The transition though perimenopause into menopause can bring many unpleasant symptoms. There are many products marketed to women searching for relief, including over-the-counter hormones.
While convenient, they put powerful products in the hands of women who likely have no expertise in using them. As a doctor of pharmacy who has worked with many women, I know there is a mindset that over-the-counter availability translates as safe. But that is not necessarily true, and there’s a real possibility of creating a potentially dangerous situation when bioidentical hormones are used incorrectly. Let’s take a look at commonly available hormone supplements.
Your body produces three types of the hormone estrogen: estriol, estradiol, and estrone. Estriol is the weakest form of estrogen in the body. It is usually abundant in women who are pregnant. Although estriol is relatively weak, it has been reported to produce beneficial effects with few side effects and health risks. Estriol is not FDA approved as a prescription drug. However, it is available over the counter in different forms.
It has been reported to improve vaginal dryness and aging skin. While systemic absorption is said to be low, my personal experience with estriol is that it greatly increases breast tenderness — which means that it was absorbed into my body.
There is conflicting information about whether a woman needs to add progesterone if she uses estriol. It is not necessary if the product is used vaginally.
Bi-Est is a combination of estradiol and estriol. In over-the-counter products, it is 80 percent estriol and 20 percent estradiol. This cream is used to help with symptoms of low estrogen, which can include hot flashes, night sweats, insomnia, brain fog, and depression.
I never recommend using Bi-Est without the guidance of a professional. If you have a uterus, you will need to add progesterone to reduce the risk of uterine cancer that increases with use of unopposed estrogen.
Side effects, which are mainly related to overdose of estrogen, include weight gain, breast tenderness, anxiety, bloating, return of periods after menopause, and headaches. Although estrogen does not cause cancer, these products should not be used by women who have a personal history of hormone-sensitive cancers.
Progesterone supplementation is a go-to for many perimenopausal women who are deficient in the hormone because of lack of ovulation. It can greatly improve anxiety, breast tenderness, heavy periods, and fatigue, and also helps with countering weight gain. Progesterone can be used topically or orally. Only the topical form is available over the counter. It comes in a number of strengths (typically 3, 10, or 20 percent) and forms.
Dosing can vary widely. Some experts recommend as little as 20 milligrams per day (what the body would normally produce on its own before menopause), but some recommend doses in the hundreds of milligrams to overcome estrogen dominance. I suggest starting low and increasing as needed.
Use of topical progesterone is a low-risk option in perimenopause, but be aware that symptoms may worsen before they get better. Also, if you suspect you have low cortisol, use of progesterone may worsen anxiety and weight gain if the body needs the progesterone to make cortisol.
I am often asked if progesterone is linked to breast cancer risk. There is no evidence that suggests this is the case.
DHEA is the precursor to testosterone and estrogen, and it’s the most abundant hormone in the body. DHEA declines with age, beginning around our mid-20s; maintaining proper levels of DHEA has been shown to increase energy and reduce the risk of various diseases. It can also be used as a “back door” way to increase testosterone, since it tends to convert to testosterone in women.
DHEA, one of your androgenic (male) hormones, is available orally, topically, or as vaginal inserts. It is typically used for adrenal support, to increase energy and overall sense of well-being. There is an increasing body of data that shows positive outcomes for vaginal dryness with inserts. DHEA is often combined into one product with estriol, vitamin E, and cocoa butter into vaginal inserts. These can be ordered online. Little of the active ingredient is absorbed systemically from the vagina, so side effects are rare.
Oral DHEA is available online and in many health food stores. It is commonly found in 25- or 50-milligram strengths on store shelves. However, this dose is much too high for women! I once had a client who didn’t mention to me that she was taking DHEA. She was having significant hair loss, so I tested her hormone levels. They were sky high — she was taking 50 mg of DHEA! I rarely recommend more than 10 milligrams for women. Side effects of DHEA (all from excess dosing) are oily skin, acne, hair loss, and irritability.
Topical DHEA cream is also available. Some studies suggest that it is better absorbed through the skin, since much of an oral dose will be sulfated in the liver. Avoiding sulfation leaves more of the parent compound available.
DHEA should not be used if you’ve had a hormone-sensitive cancer like breast or ovarian cancer, since there is the possibility that it can convert to estrogen.
A do-it-yourself approach to hormone replacement is tempting given the easy access to over-the-counter products. My opinion is that this is generally a bad idea, especially if you’ve had no testing to guide decision making. Better to work with a professional who can suggest proper testing and guide you on a safe approach to symptom relief.
Dr. Anna Garrett is a leader in the testing and treatment of hormonal imbalances and the author of Perimenopause: The Savvy Sister’s Guide to Hormone Harmony. Learn more about Dr. Garrett at drannagarrett.com and order her book at perimenopausebook.com.
