Changes Magazine 2011 by Affinity Magazines

AMERICAʼS LEADING MENOPAUSE MAGAZINE

DOCTOR’S

ORDERS All you need to know about hormone therapy Rx

PERIMENOPAUSE

CHECKLIST!

10 things to do before the change

MENOPAUSE

MELTDOWN!

Expert advice on managing menopause symptoms

DROP THE

DIET AND LOSE LBS.

How to beat the battle of the midlife bulge

MOTHER NATURE

RECOMMENDS

Your trusted guide to understanding complementary & alternative therapies

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If all of these specialists aren’t involved in your care, ask your doctor why. More information is available at www.plasticsurgery.org/choices Check out our new online forum to share and learn about breast reconstruction at http://forums.plasticsurgery.org

Contents Features 20 12

Keep Calm & Carry On All you need to know when it comes to dealing with stress.

With Complements Are complementary & alternative therapies the way forward for you?

Dear Changes… Your most frequently asked hormone therapy questions answered.

Drop the Diet Sensible, expert advice on losing those extra 10 lbs. – or more.

President / Publisher

James Pashley

Editorial Director

Amanda Gerrard

Advertising Director

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Editor

Tina White

Art Director

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Production

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Advertising Sales

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For all advertising inquiries, call (866) 495-2822 CHANGES™ magazine is owned and published by Affinity Magazines USA Ltd. www.changesmagazine.org ©2011 Affinity Magazines USA Ltd. 305 Madison Ave, Suite 449, New York, NY 10165 Phone: (866) 495-2822 Fax: (866) 201-3996 www.affinitymagazines.com ©Affinity Magazines USA Ltd. 2011. All rights reserved. No part of this publication may be reproduced without prior written permission from Affinity Magazines USA. AMUSA does not endorse or make any representation or warranty, express or implied, with respect to any of the products or services advertised herein, including but not limited to any warranty of merchantability or fitness for any particular purpose. We recommend that you independently evaluate all products and services before purchasing. The appearance of advertising in this publication does not constitute a guarantee or endorsement of the advertised product or service by AMUSA. Not all advertised products are required to meet rigorous scientific standards set by the U.S. Food and Drug Administration for over-the-counter and prescription medication. If you have any questions about a product advertised in this magazine, ask your clinician for more information.

News

Diet & Exercise

Surgical Solutions

Apples & Pears

Eat Smart

Research Roundup

The latest menopause-related news and tips for a healthier, happier you.

Perimenopause

Perhaps more radical measures are needed when diet and lifestyle changes haven’t helped?

Be Prepared

All Change

Is This It?

Postmenopausal Health

Perimenopause Checklist

How to get the most out of your healthcare visit. Take a fresh look at the menopause transition and enjoy the journey. Could you be experiencing perimenopause?

Hot Stuff

Nighttime Blues

How to keep your cool when the hot flashes hit. How to manage night sweats, insomnia, and other sleep disturbances.

Bosom Buddies

Visonary Thinking

Statuesque

Restroom Assured

Treatment Options 24

Mother Nature Recommends

Herbal Therapies

Doctor’s Orders

The natural approach to treating menopause symptoms.

Understand the facts concerning herbal treatments. When alternative therapies just aren’t enough, hormone therapy may be the answer.

Intelligent eating is a no-brainer with our menopause super foods.

10 things to do before the change!

Menopause Symptoms

Follow our tailored exercise program to help you make the most of your classic body shape.

Straight talk about breast cancer. Changes experts talk through readers’ concerns about their breast health. Look ahead to see how fluctuating hormones can influence your eyesight. Take a stand against osteoporosis and make your bone health a priority. Take control of bladder weakness and say goodbye to the bathroom dash.

Sexuality 76

Sex and the Nitty Gritty

Fifty, Feisty & Fearless!

How to get the passion back into your love life.

We looked through some of the latest research, and it’s true – life really is fab after 50!

Research Roundup Here’s the latest news for a healthier, happier you

Imagine This… A Baylor University study has shown that women who specifically pictured images associated with coolness during hypnotherapy had a dramatic decrease in hot flashes. “This is an interesting finding because it begins to shed light on what is it, specifically, about hypnotic relaxation therapy that reduces the hot flashes,” said Dr. Gary Elkins. “The finding may indicate that areas of the brain activated by imagery may be identical to those activated by actual perceived events. Consequently, it may be that while a woman suffering hot flashes imagines a cool place, she also feels cool rather than the heat of a hot flash.” While a previous Baylor study showed that hot flashes can be reduced by up to 68% in breast cancer survivors by utilizing hypnotic relaxation therapy, the specific mental imagery used by women for reduction of hot flashes is a new finding. The Baylor researchers surveyed the 51 women who were asked to identify their own preferences for mental imagery to reduce hot flashes. The most common themes utilized by the participants included cool mountains, water, air or wind, snow, trees, leaves, and forests.

CHEERS!

A review by Italian researchers of the literature regarding a chemical found in red wine known as resveratrol and moderate red wine consumption during menopause suggests that drinking a glass or two of red wine with meals could have beneficial effects on postmenopausal women. More good news for red wine drinkers can be found in a similar study from the University of Granada. Researchers found that red wine polyphenols can offer protection against cardiovascular disease. Resveratrol, which is one of those polyphenols, has shown potential for treating and preventing disorders such as heart and lung disease and some forms of cancer. But the compounds’ effects on women’s blood vessels were particularly important because of the high incidence and risk of hypertension in women after menopause. However, the researchers used a red wine chemical supplement, so the results may not extend to women who drink red wine. Resveratrol can also be found in red grapes, cranberries, blueberries, and peanuts.

Love the Sunshine Vitamin Researchers at Baltimore University have discovered what we suspected all along: Sunshine is good for us! In fact, too little vitamin D, which is best absorbed from sunlight, can cause problems with our joints and bones. In a study of 62 patients with rheumatoid arthritis, 61% were found to be vitamin D deficient. These patients had a six-times greater chance of being moderately or severely disabled, compared with those who were not deficient in vitamin D. So get out there and soak up some sunshine – but be careful to enjoy sunlight during the cooler parts of the day; and if the sun is bright, use sunscreen.

NEWS

THINK YOURSELF THIN The results of a recent study have significant implications for traditional dieting wisdom, and that’s great news for us! Researchers have found that when dieters imagine eating the food that they crave, they reduce the likelihood that they will gorge on the actual food later. While some subjects in the study were distracted from thinking about anything in particular, others repeatedly imagined eating a forbidden food (in one case, 30 M&M candies consumed one at a time), and a third group imagined a non-food topic. The group that visualized eating the 30 M&Ms was found later to have eaten significantly fewer of the candies than the other groups ate. In later phases of the study, it was discovered that simply thinking about a food was not sufficient to produce this effect; neither was visualizing a food that was different from the one later consumed. Other senses may drive the appetite, but imagining that you are eating a specific food may substitute for actual consumption. That’s great news for managing cravings and specific food weaknesses. We’re thinking chocolate; how about you?

TOMATO JUICE MAY HELP FIGHT OSTEOPOROSIS? Drinking two glasses of tomato juice a day strengthens bones and can ward off osteoporosis, claim scientists from St Michael’s Hospital in Toronto and The University of Toronto, Canada. The researchers say they have learned that lycopene, an ingredient in the drink, slows the breakdown of bone cells, protecting against the disease. Their small pilot study examined the effects of lycopene supplements and tomato juice on chemical signs of bone loss in postmenopausal women. The researchers enrolled 60 women who had been postmenopausal for at least a year and who were 50 to 60 years old. The study lasted for four months. Women taking lycopene from either juice or pills had lower levels of the chemical by-product associated with osteoporosis. The findings of this study highlight an avenue for further research. However, it is too soon to conclude that tomato juice will help fight bone disease. The researchers, though optimistic, make it clear that their study is a pilot. They say that larger studies measuring actual bone loss or fractures, rather than signs of the disease, will provide better evidence.

PAMPER YOURSELF

The menopause transition should be a time for reflection and pampering. This is a time, more than any other time in our lives, when women can indulge themselves. And we do! The spa business reports that the biggest surge in spa attendance over the past 10 years has been by midlife women. The alternative and complementary therapies offered by spas are the perfect Rx for menopause symptoms such as hot flashes, mood swings, and anxiety. Massage, reflexology, aromatherapy, acupuncture, facials, mud wraps, and water-based therapies help boost circulation and minimize hormonal imbalances, re-hydrate skin, and encourage relaxation – and are all ideal ways to relieve the symptoms of menopause. You don’t even have to leave your house: Home spa treatments, used in the comfort of your own bathroom, work well. Light an aromatherapy candle, run a hot bath, and breathe deeply.

Prepared Here are some tips to help you get the most out of your initial visit with your menopause clinician

PERIMENOPAUSE

Many women ﬁnd that a menstrual diary that tracks bleeding patterns and symptoms is very helpful when answering questions from their healthcare provider.

If you are visiting a new healthcare provider for the ﬁrst time, bring the contact details of your usual healthcare provider/s.

Bring a list of all your new and old medications and their doses, including over-the-counter medicines, vitamins, and supplements.

Know YOUR Periods When was your last period? Have you skipped any periods? Have you been spotting or bleeding between periods? Have you had a “final” period (i.e., a year without one) and if so, when was your last year of cycles? How much time did you have between cycles? Were they heavier or lighter?

Don’t forget the type of contraception, if any, you are using.

Record the dates and location of your latest health screens such as mammogram, bone density, and colonoscopy, and bring any copies of results that you have.

Tell your doctor about any change in your medical history.

Bring information about your family medical history.

Prepare a list of high-priority issues you want to address and questions you want to ask.

Know your periods – see box.

