LIFESTYLE CHANGES TO ASSIST WITH MENOPAUSAL SYMPTOMS

Simple changes in lifestyle and diet can help control menopausal symptoms such as hot flashes. Avoid hot flash
triggers like spicy foods, hot beverages, caffeine, and alcohol. Dress in layers so that clothes can be removed
when a hot flash occurs. For vaginal dryness, moisturizers (such as Rephresh and Replens), and non-estrogen
lubricants, such as Sliquid, Liquid Silk and Good Clean Love are available.
Heart Health Recommendations
When women reach menopause, they are at increased risk for heart disease. A heart-healthy diet and other
lifestyle changes are important ways to control cholesterol and blood pressure levels.
Heart-health recommendations include:

Quit smoking. If a woman smokes, she should quit. Smoking is linked to a decline in estrogen levels.
Women who smoke reach menopause about 2 years earlier than nonsmokers. Smoking doubles a woman’s
odds of developing heart disease and is a major risk factor for osteoporosis.
Balance calorie intake and physical activity to achieve or maintain a healthy body weight. (Controlling
weight, quitting smoking, and exercising regularly are essential companions of any diet program. Try to get
at least 30 minutes, and preferably 60 – 90 minutes, of daily exercise.)
Consume a diet rich in a variety of vegetables and fruits. Vegetables and fruits that are deeply
colored (spinach, carrots, peaches, berries) are especially recommended as they have the highest
micronutrient content.
Choose whole-grain, high-fiber foods. These include fruits, vegetables, and legumes (beans). Good
whole grain choices include whole wheat, oats/oatmeal, rye, barley, brown rice, buckwheat, bulgur, millet,
and quinoa.
Eat fish, especially oily fish, at least twice a week (about 8 ounces/week). Oily fish such as salmon,
mackerel, and sardines are rich in the omega-3 fatty acids eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA). Consumption of these fatty acids is linked to a reduced risk of sudden death
and death from coronary artery disease. Women with heart disease may also consider taking a daily dietary
supplement of 850 – 1,000 mg of EPA and DHA.
Limit daily intake of saturated fat (found mostly in animal products) to less than 7% of total calories,
trans fat (found in hydrogenated fats, commercially baked products, and many fast foods) to less than 1%
of total calories, and cholesterol (found in eggs, dairy products, meat, poultry, fish, shellfish) to less than
300 mg per day. Choose lean meats and vegetable alternatives (such as soy). Select fat-free and low-fat
dairy products. Grill, bake, or broil fish, meat, and skinless poultry.
Use only a little salt in your foods. Reducing salt can lower blood pressure and decrease the risk of heart
disease and heart failure.  However, table salt should be iodized.  We are now seeing many patients with
iodine deficiency due to the trendy use of sea salt instead of iodized salt in our cooking.
Cut down on beverages and foods that contain added sugars (corn syrups, sucrose, glucose,
fructose, maltrose, dextrose, concentrated fruit juice, honey).
If you consume alcohol, do so in moderation. The American Heart Association (AHA) recommends
limiting alcohol to no more than 1 drink per day for women.
The AHA does not recommend antioxidant supplements (such as vitamin E, C, or beta carotene) or
folic acid supplements for prevention of heart disease.
For women ages 55 to 79 years who have never had a heart attack or stroke, but are at risk of heart
disease, a daily low dose (75 – 81 mg) of aspirin may be helpful for primary prevention.

Calcium and Vitamin D
A combination of calcium and vitamin D is important for helping to prevent the bone loss associated with
menopause.

Calcium. Women should consume low-fat dairy products or calcium-enriched orange juice to get enough
calcium  in their diet. Calcium supplements may be another option for some women. For calcium
supplements, calcium citrate (Citracal) is better absorbed than calcium carbonate (Tums, Os-Cal) and other
types of calcium compounds. Between dietary and supplement intake, women should not exceed 1200 mg
calcium per day.  Recent data indicate that calcium intake in excess of 1200 mg daily increases the risk of
cardiac related deaths.  

