Some health changes associated with menopause - such as hot flashes, mood swings, irregular bleeding, and difficulty sleeping - are acute (short-term) effects, typically lasting a few months or a few years during perimenopause and early postmenopause. They will usually go away on their own, even without treatment. Prolonged periods of reduced estrogen levels, however, have the potential to cause chronic (long-term) effects in later years, such as osteoporosis, vaginal atrophy, and, possibly, heart disease.
A full discussion with your doctor about current disturbances and future health risks will help determine an individual woman's best treatment options. Some women will find treatment improves their quality of life significantly. Other women do not require or request specific medical management for the hormonal changes of menopause and choose only to maintain a healthy lifestyle. However, all women will benefit from a visit to their menopause specialist (gyn, family doctor) to make sure that the decisions they are making about their health are informed decisions.
For acute symptoms of menopause and for lowering the risk of chronic diseases that can increase after menopause, various treatment options are available, including lifestyle changes, nonprescription remedies, prescription therapies, and complementary and alternative medicine (CAM) therapies. These four categories of options are discussed fully in the next sections of this booklet.

Positive lifestyle changes can have an enormous impact on health. A customized lifestyle modification strategy is an essential element in a comprehensive therapeutic plan that can apply to a woman throughout her life span. These adjustable lifestyle choices include substance use, exercise, nutrition, weight management, and stress reduction.

Use of tobacco and illegal substances, as well as excessive use of alcohol and caffeine, contribute to poor health. Without doubt, smoking is the single most preventable cause of illness and premature death. The reasons to quit or never to start are numerous. Smoking increases the risk of heart and lung disease, osteoporosis, and many types of cancer, including lung and cervical cancer. It may double the risk of Alzheimer's disease and other similar mental diseases. Smokers may also experience menopause up to two years earlier than nonsmokers. Many women successfully quit smoking, sometimes after several attempts. Healthcare providers can offer a variety of smoking cessation aids, including prescription nicotine products (in gum or skin patch regimens) and antidepressants to decrease psychological dependence on smoking. Nicotine products and two prescription meds (Zyban, and Chantix) are FDA-approved to help "kick the habit." Support groups and hypnosis are other potentially helpful options. A combination of behavior modification techniques and prescription drug therapy appears to be the most successful.

For many serious diseases, physical inactivity is a lifestyle risk factor. Adequate exercise is a crucial ingredient often missing from daily life. Brisk walking, running, aerobics, dancing, tennis, and weight-training are but a few of the activities that help the heart, bones, muscles, balance, and body weight.
Proper exercise is a powerful remedy for many menopause complaints and can help prevent future menopause-related diseases. It promotes better, more restorative sleep, and it stimulates production of "feel-good" brain chemistry (endorphins) that turns aside negative thoughts and depressed feelings. Some women report having fewer hot flashes when they exercise regularly. A key first step is to develop a practical, long-term, individually suited exercise plan.
There are three types of exercise: aerobic, weight bearing, and flexibility (stretching). A moderate aerobic exercise regimen of at least 30 minutes each day has the greatest effect on heart and lung health. A brisk two-mile walk is a good aerobic exercise. Weight-bearing exercise, such as walking or working with weights to build muscle, can delay or prevent bone loss. Early in life, exercise promotes higher bone mass; later in life, it can have a modest effect on declining bone loss. Flexibility exercises, such as yoga and stretching, help maintain function while aging and may improve balance, which can decrease the risk of fractures caused by falls. A healthcare provider can help determine the initial level of exercise appropriate for individual needs. Then, finding ways to make exercise a permanent part of daily life will help ensure a healthier future.

"You are what you eat" may sound trite, but it's true. A balanced diet low in saturated fat and high in whole grains, fruits, and vegetables, with adequate water, vitamins, and minerals contributes to good health. Women at perimenopause and beyond have special dietary concerns, because both heart disease and osteoporosis are greatly affected by diet. Heart disease risk can be lowered by using little or no cholesterol or animal fat. Instead, choose olive or canola oil for cooking, and avoid hydrogenated oil found in some peanut butters and margarines. Limit salt and alcohol intake, include five or more servings daily of fruits and vegetables, and include soy foods (such as soy milk and tofu) to lower cholesterol levels (see Phytoestrogens & Soy).
A balanced diet is important for bone development and maintaining bone strength. Some women - especially those who are elderly and have reduced appetites, who diet frequently, who don't consume dairy products, or who have eating disorders - may not consume adequate vitamins and minerals to maintain optimal bone mass.
Osteoporosis risk can be lowered by an adequate intake of calcium, starting in the teen years. This builds bone mass and bone strength to a peak during the 20s and allows the body to draw from this "bone bank account" from then on. As women reach menopause, consuming adequate calcium is still important as ever. NAMS recommends that postmenopausal women consume 1,200 to 1,500 mg of elemental calcium daily. This is significantly more than the average amount consumed each day by women aged 50 to 65 (only 700 mg).
Calcium intake can be increased by eating more calcium-rich dairy products (low-fat or nonfat preferred). A glass of milk or portion of other dairy product provides about 300 mg of calcium. Increased intake of leafy green vegetables and calcium-fortified foods and juices also increases calcium intake. If sufficient calcium is not found in the diet, a calcium supplement can be used (see Nonprescription Remedies).
Vitamin D also plays a major role in helping the body absorb calcium. At least 15 minutes of sun exposure daily (without a sunscreen) is the generally accepted amount the body needs to form its supply. Certain foods (such as fortified milk, liver, and tuna) or a vitamin D supplement can help reach the recommended daily level for postmenopausal women - 400 to 600 IU (see Nonprescription Remedies). New research suggests that at least this amount is needed by women who are never in the sun or who live in northern regions.