6 Ways to Fight a Potbelly
It is not uncommon for women to lament that as they approach menopause, they are gaining weight, especially in their midsections. This potbelly, unaffectionately called a menopot, can make women feel insecure about their appearance and can also be a health issue.
A potbelly is more a product of aging in general than menopause, says Dr. Stephanie Faubion, medical director of The North American Menopause Society, and it’s not just a problem for women. “Both genders gain weight as they age due to a decrease in metabolic rate caused by the loss of muscle mass,” she says. “As people age, they don’t burn as many calories when they exercise or sit still, so it is harder to maintain or lose weight.”
For women, the problem is compounded by the loss of estrogen, causing a redistribution of weight to the stomach and waist. Faubion says, “This hormonal change can cause women to go from a pear shape to more of an apple shape in midlife.” On average, women gain 1.5 pounds per year in midlife.
Is It Dangerous?
Weight gain, especially in the midsection, can adversely affect a woman’s health. Faubion says, “Heart disease risk goes up as we age, especially in women that gain weight in their abdomen. Even women of normal weight have a higher cardiovascular risk if they hold excess pounds in their midsection.” Excess belly fat has also been associated with a higher risk of many cancers (including breast and colon) as well as an increased risk of diabetes.
Faubion says the biggest complaint she hears from patients is that they haven’t changed their diet or exercise intensity and yet somehow, they are gaining weight. “What always worked in the past as far as maintaining or losing weight, won’t work anymore,” she says. “It’s like someone changed the rules of your body without telling you.”
What to Do About a Potbelly
1. Keep your weight down. Since it’s harder to lose weight as we age, it’s better not to gain it in the first place. Ideally, women should begin to adjust their diet and exercise routine before they are in full menopause to maintain their weight. Faubion says, “Use common sense. Older women need to focus on eating vegetables, fruit, and lean proteins. Limit simple carbs such as white rice and white pasta.”
2. Go easy on the alcohol. A big sabotage for many women is alcohol. “The kids are gone and there are more parties and dinners out, so older women tend to drink more. The body reads a glass of wine as a glass of sugar, so try to limit alcohol consumption for weight maintenance,” Faubion says.
3. Watch belly bloat. In addition to actual fat, a menopot can be exasperated by bloating, which can occur more frequently in older women. Erin Parekh, holistic health coach and culinary nutrition expert, says, “As women age, their stomachs can get more sensitive. They may need to play with their diet to see if dairy or gluten is contributing to their belly bloat. Fiber, while important, can cause stomach discomfort, so don’t go crazy adding too much fiber too quickly. To keep a healthy balance of gut bacteria, I recommend my clients take a probiotic supplement daily.”
4. Exercise daily. While weight maintenance is 90 percent food related, regular exercise is vital to good health. Aim for one hour of cardio/movement per day plus strength training. While sit-ups or other spot-toning exercises alone will not eliminate a meno-pot, strength training can increase a slowing metabolism and help combat lost muscle tone.
6. Keep stress levels in check. Parekh explains, “Higher levels of the stress hormone cortisol contribute to belly fat, even in women that are not overweight. So, it’s important for women to find ways to reduce their stress, especially as they age. Practicing mindfulness techniques and getting more sleep can help.”
Photo: Wave Break Media
How to Get Excited About Cooking for One
Last week I made chicken wings for dinner using a new rub and marinade. My husband, daughter, and son raved. When I saw that my son had come down in the middle of the night to eat more (a bowl of bones in the kitchen sink gave him away), I was thrilled that my culinary skills were so appreciated.
But I have a lot less enthusiasm when it comes to cooking for just myself. On an evening when my husband and kids aren’t home, I usually order in or just eat a bowl of cereal on the couch.
My feelings about cooking for one are not unusual. Liz Josefsberg celebrity health, wellness, and weight loss expert says, “People feel that it is fun to prepare something with someone else in mind. Cooking for a crowd is festive. It’s a communal and loving act. After all, food is love, right? ”
Conversely, when you cook just for yourself, you may feel less inspired. Cooking for one may feel more like a chore than a gift.
Why You Should Cook for Yourself
Healthy, mindful eating is an essential part of looking and feeling good, especially for women in midlife. Typical take-out food or restaurant meals tend not to be as nutritional as meals made at home. The food is usually higher in fat and sodium, and the portions tend to be too large.
Erin Parekh, holistic health coach and culinary nutrition expert, says, “When you cook for yourself, you control the quality of ingredients, the quality of the oils, the amount of sodium, etc. You know exactly what you are putting into your body.”
“Research proves that our metabolism actually gets started in a healthier way when we cook our food,” Josefsberg says. “The smelling of the food sets our mouth watering. The belly prepares for the incoming meal, unlike just eating prepared foods and fast food.”
Cooking at home is also more cost efficient. In 2018 Forbes reported that, on average, restaurant food delivery costs almost five times as much as cooking for yourself.