       There are differing views on the use of calcium and vitamin D. Some doctors recommend that women
over age 60 should take calcium and vitamin D for bone health. Other doctors feel that due to the risks of
kidney stones, supplements are beneficial only for women (especially those over age 70) who do not get
enough calcium in their diets. Ask your doctor whether you should take calcium supplements.

Vitamin D. Vitamin D is necessary for the absorption of calcium in the stomach and gastrointestinal tract
and is the essential companion to calcium in maintaining strong bones. Vitamin D is manufactured in the
skin using energy from the ultraviolet rays in sunlight. It can also be obtained from dietary supplements. As
a person ages, vitamin D levels usually decline. Levels also fall during winter months and when people
have inadequate sunlight.  

       Women should discuss with their providers the appropriate amount of Vitamin D supplementation.
The maximum dose currently recommended is 4000 IU of Vitamin D3 daily.  The recommended daily intake
of vitamin D is 600 IU a day after age 50. Drinking milk fortified with vitamin D and sunlight exposure supply
most people’s need for vitamin D. (One cup of whole milk provides about 100 IU of vitamin D.) Oily fish
(sardines especially, as well as salmon, fresh tuna, and mackerel) are also important dietary sources of
vitamin D. Wild salmon has a much higher vitamin D content than farmed salmon.

Alcohol

Effect on the Heart. One drink a day in women who are not at risk for alcohol abuse may be beneficial for
the heart. Red wine in particular contains a substance called resveratrol, which is classified as a
phytoestrogen and has estrogen-like effects.
Effect on Bones. Alcohol has different effects on bones, depending on how much is consumed. Three or
more drinks per day are considered a risk factor for brittle bones and osteoporosis.
Effect on Breast Cancer . Women who drink have an increased risk for breast cancer, but the risk
associated with mild-to-moderate drinking is small.

Controlling Weight Gain
Many women need to increase physical activity and reduce caloric intake before and after menopause. Weight
gain is common during these years, and it can be sudden and distressing, particularly when habitual exercise and
eating patterns are no longer effective in controlling weight. Gaining weight around the abdomen (the so-called
apple shape) is a specific risk factor for heart disease, diabetes, and many other health problems.

Exercise
For protection against all aging diseases, women should pursue a lifestyle that includes a balanced aerobic and
weight resistance exercise program appropriate to their age and medical conditions. Brisk walking, stair climbing,
hiking, dancing, and tai chi are all helpful. Several studies report that exercise can help control hot flashes. A
healthy diet plus regular, consistent exercise can also help ward off the weight gain associated with menopause.
Weight-bearing exercises are specifically helpful for protecting against bone loss.
Women should get at least 30 minutes of exercise each day (for weight loss, 60 – 90 minutes is preferred).
While more exercise is better, any amount of exercise is helpful.
Alternative Therapies
There are many unproven methods for relieving menopausal symptoms, some more effective than others.
Acupuncture, meditation, and relaxation techniques are all harmless ways to reduce the stress of menopause.
Some women report great benefit from these practices, but there is no scientific proof of effectiveness.
Acupuncture, hypnosis, and biofeedback are all alternative ways to control pain. Acupuncture involves the
insertion of tiny sterile needles, slightly thicker than a human hair, at specific points on the body.

Herbs and Supplements
Women often try herbal or so-called natural remedies to treat menopausal symptoms. There have been
numerous studies conducted on various herbal products and other complementary and alternative therapies.
These studies have found varying effects.  Some herbs and supplements can have adverse side effects.

