Menopause

What is menopause?

If my periods stop, does that always mean menopause?

Will irregular periods predispose me to cancer?

What is the healthy way to transition into menopause?

How can menopause be diagnosed?

When should women seek treatment for menopause?

What causes the weight change in menopause?

What is Perimenopause?

What is hormone replacement?

What is natural hormone replacement?

What is bioidentical hormone replacement?

What are the different ways I can replace my hormones?

Who is a candidate for natural hormone replacement?

How will Dr. Paoletti treat me?

What about the concerns of cancer and hormone replacement or HRT?

What are the risks of estrogen deficiency?

Does everyone need hormones?

Summary of estrogen treatment

What is menopause?
Menopause is defined as the end of periods for one year in women who once had regular periods. However, you should not wait one-year until seeking treatment or evaluation of menopause. You should seek an evaluation after symptoms start (such as hot flashes) or your period is missed for more than 2 consecutive months.
back to top

If my periods stop, does that always mean menopause?
Some women stop their periods and are not experiencing true menopause. Often periods stop but the ovaries do not stop functioning. Frequently the ovaries continue to produce estrogen but not enough to ovulate (produce an egg for fertilization) and hence not enough to produce a period. When this happens, there is no menstruation but true menopause has not occurred because the estrogen is still high.
Generally in this instance there are no symptoms of menopause such as hot flashes as the ovaries are still producing estrogen. This situation may be dangerous sometimes leading to cancer so you should visit your doctor at once if you experience any of these changes. When periods stop coming regularly it is important to seek the care of a physician since it impossible to know your condition without an examination and lab testing.
back to top

Will irregular periods predispose me to cancer?
It is important to distinguish between true menopause and the mere absence of periods. If the ovaries continue to function but fail to ovulate they may produce estrogen alone for long periods of time. The reason this may be harmful is that estrogen without the opposing influence of progesterone (a condition known as unopposed estrogen), may contribute to a precancerous or cancerous change in your body. It is important to see a physician as soon as your periods become irregular to help prevent this condition.
Dr. Paoletti often examines women who are happy because their periods are now coming only once or twice a year. Yet, they are dismayed to find out that this was not a natural, harmless way to transition into menopause that they believed. Some of these women developed hyperplasia—a change that is often precancerous unless treated. Typically, women with hyperplasia are treated with a biopsy and progesterone treatment to prevent future problems.
back to top

What is the healthy way to transition into menopause?
There is a great and natural way to transition to menopause. Ideally, women should have regular periods that become lighter and lighter until they cease entirely. This progression assures you that your system is balanced as your periods diminish, that may create other aging and degenerative problems, but unlikely to cause a precancerous or cancerous condition.
back to top

How can menopause be diagnosed?
The real way to know whether you are experiencing menopause is to test several hormones – Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH) and estrogen. FSH and LH are produced by the pituitary gland in your brain. These hormones encourage the ovaries to produce estrogen and to ovulate. When the function of the ovary starts to fail, the brain-pituitary system is forced to work harder to get the ovaries to produce the same amount of estrogen or to ovulate.
back to top

In menopause estrogen is not produced and FSH and LH levels rise dramatically, as much as 10 times the normal amount, to signal the end of reproductive function and the beginning of menopause. At this point, women experience low estrogen and an elevated FSH and LH.
FSH and LH can be high during the normal cycle when you are ovulating but the estrogen levels, unlike in the menopause, will be high at this point. This is why you always need to measure the estrogen along with the other two hormones (FSH and LH) to be sure that it is the real menopause and not just a mid-cycle surge of hormones due to ovulation.

When should women seek treatment for menopause?
Whenever your periods become irregular, noticeably lighter, or unusual symptoms occur you should seek medical advice. The treatment of menopause should not wait a whole year after your periods stop. It is possible to potentially loose as much as 20% of your natural bone, 30% of your collagen (skin and vessel support) and notice a definite memory loss over a period as short as a year.
This is not to say that every woman needs treatment at menopause for symptoms, but usually, if there is no bone loss, there will be some negative changes in the cholesterol, vagina, and blood pressure along with a significant change in weight.
back to top