Get Out of Your Comfort Zone
Cooking for one can be less stressful than cooking for a crowd. If you are the one eating, you don’t have to consider anyone else’s palate or dietary needs. This freedom can translate to a lot more creativity in the kitchen.
When you cook for one, you can ditch your typical repertoire of meals. If you never cook spicy foods or avoid making shellfish because your family doesn’t care for it, now is your chance. Parekh suggests, “Experiment with new recipes, spices, and cuisines. You don’t need to be intimidated because you aren’t cooking to satisfy anyone but yourself.”
Browse cookbooks or food blogs for inspiration.”Imagine you are cooking for a famous table of your favorite people. What would you prepare?” Josefsberg asks.
Keep It Simple
Many of the best meals require very few ingredients. “You don’t need to overwhelm yourself. You can make delicious, nutritious meals with just 10 ingredients or less,” Parekh says.” Just be sure to use good-quality ingredients.” Or think about subscribing to a delivery service like Blue Apron or Plated, which brings you creative recipes and the ingredients to make them.
If you are too busy to cook during the week, meal prep on Sunday. “Roast vegetables, broil a chicken, make quinoa,” Parekh says. “During the week, you can put the components together and have a healthy meal ready in less time than it takes to order a pizza.” If you can’t pre-prep, take some short cuts by buying a rotisserie chicken or cut-up vegetables from the salad bar on your way home from work. You can also keep cleanup simple by choosing one-pot recipes.
And don’t shy away from recipes written for serving several people. “Invest in good glassware that freezes well so that you can parcel large meals into individual portions and freeze for later,” Josefsberg says.
Let It Be About You
If you are the only one eating, you may not feel that it’s worth the effort of prepping a meal from scratch, but it’s time to change that mindset. Look at it as an opportunity for self-care. Set the mood: Put on some music you love and maybe pour a glass of wine. Get creative. And show yourself some love.
Looking for inspiration? Try these recipes.
Is It Normal… To Be So Anxious
From butterflies in your stomach to a full-blown panic attack, anxiety can take many different forms. At its core, anxiety is nothing more than a physiological response to a situation that creates internal conflict.
“It’s a feeling designed to give you caution and get your attention, so that you make adjustments in your environment or boundaries,” explains Theresa Moore, LCSW, LPC. “These are actually healthy feelings.”
Even if you’ve never been one to suffer from anxiety, you might find that changes the older you get — and, yes, it’s perfectly normal. In fact, getting older can be one of the major causes of anxiety for many people.
Why Does It Happen?
There are many things that can contribute to stress as we age, but in a country where we are expected to look, feel, and act younger than we are, watching our bodies go through the natural aging process can be one of the biggest — and it’s more than just the physical.
“We fear that it means that we will cease to be useful, engaging, or exciting,” Moore says, adding that a core fear from the moment we are born is a fear of being irrelevant or not belonging. “In our country we neither honor nor respect elderhood,” she says. “ We fear being thrown out or being seen as having no value to society.”
Add to that the fear of our own mortality and you can see where anxiety can get into your system and set up shop.
What Can You Do About It?
One of the first things you can do to manage increased anxiety is to realize that although you may not be able to control the aging process, you can control how you handle it. “There is a lot that is still within our control,” says Moore. “We can accept that this is a time of wisdom and life experience, and acknowledge that things are shifting and that this is the next step in life.”
No, we can’t expect to remain at our 40-year-old peak for the rest of our lives, but we can remain fit and active as it relates to our environment, nutrition, and mental health. And by accepting the aging process for what it is, we can enjoy the relationships around us and become more aware and present rather than disheartened or anxious.
“Our relevance has to do with relationships, not accomplishments and tasks,” Moore says. “That’s an important thing to remember.”
Do I Need Help?
Again, an increase in anxiety as we age is perfectly normal. The degree in which it manifests, however, can be problematic. And some women find that even “normal” requires a little extra help in the form of medication or therapy. How do you know the difference? “Anything that is ongoing or exhibits a significant pattern might indicate the need for a life coach or therapist to help you get some new tools for dealing with stress,” Moore says.
If you are anxious to the point that it is affecting your sleep, moods, ability to focus, memory, etc., then you should see your doctor or therapist and ask if short-term medication could provide some relief. “If you are so easily distracted that it is hard for you to complete a task and other people or co-workers are noticing, then that’s a problem that could possibly benefit from medication coupled with counseling,” suggests Moore. “Trying to do it on your own only increases the anxiety.”
If you are still unsure if you are just going through a phase or if it’s something more serious, check in with your squad.
“Having a good support system of people in your life who are objective and supportive is important regardless of stage of life, and this is the first place you should go to check things out,” Moore says. “These are the people who will tell you if you seem over the top.”
A stress-free life is pretty unrealistic, regardless of age. But accepting each stage of your life for the beautiful and wonderful gift that it is can go a long way in helping you manage, if not alleviate, some of the anxiety along the way.
Photo: Rido Franz
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