Many women also ﬁnd that a menstrual diary that tracks bleeding patterns and symptoms is very helpful when answering questions from their healthcare provider.

Are you having any other symptoms?

» Mood swings and irritability » Hot ﬂashes, night sweats » Insomnia and sleep disturbances » Difﬁculties with memory or trouble focusing » Weight gain » Vaginal dryness or discomfort » Decrease in sexual drive or sexual responsiveness

» Urinary incontinence » Hair loss Remember, the checkup can be brief, so being prepared will make your visit more efﬁcient and beneﬁcial.

ALL CHANGE Rather than seeing the menopause transition as a rough road from youth and fertility, you should view it as an invigorating journey to a revitalized new you

hen Rita Shapiro, a 52-year-old dentist from St. Cloud, Minn., realized a year ago that she was oﬃcially postmenopausal, she threw her arms in the air and danced for joy. “I’d had enough of the whole fertility thing, menstruation, period pain, the threat of pregnancy, and just the whole inconvenience of it all,” she says. “I was thrilled when I realized I hadn’t had a period for a full 12 months. Hooray, this is it! I’m free!” she recalled singing to herself. This is a common message, reports Marcie K. Richardson, M.D., co-director of the Menopause Consultation Ser-

vice, Harvard Vanguard Medical Associates, and previously editor of Changes magazine. “Menopause is a passageway to a new part of life when most women report feeling more confident, empowered, involved, and energized than in their younger years,” Richardson says. She echoes Shapiro’s feeling of liberation from those fertile years: “The end of fertility can bring liberation from concerns about birth control, menstrual periods, and associated disorders such as endometriosis and PMS.” Of course, as with all aspects of change, some things are good and some things are not so good, and menopause has its downside too. “Menopause is a reminder of aging, which may cause diﬃculties in

MEMO

Symptoms of the menopause transition The most common symptoms are:

» Irregular periods (except surgical menopause)

» Hot ﬂashes » Vaginal dryness » Mood swings » Insomnia

(from hot ﬂashes)

» Irritability

(from insomnia)

PERIMENOPAUSE

a society that values youth and fertility,” Richardson says. “Health problems may also arise when changing hormone levels and the physical effects of aging are coupled with the stresses of midlife.” However, she goes on to say, stick with the journey because “menopause presents an opportunity for you to assess and enhance your health practices.” For many women the time after menopause is a time of empowerment and invigoration. The North American Menopause Society reports that women in a recent survey reported feeling a sense of empowerment and freedom just after they reached menopause. More than half said their postmenopausal years were

the happiest and most fulfilling of their lives. Only 10% said they felt that way about their twenties, 17% about their thirties, and 16% about their forties. So what’s going on here? Our mothers didn’t enjoy this good a time of it, did they? “Instead of whispering about ‘The Change’ as their mothers did, the ‘let it all hang out’ generation is joining support groups, logging onto websites, and reading books about this next stage in their lives, embracing it as fully as they embraced sex, parenting, and the workplace,” says Karen Giblin, founder of The Red Hot Mamas, a support and educational program for peri- and postmenopausal women. We baby boomers are coming of age, and we are not doing so passively. We are also living longer and healthier lives than ever before. A hundred years ago the average life expectancy for women was just 60, which meant that postmenopause did arrive for many at the end of their lives. This is no longer the case, with average life expectancy increasing to around 80. It makes sense, too, that many women feel they have earned the right to a sense of self-satisfaction and self-worth. After 20 or so years of child rearing, and putting family and home first, they have earned the right to some time off, or what Shapiro calls her “big moment of selfishness.” And for good reason: She raised four beautiful kids, now all grown up and flown the nest. She worked hard to maintain her career as a dentist – putting in part-time and often irregular hours in order to fit in with child-care opportunities – and now she feels that she deserves to have her time off. “I can afford to go to Cabo, Europe, pretty much anywhere I fancy, and to enjoy it while I have the chance,” Shapiro says. “I have my health, which has always meant a lot to me, and I look after myself pretty good. The kids are happy for me, my husband respects and loves me – and you know, I do too.”

PERIMENOPAUSE

Is This IT Is your body trying to tell you something?

ow do we know when we’re transitioning into menopause? For many women, there are no clear signs that they are experiencing menopause or perimenopause, the stage before a woman’s periods stop, which can last from a few months to several years. While some women go straight from experiencing regular periods to having no periods at all, for others, menstrual irregularity of all varieties can occur. So, knowing whether you’re entering perimenopause or not isn’t always straightforward. Jessie Morgan, a photographer from Augusta, Maine, usually put her irregular periods down to stress. “Whether I was traveling, working to tight deadlines, or suffering from a viral infection, the first thing to go would be my menstrual cycle,” she says. “I don’t think it’s ever been regular.” So when Morgan’s periods stopped in her late 40s, she didn’t think much about it. “It wasn’t until I started getting hot flashes that I realized I was entering menopause.”

Home Tests

If you’d like to know your menopause status, home testing kits aim to give you some indication. These tests measure urine levels of follicle-stimulating hormone (FSH), a hormone made by the pituitary gland in the brain, which increases as estrogen levels drop. They won’t work for everyone, though: They’re invalid if you’re using hormone therapy, including oral contraceptives. Self-tests work by measuring urine FSH levels, usually at least twice over a period of time. A urine sample is checked against a test panel, and menopause is supposedly indicated when all results indicate high FSH. But the tests, which cost about $20, can be inconclusive. Unlike a pregnancy test, which provides a simple “yes” or “no” answer, the question of perimenopause isn’t so simple. “During perimenopause, any FSH test can only give you a snapshot of your hormone level on that particular day, information that may

not be very useful,” says Felicia Cosman, M.D., director of Helen Hayes Hospital in West Haverstraw, N.Y. This is because hormone levels can fluctuate wildly during perimenopause. Self-tests try to compensate for this by requiring two or three tests at various intervals. You also may ask your healthcare provider about getting an FSH blood test, but it, too, may be unreliable.

Tracking Your Periods

Traditionally, you are considered to have reached menopause after 12 months without any periods. However, for some women this method is not suﬃcient. Oral contraceptives often extend periods beyond menopause. And if you had your uterus removed, you’ll no longer have periods, even when your ovaries continue their monthly hormonal ups and downs.

Your Best Bet? Pay attention to your body and your symptoms. Use a home test kit if you want, but if you’re in your forties and having night sweats and hot flashes, skipping periods or having them more often, or find that your flow is lighter or heavier, you’re probably in perimenopause. The important thing is that you don’t try to guess. Discuss your symptoms with a knowledgeable healthcare provider to assess your personal situation.

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PERIMENOPAUSE

10 things to do before the change!

FIND THE RIGHT HEALTHCARE PROVIDER

Choosing the right healthcare provider at this important time in your life is crucial. “In the childbearing years, when health risks are lower, women tend to have annual visits with a gynecologist and may not be as likely to seek care from an internist or family practitioner. An internist is a specialist dealing with the prevention, diagnosis, and treatment of adult diseases,” says Maureen Connelly, M.D., co-director of the Harvard Vanguard Menopause Consultation Service in Boston. “Perimenopause is the perfect time to find a healthcare provider you can trust

to manage any serious medical problems should they arise in the future.” Ask friends for recommendations or check out the NAMS list of credentialed menopause practitioners in your area: www.menopause.org. “Always interview your potential choice before committing to becoming a patient,” recommends Connelly. Talk with the clinician about your high-priority concerns and assess compatibility.

BE PREPARED See page 4 for essential tips on preparing for your first visit to your menopause clinician.

BOOK YOUR PHYSICAL EXAMS

It is essential that you have all the major risk tests scheduled now. “Have your blood pressure and cholesterol levels checked and ask for a thyroid test,” says Connelly. “About one-quarter of perimenopausal women develop hypothyroidism, in which thyroid levels drop too low. Symptoms include irregular periods, mood disturbances, low energy levels, and sleep disturbances – quite similar to those of perimenopause. And if you haven’t had a mammogram, schedule one today. Then check with your clinician about how frequently you should have one in the future.”

PERIMENOPAUSE

STOP SMOKING

If you smoke, stop now! Smoking reduces estrogen levels and brings on menopause an average of 1.5 years earlier, says Connelly. Nicotine also increases the frequency and duration of hot flashes. If you use oral contraceptives and are over 35, you are at high risk of blood clots and cardiovascular disease. But that is only the beginning; smoking increases the risk of fatal diseases such as cancer, heart disease, and stroke. It affects bone density and can increase the risk of osteoporosis, rheumatoid arthritis, and other joint problems. Lung disease and other respiratory diseases are also highly associated with smoking. Smoking is the most preventable cause of death in this country. Stop now!

LIMIT ALCOHOL

Some women may turn to the bottle to deal with the changes in their body and the symptoms of menopause such as anxiety. However, this is not a solution. Consuming excessive amounts of alcohol – more than the recommended two units of alcohol per day for women – intensifies menopausal symptoms such as hot flashes and is a depressant that intensifies anxiety, insomnia, mood swings, and depression. Alcohol also increases the risk of osteoporosis, cardiovascular disease, stroke, and diabetes. Connelly also suggests that “alcohol may affect the liver’s ability to process estrogens eﬃciently.” The risk of breast cancer is further increased with alcohol consumption: The Harvard Nurses’ Health Study found that women who drank just one or more drinks per day had a 60% greater risk of breast cancer than those who abstained.

LOSE EXCESS WEIGHT

Obese women (those with a BMI over 30) or women carrying excess weight (BMI over 25) are at greater risk of heart disease, diabetes, breast cancer, and stroke. Postmenopausal obesity is a serious health concern. Research by J.C. Lovejoy, of the Women’s Nutrition Research Program, Louisiana State University, suggests that“menopause tends to be associated with an increased risk of obesity and a shift to an abdominal fat distribution with associated increase in health risks. Changes in body composition at menopause may be caused by the decrease in circulating estrogen.” Lovejoy stresses that “Women need to be aware of the likelihood of weight gain during the perimenopausal and postmenopausal years because weight loss or prevention of weight gain is likely to have significant health benefits for older women.” Calculate your BMI at: www.nhlbisupport.com/bmi.

