteoporosis and osteopenia in postmenopausal women. By inhibiting osteoclasts, they decrease resorption. By decreasing resorption, they bring the equation of formation = resorption toward zero, slowing bone loss. Bisphosphonates were one of the very first nonhormone tools that could control bone loss in menopausal women. Their safety record was awesome for about 15 years. If you didn’t get heartburn, and your kidneys were healthy, they appeared to have very few contraindications and virtually no complications.

    Over time, the use of bisphosphonate drugs increased, and doctors began questioning why we should wait until women had osteoporosis to treat them for bone loss. After all, there were no known drugs that could actually increase bone formation—all we could do was stop women from losing any more. If we waited too long, we would miss women who had already developed severe osteoporosis before we ever screened them. Why not screen and treat earlier? Only a few dissenting voices could be heard among the enthusiasts. Typically, these were the doctors who had done the most research on the science of bone. They appreciated the see-saw equation of formation and resorption and worried that if you inhibited resorption, you would also inhibit formation and over time would reduce or even halt bone turnover, a condition called adynamic bone.

    There wasn’t much attention paid to this until the reports began to accrue about just this type of fracture. The initial information was reported by dentists, when women who were taking bisphosphonates and had jaw fractures or dental implants or other procedures that involved bone growth for proper healing did not heal. Then the femur (thigh bone) fractures started to appear. These fractures are usually found in women who have taken the highest doses of medication for the longest time.

    On the way to my mother-in-law’s party last weekend, two good friends, a married couple, were walking from the parking lot to the restaurant, and the wife tripped on the sidewalk . . . and broke her hip. My friend, whose mother has severe osteoporosis, had been treated with Fosamax for more than 10 years. She suffered a hip and femur fracture and just had her bones set. Unluckily, she has developed adynamic bone. They are predicting a long recovery.

    So what are the lessons we can learn from my mother-in-law and my friend? First of all, it’s a great idea to do everything you possibly can to avoid having to take a medication for osteoporosis. Make sure you are taking enough calcium (the National Osteoporosis Foundation Website has the calcium content of most foods on it—I find it very handy: www.nof.org). It’s best to get calcium through the diet. Recent studies indicate that women who take lots of calcium supplements might be at a slightly higher risk of heart attacks. Women should aim for about 1,200 mg of calcium a day. It’s important to remember that your body won’t absorb all of your daily calcium in one meal—so most of the time, calcium should be taken with food, and if you are taking in more than 600 mg, it’s unlikely that you will absorb the excess.

    Weight-bearing exercise is a terrific preventive. Forty-five minutes a day, most days of the week, walk, run, or do step aerobics. Swimming and biking won’t do. Make sure you are getting enough vitamin D. If you hate milk as much as I do, this means you may need a supplement—vitamin D3, 1,000 to 2,000 units a day, is plenty for most women. Get a bone density checked, especially if you have risk factors or relatives with osteopenia or osteoporosis. Even if you have no risk factors, it is recommended that ALL women get a screening bone density test by age 65. A shout-out to women of color: don’t assume you can’t get osteoporosis. Darker skinned women tend to have lower levels of vitamin D, and this factor can combine with other osteoporosis risk factors to cause the disease.

    Finally, you should know your own risks for fracture. The FRAX algorithm factors in a number of factors that influence your fracture risk (www.shef.ac.uk/FRAX/). It’s one thing to worry about bone density, but thin bones won’t break unless you fall. Preserving muscle strength and balance will help prevent a fall, as will making your home safer by avoiding common household hazards. Area rugs, slippery steps, and bathroom mats should all be addressed. Shower rails can be installed inexpensively.

    Hope this is helpful. Gotta go. Just ate my yogurt (400 mg calcium), took my vitamin D3(2,000 IU), and am suited up for a run.


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  • More About Menopause Symptoms—Tired and Cranky?

    by JoAnn Pinkerton | Oct 18, 2016


    We're pleased to have a guest post from Dr. Katherine Newton.









    Katherine M. Newton, PhD
    NAMS Board Member

    We often think of hot flashes as the most troublesome, and sometimes the only, menopause symptom—and we tend to think that estrogen is our only treatment option. Estrogen works well, but many women prefer not to use, or cannot use, this hormone. And as our research has matured, so has our view of this important stage in a woman’s life. Whereas some women are very bothered by hot flashes, for others it is the mood changes and sleep disturbances that lead them to ask for help. The menopause transition is a time of increased risk for both a recurrence of depression and a first-time episode of depression. It isn’t so much the hot flashes but the fatigue and crankiness or depression that women sometimes find most difficult. So, what about treatments for these other important menopause symptoms?

