MiddlesexMD

Q: Are these change in my periods concerning?

You’re in your mid-50s, and while you’ve always had light and regular periods, you’re now menstruating every three weeks with a quite heavy flow, including some clots. You’re wondering whether you should be concerned.

These are very typical changes in periods in perimenopause. Classically periods will get closer and heavier, and eventually they will get lighter and further apart—and ultimately stop! Unpredictability is the norm for perimenopause.The periods reflect the relative production of ovarian hormones of estrogen and progesterone.  

Fortunately, most healthy women can tolerate intermittent blood loss and have no ill effects. If lessening the bleeding is required, it can be done with simple options like Ibuprofen (800 mg every 8 hours), which, when started right away at the onset of the period can reduce blood loss by up to 30 percent. Usually, within two or three days the bleeding is less and you can discontinue the Ibuprofen. 

When the bleeding is excessive and prolonged, contributing to anemia, we look to options to lessen the bleeding. We have prescription options that are very effective at reducing blood loss; tranexamic acid (Lysteda) works very well. Insertion of an IUD (e.g., Mirena IUD) or oral contraceptives are also options; surgery is rarely needed.

Clots per se are not worrisome, reflecting that there is heavier bleeding at that time. Your body is doing what it is well designed to do, and clotting is important.

Take care of yourself as you navigate this transition! 

Q: How do I prepare for wanting more than a long passionate kiss?

You say you haven’t been sexually active for more than 20 years, because of your own surgery, your husband’s impotence, and then being widowed. I’m touched to hear you’ve reconnected with a high school friend and hope the relationship develops exactly as it should!

Based on your history, it is likely intercourse wouldn’t be possible without some work in advance “getting things ready.” With menopause, it’s normal to expect vaginal dryness and some atrophy, which means the tissues shrink and become less elastic.

The products that would be necessary are vaginal moisturizers, which restore some moisture to the vagina and then dilators, the use of which gently stretches the tissues. Most women successfully regain sexual function with consistent use of dilators. 

A pelvic exam with your provider may be helpful as well to make sure there aren’t any other factors to consider.

Enjoy this new relationship, wherever it leads!

Q: Is there a nonprescription alternative to Premarin?

You note that the Premarin you’re using several times each week is expensive, and wonder about a nonprescription alternative. It’s the estrogen contained in that treatment that makes it both a successful treatment and available by prescription. The tissues of the vulva and vagina are very receptive to the healing effects of estrogen, and nothing else is equally effective.

Vaginal moisturizers offer benefit to retain moisture especially when the vulva and vagina are healthy; they aren’t able to reverse the atrophy that occurs in menopause. If you’d like to try a vaginal moisturizer, be sure to use it very consistently, two to three times a week. 

You can experiment with a moisturizer to see whether it helps to maintain comfort. 

Exploring the Role of Estrogen and Progesterone in Fighting COVID-19

Doctors and scientists are working with urgency to understand the coronavirus, and making new observations as more data becomes available. Perhaps you’ve seen some of these observations in the news, including that COVID-19 has been hitting men harder than women, and that pregnant women who contract the virus seem to have milder cases.

This has led to a hypothesis that the female sex hormones estrogen and progesterone may play a role in fending off the virus or minimizing the damage it does. We do know that, generally speaking, women have a stronger immune system than men and that sex hormones can affect different steps in the immune system. 

To learn more, Cedars-Sinai Medical Center and the Renaissance School of Medicine at Stony Brook University are both conducting trials. Stony Brook will be giving half of the 110 COVID-19 positive (or presumed positive) participants in its study an estrogen patch for a week; the other half will receive standard care. 

Meanwhile, Cedars-Sinai will give the 40 participants in their trial progesterone, which affects inflammation. The hope is that progesterone will minimize or prevent an overreaction of the immune system (a cytokine storm). 

Hormones are just one possible explanation that COVID-19 is worse for men than women. As we all know, correlation is not causation. But it will be interesting to see what the researchers learn.

Why the Onset of Menopause Might Take Your Breath Away

From weight gain and mood swings to vaginal dryness and thinning hair, many of the symptoms of menopause can be attributed, at least in part, to the body’s dramatic decrease in production of estrogen and progesterone. 

The drop in estrogen may also affect your breathing. While the research isn’t conclusive, it shows that the onset of menopause was associated with a higher chance of developing asthma compared with before menopause. Starting periods early (before age 11) and having irregular periods were also associated with a higher rate of asthma. So hormones seem to play a role, but it’s unclear exactly what that role is.