GET MOVING

Not only will you feel better if you exercise, but a regular physical activity routine has been shown to help alleviate depression, curb weight gain, lower heart disease risk, maintain bone health, and provide a host of other benefits. “Any movement is better than nothing, even if it’s just getting off the couch and taking your dog for a walk,” says Connelly. Clip a pedometer onto your waistband and aim for 10,000 brisk steps a day. “You might not get there, but you’ll at least get a realistic assessment of your level of physical activity,” she says.

WATCH YOUR FAT INTAKE

Limiting saturated fats may help curb the gain of the five or more pounds that most women experience in midlife, says Veronica Ravnikar, M.D.,

clinical professor of obstetrics and gynecology at Mount Sinai School of Medicine in New York City. It can also help reduce the menopause-related rise in LDL cholesterol, the “bad” cholesterol known to increase your risk of cardiovascular disease in later years. Be sure your diet includes lots of fatty fish like salmon, which is rich in heart-healthy omega-3 fatty acids. Other sources of these healthy fats include flaxseeds, flax oil, and walnuts.

EAT RIGHT

A healthy diet low in fat, salt, sugar, and processed carbs and high in lean protein, fish, fruit, vegetables, whole grains, and pulses will help alleviate unpleasant menopause symptoms and postmenopause health risks such as cancer, cardiovascular disease, osteoporosis, and diabetes. For more advice and inspiration, check out our nutritional advice starting on page 50.

THINK POSITIVELY

According to Christine Northrup, M.D., an obstetrician, gynecologist and writer, “Menopause often marks the beginning of a woman’s most sexually passionate, creatively inspired, and professionally productive phase of life.” Thinking positively can help guide women through this transition. Northrup suggests that positive thinking is essential because optimistic thoughts – such as seeing problems as challenges – are a healthier perspective. Research also suggests that laughing out loud and spending fun time with family and friends all help to release endorphins – “happy chemicals” – and can help women through this time of change.

HOT STUFF Hot ﬂashes can happen anywhere, without warning, and sometimes in the most inconvenient situations. Here’s how to keep your cool

or the 75% of menopausal women who experience them, hot flashes are sometimes the worst symptom associated with menopause. Most women feel a sudden wave of heat spread over the body, especially the upper body. Sweating follows, and heart rate increases by seven to 15 beats a minute. As the flash passes, skin temperature gradually returns to normal, but this can take several minutes. If you’ve ever had a hot flash, you’ll know they’re no fun, but these flashes are the body’s way

of reacting (or overreacting!) to internal temperature changes.

What Is a Hot Flash? Some researchers believe hot flashes are related to unstable levels of estrogen that confuse the hypothalamus, the area in the brain that regulates body temperature. The dropping estrogen levels change the way the hypothalamus responds to heat, and tells the body to get rid of it, so the heart pumps faster, blood vessels in the skin dilate, and sweat glands activate to

cool you off. Flash! This sounds like a good theory, but studies find no differences in estrogen levels between women who have hot flashes and those who don’t. So why do some women suffer while others stay cool and collected? “(Post)menopausal women who suffer from hot flashes have a lower-than-normal sweating threshold, thus it’s easier to trigger sweating,” says Robert Freedman, Ph.D., professor of psychiatry at Wayne State University School of Medicine in

MENOPAUSE SYMPTOMS

Detroit, who has studied thermoregulation and menopause. Fluctuating levels of estrogen trigger hot flashes by decreasing the sweating threshold, he says, although we don’t know just how it does this.

Managing Hot Flashes Lifestyle Changes Experts advise to first try cooling off with lifestyle changes. For many years women have passed on the following advice to one another, confident that these strategies helped them reduce the severity of their hot flashes. There is some evidence that small changes such as choosing fabrics that breathe – cotton and washable linens, for example – and avoiding turtlenecks can make hot flashes more bearable. The following

suggestions will do no harm, often cost nothing, and are just common sense – and they can provide relief, particularly from mild hot flashes. Stay cool. Dress in layers so you can peel clothing off before and during flashes. Keep ice water in an insulated bottle handy for sipping, and use a fan and open windows to keep air flowing. Identify your triggers. Alcohol, caffeine, sugar, and spicy food trigger hot flashes in certain women. Keep a daily hot flash diary and limit foods and beverages or activities you notice act as triggers. Stop smoking. This habit is linked to increased hot flashes as well as serious health conditions, such as heart disease, stroke, and cancer. Even passive exposure to smoke has been shown to reduce estrogen levels; cigarette smoke is toxic

to the ovaries. Remain physically active. Exercise is important during the perimenopausal years and beyond, not just for the health benefits but because studies find that it may help reduce hot flashes and improve sleep (provided the exercise is not too close to bedtime). Keep your cool. A study conducted by doctors at the University of Pennsylvania found that controlling stress in our lives may help reduce the number and severity of hot flashes. The researchers studied more than 400 women between 37 and 47 who still had regular menstrual cycles at the beginning of the study over a six-year period and found that those women with the highest anxiety reported

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MENOPAUSE SYMPTOMS

MEMO

Herbal Therapies

almost five times as many hot flashes as less-anxious women. Studies were needed, however, to determine whether specific anxiety treatments could effectively reduce menopausal hot flashes. But effective ways to stay calm include low-intensity forms of exercise like tai chi, deep breathing techniques, and meditation. Breathe deeply. Slow, deep, rhythmic breathing calms the nervous system, making this one of the simplest, most effective ways to avert hot flashes as they come on or to stop them mid-flash, says Freedman. Inhale deeply, then exhale, trying to make your exhalation as long as your inhalation. Repeat several times as needed. This paced respiration technique has been studied and definitely works for some.

therapy is the most effective therapy for treating hot flashes but is approved for moderate to severe hot flashes. Today, estrogen-containing therapy is recommended for the shortest time necessary – and at the lowest effective dose consistent with treatment goals, says Nanette Santoro, M.D., professor and director of the division of reproductive endocrinology at the Montefiore Medical Center in Hartsdale, N.Y. During perimenopause, a woman who needs contraception plus hot flash relief can choose a combination estrogenprogestin birth control pill, provided she is healthy and doesn’t smoke. Progestin-only contraceptives are available for women who can’t use estrogen.

Prescription Hormone Therapy

Other Prescription Drugs

If you’re having flashes severe enough to interfere with your quality of life, you may want some help. Multiple studies have proven that prescription hormone therapy that includes systemic estrogen (levels that circulate in the bloodstream through the body, provided by pills, skin patches, gels, and even one type of a vaginal ring) remains the most effective treatment for hot flashes and often with lower doses than those used in the past. Hormone

When hormones are not an option, some other prescription drugs are available to ease hot flashes, although they haven’t been approved by the FDA for this use. However, clinical evidence shows that antidepressants such as paroxetine (Paxil®/ Paxil CR®), fluoxetine (Prozac®), venlafaxine (Effexor®), and desvenlafaxine (Pristiq®); the antiseizure medication gabapentin (Neurontin®); and the blood pressure medication clonidine (Catapres®) can relieve hot flashes in some women.

Some women report that various herbal remedies helped relieve their hot flashes, although scientific studies supporting their use have found mixed results. The most-tested black cohosh supplement, Remifemin®, may provide some relief from mild hot flashes and has few side effects. And vitamin E (400 to 800 IU a day) is another option, although evidence of its efficacy is inconclusive. Clinicians may also recommend soy foods or soy supplements; food sources may be preferable to prevent the possibility of overdosing on isoflavones. Consult your healthcare provider before increasing your soy intake.

Heat Wave Hot flashes are the second most common perimenopausal symptom (after irregular periods). An individual flash lasts from one to five minutes, and skin temperature in the fingers and toes may rise by as much as 10ºF. Hot flash frequency peaks in the first two to five years of postmenopause and then declines. Most women experience hot flashes between six months and three to seven years.

Nighttime Blues Sleep, the regenerative gift that we all look forward to, is often a ﬂeeting memory for many women approaching menopause. Midlife pressures and menopause symptoms can turn our hopes of a good night’s sleep into a distant dream

aking up after a restful sleep can make getting through the day a lot easier, and also comes with many health benefits. But sleep disturbances and insomnia are common among perimenopausal and postmenopausal women. There are ways to get back on track and get the sleep you require to stop the inevitable cycle of sleeplessness, worrying, and irritability of insomnia.

Night Sweats Hot flashes can occur at night or during the day. At night, if sweating accompanies the flashes, this is known as night sweats. As with hot flashes, the cause is uncertain, but it’s thought to be the result of changes in the hypothalamus – the part of the brain that regulates body temperature. The hypothalamus mistakenly senses that the woman is too warm and begins a chain of physiological

events to cool her down. Blood vessels close to the skin dilate to increase blood flow to the surface and give off heat. This produces a red flushed face and neck, as well as an increased pulse rate and a sensation of rapid heart beating. A chill often follows. The first time this happens can be very upsetting – no matter how prepared you might be. Jan Makovick, a hairdresser from Baltimore, Md., couldn’t believe the intensity of her night sweats. “The first time it happened I was shaken by the experience. The sheets were drenched, and I had to strip the bedclothes and replace them, and then an hour or so later it happened again. I sat on the floor and cried. My husband couldn’t believe it. He just said, ‘OK, well, here we are with this. Let’s work it out.’ ” The next day, Makovick made an appointment to see her clinician, who understood just how disturbing and

inconvenient it was but explained that it was really quite normal. The clinician suggested she consider hormone therapy. Makovick gave it a try, and very quickly the night sweats reduced, dwindling to no flashes over time. She hasn’t looked back.