Phytoestrogens and Isoflavones . Many studies have researched plant estrogens (phytoestrogens), which are
generally categorized as isoflavones (found in soy and red clover) and lignans (found in whole wheat and
flaxseed). No evidence to date indicates that phytoestrogen foods or supplements provide any benefit for hot
flashes, night sweats, or other menopausal symptoms. They also do not appear to help lower cholesterol or
prevent heart disease.
Nevertheless, soy is a healthy food choice. Soy is rich in both soluble and insoluble fiber, omega-3 fatty
acids, and provides essential protein. Soy proteins have more vitamins and minerals than meat or dairy proteins.
They also contain polyunsaturated fats, which are healthier than the saturated fat found in meat. The best
sources of soy protein are soy food products (tofu, soy milk, soybeans), not supplements.
Soy isoflavones contain genistein and daidzein, which are estrogen-like compounds. Some studies have
suggested that high intakes of soy may increase the risk of estrogen-responsive cancers such as breast cancer.
The American Cancer Society recommends that women with breast cancer eat only moderate amounts of soy
food and avoid taking dietary supplements that contain high amounts of isoflavones.

Other Herbs and Supplements. The following herbs and dietary supplements are sometimes used for
menopausal symptoms and have certain risks:

Black cohosh ( Cimicifuga racemosa ), also known as squaw root, is the herbal remedy most studied for
menopausal symptoms. Although it contains a plant estrogen, this substance does not act like an estrogen
in the human body. Studies have shown mixed results in preventing hot flashes. High-quality studies have
found that black cohosh works no better than placebo for treating hot flashes and night sweats. Headaches
and gastrointestinal problems are common side effects. This herb has been associated with liver toxicity.
Dong quai ( Angelica sinensis ) does not appear helpful for hot flashes or other menopausal symptoms. Do
not use dong quai with blood-thinning drugs, such as warfarin, because it may cause bleeding
complications.
Ginseng ( Panax ginseng ) may help menopausal symptoms of depression and sleep problems, but it has
no effect on hot flashes.
Kava ( Piper methysticum ) may relieve anxiety but it does not help hot flashes. This herb is considered
unsafe if used in large quantities, due to several reports of liver failure and death, especially in people with
liver disease.
Wild yam ( Dioscorea villosa ) is an herb sometimes used for menstrual problems as well as menopausal
symptoms. It contains a plant progesterone. However, like black cohosh, there is no evidence that the
human body can convert this substance into a hormone. Patients should be aware that some commercial
herbal wild yam products contain prescription progesterones. (For more information on progesterones, see
Hormone Replacement Therapy in Medications section.)
Evening primrose oil has not been shown to be superior to placebo. It may increase the risk for seizures
when taken with certain types of drugs associated with seizures.
Dehydroepiandrosterone (DHEA) is a weak male hormone secreted by the adrenal gland. It is available as
a dietary supplement. DHEA has no benefit for hot flashes and may increase the risk of breast cancer.

Warning:  Generally, manufacturers of herbal remedies and dietary supplements do not need approval from the
Food and Drug Administration to sell their products. Just like with drugs, herbs and supplements can affect the
body’s chemistry, and therefore have the potential to produce side effects that may be harmful. There have been
a number of reported cases of serious and even lethal side effects from herbal products. Patients should check
with their doctors before using any herbal remedies or dietary supplements.

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Gynecology & General Health

Osteoporosis is a disease of thinning bones that predisposes women to fractures caused by low
bone mass and disordered bone architecture.  10 million Americans are affected by osteoporosis,
most of whom are women.  1.5 million fractures occur every year in those suffering from
osteoporosis.  50% of women over fifty years of age will suffer an osteoporotic fracture in their
lifetime leading to pain, disability and even death.  Hip fractures double the risk of death for women.
Definitions

Osteopenia – a bone density T-Score between -1.0 and -2.5
Osteoporosis – a bone density T-Score at or below -2.5.  Osteoporosis is a disease of the
bone characterized by a predisposition to fractures caused by low bone mass and
disordered bone architecture.  Osteoporosis is also diagnosed by proving the presence of a
low-impact fracture of the hip, vertebrae or wrist.
DEXA Scan – (Dual Energy X-ray Absorptiometry) is the form of x-ray testing to determine a
woman’s (or man’s) bone mineral density (BMD).
T-Score – the score given by bone mineral density (BMD); the score is calculated by
comparing a woman’s BMD as compared to the normal bone density of a woman aged 25-
45 years.  
FRAX – a risk assessment tool offered by the World Health Organization (WHO) that helps
clinicians decide which patients with osteopenia should be offered medical treatment to
avoid an osteoporotic fracture.  Components of the FRAX include the T-score at the hip, age,
personal history of a previous fracture, weight, height, history of glucocorticoid (steroid) use,
cigarette use, consumption of more than 3 alcoholic beverages per day, history of
rheumatoid arthritis, history of a parent with a hip fracture and history of disease that causes
osteoporosis (e.g. hyperthyroidism, parathyroid tumor).  The FRAX score can be calculated
online at http://www.shef.ac.uk/FRAX/.  This tool calculates the 10-year risk of sustaining
either an osteoporotic hip fracture or an other osteoporotic fracture (i.e. of the spine or wrist).

