Menopause and Osteoporosis: Options for Treatment

A lot of options are available for menopause treatment, options that can be tailored to each individual woman. Women do need to have some guidelines about menopause, what to expect, and what that means. At this stage of their life, many female patients visit their physician not just because of symptoms they’re experiencing that are troubling them, but also because of an overall concern about entering menopause. 

“My practice is probably biased because I am considered a menopause specialist in my region, so a lot of the women who do have more troubling symptoms, those who haven’t found answers elsewhere will come to me.  But despite that, the majority of my mid-life patients are just coming in for well woman care and they’re doing quite well without anything other than their multivitamins,” says Marjorie Gass, a Professor of Obstetrics and Gynecology, at the University of Cincinnati, and Director of University Hospital, Menopause and Osteoporosis Center.

Dr. Gass notes that many women have been seeing an OB/GYN doctor since the time they needed contraception, and they’ve gone through pregnancies with that doctor and they expect to stay with them through menopause. Women continue to visit their OB/GYN for their annual exam and, as they experience symptoms of menopause, they mention them to the physician. Depending on how that physician responds to them, women may stay with that doctor or, if they perceive that the doctor is primarily interested in obstetrics, they may seek someone who specializes only in gynecology and, in particular, has an interest in midlife women.

If a woman gets to a point where she has more questions concerning menopause for her healthcare provider, who has probably been great with their children and their pregnancies and having their babies, but is getting a feeling that this is not really an area of interest to him/her, that is a good time to consider finding a doctor who specializes in gynecology.

Women should ask themselves, how am I doing?  Am I feeling okay about my health and my risk factors for the future, or do I have some health concerns that I should bring to the doctor’s attention at my next visit?

There are not any certain questions that a woman could ask a physician that would help her assess whether or not that physician is going to be a good resource for her in menopause?  The person will probably just have to judge by the response of the physician. Doctor-patient rapport is also important, according to Dr. Gass.

“What I hear patients saying, who have changed from another office, they may say things like, ‘I just didn’t feel that he was interested in menopause.’ Or ‘They just seem to tell everybody to take hormones,’ or whatever, and that’s a one-sided approach in some offices,” says Dr. Gass.

A woman needs to find a physician with whom she feels comfortable, and where she feels her medical concerns and needs are being met because menopause can be a long process.

Dr. Gass sees a lot of patients in her role as a specialist. She has noticed that more women are coming to her for preventative care, rather than just for symptomatic problems, than they were in the past. 

The increasing patient concern that Dr. Gass sees today is about osteoporosis, probably due, she says, to advertising and public education about the fact that osteoporosis can be prevented.

Preventative measures for osteoporosis that women should be aware of are that smoking is detrimental to their bones, just as it’s detrimental to many other aspects of their health.

“We want women to realize that they should be eating healthy food, not becoming excessively thin, we want them to exercise and get adequate calcium and vitamin D. All those things are very positive measures that they could adopt at any age in order to help prevent osteoporosis,” states Dr. Gass.

As for menopause, symptoms like hot flashes are certainly not dangerous, but a nuisance to many people.  Dr. Gass sees a whole range of, “oh, sure, I have hot flashes, what’s the big deal?  So I get a little warm once in a while, no problem,” to the person who is having sleep disruptions, feels all tired out because she is waking up several times a night with hot flashes.  She may be particularly bothered when they happen in a public setting because she is a professional and giving presentations, and we know that some hot flashes are triggered by stress so they’re embarrassing her on the job. The range is quite considerable and women need to decide how troubling that is and how much they want to do. 

Practical measures that women can take to reduce the occurrence of their hot flashes depend on when and where she is having these hot flashes. There is often a pattern, notes Dr. Gass, because there are certain triggers. Some women may notice that they tend to get warm as they’re getting ready to go off to work in the morning and they may have one of these well-lit bathroom mirrors that are putting too much heat on them. There is a lot of heat that emanates from light and we just don’t think about it because we are so used to being under lights all day long. If that light you’re sitting under seems to affect you, then try moving it a little further away, or try using a different type of light, and you probably wouldn’t get that hot flash.