Night Sweat Treatment The treatment options for night sweats are the same as for hot flashes. Prescription estrogen therapy remains the most effective treatment, particularly for moderate to severe symptoms. A systemic level of estrogen, delivered by a tablet, through the skin, or by one type of vaginal ring, is required. Most local vaginal estrogen therapy is not enough for relief of hot flashes or night sweats. Lower doses than were used in the past have been shown to be effective in helping with hot flashes, and experts and the FDA recommend using the lowest possible dose for the shortest possible time.

MENOPAUSE SYMPTOMS

Is It Anxiety? Although night sweats account for a dramatic form of sleep disruption, it’s not uncommon to experience insomnia caused by anxiety. If a perimenopausal woman is not experiencing hot flashes or night sweats, then hormone therapy may not be of any use, and lifestyle changes should be tried instead. Ally Parker, 52, a fashion buyer from Michigan City, Ind., remembers her sleeplessness taking its toll on her family. “I was uncharacteristically irritable, particularly in the mornings and evenings, and so short-tempered and stressed.” Although Parker had not discussed the possibility of her being perimenopausal with her family, the tag was soon attached. “I became aware of my lack of patience when I was 48, and my daughters identified me as ‘menopausal.’ ” Parker thought it was normal to be miserable around menopause. “After all, we all know your hormones dictate your mood, right?” The red light came on when her eldest daughter threatened to move out. Parker sought help from her doctor, who asked a whole range of questions, many about her sleep patterns. Through the completion of a sleep diary, Parker realized she was getting enough hours of sleep for her age, but that she was restless and constantly waking. Her physician recommended a sleep specialist, who found that the probable cause of her sleeplessness was anxiety. “It was anxiety about getting older,

but mainly anxiety about my two teenage daughters growing up and leaving home,” she admits. Midlife can bring with it associated anxieties such as older children leaving the nest (or, as is more and more the case for older mothers, bringing up young children), caring for aging parents, floundering relationships, divorce or widowhood, career issues, and anxiety about aging in a society that values youth.

Or Is It Depression? Lying awake or waking very early in the morning and not being able to go back to sleep may be a sign of depression. Depressed women feel blue or discouraged most of the time. Sometimes they sleep all the time or lose or gain weight. A lack of motivation and sadness, coupled with fatigue caused by prolonged sleep deprivation, is not pleasant and sometimes can be paralyzing: It can disrupt relationships and interfere with work or home life.

Treatment for Anxiety and Depression While stressful times happen, and we may cope with them adequately most of the time, there may be times when professional assistance is needed. Talk therapy (psychotherapy) with a trained psychotherapist can often be helpful. Cognitive behavioral therapy (CBT) is a way of changing your thought patterns and behavior in small ways, which can then help you see and deal with problems differently. Drugs such as oral contraceptives may help with mild perimenopausal mood swings, particularly if you’ve suffered from diﬃculty with hormone fluctuations (such as PMS or postpartum depression) in the past. However, no hormone drug is FDA-approved for the relief of anxiety or depression. For mild to moderate depression, herbal remedies such as St. John’s wort may be

Maintain a regular schedule of going to bed at the same time each night and getting up at the same time each morning, even on the weekend. helpful, but always consult with a clinician before taking any herbal remedies. If other options don’t provide the needed relief, prescription antidepressants may be the best choice. Prescription anti-anxiety drugs are also available. Studies show drug therapies work best when accompanied by talk therapy.

Everyday Stressors And if you’re not suffering from anxiety or depression? Well, the regular everyday stresses of life can take their toll without you even realizing it. Make sure you’re allowing yourself to get into the “zone” before going to bed. Breathing exercises or practices such as Hatha yoga, which focus on concentrating on and slowing the breath, are great for relaxing the mind in preparation for sleep. Simply setting aside 15 minutes to read a book or magazine before you turn the lights out also can help you empty your head of the day’s worries. Certainly you should make sure you’re tired both physically and mentally

before you hit the sack. Ensure you’ve had some exercise during the day, but don’t exercise within two hours before bedtime, as it can overstimulate your body and brain. Hunger can also keep you awake or cause you to wake in the early hours when your blood sugar levels drop, so eating a snack before getting some shuteye can help bring a restful night’s sleep. And before you get any ideas, we’re not talking milk and cookies!

Getting a Restful Night Treatment of sleep disturbances should first focus on improving sleep routines and maintaining an environment conducive to sleep. Try the following: Maintain a regular schedule of going to bed at the same time each night

Medical Causes of Insomnia There are several medical conditions that lead to sleep disruption, and some of these are made worse by menopause.

» Sleep-disordered breathing – or sleep apnea – can emerge at midlife » Restless legs syndrome interferes with sleep » Some medications interfere with sleep patterns Be sure to talk with your healthcare provider and consider attending a sleep clinic if you have ongoing sleep difficulties.

MENOPAUSE SYMPTOMS

and getting up at the same time each morning, even on the weekend. The bedroom should be quiet, cool, and dark. Research has found that without full darkness, the body cannot produce the hormone melatonin effectively. Melatonin is vital in inducing sleepiness within the body, and during the menopausal transition it is in short supply as the decline in estrogen reduces melatonin levels. Make sure

to keep light out suﬃciently until morning, when light levels should gradually increase, helping you to wake naturally. Your bedroom should be cool and have good air circulation – this is especially important for women with night sweats. Make sure you use your bedroom only for sleeping and sexual activity; otherwise it could become associated with things like work or study.

If you don’t fall to sleep within about 15 minutes, get up, leave the bedroom, and do something relaxing, such as reading, until you become drowsy. If this doesn’t help, keep trying. The following can all trigger poor sleep, so try to avoid: ➤ ➤ ➤ ➤ ➤ ➤

Heavy meals in the evening Exercising close to bedtime Alcohol Nicotine Caffeine OTC medicines with stimulants

Prescription therapies are also available, but these should be used only for a short time. If you and your primary-care clinician cannot solve the problem of sleep disturbances, consider consulting a sleep specialist. Adequate sleep is an important component of good heath and a healthy life.

Sweet Dreams If you need additional help to get to sleep, discuss these options with your healthcare provider. Tryptophan is an amino acid that stimulates the production of serotonin. It, in turn, produces the hormone melatonin, which is needed for sleep. Tryptophan is found naturally in turkey, bananas, figs, dates, yogurt, tuna, and whole-grain crackers, all great for snacking on before bedtime. Don’t overeat, though. Maybe try a light dinner with a small snack later to avoid gaining weight. The botanical sedative valerian has been recognized by the World Health Organization for treating insomnia and nervousness, and chamomile tea is another old favorite remedy for easing into sleep.

KEEP KEEP CALM CALM & &

CARRY ON

Anxiety, depression, and tiredness are linked not only to menopause but also to the everyday stresses of midlife. Just breathe, and follow some of these tried and tested tips on controlling your ‘midlife crisis’

he wake-up call came in the form of sheer embarrassment for Allison Nichols, a 51-yearold architect from Plymouth, Minn. “I had a million things on my mind. Running late for a morning meeting, pulling into the parking lot, the lever wouldn’t go up to allow my car to pass, and I just about had a meltdown with the parking lot attendant. My heart was

racing, I was breaking out in a sweat, and I just felt complete panic. I mean this is a guy I see every morning and I just lost it with him, and right behind my car was my client. I could have died on the spot.” Nichols learned to manage her stress levels with relaxation techniques, regained control of her short fuse, and the panic attacks subsided. But her experience is common, say experts, who utilize such

techniques to help women cope with midlife stresses. It’s not menopause itself that is the main stressor, but rather the fact that menopause occurs at a time when most women’s lives are incredibly full, juggling career, family, and aging parents. Women are typically incredible multi-taskers, but they may need time to develop coping strategies for the new

MENOPAUSE SYMPTOMS

Relaxation Techniques Progressive Muscular Relaxation When you ﬁnd your shoulders up against your ears, try this simple but effective technique. It allows your muscles to relax more fully than they would when you try to relax them normally. Tense a group of muscles as tightly as you can for a few seconds. Then relax the muscles normally. Consciously relax the muscles further, to fully release tension. You may like to try this lying down and working down the body from your head and neck, through your shoulders and back, arms and hands, and so on. Aim to include both large and small muscle groups. For example, when focusing on your head, tense and relax the muscles of the eyes, eyebrows, lips, tongue, nose, forehead, jaw, and so on.

challenges that menopause brings. Not only are some menopausal symptoms unpleasant in themselves, but midlife stresses may also aggravate the symptoms of menopause, according to research. But there is good news. Learning to better manage your stress can also help minimize your menopause symptoms.

Stressors Everywhere The stressors that perimenopausal women confront are as varied as women themselves. To begin with, the symptoms of perimenopause – hot flashes, menstrual irregularities, and poor sleep from night sweats – can be tremendously stressful, says Leslee Kagan, M.S., N.P., co-author of Mind Over Menopause: The Complete Mind/Body Approach to Coping With Menopause

and director of the menopause program at the Benson-Henry Institute for Mind Body Medicine in Boston, Mass. Her program is designed to help women use stress management tools such as breathing techniques or meditation to manage their symptoms.