    If the primary symptom bothering you is mood, there are some good alternatives that may not only help with mood but with hot flashes as well. Several antidepressants in the SSRI (selective serotonin reuptake inhibitor) and SNRI (serotonin–norepinephrine reuptake inhibitor) categories can be used to treat the mood changes of menopause. Those that may also help with hot flashes include paroxetine, escitalopram, citalopram, venlafaxine, and desvenlafaxine.

    What about sleep? A drug called gabapentin, which is approved to treat epilepsy, can help with hot flashes and has a sedative effect. If it is taken at bedtime, the drowsiness it causes may help you to sleep better. An approach called cognitive behavioral therapy for insomnia works very well to improve sleep in menopausal women with insomnia. This approach requires either attending a series of classes or receiving the counseling over the phone.

    Are there nonpharmaceutical approaches that can help? Yes. Although yoga and exercise don’t appear to decrease hot flashes, they can improve mood and sleep and may decrease how bothered you are by your hot flashes.

    All these therapies have their pros and cons. You should discuss all your symptoms with your healthcare provider to come up with the treatment regimen best suited to your needs.

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  • Loss of Sexual Desire Is Not a Medical Myth

    by JoAnn Pinkerton | Sep 28, 2016


    We're pleased to have a guest post from Dr. Sheryl Kingsberg.


    Kingsberg, Sheryl 2016








    Sheryl A. Kingsberg, PhD
    NAMS Board Member


    Many women wonder whether they should quietly accept that they have lost their interest in sex, because even in 2016, society still sends a message that women, especially women of a certain age, are not supposed to want sex. They worry and suffer in silence that they have lost the desire they used to have, but they don’t understand why this has happened or what to do about it.

    The message that these women actually need to hear is that sexual health is a basic right for all women and men and is an important component of overall health. It is only recently that women’s sexuality is being acknowledged within our society. Although the approval of “the pill” in 1960 was supposed to mark the beginning of the women’s sexual revolution, control over reproduction is not sufficient, and 55 years later, equality in sexual health is long overdue.

    Distressing loss of sexual desire is a real medical condition and is known as hypoactive sexual desire disorder, or HSDD, and is defined as the absence or lack of sexual thoughts, dreams, or interest in sexual activity that causes personal distress. It is estimated that 6% to 7% of US women suffer from HSDD, with the highest prevalence in women ages 45 to 64. That translates to millions of women who lost their desire and want it back.

    Women want to want, but they don’t know who to talk to about it. Sexuality is an important part of our personal identity, but because many of us lead busy professional and personal lives as wives, mothers, CEOs, teachers, clerks, caregivers, it’s easy to put sex aside. But when I talk to women about their sexual desires, they don’t typically say, “I can live without it.” Instead they want to talk about how to get it back. They want to want.

    However, many healthcare professionals are still hesitant to talk to women about their sexual health, and women aren’t comfortable bringing it up on their own. This, along with the societal notion that it’s normal to lose desire, can stifle women from discussing the real sexual problems they are facing.

    Low sexual desire affects more than just sex. The effect of HSDD on women goes way beyond the bedroom and can influence every aspect of their lives.

    One thing is that it affects their connections to their partners. If a woman doesn’t desire sex, then the whole sexual encounter tends to be disappointing and may lead her to avoid sex altogether. And this avoidance affects overall communication and intimacy with her partner. Furthermore, a couple may not talk as much out of the bedroom, or they avoid engaging in activities together, especially if she’s worried that she’ll lead her partner on in some way. Overall, we know that when sex is bad or nonexistent, it is extremely draining and can greatly change an otherwise good relationship. Low sexual desire can also deeply affect a woman’s body image, mood, self-confidence, and self-worth.

    It’s not a simple on/off switch for women. The complexity of what it takes to turn a woman on in the brain has finally started coming into focus. Most sexual problems have multiple contributing factors—psychological, cultural, and physiological. Recent research has indicated that HSDD may arise from an imbalance of the neurotransmitters or chemicals in the brain that regulate sexual desire.

    The good news is that research into women’s sexual health has advanced, and we have better tools to evaluate which factors are contributing to sexual problems, and we now have psychological and biological treatment options. 