Being overweight increases the risk of heart disease and invites other diseases, such as diabetes and arthritis. The most dangerous location of body fat for heart health is the waistline and stomach. As they age, midlife women often gain two pounds a year. When diet and exercise are not enough to control weight, support groups or weight-management organizations may help. Additional therapies are available for those who have a more severe weight problem.
Being too thin is not necessarily healthy either. Premenopausal women who over-diet or over-exercise can become so thin that their menstrual periods stop temporarily. This temporary low estrogen state increases the risk of osteoporosis later in life. Everyone needs to work on strategies to maintain a healthy weight.

Prolonged stress can have a severe impact on health. Although menopause has not been shown to raise stress levels, women at midlife face many stressors, some of them new. A number of coping strategies can be used to help reduce stress (see Psychological Changes). Exercise and meditation may help. Deep, slow, abdominal breathing can increase relaxation and may also reduce hot flashes. Some women report fewer hot flashes when they engage in meditation, yoga, massage, or just a leisurely bath. It is beneficial to reduce stress and take time to relax each day. Women need to care for themselves, both physically and spiritually.

There are many products available without a prescription ("over-the-counter") that may help with specific menopause-related complaints. Healthcare professionals can provide information about these products, including vitamin and mineral supplements, other nutritional supplements, and vaginal lubricants and moisturizers. A woman's healthcare provider should be involved in the decision to use nonprescription products because no therapy is without potential risk.

Probably every woman could benefit from a good quality, daily multivitamin and mineral supplement. After menopause, the chosen supplement typically should not contain iron, because a woman no longer loses iron through menstrual bleeding. During perimenopause, when periods may be quite heavy, the clinician may recommend that a woman take extra iron to avoid anemia. Most daily supplements contain 400 IU of vitamin D, providing the amount that most women need. For those who are never in the sun, 600 IU is recommended.
A "multi" preparation may not contain the daily requirement of calcium, however, because the tablet would be too large. If adequate calcium cannot be obtained from the diet, a separate calcium supplement may be required to reach the recommended level of 1,200 to 1,500 mg elemental calcium daily. Several types of calcium are available, such as calcium carbonate (eg, Tums) and calcium citrate (eg, Citracal). Calcium-fortified foods provide another source.

In early 2000, the FDA began allowing dietary supplement marketers to make health claims for certain conditions without providing documentation for efficacy or safety. These conditions include hot flashes and age-related memory loss, for example, but not prevention of diseases, such as osteoporosis and heart disease. The marketer, not the FDA, is responsible for ensuring that labels are truthful and not misleading, that they contain enough information for consumers to make an informed choice, and that all dietary ingredients are accurately listed.
Some women choose a combination supplement of calcium and vitamin D (eg, Oscal). Calcium is best absorbed when taken with meals in 250 to 500 mg doses throughout the day. Calcium should not be taken with fiber or iron supplements. Up to 1,500 mg of calcium per day does not increase the risk of kidney stones, but drinking plenty of water is advised.
Some women find vitamin E (daily doses of 400 IU or more) helpful in reducing hot flashes, although studies do not support this benefit. For easiest digestion, this supplement should be taken along with a meal that contains fats. It may take two to six weeks before feeling the optimum effects, if any. Vitamin E supplements thin the blood, so these supplements should not be used by women using blood-thinning prescription drugs or aspirin.
Other vitamins and minerals are available over-the-counter. A woman's healthcare provider can provide guidance regarding her needs for these products.

Also available without a prescription are products containing hormones such as topical progesterone and DHEA, marketed under the dietary supplement regulations (see box). None of these products is FDA-approved to treat a menopause related condition.