So What’s Menopause Got to Do With It? OK, so midlife is a stressful time. Does menopause itself – that is, the petering out of your body’s production of estrogen and progesterone – actually add to that? To understand that question, you need to understand how stress and your health fit together in the first place. Although stress has gotten a bad rap in recent years, it’s actually a valuable reaction designed to keep us alive when we’re in danger. Called the fight-or-flight

Deep Breathing It can be difﬁcult to slow yourself down and focus on breathing when you’re in a state of agitation, but this exercise can help. Sit quietly, or lie on the ﬂoor, and close your eyes. Begin by relaxing the muscles in your feet and work your way up the body. Focus your attention on your breathing. Breathe in deeply and exhale. As you continue to breathe, count down from 10, imagining with each number that you are taking a step down on a staircase. Allow yourself to relax more fully with each step, and imagine the light is fading progressively, until you are in absolute darkness at zero. Enjoy the state of total relaxation, and allow yourself to become aware of your breathing. Open your eyes only when you are ready.

Women with higher levels of perceived stress were more likely to report hot ﬂashes and night sweats than those who had more relaxed lives. response, a hormonal cascade is triggered by danger, releasing chemicals (including adrenalin) designed to help you focus, speed your reaction time, and increase your strength. This is great if you’re facing an outof-control car. Unfortunately, everyday situations like a nasty boss, grumpy teenager, or overdue credit card bill can also trigger this response. Even your own thoughts and worries can initiate the release of adrenalin. Such constant stress means your body doesn’t get a chance to rest and

recuperate. Over time, that damages your health. Studies find that such chronic stress also increases your risk of obesity, insomnia, heart disease, depression, and digestive problems, while suppressing parts of your immune system, making you more susceptible to illness such as cancer. Long-term or chronic stress is also biologically linked to your reproductive system, says Kagan, with the ongoing stress response exacerbating menopause symptoms such as hot flashes. The Study of Women’s Health Across the Nation (SWAN) researchers, who followed

more than 3,300 women through their perimenopausal years, found that women with higher levels of perceived stress were more likely to report hot flashes and night sweats than those who had more relaxed lives. Other clinical trials found that breathing techniques designed to reduce stress (taking slow, deep breaths when a hot flash is starting) can significantly reduce the frequency of hot flashes, while other stress reduction techniques such as yoga or meditation can also reduce their severity. The body has an innate ability to calm itself through its relaxation response – a

MENOPAUSE SYMPTOMS

The body has an innate ability to calm itself through its relaxation response – a state of deep relaxation that lowers your heart and breathing rates while reducing muscle tension.

For Crying

Out Loud

state of deep relaxation that lowers your heart and breathing rates while reducing muscle tension. If you elicit this response every day, research shows that, over time, your body becomes less responsive to stress hormones, says Kagan. This can curtail symptoms such as hot flashes and help you cope better when stressful events occur, she says. Eliciting the relaxation response is simple, says Kagan. Meditation, certain breathing and other relaxation exercises, yoga, various religious traditions, and even knitting can bring it on. In fact, any soothing activity you enjoy can be turned into a relaxation therapy simply by focusing on repetition, be it a word, a prayer, or a motion. One way to do this is through tai chi, a gentle, low-intensity form of exercise that is often recommended in the transition to menopause. Indeed, a report by Natural Standard and the faculty of Harvard

Uncontrollable crying jags are common during the menopause transition. You may ﬁnd that everything makes you cry – whether out of sadness, frustration, being tired, or even for no reason at all. It’s not something to worry about, although it can be embarrassing and cause you to withdraw. One way to deal with this is to provide yourself with a routine and stick to it, even if you don’t feel like it. This will distract your mind and help you focus your energies in a positive way. Light exercise, such as stretches or going for a walk, can also clear your head. Your tears may be simply related to unstable hormone levels of perimenopause, poor or interrupted sleep, or sleep deprivation associated with nighttime hot ﬂashes, but if you feel they could be related to depression, talking with a therapist may be helpful. (For more on getting sound sleep, see “Nighttime Blues” on page 16.)

Medical School found that practicing tai chi regularly may not only reduce anxiety and depression, but may also increase bone mineral density after menopause. You also need to cultivate a nonjudgmental awareness that allows you to gently dismiss any upsetting thoughts without getting drawn in to negative thinking, says Kagan.

Long-Term Beneﬁts Last Beyond Menopause Learning to bring about a state of relaxation certainly worked for Nichols, who joined a yoga and meditation program that focused on breathing techniques. “I use some of the breathing techniques I learned in class whenever I feel myself getting worked up,” she says. “I don’t feel so stressed, my fuse isn’t so short, and my hot flashes seem to pass more quickly.” That response is common, says Kagan. Just having a tool to use when a hot flash occurs reduces women’s anxiety. Kagan’s program takes a holistic approach to stress management, emphasizing nutrition, exercise, and cognitive approaches that help women take a more positive approach toward menopause. Plus, such an approach helps women learn to reframe their worries about symptoms so they focus on curtailing them rather than anticipating them, says Kagan. This can reduce the stress response when symptoms strike. It’s not a question of eliminating all stress from your life; it’s how you handle it that matters.

Mother Nature

Recommends Because of the potential risks and side effects of hormone therapy, many women look to more natural remedies to counteract the troublesome symptoms of menopause

TREATMENT OPTIONS

or Marcella Northeim, 56, the sleep deprivation, hot flashes, and mood swings she experienced as she approached menopause sent her spiraling into depression. Her anxiety was made worse by a growing dependency on alcohol that she had developed to get her through the experience. She tried hormone therapy, but the side effects worsened her symptoms. Instead of taking more drugs, the marketing V.P. from Chicago turned to Ayurveda, a 5,000-year-old Eastern healing tradition that relies on herbs, nutrition, exercise, and other alternative approaches to maintain health. “The depression lifted, and it’s never come back,” says Northeim, who began taking various herbal mixtures, following a special vegetarian diet, and doing yoga about five years ago, when her menopausal symptoms were at their

worst. “I’m sleeping fine. I lost the weight. I don’t even remember having a hot flash at all after I started my Ayurvedic lifestyle.” Not all women who try complementary and alternative medicine (CAM) approaches to treat their menopausal symptoms have such success. But more women are giving alternative approaches a try than ever before. And what was once called CAM in some cases is being evaluated and then embraced by mainstream medicine. The Study of Women’s Health Across the Nation, or SWAN, surveyed menopausal women in 2003 and found that about half had tried at least one CAM therapy in the past year. However, included in its definition of CAM therapy were therapies such as vitamin/mineral supplements – considered mainstream by many. “The first thing I say to women is they need to look at why they’re avoiding hormones and whether they understand what the real risks and benefits are,’’ says Alan Altman, M.D., an assistant clinical professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School. “Too many women avoid hormone therapy because they’re worried about long-term risks that may not apply to them,” he says. “Estrogen therapy (with or without progestogen) remains the most effective treatment for hot flashes and other menopausal symptoms. Alternative approaches just don’t seem to work for those with the most severe symptoms,” he warns. Still, for those who want or need to avoid hormones, alternative approaches may help, says Machelle Seibel, M.D., a professor of obstetrics and gynecology at the University of Massachusetts in Worcester. “Just be realistic about your expectations,” she says. “For instance, alternative therapies may not completely eliminate symptoms, and they may take

several weeks to begin working.” “Sometimes alternative remedies that help don’t make things perfect, but they improve things enough so the symptoms can be tolerated,’’ Seibel says. “You can’t promise the moon, but you can promise to work with women to see what’s out there; then they can make an informed choice.”

Looking at Other Options After four months, Bonita Salvarez, 53, from Silver Spring, Md., decided that the side effects of her combined estrogen-progestogen therapy, particularly the headaches and nausea, were enough to motivate her to seek alternative treatments. “Even after dosage regulation and switching to a skin patch, I still felt nauseous, and the daily headaches didn’t stop.” Her first priority was “to look for something to help with the hot flashes.” CAM includes a diverse group of practices and products not currently used in conventional medicine. Complementary medicine is used with traditional medicine, while alternative medicine is used in place of it. “A good place to start is with treatments that don’t require you to take anything internally,” says Tieraona Low Dog, M.D., director of the fellowship for the program in integrative medicine at the University of Arizona School of Medicine in Tucson, “because they are far less likely to cause side effects.” Marcella Northeim believes that herbal products should be used only as a single component in a holistic approach to treating menopause, not on their own. Through Ayurveda, she notes, she’s overhauled her entire lifestyle, adopting a vegetarian diet, regular massage, and yoga sessions – all of which work together. “My body works about a hundred times better than it ever did,’’ she says.

I am in menopause and â&#x20AC;&#x201C; Lisa Aaron Estroven user since 2009

More women rely on all-natural Estroven to relieve hot flashes, night sweats and mood swings than all other hormone-free supplements combined. Read their stories at MyEstroven.com/ch

TREATMENT OPTIONS

The

PlaceboEffect

When researchers study products for the treatment of menopausal symptoms, most studies find that more than 30% of women improve even when they’re given a pill with no active ingredients in it. This is the placebo effect. Just thinking that you’re receiving the treatment, whether or not you actually are, seems to improve symptoms in many people. In well-designed clinical trials, researchers compare the real treatment with a placebo so they can tell whether the treatment really worked or whether the benefit it produced was due to the placebo effect. Not that the placebo effect is necessarily a bad thing. “So they get better with a placebo – so what?” says Machelle Seibel, M.D., a professor of obstetrics and gynecology at the University of Massachusetts in Worcester. “What does it matter if 30% (of women) are seeing improvement in hot flashes?” For instance, Seibel says, many women who add soy foods to their diets and claim their hot flashes improve may be experiencing a placebo effect rather than a real benefit from the soy. But if they feel better and that improves their quality of life, why worry so long as the treatment is safe?

“I sleep better and my energy’s back. I’m going to have a healthier old age because of Ayurveda and yoga.” Salvarez is still searching for the “wonder cure.” Although she is very positive about the improvements she has experienced through her use of soy products and a black cohosh supplement, she does still experience the odd hot flash. “I try to avoid hot flash situations. I have tried to reduce stress in my life by working fewer hours, and I do follow a sensible diet – avoiding alcohol and spicy foods as well as aiming toward a heart-healthy diet. I believe that if I incorporate many positive lifestyle changes, that will reduce my symptoms. And if things continue to improve, I’ll never need to go back to prescription hormone therapy.”