Heat-generating appliances and lights and things like that can trigger hot flashes. Spotlights that are very high in auditoriums, because you’re in your own cone of light. At night, we need to realize that we’re getting too warm at night if we’re waking up frequently, sweating.  Down comforters are one of the worst offenders because they are simply too good at trapping heat and that heat will gradually build up, then you’re nice and toasty warm and your body says it’s getting too warm in here and it turns on a hot flash. 

Dr. Gass thinks that Dr. Robert Friedman’s work has been very enlightening because has demonstrated that our thermal comfort zone shrinks as we get older.  So, whereas we used to be fairly comfortable at a wide temperature range, as we get older, it changes and we get hot faster, we get cold faster, and we get picky about our environment.

Her advice for women is to wear layers of clothing. Many of her patients have told her that they’ve given away all their turtlenecks, because they’re too warm and they can’t wear them any more. Dr. Gass advises women to keep their neck and upper chest open, because it’s a big area for triggering hot flashes and so if you can just have a neck blouse that’s open, and not wear turtlenecks or high collars, you’ll be much more comfortable.  Jackets can be taken off, so they are a good wardrobe choice.  Many people think that natural fibers will breathe a little bit better than some other synthetics, so that certainly is worth trying.  Sunlight can trigger hot flashes, too.  For some women, alcohol can be a trigger, stress can be a trigger, feeling emotional, and sometimes spicy foods can be a trigger.

“A patient of mine was complaining of these hot flashes and how they were interfering with her work something terribly and I said, ‘Well, is there a place where you have them the most?’ She said, ‘Yes, and it’s just so embarrassing. I’ll be with a client who’s interested in this very expensive jewelry and in the middle of all this, I’ll just have this embarrassing breakout of sweat,’ you know, not just feeling hot but she’ll sweat. And I said, ‘Are you showing this jewelry under a bright light?’ ‘Oh my, yes, this is a big halogen light because it really makes all these look so much better,’” says Dr. Gass.

This patient just didn’t realize that the intense, bright halogen light was triggering her hot flashes. She was so used to being under them that she didn’t even give it a second thought. Her experience won’t account for all women’s hot flashes, but there are things women can do to modify their environment and reduce the incidence of hot flashes.

Another major symptom of menopause is vaginal dryness, and it’s just so important that women stay sexually active and maintain regularity of their sexual activity.

“I hate to say this, but it’s almost like playing a sport. If you stop playing for an extended period of time, it’s much more difficult to get back into it without a few aches and pains. But if you are staying in condition, so to speak, the entire time, then you will have a much easier time of it and I think it’s very important that we try to share that information with women before they have the problem of vaginal dryness,” explains Dr. Gass. “Because with less sexual activity, the condition gets worse and then there’s less sexual activity, so then it becomes even worse. It’s just a downward spiral, so I try very hard to give women the ‘head’s up’ in the office as they’re entering their menopause and if they’re not going to use hormones, that is they want to preserve comfort and enjoyment of their sexual activity, they need to be fairly intentional about staying regular with it.”

If people are having intercourse once a week, they can generally maintain comfort. Some people can do better than that. Data is available that indicates that women who are more overweight actually probably have less vaginal dryness and discomfort than very thin women, who are not making much estrogen on their own, because adipose tissue makes more estrogen and in general, heavier women have higher natural levels of estrogen than thin women have.

Dr. Gass also recommends the use of non- petroleum-based lubricants for women to counter vaginal dryness. She also doesn’t generally recommend lubricants that are bacteria static, because the bacteria we have in the vagina normally is beneficial and they keep down our yeast population. Some of the commercial lubricants Dr. Gass suggests are Silk, KY Personal Lubricant (not KY Jelly because that’s the bacteria static one), KY Personal Lubricant, KY Warming Liquid (that’s a warmer one, it feels warmer), and Moist Again are the main ones right now. These can all be found in local stores.  Read the label to find out whether or not the product is bacteria static, and avoid those.