Topical progesterone creams. These come in strengths ranging from 2 to 400 mg per ounce and are marketed for a variety of claims, including relief of hot flashes and protection against osteoporosis and breast cancer. These claims have not been confirmed through clinical studies.
Studies with one topical progesterone cream have shown that after applying the cream on the skin's surface, progesterone is absorbed into the bloodstream, but studies show that the products are not consistent in delivering levels high enough to protect the uterus when using estrogen replacement therapy. Some topical progesterone products have been found to contain no progesterone at all. A prescription progestogen is a better choice to provide the needed protection. Because of these concerns, NAMS does not recommend the use of over-the-counter progesterone creams.

DHEA (dehydroepiandrosterone) is an androgen hormone made by the human adrenal gland. It can be synthesized from wild yams. DHEA is marketed with a wide range of claims, such as improving immune function, slowing the aging process, increasing energy, improving cholesterol levels, causing weight loss, improving mood, and increasing sex drive. However, very few clinical trials have been conducted regarding its use in humans, and more are needed to support not only its effectiveness but also its safety. Because of these reasons, NAMS does not recommend its use. High doses can produce side effects, such as liver damage and depressed mood. DHEA is contraindicated in women who have a history of hormone-sensitive tumors or who might become pregnant (because of possible masculinization of a female fetus).

Vaginal Lubricants & Moisturizers.  Minor vaginal moisture problems can often be solved by using one of many water-soluble vaginal products designed for this use. A wide selection of lubricants (eg, Astroglide, Lubrin, Moist Again) and moisturizers (eg, Replens, K-Y Long-Lasting) are available. Unlike lubricants, moisturizers act directly on tissue to make it less dry. Moisturizers have the extra advantage of a low pH that helps keep the vagina acidic and less inviting for infection. Only products designed for vaginal dryness are recommended. Hand lotion contains ingredients such as alcohol and perfume that can irritate vaginal tissue. Oil-based products such as Vaseline petroleum jelly and baby oil can also cause irritation, damage condoms and diaphragms, and cling to vaginal tissue, providing a habitat for infection. One exception may be vitamin E oil, which some women have found to provide lubrication and relieve itching and irritation. Vinegar douches and vaginally applied cultures of lactobacilli or yogurt are not effective for vaginal dryness and are not recommended. Antihistamine pills taken for allergies have a drying effect on all mucous membranes, including those in the nose and in the vaginal wall. It is also advisable to limit the use of soap, bubble baths, and bath oils as well as to avoid talcum powder in the vaginal area because of a possible link with ovarian cancer. No vaginal lubricant or moisturizer treats the cause of menopause-related vaginal dryness and atrophy. Since the cause is a lack of estrogen, vaginal tissue can best be restored with prescription estrogen therapy. Estrogen is FDA-approved for treating vaginal atrophy.

Several prescription drugs are available to help with menopause-related changes. By far, the most often used drug for these conditions is the
hormone estrogen, which is prescribed to replace the lowered levels secreted by the ovaries at menopause. Estrogen is FDA-approved for the treatment of hot flashes and vaginal atrophy as well as the prevention of osteoporosis. A number of factors need to be considered when a woman, with the guidance of her healthcare provider, decides whether therapy with estrogen is right for her. There is no "one size fits all" when it comes to menopause therapy. Each woman is unique and must make her own decision after totally understanding her personal situation.

Therapy with estrogen for menopause-related conditions is usually called estrogen replacement therapy (ERT). However, the term "replacement" is a misnomer because ERT provides only a small fraction of the estrogen once produced by the ovaries; estrogen supplementation is more accurate. The new term is estrogen therapy (ET).ET has been widely studied and used for more than 50 years by millions of women. ET is unique because it has the potential to help with a wide range of short-term disturbances, such as hot flashes and vaginal dryness. It also has the potential to prevent major diseases, such as osteoporosis and, possibly, heart disease. Some women report that they simply "feel good" while on therapy. Thus, if a woman needs therapy for many conditions, ET can be viewed as relatively economical "one stop shopping." If fewer conditions need treatment or if ET is not an option, more targeted therapies must be used, usually one therapy for each condition. There are many approaches other than ET for treating acute disturbances and preventing major diseases related to menopause.
Estrogen benefits women at particular risk for osteoporosis. Its role in prevention of heart disease, Alzheimer's disease, and other conditions later in life is still unclear. Women who have no identifiable risk factors for these diseases may still benefit from estrogen use for treatment of short-term conditions. Research is currently underway to determine which women will benefit most from estrogen therapy, at what dosage, and at what time of life. No ET is approved for use before menopause, although many clinicians offer ET for relief of symptoms during this transition time, and it frequently works.