What causes the weight change in menopause?
No one knows for sure but it is suspected that the rise in some of the brain hormones that react to the elevated Follicle Stimulating Hormone (FSH) and Lutenizing Hormone (LH) are responsible. These hormones sense the increased activity produced by the LH and FSH and increase also. One of the hormones that increase in this way is ACTH, which produces cortisol by the adrenal gland.
Similarly, cortisol will cause you to put on weight around the middle section of your body even when your diet has not changed. We know that ACTH rises with menopause after the FSH and LH rise. It may be that the strategy for losing or preventing the weight gain in menopause is to prevent the rise of ACTH by preventing the rises of LH and FSH. This is possible with natural hormone replacement. Artificial hormones currently do not prevent the rise of these hormones and there is much anecdotal evidence that the natural hormones do (see Susanne Summer’s book – the sexy years).
Theoretically, normal levels of estrogen and progesterone signal the brain that it no longer needs to produce high levels of FSH or LH and therefore lower the ACTH as well.
back to top

What is Perimenopause?
Perimenopause means that a woman is beginning to experience some of the estrogen deficiencies that exist during menopause. Usually this means that you will experience hot flashes once a month or even once every three months. Most of the time your system will function adequately, but the loss of bone, collagen, and memory has already begun.

In addition, with the advent of the perimenopause, you begin to loose the ability to become pregnant. There are always exceptions so you should not despair when the hot flashes begin for the first time. Many women in their early forties can become pregnant with the help of infertility assistance or even spontaneously on their own.

Usually most women experience the perimenopause approximately 10 years before they actually enter menopause and they may benefit from treatment with estrogen replacement very early in this transition. If it is determined that your periods are lighter and you are beginning to loose bone or to experience many of the severe mood swings that begin in the mid to late forties with the perimenopause, it may be friend-saving and marriage-saving to consider early intervention with some supplementation.
back to top

What is hormone replacement?
Hormone replacement usually refers to the replacement of estrogen with an estrogen-like substance because the ovaries are no longer producing the hormone. Typically, another hormone, progestin must accompany the estrogen replacement. Progestin balances estrogen and prevents the uterine lining from growing too much, too thick, and becoming precancerous or cancerous. The combination of the estrogen and progestin is considered complete hormone replacement.

There are many other kinds of hormone replacement—synthetic, natural or bioidentical hormone replacement.
back to top

What is natural hormone replacement?
The word natural hormone replacement can be a bit vague. Manufacturers and people use the term, “natural” in a variety of ways. Natural can imply anything that is derived from nature. This can include in the strict sense Premarin since it is from horse urine found in nature. It also includes plant derivatives of estrogen. However, when one considers the optimal replacement, it would be neither horse nor plant. The real optimal way to replace would instead be with the bioidentical hormone that the human body produces on its own.
back to top

What is bioidentical hormone replacement?
Bioidentical hormone replacement means that the hormones have the exact same (identical) appearance chemically as the ones that your body makes. By treating menopause or perimenopause in this truly natural way, especially with transdermal creams or patches (mentioned below) or sublingual estrogen you may eliminate the risks seen with the nonbioidentical or “chemicalized” hormones.
back to top

What are the different ways I can replace my hormones?
There are a variety of methods and this will not, in any way, exhaust all of the possibilities. In general, the methods can be divided into 1) estrogen or progestin 2) nonbioidentical and bioidentical and 3) oral and topical.

Replacement of estrogen can be done either orally, transdermally or sublingually and either nonbioidentically or bioidentically. The transdermal methods can be patches, creams, gels, or even rings which can be inserted into the vagina. These can be available either pharmaceutically or through a compounding pharmacy.

Compounding pharmacies are special pharmacies that make their own compounds to give to you. They start from FDA approved natural substances and offer the advantage of mixing more than medicine in one pill or cream. They can offer you the same medicine in different concentrations than are traditionally available in the pharmaceutical market and can often mix them in special hypoallergenic formulations if necessary. Many of the transdermal methods are bioidentical, which are what I prefer. Bioidentical hormones can now be obtained from either the compounding pharmacies or the traditional pharmacies.

The progestin should be replaced only orally for it to be absorbed adequately into the blood stream. There are some progesterone (a natural type of progestin) creams, but they really have another purpose other than use for hormone replacement. They are absorbed mainly as an estrogen into the blood stream and only a small part of the progesterone cream is absorbed as a progestin. For you to get enough hormones into your blood stream to prevent hyperplasia or precancerous thickening of the uterine lining, progesterone needs to be in the oral form. Women who are taking only the topical form of progesterone are getting mostly estrogen and very little progesterone and therefore suffer the same risks as the women mentioned in the first paragraph of this section of getting a precancer or cancer.