Soap can be irritating, and Dr. Gass thinks that women do use too much soap in their vaginal area. Soap can be drying and irritating to the vulva for many women. She tells her patients to use water, just plain water and air. If they’re having a problem, the first thing she tells them to do is to stop their soap, and just use water, because they can get very clean with water. Dr. Gass does not recommend using Cetaphil or any other emollient cleansers because they all contain chemicals. Even a dermatologist will tell patients who complain about their dry skin to quit using soap.

Sleeping patterns also change as women get older and go through menopause, but they’re not alone. Even men notice a little more disruption to their sleep pattern as they get older.

Sleep medications should not be the first line of help against disrupted sleep patterns. There are a lot of sleep hygiene tips, according to Dr. Gass, like trying to have regular sleep and wake times, and not getting too warm at night. Caffeine and chocolate sometimes starts to bother people at night. People who never used to be bothered by it when they were younger tend to be more susceptible to those effects as they get older, so they may need to try avoiding them to see if that helps them sleep better. Alcohol sometimes helps people get to sleep, but then it disrupts their sleep later in the night, so most people are really not recommending using that as a sleep inducer.

Another aspect of menopause is that many women feel dysphoria as they’re going through menopause. Dysphoria is just uncomfortable feelings about your life. You just don’t feel the way you would like to feel. Something is unpleasant. There are unpleasant feelings, but it’s not full depression.

“Menopause for some women, perimenopause for some women, can be like a continuous PMS, so you have those unpleasant feelings, you have moodiness, you have some anxiety, you have irritability, you are not the person you would like to be,” says Dr. Gass. “What I would like women to perceive is that all of things, except for vaginal dryness, are temporary. This is a phase coming out of your reproductive years, and it’s like puberty in reverse.  And we’re all willing to accept emotionality and all of these uncomfortable feelings at puberty as a short-term event, but I think women are not so sure that these feelings are going to be time-limited at menopause and they’re afraid they’re going to be stuck with them for the rest of their lives, and they’re not.  Most women, even if they do have a very troublesome transition, reach a new plateau of equanimity down the road.”

There is no set time or average for going through menopause. Different women have different experiences, and Dr. Gass notes that it may be a three year time of having your period start to change and then finally stop, and then having your year right after stopping would all be part of it.

The two biggest aspects of menopause that frighten women and that women want to try to avoid or minimize their risks of getting are heart disease and osteoporosis.  In order to help offset future health problems during menopause, Dr. Gass urges women to stop smoking, and incorporate exercise into their life, and try to keep their weight in the normal range.

“I would encourage women, before they get to menopause, to try not to start gaining two or three pounds a year because you multiply that by ten and you’re up 30 pounds. It’s indicating that your energy intake is greater than your energy output and we’ve got to keep that in balance as we get older or we’re just going to get bigger and bigger. So if people can attend to that early, it’s going to be easier than having to take off 100 pounds later,” she explains.

A bitter misconception about menopause, in particular, hot flashes, is that it’s a matter of just living beyond your hot flashes. Many women think hot flashes are a time-related thing or a “year associated with the menopause event” type of problem. What they do not realize is that it’s a drop in the estrogen levels that trigger the hot flashes, so for women who take hormones and who are having severe hot flashes, probably at least 50% of them are going to have a recurrence of those hot flashes whenever they stop their hormones.

 “It’s worse than taking the estrogen to avoid the hot flashes, then after a year, the fact that the estrogen is still being dumped into the body might make the body say, whoa. It’s not for everyone, because many are sensitive to the drop in estrogen,” says Dr. Gass.

The predictor of good health is your previous good health, and the same can be true for effective menopause on your sexual relationship. If you have a good sexual relationship, the chances are very good that you’re going to have a good sexual relationship as time goes on. If you had a poor sexual relationship, menopause can then be the straw that breaks the camel’s back because it’s one more problem thrown on to a situation that was not really good to start with and then it just puts the nail in the coffin, concludes Dr. Gass.