Several dosage forms of ET are available, allowing a woman who needs estrogen to use exactly what is best for her:
• Systemic. When administered as an oral tablet, skin patch, intravenous injection, or in a custom made product such as a pellet implanted under the skin, estrogen circulates throughout the body's system (hence the term "systemic"), affecting many different tissues. All of these forms have the potential to reduce or completely stop the short-term disturbances of menopause and help in preventing osteoporosis and, possibly, heart disease. Although available, estrogen injections are not recommended for menopause therapy, since the estrogen level in the blood tends to peak too high after an injection and goes too low between injections, causing adverse effects.
• Local. When administered as a vaginal cream, vaginal ring, or vaginal tablet, estrogen is considered "local" therapy (one that affects only a specific or localized area of the body). Local dosage forms of ET are available to treat vaginal dryness and more severe vaginal atrophy and are, therefore, sometimes called "vaginal" forms. With a local form, only a very small amount of estrogen circulates through the body. Therefore, vaginal ET rarely helps with hot flashes or the prevention.
• Custom-made formulations are prepared by a compounding pharmacist from a prescription.
They allow even more specific tailoring of therapy, depending on what's best for a particular woman. Often-prescribed custom estrogen products are estriol cream and Tri-Est (a mixture of three estrogens: 80% estriol, 10% estrone, and 10% 17-beta-estradiol). Most women do not need customized formulations. Although much may be known about the active estrogen ingredient(s), little or nothing is known about the custom formulation that delivers the estrogen into the body. These products have not been tested in proper scientific studies as to purity, reliability, effectiveness, safety, and optimal dose. Since custom products are experimental, they must be used with caution.
The availability of estrogen in a variety of dosage forms, types, and strengths gives each woman a better chance to find what is best for her.
Finding the right regimen may require time, patience, and trying various prescriptions and delivery systems.

Some women have risk factors that are contraindications to ET use. Contraindications are reasons not to use treatment. However, the potential benefits sometimes outweigh the potential risks, leading a few women to accept therapy after careful consideration. In general, women who have the following should not use ET:
• Known or suspected pregnancy;
• History of breast cancer;
• History of hormone sensitive cancer;
• Unexplained uterine bleeding;
• History of blood clotting disorders.
(Cigarette smoking is not a contraindication for ET, as it is with oral contraceptive use in older women, but smokers are urged to stop before treatment starts for general health reasons.)
Side effects of ET. Potential side effects of ET are listed below. Many of these side effects can be managed using a variety of techniques (see Dealing with ET/HT Side Effects, later).
• Uterine bleeding (starting or returning);
• Breast tenderness (sometimes enlargement);
• Nausea;
• Abdominal bloating;
• Fluid retention in extremities;
• Changes in the shape of the cornea of the eye (sometimes leading to contact lens intolerance);
• Headache (sometimes migraine);
• Dizziness;
• Increased breast density (making mammograms more difficult to interpret).
Estrogen does not cause weight gain. However, in some women, ET can cause fluid retention in the hands and feet and/or abdominal bloating with gaseous bowel distension, sometimes resulting in a temporary weight gain. Increasing fluid intake, limiting salt consumption and participating in regular exercise will help reduce water retention.
There is one "side effect" issue that is important to keep in mind when ET is to be discontinued - stopping all at once typically brings on hot flashes. Tapering the dose over time is advised.

Estrogen probably does not cause cancer, but it may cause estrogen sensitive cancer cells to grow. It is well documented that using estrogen for five or more years can triple the risk of developing cancer of the endometrium. However, it is also well known that adding another prescription hormone - progestogen - to estrogen therapy reduces that risk to, or possibly even below, the level of taking no hormones. Combined estrogen and progestogen therapy is known as hormone therapy or HT.
Many women reject estrogen because they fear it may increase their risk of breast cancer. The relationship between hormones and breast cancer is currently a controversial issue. There is no evidence that the dosage known to relieve hot flashes and other acute changes during perimenopause increases the risk of breast cancer in the short term. However, the risk increases by as much as 40% when estrogen is used for long periods of time (defined by some studies as five years or more).
Thus, there is concern regarding ET/HT use for many years to help prevent diseases, such as osteoporosis which may not strike for 15 or more years after menopause.
Some scientists point out that the risk of breast or uterine cancer with ET/HT use is small compared with the benefits, which include the possibility of reducing the risk of heart disease. Heart disease is the leading cause of death for women. In fact, the risk of death from heart disease is many times higher than from breast cancer. In the United States, for example, a female at birth has a 23% lifetime risk of dying from heart disease compared with a 4% risk of breast cancer and 2.5% risk of bone fractures from osteoporosis. Further research will hopefully clarify some of the current uncertainties.
Weighing benefits and risks of ET. Studies have conclusively documented that estrogen taken for many years helps prevent osteoporosis and may also decrease the risk of heart disease. However, estrogen's protection against these diseases depends on its long-term, continuous use, which may slightly increase a woman's risk of breast cancer. Each woman must decide for herself if these potential rewards outweigh the potential risk. Only after examining and understanding her own situation and after a thorough consultation with her healthcare provider can a woman make the best treatment choice.
An informed decision does not rely on impersonal statistics or someone else's choice. It relies on the individual's current health status, her risk of developing more serious disease associated with prolonged low levels of estrogen, and the possibility that potential benefits of treatment outweigh the risks for her. If estrogen is not an option, there are many other effective options. A woman's decision about hormone therapy may also change as more
is learned through clinical trials and/or as personal situations and risk factors change.