Who should have a DEXA Scan to determine her BMD?

1.  Women 65 and older
2.  Women 50 to 65 if risk factors or clinical concerns are present
3.  Any woman who sustains a low-trauma fracture.

Lifestyle modifications for prevention and treatment:

1.  Calcium 1500 mg daily
2.  Vitamin D3 1000 IU
3.  Daily weight-bearing and muscle strengthening exercises
4.  Stop smoking
5.  Decrease alcohol consumption to no more than 1 drink per day (i.e. 12 oz. of beer, 5 oz.
of wine or 1.25 oz of hard liquor)

Who should be considered for medical treatment?

1.  Women with osteoporosis (BMD less than or equal to -2.5)
2.  Women with osteopenia whose FRAX score indicates a hip fracture risk of greater than
or equal to 3% or an overall osteoporotic fracture risk of 20% over the next ten years.

Medical treatment options

1. Bisphosphonates (most common medical treatment).  
Bisphosphonates must be taken with plain water (tablets 6-8 oz; oral solution follow with 2
oz) first thing in the morning and ≥30 minutes before the first food, beverage, or other
medication of the day; remain elevated fro 30-60 minutes after taking.
Most common side effects: abdominal pain, reflux, diarrhea, headache, body aches, rash,
bladder infections
Severe side effects: Atrial fibrillation, ulcer formation, hypertension, low serum calcium, low
serum phosphate, severe joint and muscle pain, osteonecrosis of the jaw.  .  (Women who
have taken bisphosphonates for three or more years should discontinue the medication for
three months prior to invasive dental surgery.)  The bisphosphonate can be restarted once
the bone is healed.
Contraindications: kidney disease, underlying GI disease
Brand Options:

  • Fosamax (alendronate) taken daily, weekly
  • Boniva (ibandronate) taken daily, monthly or I.V. every 3 months
  • Actonel (risedronate) taken daily, weekly or monthly        

2. Hormone therapy (estrogen or estrogen + progesterone)
Daily oral dose
Not recommended for primary treatment of osteoporosis or osteopenia.  Possible
complications with hormone therapy include clot formation, stroke, heart attack, Alzheimer’s
disease, etc.
3. Evista (raloxifene) is a Selective Estrogen Receptor Modulator (SERM)
Daily oral dose
Most common side effects: hot flashes, swelling, muscle aches, headaches, flu-like
symptoms and infections including bronchitis.
Rare but serious side effects: increased clotting, stroke, elevated triglycerides
Contraindicated in women with clotting disorders, kidney disease, heart disease, abnormal
uterine bleeding, pregnancy and breastfeeding
4. Teriparatide (parathyroid hormone)
Daily injection
5. Calcitonin
Daily nostril spray
Most common side effects: rhinitis, back pain

Suggested follow up:

1.  Reassess BMD in 1-2 years.  If bone density is stable or improving, continue therapy.  If
not, consider a new regimen and reassess in 1-2 years.
2.  Measure fasting cross-linked N-telopeptides of type I collagen (NTX) or serum type I
collagen C-telopeptides (CTX) before and 6 months after initiating therapy.  Therapy is
adequate if markers are reduced by 50%.

Reference:
1.  Barbieri RL. Are you assessing risk and discussing new treatments for osteoporosis? Sexuality,
Reproduction & Menopause 2008;6(3):8-11

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