Pause for Thought Although these therapies have some inspiring anecdotal evidence, and some science behind them, often the science is weak in that the evidence was gathered from small sample groups and the

findings are mainly qualitative. Where herbal supplements and therapies are concerned, the benefits may be the result of the placebo effect. “So what?” you may say. If it works, it works, placebo or not. In fact, all the better than consuming possibly harmful substances and chemicals.

Lifestyle Changes Lifestyle changes such as committing to a healthy diet, plenty of exercise, and time to relax and unwind seem to have the best press of all. Lifestyle changes offer you the lowest risk option and have benefits beyond menopause symptom relief. Let’s face it – if you could take a pill to relieve stress, anxiety, depression, hot flashes, night sweats, and sleep deprivation with no high-risk side effects, you’d take it, right? Lifestyle changes needn’t be expensive either. Walking 30 minutes a day doesn’t cost anything, but it has been shown to reduce the main symptoms of menopause and can help you lose those extra few pounds you have piled on recently. See box at right.

Let’s Walk! For middle-aged women the key to happiness could be as simple as a walk in the park. According to a recent U.S. study, brisk walking can help not just physical health but mental health too. “You don’t need to run 20 miles a week to reap the benefits of exercise,” says Dr. Deborah Nelson of Temple University, who headed the study. “If you stick to a moderatepaced walking schedule, it can keep your weight down and lower the risk of stress, anxiety, and depression.” The study followed 380 women older than 40 and found over an eight-year period that the more active the women, the greater the benefits. High levels of activity were particularly beneficial to postmenopausal women. Walking five times a week for up to 60 minutes improved emotional wellbeing and helped women to handle the stresses of everyday life. However, there was little benefit for the lower-activity group, who walked for only 15 minutes a day five times a week. The official recommendation for maximum benefits is 30 minutes a day five times a week, so perhaps less is more. Either way, our advice is to get those walking shoes on and just do as much as you can.

Herbal

Therapies Herbal supplements may be the right choice for you, but know the facts and follow your doctor’s advice when using these often powerful and effective therapies

he increased interest in herbal supplements for treating menopause symptoms has meant that the market growth in these remedies has been significant in recent years. More and more women are worried about the side effects of hormone therapy, particularly after the WHI scare linking an increased risk of breast cancer in postmenopausal women who had used or were still using hormone therapy. This was true of 53-year-old Shirley Jackson, of Chicago, who stopped taking her hormone therapy a year ago. “I recently learned that I have a family history of breast cancer,” she says. “I was an adopted child and only met my biological sister a year or so ago. She mentioned that our mother had died of

breast cancer. I told my doctor, and she recommended I either reduce my dose or I stop altogether.” Jackson wasn’t going to take a chance, so she asked her doctor about other therapies. The doctor recommended black cohosh for her hot flashes and St. John’s wort for her depression. Jackson worked with her practitioner for three months, gradually increasing the dosage and balancing the supplements to her needs – and finally they got it right. “The hot flashes reduced, and I began to feel a lift in my mood. It’s a little up and down, but I think it’s working for me. I walk the dog twice a day and I started a dance class a couple of months ago, and that has really helped too. I think it’s a whole more rounded approach that works for me.”

Always Seek Professional Help Herbal and nutritional remedies have been found to have beneficial and positive results for the treatment and management of menopause symptoms. But women should always seek professional guidance from a qualified and accredited practitioner. Your doctor is a good place to start when looking for recommendations. “It is not advisable to go and buy over-the-counter remedies without seeking professional advice,” says Tieraona Low Dog, M.D., director of the fellowship for the program in integrative medicine at the University of Arizona School of Medicine in Tucson. Although most non-supplement approaches are relatively safe, Low Dog notes that there is a somewhat greater

TREATMENT OPTIONS

The

Facts The following resources offer information on quality herbal products: U.S. Pharmacopeia This nonprofit company sets quality standards and verifies compliance for supplement makers. www.usp.org/ USPVerified/ The National Sanitation Foundation An independent nonprofit that tests supplements to make sure they contain what they promise. www.nsf.org Consumer Lab Unbiased testing information for betterquality health and nutritional products. www.consumerlab.com

risk when it comes to herbal products, particularly those sold over the counter as supplements versus herbal teas and other mixtures individually prepared from plants by a trained herbalist. If they are strong enough to potentially help your symptoms, she says, supplements are also strong enough to cause side effects. But we may not know what the risks are because in this country, herbal supplements are not required to undergo testing for effectiveness, safety, proper dosage, or purity like prescription drugs. Thus, says Alan Altman, M.D., an assistant clinical professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, there’s no guarantee you’re getting what the label promises. For instance, supplements may be contaminated with harmful ingredients that aren’t listed on the label. “Buying an over-the-counter herbal supplement is a shot in the dark,” he says. He prefers to refer his patients to a reputable herbalist. The practitioner should take a medical history to make an informed recommendation on what herbs to try and in what doses, Altman says. “That’s better than relying on the advice of a health food store clerk.” Many of today’s herbal supplements are highly concentrated and much stronger than the original herbal teas, says Low Dog. Don’t assume that an over-the-counter product is safe just because it’s based on thousands of years of tradition – it could have many times the recommended dosage, she warns.

What Do We Know About Herbal Supplements? When it comes to herbal supplements for relieving menopause symptoms, the quality of evidence is fairly weak, says Low Dog. However, the National Institutes of Health has funded studies of black cohosh, red clover, and soy for the treatment of menopause symptoms. Here’s what we know about common remedies. As all of the therapies listed can

cause side effects and most interact with medications, make sure your clinician agrees that it’s safe for you to try them. Black cohosh. This herb appears to be the most promising for relieving hot flashes, although the results are not conclusive, says Low Dog. A 2002 review of existing evidence found that three of the four reviewed trials showed a potential benefit with mild hot flashes. Only mild side effects have been noted. However, more research is needed before this herb can be strongly recommended, particularly for long-term use. There are more studies in progress showing the effects of black cohosh. Soy. Consuming isoflavones, weak estrogen-like compounds most commonly found in soy foods, has been found in some studies to reduce mild hot flashes by 15%, but many other studies show no effect. Eating one or two servings of soy foods daily may bring greater benefit than soy supplement pills. Diets high in soy are considered safe, Low Dog notes, but supplements that provide highly concentrated doses of isoflavones are more questionable. Red clover, evening primrose oil, vitamin E, wild yam, dong quai. Studies are inconclusive on the benefits of these supplements in relieving menopause symptoms, notes Low Dog. St. John’s wort. This supplement may be helpful for women who are experiencing some mood problems along with menopause symptoms, says Low Dog, with several studies documenting eﬃcacy for relieving mild depression. Side effects include gastrointestinal upset, fatigue, and increased sensitivity to sunlight. Users should avoid sun exposure. The herb should not be taken with psychotropic medications and may decrease the activity of blood-thinners and other prescription medication.

With

Complements Complementary therapies are rapidly growing in popularity as many women enjoy the additional beneﬁts that these therapies offer

omplementary therapies aim to treat the whole person rather than specific menopausal symptoms, and women report improvements in symptoms such as hot flashes, night sweats, and overall mood and well-being. There is a great deal of choice in complementary therapies, and this can be confusing at first. If you are interested in exploring a complementary therapy, the best advice is to start with one that feels comfortable for you or has been recommended by a friend. Always take advice from your healthcare provider, who may also be able to recommend a reputable practitioner. When choosing a practitioner, take care to get recommendations and always ensure that they are fully qualified and experienced in menopause treatments.

Homeopathy Homeopathy is a system of medicine that is based on treating the individual with highly diluted substances, given mainly in tablet form, which trigger the body’s natural system of healing. A homeopath will match the most appropriate medicine to the patient based on symptoms experienced. Your homeopath will make an assessment of your symptoms, including the physical, mental, and emotional effects of menopause. How you feel, what type of personality you have, and how you respond to your environment are important too. All

these factors will be considered when determining the right medicine for you. Homeopathic treatment has been shown to be effective for hot flashes and sweats, tiredness, anxiety, sleeping diﬃculties, mood swings, and headaches. Although there is little hard evidence to support the use of homeopathy for the treatment of menopausal symptoms, a small U.K. study carried out in 2005 at a WellWoman clinic in Sheﬃeld found that 81% of 102 patients reported improvement of these menopause symptoms after homeopathic treatment.

TREATMENT OPTIONS

Massage

Reﬂexology Reflexology involves the manual stimulation of reflex points on the ears, hands, and feet. It is similar to shiatsu and acupressure. Thumb pressure is applied to specific points that correspond somatopically to specific areas or organs of the body. Reflexology is a deeply relaxing and re-energizing therapy. Regular reflexology treatments can support menopausal women physically, mentally, and emotionally. They can help a woman tune into her body’s needs, highlighting imbalances and areas that demand attention.Reflexology stimulates areas of the body such as the hypothalamus, pituitary gland, and the heart. It also promotes the elimination of toxins and can boost the immune system. It can provide a safe space in which to relax, receive, and be self-focused. Having an empathic reflexologist who understands the physical changes

behind menopausal symptoms and takes a patient’s problems seriously can, in itself, relieve stress. Although quantifiable evidence is patchy, in a small, controlled clinical study reported by the Guilin Sinowestern Joint Hospital Chinese Medicine Advisory Department in 2003, researchers examined the effects of a 30-minute reflexology treatment on 38 women with premenstrual syndrome. Those receiving the eight-weeklong treatment were treated by ear, hand, and foot reflexology. Those in the control group were given placebo, or sham, reflexology. Based on a daily diary that monitored the severity of more than three dozen premenstrual symptoms, researchers found that the treated group had a 46% reduction, significantly greater than the 19% reduction of the controlled group.