Treatment that combines ERT plus a progestogen is called hormone replacement therapy or HT. When a woman with a uterus chooses to use ET,
the progesterone that the ovaries once produced  must be replaced to help counteract the increased risk of uterine cancer from taking ET alone. Replacement therapy is available as progesterone or as progestin (synthetic progesterone). Both forms are called progestogens. Women who have had their uterus removed (hysterectomy) are not at risk for uterine cancer and, thus, have no reason to take progestogen with ET.
Estrogen was prescribed alone (without a progestogen) in the United States until the early 1970s, when the associated increase in uterine cancer was recognized. Researchers found that combining a progestogen with ET kept the endometrium from thickening, which essentially eliminated the risk of uterine cancer from ET use. FDA-approved progestins (synthetic progestogens) were used initially because they were the only kind of progestogen that could be taken orally. More recently, micronized progesterone has become available in an FDA-approved oral formulation. Today, there are several progestogen options to allow tailoring to a woman's unique needs.

In most women, using a progestogen causes the lining to shed and pass from the uterus as bleeding, similar to a menstrual cycle, although there is no fertility. Some women find this unacceptable. For many women, it is difficult to decide whether to tolerate the bleeding in exchange for estrogen’s benefits, including relief from hot flashes and prevention of future diseases, such as osteoporosis.
Newer dosage schedules that combine estrogen and progestogen daily can eventually result in no bleeding in some women while still protecting the lining of the uterus from becoming cancerous. However, many women, particularly those recently menopausal, do have vaginal spotting and bleeding during the first six months of the regimen. Each woman will develop her own typical bleeding pattern when taking HT. Any change from that pattern should be reported to her clinician right away.
There are various HT schedules that can be used. Each woman should feel comfortable exploring different options with her clinician to determine which is best for her. These schedules include the following:
• Cyclic HT provides estrogen for 25 days each month, adding progestogen on the last 10 to 14 days, followed by three to six days of no therapy. Thus, both hormones are "cycled." The popularity of this regimen has waned because of uterine bleeding each month when the progestogen cycle ends and the possibility of hot flashes returning during the therapy-free interval.
• Continuous-cyclic HT (sometimes called sequential HT) provides estrogen every day, with progestogen added for 10 to 14 days each month. With this regimen, uterine bleeding occurs in about 80% of women when the progestogen cycle ends each month.
• Continuous-combined HT provides both hormones every day. The daily dose of progestogen used is much lower than the daily doses used in cyclic therapy, resulting in a lower cumulative dose over a month's time. Progestogen can stimulate bleeding, but since it is taken every day, the timing of uterine bleeding is unpredictable. With this regimen, bleeding occurs in about 50% of women, perhaps more in recently postmenopausal women. After several months of therapy, uterine bleeding often stops. However, the uterus is still protected from estrogen's effect on cancer risk. US women have been choosing this regimen more and more.
• Intermittent-combined HT is a new regimen (available as Ortho-Prefest) that provides estrogen every day, then adds progestogen intermittently in cycles of three days on, three days off. The cumulative monthly dose of progestogen is half that of a daily, continuous pattern. Bleeding and endometrial protection are similar to that with a continuous combined regimen. Some studies suggest that this regimen is better at preserving the beneficial effects of estrogen on cholesterol, thus helping heart health.
Dosage forms of progestogen and HT.
Progestogen is available in different forms - either alone or in combination with estrogen - allowing for individualized therapy. Not all progestogens are good choices for endometrial protection, but they can be used for other indications.
Progestogens are also available in custom-made formulations prepared by a compounding pharmacist following a healthcare provider's prescription
Hormone Replacement Therapy (HT) Is Not A Contraceptive.
Estrogens and progestogens are used in HRT to treat menopause-related changes; these hormones are also in most birth control pills. However, the doses of estrogen and progestogen used as HT are not high enough to provide birth control (except FemHRT). The doses used in birth control pills are about four or five times higher. Until menopause is reached (12 straight months without periods), hormonal or nonhormonal contraception must be used to avoid an unwanted pregnancy.
Progesterone creams that can be purchased over-the-counter may or may not contain progesterone. Even if they do, the amount of progesterone absorbed through the skin may not be sufficient to protect the uterus against cancer if estrogen is used.

