Frequently asked questions
Q: I am 47 years old. I started having hot flashes at night, but I still get my period every month. When will I go through menopause?
A: The length of time it takes to become menopausal (one year without a period) varies from woman to woman. A woman’s body may begin to go through subtle hormonal changes as early as age 35. The average age of menopause is between the ages of 50 and 51. What happens between start and finish is unique to each woman and difficult to predict. Some women stop menstruating abruptly with or without hot flashes. Others skip their periods on and off for two to five years with associated and sometimes frequent hot flashes. Skipped periods are normal although it is still possible to conceive during this time and pregnancy should be considered if contraception is inadequate. Additional symptoms some women experience are fatigue, decreased ability to concentrate, and reduced libido. Frequent menses more than every 21 to 28 days may not be normal and should be evaluated by a healthcare provider familiar with menopausal issues.
Q: There are many different alternative medications available for the treatment of menopause. Are they safe? What is most effective?
A: Alternative therapy choices for the treatment of menopausal symptoms are abundant. Both major grocery stores as well as health-oriented stores offer numerous over-the-counter options. Black cohosh has been used for centuries for the relief of menopausal symptoms and is one of the most widely studied supplements. It has been demonstrated to be safe and effective. Other products containing ginseng, red clover, dong quai, St. John’s wort, chaste berry, and ginkgo are commonly recommended for the treatment of menopause. These supplements are less thoroughly researched and may interact with medications and/or have dangerous side effects. It is important for all women to discuss alternative therapies with their healthcare provider prior to taking any available preparations.
Q: What are bioidentical hormones and are they safe?
A: Bioidentical Hormone Therapy is the process of restoring and maintaining hormone balance with hormones that are biologically identical to hormones produced by the human body. Bioidentical hormones are plant-derived hormones that are prepared by a compounding pharmacist. The use of bioidentical hormones addresses a patient’s unique needs and body chemistry through a multitude of dosing and formulations. Compounded hormones have the same risk and safety issues as hormone therapy products approved by the FDA. Sometimes salivary testing of hormone levels is recommended to help individualize dosing; however, hormone therapy does not belong to a class of drugs which requires such testing. There is no scientific evidence to support increased benefit or safety with use of bioidentical hormones, although many women experience significant relief from menopausal symptoms with bioidentical hormone therapy. Any decision to use hormonal therapy should be discussed with your health care provider.
Q: Is hormone replacement therapy safe?
A: Recent studies have shown that hormone replacement therapy has minimal risks if initiated at the time of menopause in women who do not have contraindications for taking estrogen and progesterone. Current recommendations are to use the lowest dose that alleviates most symptoms and to continue treatment for two to five years. The decision to start HRT is one that should be discussed with an experienced health care provider and be individualized according to a woman’s health history and symptoms of menopause.
Q: I am 42 years old and recently my doctor suggested that I start a low-dose birth control pill to help regulate my heavy and unpredictable menstrual periods. Is this safe?
A: Yes. Women over 35 years of age who are nonsmokers and do not have a history of high blood pressure or blood clots may take a low-dose birth control pill until menopause. As a matter of fact, there are many non-contraceptive benefits from using hormonal contraception in women in this age group.
Starting at age 35 and lasting until menopause, women experience subtle hormonal changes. These changes may lead to irregular cycles, heavier cycles, increases in premenstrual symptoms (PMS), hot flashes, and sleep disturbances. Hormonal contraceptives, in the form of pills, patches, and vaginal rings, suppress ovulation and therefore reduce monthly fluctuations in hormonal levels. Stimulation of the lining of the uterus is reduced, thus monthly flow may significantly decrease. Because the hormonal contraceptive is controlling the onset of menses, cycles usually become more predictable and regular. It is important to rule out other causes of irregular and heavy periods prior to initiating hormonal contraception. This evaluation can usually be accomplished in one to two visits with your gynecologist.
Suppression of ovulation eliminates the cyclic production of hormones, which frequently contributes to symptoms of PMS. A steady dose of daily estrogen daily may considerably reduce hot flashes that frequently disturb sleep, particularly around the time of menses.
Other non-contraceptive health benefits from the use of hormonal contraception are: a reduction in postmenopausal hip fractures, a reduced risk of epithelial ovarian cancer by as much as 40% compared to non-users, a reduced risk of endometrial cancer, and a reduced risk of colon and rectal cancer. Many women are concerned about hormonal contraceptive use and the increased risk of breast cancer. Large studies have consistently shown that the risk of breast cancer in women who have ever used currently available low-dose oral contraceptives is not increased.