Women who haven’t experienced breathing problems earlier in life, especially those who view themselves as fit and healthy, may ignore the symptoms, which include a tightness in the chest and wheezing, or convince themselves that it’s just allergies. If your breathing has changed, talk to your doctor. There isn’t a cure, but with treatment, asthma can be controlled. And as with other medical conditions, the early you start treatment, the easier it is to control.

Also, asthma is another factor you should take into consideration when you’re thinking about whether to start hormone therapy (HT). And it’s a complicated factor! Research shows that HT might actually help asthma in women who have it before menopause. But if you’re postmenopausal and haven’t had it, reintroducing estrogen back into the body could increase your chance of developing asthma. 

Again, more research needs to be done on the relationship between hormones and asthma, but talking with your doctor about any breathing issues is important to making the right choice about HT, given your health history and the severity of your menopausal symptoms.

Weight Maintenance in Trying Times

Staying home is the best thing we can do right now. But stress coupled with a lack of routine and constant access to snacks creates a perfect storm for weight gain. Knowing it’s a perfect storm is the first step in weight maintenance.

Now you can make a plan. To address stress, make sure you’re practicing some form of mindfulness and getting some exercise every day. (Here are more tips for managing stress that work during a pandemic or during the holidays!)

Regarding routines, I think the answer is to make a new one. It doesn’t have to mimic the old, but it does have to help you be functional during the day, with designated blocks of time for things that need to get done, whether for work, pleasure, household, or community. Established mealtimes and sleep schedules are also important.

As part of a new routine, you might also establish new healthy habits. For one person I know, the inability to pick up a caramel latte reduces her intake by a couple hundred calories each day. Another has set a daily habit of a salad for lunch. And one more has upped her breakfast game with fresh fruit and granola, which she’s finding sets her up well for a day of intentional eating. 

From the conversations I’ve had, it seems like snacking is the most pervasive eating issue at this time. If that’s true for you, there are a couple of tactics I’d recommend.

• If you’re eating because you’re bored, pick an activity that you’ll do instead, when the urge to snack hits, e.g., arm exercises, cleaning out a drawer, or calling a friend. The urge will pass, I promise.
• If you’re snacking because you’re a little hungry, respect the hunger but choose a low-calorie option. A cup of hot tea will both occupy you in the making and satisfy low-level hunger pangs. Celery or carrot sticks, a handful of nuts, or an apple can satisfy your craving and make you feel virtuous at the same time.

For me, eating and exercise go together. When I’m consciously caring for my body, I make better choices about food. I don’t want my exercise to go to waste! If you haven’t already, design a fitness routine that fits your circumstances, whether solitary hikes, yoga, or online dance class.

Finally, it’s okay to indulge in a favorite comfort food once in a while, even as you work to get yourself back on a more healthful, sustainable path. With some thoughtful consideration, you can make room for that Chunky Monkey ice cream—after your green salad lunch and your afternoon workout.

Spending Time Together

Here we are, another week in our homes. Readers live all over the country (even the world), and we’re not all experiencing the same level of restrictions. I’m among those who are telecommuting, which keeps me occupied (and telemedicine is all new to me!) for much of the day. You may be retired or your job may not translate to remote work, so you may not have a similar focus for your attention. For all of us, whether we’re working or not, the pandemic has meant more alone-time with our significant others, without our usual distractions.

At its best, this can be an opportunity to remember why we fell in love in the first place, or to reinforce the friendship that’s at the core of our relationships. I’ve talked to women who are playing Scrabble or Monopoly or doing jigsaw puzzles with their partners. I’ve heard about a private dance party. One woman told me she’s pulled out photo albums from their early time together. They reminisced (and sometimes their memories varied!) with a glass of wine, and recalled some of what they’d had before kids and careers.  Several women have told me about deep conversations they’ve had, considering how the pandemic might change the way they look at their future together. 

Sometimes those conversations lead to intimacy, and if you’ve read this blog for any time at all, you’ll know I think that’s just lovely. Sometimes those conversations lead to more challenging destinations, in which case you might reread “Why Difficult Conversations Can Be the Best Conversations,” which recounts what I learned from psychotherapist Ann McKnight. Keep in mind that this is a stressful time. You and your partner may not be processing the current reality at the same speed or in the same way, and it’s perfectly okay to set aside a topic for another time.

(Stress can lead to increased domestic violence; we’ve likely all seen news of disturbing trends in this unusual time. If you or your children feel threatened, please take steps to secure your safety.)

We shared a quote in our most recent newsletter that we also heard from Ann McKnight. It resonated with so many of us that I’ll share it again: “Fear makes us lose our sense of connection. Because it often takes the form of numbing ourselves or denial or withdrawal, it makes our [inner] world shrink. When we live in fear, we fall into the delusion of our separateness. We need to widen our circle of compassion. That’s how we liberate ourselves from fear.”