In addition to uterine bleeding, the following side effects, some of which are similar to those of the premenstrual syndrome (PMS), may be experienced with progestogen use:
• Fluid retention
• Headache;
• Breast tenderness;
• Alterations in mood.
In some women, these side effects may be substantially reduced with the use of a bioidentical (natural) progesterone instead of a synthetic progestin. In addition, unlike progestin, progesterone does not appear to lower HDL, the good cholesterol that increases when estrogen is taken alone. More research is needed to clarify the effects of these hormones on heart disease risk.
Using progestogen is a complicated issue that depends, in part, on the type and dose of estrogen being used. The contraindications for treatment with progestogen are generally the same as those for estrogen.

There are various strategies to deal with the side effects that may occur with the use of ET or HT. Many side effects are temporary until a woman adjusts to the hormonal changes. Unless side effects are severe, a trial of three months of hormonal therapy is advised to see if side effects resolve. One strategy is appropriate for any side effect: stop ET/HT (by tapering slowly) to see if hormones are the cause, because side effects could be the result of something else.

• Fluid retention.- Restrict salt intake, maintain adequate water intake, exercise, try a mild diuretic.
• Bloating. -Lower the estrogen dose, switch to another estrogen, switch from oral estrogen to a skin patch, lower the progestogen dose, switch to progesterone or another progestin.
• Breast tenderness. -Restrict salt intake, cut down on caffeine and chocolate, lower the estrogen dose, switch to another estrogen, switch from oral estrogen to a skin patch, switch to progesterone or another progestin.
• Headaches. -Restrict salt, caffeine, and alcohol intake, ensure adequate water intake, lower the dose of estrogen and/or progestogen, switch to a continuous dosage schedule or a skin patch to avoid hormone fluctuations.
• Mood changes. -Restrict salt, caffeine, and alcohol intake, ensure adequate water intake, lower the progestogen dose, switch to progesterone, switch to a continuous dosage schedule or to a skin patch to avoid hormone fluctuations, exercise regularly.
• Nausea. -Take oral estrogen tablets with meals, lower the estrogen and/or progestogen dose, switch to another estrogen, switch from oral estrogen to a skin patch.
• Skin irritation under patch. -Switch to a patch with a different adhesive, apply patch to a different area, change to oral estrogen.

Many women are surprised to learn that androgen, which is considered primarily a male hormone, is also a female hormone. It is secreted by the ovaries as testosterone and androstenedione. Aging ovaries produce less androgen as well as less estrogen, although the decline is not so steep as with estrogen. Conditions that accelerate the decline of internal androgen levels include surgical removal of one or both ovaries prior to menopause, pituitary and adrenal insufficiency, corticosteroid therapy, and some chronic illnesses. Because of the lack of androgen, some women suffer a decline in sex drive. Androgen therapy may help. Some women have also reported an increase in energy while taking androgen. However, androgen therapy is appropriate only when a woman is also using estrogen - never androgen alone.
There have been many studies in which androgen was added to estrogen therapy for menopausal women. Currently, the only androgen-containing product that is FDA-approved for use in women is Estratest, a prescription oral tablet containing an androgen (methyltestosterone) and an estrogen (esterified estrogens). However, no product, including Estratest, is FDA-approved for boosting sex drive in women. Estratest is approved for the treatment of hot flashes that are unresponsive to ET alone. Some women, however, find that sex drive is improved by taking this product.
A skin patch product containing another androgen (testosterone) is being developed. Testosterone products also can be custom-made by a compounding pharmacist following a healthcare provider's prescription. One popular form contains 1% to 2% micronized testosterone USP in a water-soluble base; this topical product can be absorbed by rubbing it on the skin. Other custom forms of testosterone include tablets, injections, or pellets implanted under the skin. As with all custom formulations that are not FDA approved, therapy should be used with caution.
Dosage is very important. Too much androgen may not provide the desired improvement in sex drive and can cause feelings of agitation, aggression, and/or depression. Higher dosages can also cause facial and body hair growth, acne, an enlarged clitoris, a lowered voice, and muscle weight gain. These side effects may not go away after therapy stops. Androgen may adversely affect some of estrogen's heart health benefits, even more so
than progestin. Caution is recommended when considering this type of hormone treatment because the safety of taking androgen for extended periods of time has not been established.
Women must not use the androgen products FDA approved for men, as these contain very high doses that would be harmful to women. However, several new products are being studied for use in women, and will, hopefully, be on the market in the near fixture.