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  • Don’t DIY With Herbs and Supplements for Menopause

    by JoAnn Pinkerton | Jun 06, 2016

    You’ve seen the ads, articles, and testimonials pop up on the Internet touting this kind of supplement or that kind of herb to relieve hot flashes or help with depression and mood during menopause. But if you’re thinking of trying any of these products to self-treat your symptoms because you’ve heard bad things about hormones, you’ll likely be wasting your money and may even be courting danger. A published report last fall found that thousands of people wind up in hospital emergency departments every year after taking supplements they believed were safe but that had harmful side effects.

    NAMS brought together a team of experts to take a critical look at all the available studies on herbs, supplements, and other nonhormonal approaches for treating hot flashes. What did they find? They found that besides maybe soy foods and supplements, no other herbal or supplement showed an effect any greater than a sugar pill (placebo). Soy did get a qualified nod from the team because it may help some women, but only women whose bodies can use soy to produce a compound called equol. An equol supplement that may help other women is being developed, but it’s not on the market yet. The popular black cohosh, which is an ingredient in many over-the-counter combinations advertised for menopause symptoms, not only does nothing for hot flashes, but it may cause liver damage. And proponents of yam creams probably don’t know that they often don’t even contain yam. In fact, some have been adulterated with steroid drugs, including estrogen and progesterone-type compounds.

    If you are reluctant to use hormones for your menopause symptoms, there are some nonhormonal approaches you can consider. Studies show that a form of cognitive-behavioral therapy, and to a lesser extent, clinical hypnosis can help. Talk to your healthcare provider also about nonhormonal prescription drug therapies proven to reduce hot flashes. And, unless there’s a medical reason you cannot take hormones, you might want to revisit the risks and benefits of them with your healthcare provider, because we have learned over the past few years that hormone therapy begun early after menopause may not pose the dangers that later hormone therapy may.


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  • Straight Talk on Talc

    by JoAnn Pinkerton | May 20, 2016

    There have been several stories in the news about legal victories for women and their families who have sued manufacturers of talcum powder over claims that it caused their ovarian cancers. If you have used products containing talc on your body, particularly in the genital region, you may be concerned. Many studies have looked at the possible link between talcum powder and ovarian cancer, but the results have been mixed. It’s true that some retrospective case-control studies have found a slightly increased risk, but these types of studies often rely on a person’s memory, in this case of talc use many years earlier. Two studies that followed individual women over time, which did not have the potential for bias, did not find an increased risk. Some experts suggest that if there is an increased risk of ovarian cancer with genital talc use, it is very small at an increased relative risk of 1.2 (20% risk) over a woman’s baseline risk of 1.3%. Ovarian cancer is relatively rare, with approximately two out of 1,000 women developing ovarian cancer in 10 years of follow-up. If this small increased risk is true, this would mean an extra four cancers found out of 10,000 women over 10 years of follow-up. Research continues, but until more information is available, women should be cautioned against using genital talc powder. For women who have used genital talc in the past, there are no new recommendations for ovarian cancer screening, because current screening methods are not recommended for women at average or slightly increased risk. Read more on what the American Cancer Society has to say about talc here.


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  • The ABCs of SERMs

    by JoAnn Pinkerton | May 02, 2016

    If you are going through menopause, you probably have heard about alternatives to estrogen therapy that can treat your hot flashes and other menopause symptoms. These include selective estrogen receptor modulators (SERMs), which as their name implies, selectively activate or block estrogen receptors in certain areas of the body and not in others. That can make them safer than estrogen alone and result in fewer side effects.

    There are FDA-approved SERMs to selectively target, prevent, and treat several diseases, including breast cancer and osteoporosis, as well as the genitourinary syndrome of menopause, also known as vulvovaginal atrophy, which can lead to painful sex.

    And although there is no SERM that alone can relieve hot flashes, there is a SERM combination being used for hot flashes that combines estrogens with the SERM bazedoxifene. Together, they form what’s called a tissue-selective estrogen complex, or TSEC. This drug has been FDA approved to treat hot flashes and to prevent osteoporosis in women with a uterus.

    You should talk to your clinician about SERMs if you are experiencing hot flashes and have a history of breast cancer, have been told you have low bone density, want to avoid uterine bleeding or changes in breast density, or sex is painful for you. For a more thorough discussion about SERMs, see the NAMS video What Selective Estrogen Receptor Modulators (SERMs) Can Do for You.