In summary, the use of hormonal contraception in one’s forties, or at any time in a woman’s life, seems to be a safe choice while providing many non-contraceptive health benefits. The regulation of menstrual cycles, reduction of PMS, elimination of hot flashes during perimenopause, and reduced risk of ovarian, endometrial, and colorectal cancer are among the significant benefits many women receive from hormonal contraception use.
Routine Health Maintenance
Q: My daughter is 18 years old. When should she see a gynecologist?
A: The American College of Obstetricians and Gynecologists recommends a first visit with a gynecologist between the ages of 13 and 15. The decision to perform a pelvic exam is determined by the adolescent’s needs. Frequently the purpose of the visit is for the adolescent to ask questions about her changing body, birth control, gender identity, and any other issues she has. The visit is confidential. A Pap test is not needed until the age of 21; however the need for contraception, sexually transmitted disease screening, and counseling may arise before this time. It may be necessary to perform a pelvic exam for these reasons prior to needing a Pap test.
Q: What should I do to prepare for a pregnancy?
A: Preconception care is an important part of having a healthy pregnancy and baby. Some steps women can take to ensure a good outcome are: (1) Update your immunizations. (2) Avoid alcohol and tobacco. (3) Do not take any medications before checking with your physician. (4) Begin taking folic acid to reduce the risk of neural tube defects. Plant-based omega supplements have been shown to have a positive effect on the baby’s development as well. (5) Avoid exposure to occupational and environmental hazards. (6) Eat a healthy and well-balanced diet. Notify your physician as soon as you think you are pregnant.
Q: I am 55 years old and my doctor told me I should take calcium supplements. Is this necessary? Which supplement should I use?
A: When the diet does not contain enough calcium, it is taken from the bones. Most people require a supplement to reach the recommended daily intake of 1200-1500 mg per day although it is best to obtain as much calcium from the diet as possible. Calcium carbonate and calcium citrate are popular supplements. Calcium carbonate is absorbed best when taken with food. Calcium citrate can be taken at any time. Calcium is absorbed efficiently in doses of 500 mg or less. Chewable supplements and liquid calcium dissolve well and are absorbed quickly. Vitamin D is necessary for the absorption of calcium and should be taken separately in a gel cap form. Avoid calcium from unrefined oyster shell, bone meal, or dolomite without the USP label, as these may have elevated levels of toxic metals.
Q: My family doctor told me I have uterine fibroids. Should I be concerned?
A: Uterine fibroids are common. Seven out of ten women ages 30-50 may have one or more fibroid. Fibroids are made of muscular and fibrous tissue and are rarely malignant. Newly found fibroids should be evaluated with an ultrasound and rechecked in three to six months to determine if they are enlarging. If the fibroid is stable in size and is not causing symptoms, treatment may not be necessary. If the fibroid is causing symptoms like pain, heavy periods, infertility, or miscarriages, it may need to be treated. Options for treatments include anti-hormone medication to shrink fibroids, myomectomy to remove the fibroid(s), uterine artery embolization to block the blood flow to the fibroid(s), hysterectomy to remove the uterus and fibroid(s), and magnetic resonance-focused ultrasound to destroy the fibroid(s). Treatment decisions are based on the size, location, and number of fibroids as well as symptoms.
Q: I am 36 years old and I have a family history of breast cancer. Is it safe for me to take birth control pills?
A: Yes. Large U.S.-based studies have shown that the use of current low-dose oral contraceptives in healthy, nonsmoking women over 35 is safe. The Women’s CARE study conducted by the National Institutes of Health (NIH) found no increased risk of breast cancer in women who use current low-dose birth control pills, including women who have a family history of breast cancer. Other studies have shown that there is no increased risk of breast cancer in women who have benign breast disease and use hormonal contraception. A history of either benign breast disease or a family history of breast cancer is not considered a contraindication to using current low-dose birth control pill use.
Q: I feel like a different person the week before my menses. Is this normal? Is there anything I can take to alleviate my symptoms?
A: Almost every woman experiences some premenstrual symptoms during the 400-500 cycles she has during her life. These symptoms are usually a combination of mood disorders and physical complaints. About 60% of all women in the U.S. find these symptoms bothersome; however, premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) are specific diagnoses.