Treatments for menopause can be aimed at menopause disturbances or targeted to prevent the potential long-term effects of lowered estrogen levels. An array of remedies is available today, and more are under study for future use.
Although not FDA-approved for this use, low-dose oral contraceptives containing estrogen and progestin are prescribed to help regulate periods, reduce hot flashes, improve sleep, and level out mood swings. Oral contraceptives, even those with very low hormone doses, provide significantly more hormone than standard HT regimens. Since the lowest effective dose of any drug should always be used to reduce exposure to risk, women who need to continue with HT are switched from oral contraceptives to HT after menopause is reached. However, a woman taking birth control pills will continue to have uterine bleeding even after menopause, making it difficult to determine that menopause has occurred. Thus, many clinicians make the switch automatically at age 51 to 55 - the average age of menopause.
Several other prescription drugs are available as options to ET/HT in treating hot flashes, but they are not FDA-approved for this use.

Therapies considered by some to differ from traditional medical treatments are referred to as complementary and alternative medicine (CAM) therapies. These nonprescription treatments are promoted for a range of menopause symptoms, and the remedy usually depends on the specific complaint. The effect, if any, of CAM therapies may take several weeks. In contrast, prescription hormones usually begin to take effect within a few days. Some CAM therapies are expensive and many are untested. CAM therapies include foods, herbs and other botanicals (plant sources), and supplements. Often, a pharmacist or herbalist can offer advice on their use. CAM therapies can also include naturopathy, homeopathy, and acupuncture, each practiced by specialists in the field.
Many CAM therapies are advertised as "natural." This marketing word is used because many consumers believe it suggests that a product that's natural is better or safer. However, this may not be the case. CAM therapies may actually be more dangerous than prescription drugs because less is known about them, and their purity, dosage, and advertising claims are not regulated by the FDA.
These products are marketed as dietary supplements. Women need to use the same caution with CAM therapies as with all other therapies. As more research findings accumulate to support their effectiveness, some therapies now listed as CAM therapies will undoubtedly be moved from the CAM category to mainstream. Some CAM therapies may be proven to be ineffective or too risky, and they will not be included anywhere in a listing of menopause treatment options. Still others will remain classified as CAM, since not all therapies can be adequately tested, often because of lack of financial backing for studies since many CAM products are not patent-protected and, thus, do not allow marketers to recoup their research investment.

Currently, intensive research is focused on phytoestrogens (plant estrogens), such as isoflavones. These are naturally occurring compounds found in rich supply in soybeans, soy products, and red clover. They are similar in chemical structure to estrogen and can produce weak estrogen-like effects. There is some evidence that eating soy foods (such as tofu, tempeh, soy milk, or roasted soy nuts) may be helpful in reducing hot flashes and other menopause effects. The most convincing beneficial health effects have been attributed to the actions of soy foods on fats in the blood, stimulating the FDA to recommend eating a daily serving of soy foods (25 grams of "soy protein"), as part of a diet low in saturated fat and cholesterol, to help lower the risk of heart disease. There are inadequate data to evaluate the effect of soy/isoflavones on vaginal dryness, bone mass, and breast cancer.
Commercial preparations containing isoflavones - including over-the-counter supplements, additives to "multi" supplements, and fortified foods (such as candy bars) - are marketed to provide similar health benefits. It is not clear, however, whether the observed health benefits sometimes seen with soy foods are caused from the isoflavones alone or from isoflavones plus other components in whole foods. Until the effectiveness and long-term safety of isoflavone supplements have been clearly established, eating reasonable amounts of soy food is probably a better choice. Foods have widely different amounts of isoflavone , and there is great variability within the same food type, depending on many factors, such as growing conditions.

A number of botanical (plant-based) products, including herbs and multi-herb products, have been used to treat acute menopause-related conditions, such as hot flashes. They are not meant to be considered for prevention of serious diseases, such as osteoporosis. There is limited research information documenting effectiveness and safety of these products. All are regulated as dietary supplements, not as drugs. None are regulated for purity, dose, or health claims.
The most widely used products include the following:

Black cohosh (Cimicifuga racemosa), also known as black snakeroot and bugbane, is available in several forms. The most studied form is an extract used in Germany. The typical dose is 160 mg/day. The most well-known brand is Remifemin.
Pros: There are reports of effectiveness with hot flashes, vaginal dryness, and depression, and some clinical studies support these reports, although critics contend the studies are poorly designed. Results are evident within two to four weeks. Side effects are rare and include gastrointestinal upset, typically with first-time use.
Cons: Black cohosh should not be used longer than six months. It should not be used in combination with ET/HT or with antihypertensive medications.

Evening primrose oil (Oenethera biennis) comes from seeds rich in linoleic acid. It is used at 1,500 to 3,000 mg/day for relief of hot flashes.
Pros: Some women report effectiveness.
Cons: There is no scientific evidence that effectiveness is better than placebo. Side effects include inflammation, nausea, diarrhea, blood clots, and lowered immune system. Women with epilepsy or those using phenothiazines or blood thinners (including aspirin and warfarin as well as supplements of vitamin E, feverfew, garlic, or ginger) should not use this product.