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  • Dr. Pinkerton's Top 10 Tips for Menopause

    by JoAnn Pinkerton | Mar 29, 2016

    Navigating through menopause isn’t always easy. The physical and mental challenges of a changing body come at a time when women face plenty of other challenges: too much work, not enough time, and taking care of everyone—the kids, the job, the aging parents, the community—except yourself. So I regularly give women these top 10 tips to help them stay healthy and happy at this time of their lives:

    1. Make some time for yourself
    Schedule some time for exercise, friends, and yourself on your calendar. Use that you-time for things like meditation, mindfulness, yoga, prayer, reflection on where you are going in life, or to just enjoy the sunset.

    2. Eat healthy and exercise
    Because your metabolism slows down at this time, you’ll gain weight unless you change your lifestyle, so eat less, eat healthy—a Mediterranean diet, for example—and schedule time for exercise. This will not only help you avoid heart disease and other health problems but will also help keep your brain healthy. A recent study published in the journal Neurology found that older adults who did not exercise or exercised only lightly experienced a decline in their cognitive function equal to 10 more years of aging compared with those who exercised moderately or intensely. No time for the gym? Try jump-starting your day with 7 minutes of vigorous aerobic exercise, and work in exercise in 5- or 10-minute time slots.

    3. Sleep at least 7 hours every night 
    Burning the candle at both ends not only zaps energy but also makes you less focused and less productive and increases the risk of Alzheimer’s disease.

    4. Don’t fear hormones
    If you are under age 60 or within 10 years of menopause and have bothersome hot flashes, hormones can quell those while also protecting your bones and may benefit your heart and brain as well. But if you are older than age 60, don’t start hormones without a good reason because it may actually increase your risk of heart disease and cognitive problems. Do be afraid of compounded hormones because these are notFDA approved, regulated, or monitored and carry risks of over- or under-dosing or contamination. If you can’t take hormones, you don’t have to tough out the hot flashes. Some tested nonhormonal medications and alternatives can help, such as the FDA-approved low-dose antidepressant paroxetine or other antidepressants, gabapentin, clinical hypnosis, or cognitive behavioral therapy.

    5. Keeping your relationship healthy with intimacy
    Sexual intimacy with or without intercourse is very important to healthy relationships. Painful intercourse can make you avoid sex, which can put your relationship at risk. So don’t be afraid to discuss painful sex with your partner and healthcare provider, and try lubricants and moisturizers. If those are not enough, low-dose vaginal estrogen has minimal absorption and is safe and effective, despite the warnings on the label, which are really for hormones that get distributed throughout the body (systemic), such as in pill or patch form. In addition, a new oral drug ospemiphene also treats painful sex if neither vaginal nor systemic hormones are right for you.

    6. If you just don’t care about sex anymore, talk to your healthcare provider
    No longer being interested in sex can be detrimental to your relationship and could be due to medications, stress, overwork, fatigue, or other fixable causes. Medications may help, too, including the new FDA-approved drug flibanserin, which has a positive, although small, effect on desire for women who aren’t yet in menopause.

    7. Know your numbers
    Know what your blood pressure, cholesterol levels, bone density, and heart disease and breast cancer risks are so you can head off problems with diet, exercise, and other lifestyle changes, or medications.

    8. Get regular exams
    Keep up with pap smears, including the test for HPV, and mammograms. You can’t treat a problem that you don’t know about.

    9. Don’t tough out tough times
    Know the signs and symptoms of depression and burnout. If you feel overwhelmed, isolated, guilty, sad, or depressed every day for 2 weeks, gain or lose weight, or sleep too little or too much, seek help. Get outside in the sunshine, try “walk and talk” therapy with friends, or get counseling. If you are depressed, don’t be afraid to take medication to help yourself through a tough time.

    10. Don’t take lots of supplements, but do get enough calcium and vitamin D
    Get enough calcium and vitamin D from your diet and sunshine or supplements to protect your bones, but don’t take too much calcium, which can increase your risk of clogged arteries.

    Work with your healthcare provider on these 10 tips, and if they can’t help you navigate the menopause transition and help improve your health, find someone who will. You can find a NAMS Certified Menopause Practitioner (NCMP) on the NAMS website as well as a wealth of information about women’s health and menopause on our For Women pages. Our Menopause Guidebook, which is the most complete and current discussion of menopause available anywhere, can be purchased through the NAMS store or on Amazon.


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MenoPause Blog

We strive to bring you the most recent and interesting information about various aspect of menopause and midlife health. We accept no advertising for our website. We want you to have accurate, unbiased, evidence-based information. 


JoAnn V. Pinkerton, MD, NCMP
Executive Director

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