Massage can lessen some of the symptoms of menopause by allowing time and space to relax, increasing circulation and lymphatic flow, reducing pain, and encouraging a positive body image. For a menopausal woman experiencing anxiety, irritability, and fatigue, the relaxing effects of massage can bring relief. Improving circulation of both blood and the lymphatic fluid, which is the fluid outside the bloodstream, can help relieve joint pain. Massage can also improve the range of motion of the joints. Massage can reduce menopausal headaches, leg cramps, and neck and shoulder tension. Many women report that it is a wonderful way to get in tune with their body. Because each woman is unique in how she experiences menopause, the best type of massage depends on her individual needs. Swedish massage is great for relaxation, deep tissue massage may work best for someone experiencing a lot of tension or pain, and energy work may be preferable for a woman who is feeling especially sensitive or vulnerable. Aromatherapy massage uses specially selected essential oils to help ease symptoms and has been reported by many women as deeply beneficial.

Aromatherapy

Several essential oils that contain hormone-like substances related to estrogen are helpful during menopause. These include clary sage, anise, fennel, cypress, angelica, coriander, sage, and to a lesser degree, basil. Such essential oils, along with peppermint and lemon, will help relieve hot flashes. Since essential oils go right through the skin, applying them to fatty areas of the body, where hormones are manufactured and stored, will create the most direct effect. Of course, any massage is itself very therapeutic. A warm, relaxing bath is also a wonderful way to receive the benefits of these oils. Oil burners are a convenient way to enjoy the therapeutic effects of essential oils at any time, especially during a relaxation or meditation session. Geranium, neroli, and lavender are balance hormones and also help mollify menopausal symptoms.

Meditation Although research is sketchy, meditation is believed to be helpful in calming both the physiological and psychological impacts of menopause. And it may help women come to a better acceptance of such a big life change, both on its own and in conjunction with other treatments and lifestyle changes.

Acupuncture Some small studies have found that acupuncture decreased the severity and frequency of hot flashes by as much as half. Further studies, funded by the National Center for Complementary and Alternative Medicine, are under way.

TREATMENT OPTIONS

Pilates

Yoga The benefits of yoga are well documented and reported by perimenopausal and postmenopausal women. Reputable and well-established yoga classes can be found fairly easily, and women seem to reap positive benefits. Studies tend to conclusively suggest that regular and well-planned yoga sessions do have a positive impact on the direct and indirect symptoms associated with menopause, from hot flashes to mood swings. One study of 164 sedentary women by Pennsylvania State University found that after just four months of participating in a regular program of yoga and walking, most experienced physical, emotional, and sexual benefits during menopausal years. All women had previously reported menopausal symptoms such as hot flashes and night sweats. Women doing yoga and walking described “higher levels of general happiness” than those who remained sedentary, including feelings of “better emotional and sexual health.“

The type of physical training that pilates demands can be especially beneficial for women approaching menopause, since it not only helps to maintain strength for everyday activities, but improves core strength and helps women maintain a healthy weight when combined with a healthy diet. With a strong emphasis on core, pelvic, and back strength, pilates can offer help with many symptoms such as alleviating back pain and urinary incontinence and staving off bone loss. In postmenopausal women, pilates has been reported to help maintain enough strength and mobility that they are able to perform daily activities easily and more safely. Building inner-core strength through pilates can also help protect the back, hips, knees, and other joints, as well as correct the upper back.

Doctor’s

Orders For some, the unpleasant symptoms of menopause can be too much to bear. When lifestyle and alternative therapies just don’t cut it, hormone therapy can be a huge relief. Is this decision right for you?

llison Koty*, a 55-year-old communications specialist in Washington, D.C., suffered through a slew of uncomfortable symptoms once she reached menopause, including recurrent, horrible migraines that would last for three days at a time. “I’d had headaches before, but never so often or so incapacitating,” she recalls. “I also had vaginal dryness, thinning hair, which was awful, and achy joints – and not enough patience with my children added to the picture.” Rather than going on hormone therapy as a first line of defense, Koty first tried herbal remedies, exercise, losing weight, and meditation to get her body back in balance. “All were nice, but they weren’t enough,” says Koty, who decided to try hormone threapy. Nearly three years ago, her physician prescribed her a low-dose patch, which greatly reduced her symptoms. “I don’t know how long I’ll continue,” she says, “but for now, it’s working very well. I have absolutely no headaches and all the other symptoms

have greatly improved, too.” But Koty admits that she is still apprehensive about using hormone therapy. “Breast cancer is my main concern, even though I think I’m fairly low-risk,” she says. “My mother had breast cancer at age 75, after being on the earliest versions of hormone therapy for many years. I have regular mammograms, exercise a lot, I’ve been a vegetarian for 43 years, and I meditate as often as I remember to. One vice – I do drink wine, and I’m concerned that that

and the hormone therapy increase my risk of disease – but my quality of life is hugely improved by both.” If you’re one of the nearly 40 million American women reaching or in menopause right now, you’re not alone if, like Koty, you’re concerned about the safety of hormone therapy. The results of the Women’s Health Initiative hormone study – federally funded research on the effects of the most common form of hormone therapy taken by postmenopausal women in the

TREATMENT OPTIONS

“The beneﬁts of hormone therapy are many. If you have symptoms that are adversely impacting your day-to-day quality of life, it’s very effective. But women have to weigh the risks and beneﬁts for them personally.”

United States – sent a shockwave through women on or considering hormone therapy. The study revealed the therapy has several serious side effects, including increased risk for breast cancer, heart attack, stroke, and blood clots in postmenopausal women aged 50 to 79 taking oral Prempro, a type of hormone therapy containing a combination of estrogen and progestin. A second part of the study on women who had hysterectomies revealed an increased risk of stroke in those taking oral Premarin,

estrogen-only therapy. Though the numbers of the study participants who had adverse effects were relatively small – for example, for every 10,000 women using a combination of estrogen and progestin, there would be seven more heart attacks than with every 10,000 women not using these hormones – the study was abruptly halted. As a result, many women dropped the therapy altogether. However, age appears to be an important factor when it comes to hormone therapy and disease risk. In the WHI study, the average age of the study participants was 63 – much older than the 50- to 59-year-olds who typically receive hormone therapy. A re-analysis of the research found lower mortality rates in study participants younger than 60, though not for women older than 60. In addition, the Million Women Study, a new large-scale study published in January in the Journal of the National Cancer Institute, found that women who started hormone therapy close to reaching menopause were at a greater risk for breast cancer than those who waited five or more years. Women who went on estrogen-only hormone formulations shortly after menopause had a significantly higher risk of breast cancer than in nonusers, while those who delayed use until five or more years after menopause began did not have an increased relative risk. (Regardless of whether the women started the therapy less or more than five years after reaching menopause, those taking a combination of estrogen-progestin were at a greater risk of breast cancer than the women who took estrogen alone.)

Despite the potential risks, hormone therapy continues to be prescribed since no treatment is more effective when it comes to preventing hot flashes, night sweats, vaginal dryness, osteoporosis, and insomnia brought on by menopause. “The benefits of hormone therapy are many,” says Jill Maura Rabin, M.D., head of urogynecology at Long Island Jewish Medical Center in New Hyde Park, N.Y., and co-author of Mind Over Bladder: A Step-By-Step Guide to Achieving Continence. “If you have symptoms that are adversely impacting your day-to-day quality of life, it’s very effective. But women have to weigh the risks and benefits for them personally.” It’s recommended that women who still have their uterus take a combination of estrogen and progestin, since estrogen by itself can increase the risk of endometrial cancer, while those who have had a hysterectomy can use estrogen alone, notes Dr. Rabin. However, if vaginal dryness is the only reason for considering hormone therapy, low-dose local estrogen therapy, which comes in several forms including a vaginal ring or cream, is the best choice and carries minimal risk. Your smartest strategy: If you, in consultation with your healthcare provider, decide to go on hormone therapy, use the lowest possible dose of hormones to ease your symptoms for the shortest amount of time. This will help reduce or prevent health risks, according to Steven R. Goldstein, M.D., president of the North American Menopause Society (NAMS) and an obstetrician and gynecologist at New York University Langone Medical Center in New York City.

Hormone Therapy... As Individual as You! You’re not like every other woman, why should your hormone therapy be the same? Your body’s hormone needs are unique to you, just like your fingerprint. Treating your hormone imbalance symptoms with a one-size-fits-all prescription just doesn’t make sense. Our nation-wide network of specialized healthcare providers have changed the lives of women trying to manage the symptoms of PMS, perimenopause, and menopause through: • Individualized, low-dose, bioidentical hormone therapy • Free follow-up rate of bone loss testing • Symptom management and monitoring for personalized care.

Why trust anyone else? Since the first woman suffering with symptoms of hormone imbalance walked through our doors almost 30 years ago, our mission has been one thing and one thing only - to provide women with options for healthy living and healthy aging by supporting natural hormone balance - one woman at a time.