Ginkgo (Ginkgo biloba) is an antioxidant used for short-term memory loss.
Pros: Some studies document effectiveness.
Cons: Bleeding is a serious side effect. Women using blood thinners should not use this product. Use must be discontinued for two to three weeks before and after surgery. Use is not recommended for menopause symptoms.

Ginseng (Panax ginseng) is a term used to describe many different herbs used for preventing age-related cognitive decline, fatigue, and building resistance to viruses.
Pros: Some women report effectiveness.
Cons: There is a lack of scientific evidence to support these claims. Side effects include vaginal bleeding, worsening of menopause symptoms, high blood pressure, headache, aggressive behavior, mental disturbances, and insomnia. Ginseng should not be used with stimulants, diabetic agents, phenelzine, (a potent antidepressant), blood thinners, or diuretics. Use is not recommended because of side effects and lack of efficacy data.

Dong quai (Angelica sinensis), also known as Chinese angelica, tang-kuei, and dang-gui, is used for menstrual cycle regulation, easing cramps, and menopausal symptoms.
Pros: Some women report effectiveness for these conditions.
Cons: One study using 4.5 grams/day for 12 weeks found it to be no more effective than placebo in relieving hot flashes. Dong quai, however, is not meant to be used alone but in an individually tailored herb mixture.

Kava (Piper methysticum), sometimes called kava kava, is used for menstrual cramps, muscle tension, and insomnia.
Pros: Studies with postmenopausal women document efficacy in relieving mild anxiety.
Cons: Kava may be addictive and must be used with caution. Mild gastrointestinal upset has been reported; long-term use can cause yellow, scaly skin. Kava should not be used with any medication taken for psychological problems, antihistamines, or alcohol.

St. John's wort (Hypericum perforatum) is used for mild to moderate depression at a dose of 300 mg taken three times daily.
Pros: Studies show effectiveness.
Cons: Side effects include gastrointestinal upset, fatigue, and increased sensitivity to sunlight. When taking this herb, sunblock, a hat, and wraparound sunglasses should be worn when in the sun and sunbathing must be avoided. St. John's wort should not be used with drugs for psychological problems or HIV, or after organ transplant.

Wild yam (Dioscorea villosa) must be processed chemically in a lab to the hormone progesterone; humans lack the chemicals necessary to make
this change. Some products are marketed with claims of relieving hot flashes, among others.
Pros: None.
Cons: There is no scientific evidence that wild yam is effective.

For most women experiencing natural menopause, the decision to seek treatment is based on the severity of short-term complaints, risk of disease
in later years, and personal attitudes about menopause and medication. Regardless of the severity of health complaints, women in perimenopause should consult a healthcare provider.
Some women in perimenopause find adequate help from nonprescription remedies, such as vitamins and herbs. Others choose prescription hormones, either ET/HT or oral contraceptives, during this transition. Following perimenopause, some women choose ET/HT or more targeted prescription therapies to protect against osteoporosis and, possibly, heart disease.
Prescription ET/HT appears to be the treatment of choice for women who experience premature menopause (either natural or induced) because of their increased risk for osteoporosis and heart disease.
However, it is also important to assess and improve overall diet, exercise regimen, and other lifestyle factors. For all women, living a healthy lifestyle
can contribute significantly to improved well-being, not only today but throughout life.

Prior to beginning any treatment or combination of treatments, whether intended to alleviate short-term disturbances or prevent diseases later in life, a woman needs to be assured that the treatment regimen selected is the best for her. This requires an open discussion with her healthcare provider about her health status and concerns and in-depth information on available treatment options. A clinician with expertise in managing menopause can offer optimal care.

For optimal results, treatment takes time. It takes time for effects to manifest fully and for side effects to diminish. For example, the effects of ET/HT usually become stable after six to eight weeks.
Nonprescription and CAM therapies, on the other hand, may take months for the desired effects, if any.
Over time, therapy may need to change because of gradually lowering levels of ovarian hormones and the possible appearance of medical conditions unrelated to menopause or menopause treatments. Also, new research and changing ideas about medicines and health arise that have an impact on health decisions.
Before switching from one therapy to another, a "wash-out" period during which no drugs are used may be required to clear all drugs from the body. If ET/HT is to be discontinued, it should be tapered off in order to avoid severe recurrence of hot flashes.
Treatment should last as long as it is needed. Duration will be different for each woman, depending on her own unique and ongoing health profile, and risks of developing serious diseases later in life. Because of this, regular checkups are important throughout life.
For more info, go to the North American Menopause Society website.

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