There are about seven different kinds of progestins and, of them; I prefer the bioidentical progesterone which is available either as a compounded mixture, available at the compounding pharmacies or as Prometrium available commercially. The benefit of the compounded mixture is that it can be adjusted to whatever dose you may need whereas the Prometrium is available only in one dose. It may be that the dosages do not matter for you, but to some women the dosing is very important since they can have bad reactions to excessive progesterone. Too much progesterone can cause weight gain, insulin resistance, and irritability. In general, I want to keep the progesterone level to the lowest level needed to balance the estrogen and protect the endomentrium.
back to top

Who is a candidate for natural hormone replacement?
Anyone who is developing signs or symptoms of estrogen deficiency is a candidate, with the exception of those with untreated breast cancer, liver disease, or active blood clot disease or some forms of heart disease. Those women who are beginning to experience the symptoms of hot flashes ( or sweats at night), declining libido, mood swings, dry eyes, dry vagina, excessive tooth loss, rapid weight gain, fractures, worsening depression with age, fatigue, joint and generalized muscle aches, and memory losses are very likely candidates.
back to top

How will Dr. Paoletti treat me?
Since 1989, Dr. Paoletti has helped women throughout the United States resolve the symptoms of menopause and perimenopause. Her solutions are safe, natural, and effective.

Her office has an intimate setting and she sets aside special time for each patient. New patients can expect to receive a full 90 minutes of personal attention to review your problems, your history, and for your exam. We schedule appointments so that your wait, if any, is minimal because we realize that your time is valuable. Patients are highly encouraged to bring current lab results and medical records with them for us to review. Dr. Paoletti asks that you bring in all medications, supplements or alternative medications you use her to examine. As she reviews all of these factors, Dr. Paoletti keeps you abreast of her assessment and plan for you.

The historical part of your exam includes education and you will have abundant time to ask all of your questions. One of Dr. Paoletti’s passions is teaching and you will find that her explanations are thorough and clear.

When finished with the history, she will give you a brief summary of her impression and plan and then proceed with an exam. After the exam, Dr. Paoletti usually orders laboratory testing, if indicated, and then finally, she sits down with you to review and describe the strategy of the plan with you in detail. Dr. Paoletti places the plan in writing and explains it; writes prescriptions with instructions for your follow up.

In general, the first step is estrogen treatment alone, if appropriate, with instructions on what to expect and how to adjust the medication if there is a problem. You will generally be expected to return in about two or 3 weeks to discuss the lab results, finish the exam if indicated, add the second hormone – progesterone, and review the next steps in your treatment. In the future, you may have one more visit to evaluate the result of the two hormones and to consider adding testosterone, for libido. If the testing shows you to be iron or vitamin deficient, thyroid deficient, diet deficient or experiencing low adrenaline, these factors also will be addressed.
back to top

What about the concerns of cancer and hormone replacement or HRT?
Concerns about cancer are largely unfounded in my opinion. Keep in mind that no well-designed studies have shown that estrogen is the cause of cancer. Many well-respected specialists have attacked the WHI study that made all of the headlines 3 years ago. This study claimed that the group on Premarin and Provera has more breast cancer than the control group did. Many specialists disagree with this conclusion on the basis that the statistics – the mathematical calculations that determine studies validity-were faulty. This means that, of all the studies done on estrogen, none of them has stood the test of time against all of the experts. If there is a risk, it must be slight or else it would stand out and be undeniable.

Even at its worst, estrogen alone (as Premarin the “chemicalized” hormone from horse urine) showed a decrease in colon cancer, a non-statistical reduction in breast cancer, a reduction in osteoporosis, improvement in hot flashes, and a reduction in Alzheimer’s disease. The one disadvantage that Premarin demonstrated was a slight increase in stroke, a risk that disappears in recent studies when one replaces Premarin with the topical, transdermal, bioidentical estrogen.

Review the Estrogen media on the Dr. Paoletti on T.V. for more information on this topic. I mention there that if estrogen was ever found to be a cause of cancer, all of the synthetic compounds and the natural compounds would be removed from the market, and you would see a huge class action lawsuit against all estrogens. The fact that this is not happening indicates that there is no clear evidence damning synthetic estrogen.
back to top

What are the risks of estrogen deficiency?
1) The risks of estrogen deficiency are considerable. For every one person who is on estrogen and who develops Alzheimer’s in a ten-year period, 240 women without estrogen will get the same disease! There is no cure for Alzheimer’s disease.