That’s our job right now, widening our circle of compassion. We can start with ourselves and our partners, and see how far we can go.

Self-Care in the Time of Coronavirus

A month ago, I would have started a post about self-care talking about how we are at an age where we can finally tend to our own health and well-being. That’s still true, but now we are also in the midst of a global crisis that both highlights the importance of taking care of ourselves emotionally and physically and gives us the time to devote our attention to it. 

Self-care is composed of many things, including what we need to regulate our bodies. This is different for everyone, but might include a mix of exercise, social interaction, meditation, and certain kinds of food. It also includes pampering ourselves, from head to toe and everyplace in between. Our friends at Rosebud Woman are offering free PDFs of two self-care books, which you can download at these links: The Invitation: Daily Love for Your Intimate Self, which looks at how we love and care for our bodies (especially the often ignored parts), and The Body Love Journal, meant to help you strengthen the “muscle” of loving our bodies. (Buy either book in beautiful printed versions at Rosebud Woman’s website.)

Rosebud has a variety of self-care products that we’ve just started to carry, including Honor Everyday Balm, Soothe Calming Cream, and Arouse Stimulating Serum, as well as a Ritual Kit that includes introductory sizes of each. You can hear Dr. Barb and Redbud Woman’s founder, Christine Mason, talk about the philosophy behind the company and how the products came to be through this episode of The Fullness of Midlife.

During these unprecedented times, please continue to look after yourselves and make healthy choices. Stay home. Wash your hands. And give yourself lots of grace!

Coronavirus and Returning Family Members

In midlife, many of us have young adult children in transition (like from college back home for varying lengths of time), or other family members who need or choose to take shelter with us. The coronavirus has added a serious new complication to those transitions, including how to welcome your family member home and protect everyone’s health. I’m not an expert on coronavirus, but I can offer some basic guidance and additional resources.

One common scenario is that everyone in the household appears to be healthy, and the person coming to stay also appears to be healthy. Since there’s no established protocol, you’ll have to make some judgment calls. 

If your family member knows they have been exposed to the virus, or if they are coming from a coronavirus hotspot like New York, then they should definitely self-quarantine for two weeks, even if they don’t have symptoms. Otherwise it’s a matter of how much risk you can tolerate in your household, for example, whether there are others living in your house who are at risk because of diabetes or a heart condition.

According to Johns Hopkins, self-quarantining involves

• Using standard hygiene and washing hands frequently
• Not sharing things like towels and utensils
• Staying at home
• Not having visitors
• Staying at least 6 feet away from other people in your household

But if your family member hasn’t been exposed as far as they know, shows no symptoms, and isn’t coming from a hotspot, then consider social distancing in the home as much as possible for two weeks—no hugging or sitting next to them on the couch. If you can, designate one bathroom that’s to be used by the new household member only, don’t share towels, and be even more diligent about disinfecting surfaces and doorknobs. Everyone in the household should be washing their hands frequently and correctly. The CDC has additional tips on how to protect yourself and how to clean your home.

(And here’s some help from the New York Times explaining what to do if you or a loved one starts developing symptoms.)

In any case, the safest thing is to have your family member self-quarantine for two weeks; because there’s so much we still don’t know about the coronavirus, it’s impossible to know if that’s overkill or common sense. Stay healthy!

Celebrate International Women’s Day

#EachforEqual is the theme of International Women’s Day 2020, which falls on Sunday, March 8. The goal is to create a gender equal world for women of all ages. In my practice and in my work leading MiddlesexMD, I see the inequality that exists in our healthcare system. One example? Guidelines for treating heart disease in women are based largely on research that was conducted on men, a factor that might help explain the higher death rates among women with heart disease, as compared to men.

I also see the double standard when it comes to advertising sexual health (and pleasure) products for men versus for those for women. Ads for Viagra? You’ve see them anywhere and everywhere, and have for years, but ads for sexual wellness companies like MiddlesexMD are often deemed inappropriate by social media platforms. That hurts women because it’s an obstacle to getting the word out to women that sex is good for you—and still possible and pleasurable, well beyond menopause. 

In the workplace, menopause continues to be unmentionable, even though most (75 to 80 percent) of women of menopausal age are working. Menopausal symptoms can affect job performance and satisfaction. There are fairly easy ways to address these problems (like with flexible policies and a supportive environment), but first we have to simply help people get comfortable with talking about menopause in work settings.

This International Women’s Day, let’s fight the bias by talking about it. Talk to your doctor about issues you’re having, talk to your friends about the biases they experience, especially related to their sexual health and menopause. Talk to your significant other and your sons about your own experiences with gender bias. Small steps lead to big change!