The relationship of symptoms of PMS and PMDD to the menstrual cycle defines both syndromes. Symptoms intensify between mid-cycle and onset of menses. Typical affective symptoms observed with PMS include angry outbursts, irritability, anxiety, confusion, poor concentration, sleep disturbances, social withdrawal, and depression. Common physical complaints include abdominal bloating, headache, breast tenderness, change in appetite, weight gain, and swelling of the hands and feet. Symptoms are bothersome but not debilitating and at least one of them must be present and intensify during the two weeks prior to menses. PMDD is diagnosed when the symptoms of PMS are more disabling and severe. Symptoms usually interfere with daily activities at school, work, or home. Five of the following eleven symptoms must be present with one of them being the first four listed: anger, anxiety, depressed mood, moodiness, appetite changes/cravings, decreased interest in usual activities, difficulty concentrating, insomnia, extreme fatigue, feeling overwhelmed, and all the physical symptoms listed above.
An accurate diagnosis requires a thorough history and physical exam and a prospective symptom diary for two menstrual cycles. Underlying medical and psychological disorders must also be ruled out before the diagnosis of either PMS or PMDD is made. Therapy for PMS and PMDD can be divided into nonpharmacologic and pharmacologic categories. Changes in lifestyle and patient education are the cornerstones of the nonpharmacologic therapy. When women anticipate their symptoms based on their menstrual calendar, they can prepare for and better cope with mood alterations and physical complaints. An example of a lifestyle change is to plan and defer situations that may trigger or intensify one’s symptoms to a different time during the menstrual cycle. Women with severe PMS or PMDD usually require pharmacologic intervention. Some studies suggest that oral contraceptives may help with symptoms. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, have been approved by the U.S. FDA for treatment of severe affective symptoms such as depression, irritability, and anxiety. Nonsteroidal anti-inflammatory drugs like ibuprofen are used to treat physical symptoms. Diuretics are sometimes used to treat severe fluid retention.
If a woman believes her symptoms during the two weeks prior to her menses period interfere with her well-being, she should seek evaluation from a healthcare provider familiar with the diagnosis and treatment of PMS and PMDD. There are many treatment options available that should be discussed and offered to women with PMS and PMDD. Initiating either nonpharmacologic or pharmacologic therapy may help women who suffer from PMS and PMDD.
Q: I am 22 years old. I frequently forget to take my birth control pills and I am worried that I might get pregnant. My doctor suggested an IUD (intrauterine device) as a possible contraceptive choice. I have never been pregnant. Is this safe?
A: Yes. IUDs are a safe and highly effective form of contraception. Many women do not realize that they are candidates for an IUD. In 2005 the FDA expanded the guidelines for women who can use an IUD for contraception. Women who have never been pregnant as well as women who have had children can use an IUD for contraception. Having just one partner is not a requirement. Mild Pap smear abnormalities can be followed and managed with the IUD in place. Women with diabetes, HIV, and leukemia can use the IUD for effective and safe contraception. The IUD is also an option for emergency contraception. It is 99% effective up to seven days after unprotected intercourse and immediately provides long-term contraception. The IUD can also be inserted immediately postpartum.
There are two types of IUDs available in the U.S., the copper IUD and the levonorgestrel intrauterine system (LNG-IUS). Both IUDs have a long history of safety and efficacy. Both IUDs work by creating an environment within the uterus that is unfavorable for conception. The copper IUD contains a small amount of copper that results in conditions unacceptable for conception and implantation. It may be left in place for 10 years. The LNG-IUS continuously releases a small amount of levonorgestrel. This is a progestin commonly used in oral birth control pills. Not only is pregnancy prevented, menses may become light, and other symptoms, such as painful periods, may be improved. The LNG-IUS is available in three doses: Mirena, Kyleena, and Skyla. The Mirena and Kyleena are effective for 5 years and the Skyla for 3.
The IUD is an ideal form of reversible contraception for women who wish to delay childbearing. Although the length of effectiveness ranges from five to ten years, a woman can easily have the device removed should she change her mind about wanting to become pregnant. The IUD is inserted by a trained healthcare professional in an office setting. The procedure does not require anesthesia and takes about 15 minutes. Removal is also performed in an office setting.