Estrogen is responsible for keeping the arteries dilated and open to allow oxygen to pass to the organs that the blood supplies. When estrogen is low, the vessels shrink and the amount of oxygen that passes through them is reduced by virtue of the decrease in size (diameter) of the vessel. When this happens in the brain, the organs in the brain that detect the oxygen concentration notice a decline and a hot flash develops. The hypothalamus is a sensitive indicator of the body’s processes and will warn us if something is wrong. The hot flash is a warning that we are not getting enough oxygen to the brain! The hot flash is not some thing to be tolerated – it is something to be avoided at all costs since it really represents a mini-stroke of sorts.

2) For every one person on estrogen who dies – yes dies - in five years, TWO will die without it. The risk of dying in any five year period doubles without the use of estrogen. At least three independent studies confirm this.

3) For every one person with a broken bone on estrogen, three women without estrogen will suffer the same fate. Following a hip fracture one out of five will die, one- half of those with a hip fracture will require assistance walking and one of four will need long term care . These are some of the risks of aging naturally!

4) Estrogen reduces the abnormal cholesterol levels by a considerable amount. Some recent studies show that it also improves the lining of the blood vessels of the body in a way that reduces plaque. Although there are no studies that show that estrogen decreases heart disease or heart attacks, these findings are certainly favorable in the prevention of a disorder (heart disease) which is responsible for so much death in women.

5) Insomnia, a very destructive entity, is born out of estrogen deficiency, stress and aging. Estrogen deficiency is the main reason that most women lose sleep in the perimenopause and menopause. Loss of sleep contributes to mood instability, accidents, and memory loss. It can cause extreme anxiety when present for prolonged periods. Some find that lack of sleep is the most frustrating experience of all of the menopausal symptoms.

6) Vaginal atrophy is the thinning of the vaginal lining and causes pain. This will start to happen almost immediately with the onset of estrogen deficiency. It may take a few years but it will eventually leads to the involuntary loss of urine or stool, vaginal pain, loss of libido and the ability to perform intercourse.

7) Skin and connective tissue destruction develops. In the first year of menopause, you loose about 30% of all of your collagen. This means that the support for the skin, vessel, and joint lining will be affected. Collagen is the support tissue for all of the organs of the body. Tooth loss is a symptom of menopause as are joint aches and stiffness.
back to top

Does everyone need hormones?
If you are basing the need for hormones on symptoms, not everyone will need hormone replacement initially. Some women have a very high level of their own testosterone and experience almost no symptoms. This is because the testosterone converts to estrogen in the body. Men, in particular are also spared the hot flashes most of the time because their hormones, testosterone in particular, converts into estrogen. Over the age of 50 men in general have more estrogen in their systems than women of the same age.

Women, who truly lack symptoms of the menopause, will do fine without estrogen experientially. In general, when checked they seem to have normal bone turnover. The only problem that develops over time is vaginal thinning, incontinence, elevation of cholesterol and perhaps mood change. Often when the estrogen is lower, the free testosterone will rise producing somewhat less tolerance and increased irribility. Additionally the cholesterol called “Lpa”, the most dangerous subfraction of cholesterol, nicked named the “widow maker”, will become elevated as it is in men. This will place them at increased risk for the sudden death that happens with the heart attacks that happen with excessive “Lpa”. Estrogen, even in low amounts, would correct all of these problems in these particular individuals.
back to top

Summary of estrogen treatment
The needs of individual women after and during the menopause are varied. No single replacement strategy is appropriate for all women. You will need to sit down with your lab results and discuss the best treatment strategy with your doctor. However, you should know that it is possible to find the right combination of natural hormones that will help you experience some of the joy you used to feel safely. With bio-identical estrogen, and progesterone, you can feel real relief from hot flashes, fatigue, joint pain, eye dryness, insomnia, mental confusion, and anxiety. With the addition of natural testosterone (see services on libido), some women can enjoy increased self-esteem, libido, and energy. As stated before this really is an investment in your future.

The goal of using hormones is to use them early and in a timely manner and for it to happen naturally. Natural, bioidentical, hormone replacement accomplishes this. If you are experiencing early menopause, it is especially important for you to begin treatment because the younger one is, the more severe the losses that can transpire. Assuming that you are in good health, there is no upper age limit to the replacement of the menopausal hormones. If you have any other problems such as thyroid, anemia, weight gain, poor eating habits, and insomnia, treat them simultaneously for an optimal result.
back to top