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TREATMENT OPTIONS

When shouldn’t

you take HT? » If you are experiencing undiagnosed, abnormal genital bleeding

» If you have or suspect you have breast cancer

» If you have or suspect you have

any estrogen-dependent neoplasia (benign or cancerous growths)

» If you have a history of blood clots

in your legs (deep vein thrombosis) or lungs (pulmonary embolism)

» If you have had a stroke or

heart attack in the past year

hypersensitivity to HT

An Alternative to Hormone Therapy The quest for a safer alternative to hormone therapy has fueled an interest in and demand for bioidentical hormones. “Bioidentical hormones are derived from natural sources, such as plants, to have a chemical structure that is identical to that within the human body,” explains Marla Ahlgrimm, pharmacist, founder and CEO of Women’s Health America, and co-founder of Madison Pharmacy Associates. These hormones mimic the body’s natural hormones and are customcompounded so dosages can be tailored to the individual. For example, there’s a new advanced dosing delivery technology called Aplia, which enables metered dispensing of hormone therapy cream that can contain just one prescribed compounded hormone or up to nine combinations of prescribed bioidentical hormones, according to Ahlgrimm. “When dispensed to the labia, the prescribed hormones are absorbed transmucosally,”

she says. “The best thing about Aplia is how convenient it is. Just a tiny dot of medicated cream as prescribed and the patient is on with her busy life. Another great thing about Aplia is how portable it is. About the size of a highlighter, it can fit in any purse or clutch.” However, most compounded hormones aren’t FDA-approved because individually mixed medications haven’t been tested to prove there are consistent amounts of the active ingredients or proper absorption with each dosage. “Patients think because it’s natural, it’s safe, but it doesn’t have the same quality controls” as traditional hormone therapy, says Dr. Goldstein. “Whether it’s synthetic or bioidentical, once it’s metabolized, they’re probably the same.” What’s more, there aren’t randomized, controlled studies yet comparing traditional hormone therapy and bioidentical hormones, so the jury is still out for many in the medical field. However, there are many bioidentical hormones commercially available in

several well-tested, FDA-approved, brandname prescription drugs, according to NAMS – namely, Estrace, Prometrium, Vivelle-Dot, and Divigel. If you’re considering bioidentical hormones, speak with your healthcare provider about the risks and benefits based on your personal and family health history, and find a reputable compounding pharmacy that has experience with this type of therapy. “There are many things a woman considering bioidentical hormones should look for in a pharmacy,” says Ahlgrimm. “First, look for a compounding pharmacy that specializes in making prescriptions on-site. There are a few that offer nationwide shipping. Inquire about the different dosage forms they offer, if they work with prescription insurance plans, what precautions they take to ensure quality control and consistency, how long have they been specializing in hormone replacement compounds, and do they have certified specialists on staff to help when there are questions.” Being fully aware of your options and weighing the risks and benefits of different therapies with your healthcare practitioner can help you decide what is best for you.

* Not her real name

» If you suffer from liver dysfunction » If you may be pregnant » If you have a known

. . . s e g n a h Dear C Your Menopause Questions Answered Need advice on resources available to you for controlling menopausal symptoms? Here are some answers to your most frequently asked HT questions What is the best way to relieve my typical symptoms of hot flashes and vaginal dryness? And if it’s estrogen, what dosage form is the best? Prescription estrogen therapy (ET) – as an oral tablet, skin patch, gel, mousse, spray, or lotion – remains the most effective treatment for hot flashes. When this type of “systemic” (circulated through the body) ET is chosen, women with a uterus must also use another prescription hormone, progestogen, to protect the uterus. This combined estrogen-progestogen therapy is called EPT. If hot flash relief from hormone therapy is the goal, systemic ET or EPT is best. ET in all dosage forms (oral tablets, skin products, and vaginal products) is also the most effective treatment for moderate to severe vaginal dryness. Vaginal forms of ET provide estrogen “locally” (not circulated through the body); in this case, progestogen may not be required. If vaginal symptoms are the only reason to consider hormone therapy, local vaginal ET is the most appropriate choice. Choices include vaginal creams (Estrace Vaginal Cream, Premarin Vaginal Cream), a vaginal ring (Estring), and a vaginal tablet (Vagifem). The newer vaginal ring (Femring) has both local and systemic effects.

TREATMENT OPTIONS

These decisions will be based on ﬁnding a treatment that works while minimizing any associated risks. Is hormone therapy for life? In the past, most women who started hormone therapy for relief of symptoms such as hot flashes and vaginal dryness stayed on hormone therapy for life. Although the time of symptoms may have passed, women liked the fact that using estrogen reduced their risk of fractures from osteoporosis. Newer research has resulted in a different practice for most women. Hormone therapy, even at the lowest dose, should always be used for the shortest duration possible consistent with treatment goals. A woman should eventually attempt to reduce or stop hormone therapy when appropriate for her, and always in consultation with her healthcare provider. If bothersome symptoms persist, hormone therapy can be resumed or other strategies can be tried. For the majority of women, a point will be reached when symptoms are gone for good, and hormone therapy can be stopped. Importantly, however, hormone therapy is an effective option for some women to use long-term to keep bones strong. Some women may decide to continue long-term hormone therapy for other potential or perceived benefits. The decision should be revisited regularly to reassess the risk/benefit ratio for each individual in light of her health and research advances.

I have a very similar body type to my sister, so why do we receive very different dosages of hormone therapy? Each woman experiences her menopausal transition in a unique way, and therapy needs can vary. Several factors to consider include the kind of therapy as well as the dose. These decisions will be based on finding a treatment that works while minimizing any associated risks. One way to lower potential risk with any type of drug treatment, including hormone therapy, is to use the lowest effective dose. Some clinicians start with a standard dose and adjust up or down as needed for symptom relief. Other clinicians start very low and go up when required. Today’s

hormone therapies are available in very low doses to help with this approach. Research has shown that “lower than standard” doses of estrogen are almost as effective for symptom relief as standard doses. It is important to remember that 1 milligram of one type of estrogen doesn’t always equal 1 milligram of another in its effects on the body. More oral estrogen is required, because much of it is lost as it passes through the gastrointestinal system and is broken down in the liver before it reaches the blood stream. Transdermal estrogen goes through the skin and right into the bloodstream. The best thing is to listen to your body and have your clinician monitor you and continuously reassess your options.

Is saliva testing effective for people taking hormone therapy? Salivary hormone testing is often used by compounding pharmacies to tailor the prescription of bioidentical hormones – hormones derived from natural sources, such as plants, that have a chemical structure identical to the body’s own natural hormones – to a patient. However, the American College of Obstetricians and Gynecologists stresses that salivary testing of a woman’s hormone levels is not useful because these levels vary within each woman depending on her diet, the time of day, and the specific hormone being tested. According to the FDA, some compounding pharmacies claim that estrogen levels in a person’s saliva can be tested by practitioners to help them estimate the hormone dosage a person needs and then to customize the therapy for her. “There is no scientific basis for using saliva testing to adjust hormone levels,” notes the FDA. “Instead, practitioners should adjust hormone therapy dosages based on a patient’s symptoms.”

REMEMBER: Every woman experiences menopause differently. Always discuss your options with a clinician.

Drop Diet the

There are no quick ﬁxes when it comes to losing the extra 10 lbs. you’ve piled on recently, so forget the low-carb, low-fat, blood-type, body-type, or raw food diets. Our experts answer your most common menopauserelated weight loss questions I have heard that carrying extra weight around your waist is very bad news. But it just keeps piling on. Is it because I’m postmenopausal? Yes and no. Many women gain an average 10 pounds during the menopause transition, but there’s little scientific evidence to link the weight gain to either menopause or hormone therapy. Instead, research suggests that weight gain is largely a result of lifestyle and aging factors. As you get older, reduced activity levels play an important part. Lack of sleep, which, in turn, can make you less active during the day, may contribute. In the Nurses’ Health Study, researchers found that women who slept for five hours or less gained 2.5 pounds more than those who slept for seven hours a night. There is some suggestion, however, that

menopausal changes to body composition or fat distribution could be part of the picture. Research shows that menopause is associated with increased fat around the abdominal region. It’s important to control weight gain in this area because not only does it make it harder to zip your pants, an increase in central abdominal body fat increases your risk for type 2 diabetes, high cholesterol, hypertension, and heart disease.

Could my hormone therapy be causing the weight gain? No. Don’t blame your hormone therapy for those 10 pounds you’ve packed on since perimenopause. Despite previous beliefs that hormone therapy led to weight gain, well-designed clinical trials show that

isn’t so, says JoAnn Pinkerton, M.D., director of Midlife Health Center at the University of Virginia in Charlottesville and professor of obstetrics and gynecology. In the Postmenopausal Estrogen/Progestin Intervention (PEPI) trial, a three-year study of 875 women aged 45 to 64, researchers found no differences in weight change between women using any of four types of hormone therapy and women taking a placebo. This doesn’t mean you should look to hormone therapy as a means of weight loss or maintenance. Most health experts, such as the North American Menopause Society, recommend using hormone therapy only to help with specific menopause-related symptoms, such as hot flashes and vaginal dryness, and for preventing menopause-related diseases such as osteoporosis.

DIET & EXERCISE

The number of calories you burn a day – called your basal resting metabolic rate – drops steadily with each passing decade. I’ve started eating healthily and exercising more, but rather than losing weight I’m losing faith. Does it have to be this hard to lose weight after 50?

There are no tricks or magic when it comes to losing weight. So forget lowcarb, low-fat, low-sugar, body-type, or any of the other dozens of diets out there that promise to let you eat whatever you want, watch TV all day, and still lose weight. To maintain a healthy weight you must balance the calories coming in with the calories going out. And the drop in estrogen and the eventual slowing of your metabolism means you will have to work harder. It is a simple math problem. The number of calories you burn a day – called your basal resting metabolic rate – drops steadily with each passing decade. “So a 5-foot-8-inch woman who needed 1,411 calories a day at age 35 will only need 1,313 at age 55,” says Ivy Alexander, Ph.D., Changes medical advisor and a women’s health expert at Yale University School of Nursing. If you don’t adjust the amount of food you eat to match this decrease in your metabolism – or balance it with increased energy expenditure – the weight will slowly but surely pile on.

How Many Calories? What to eat to maintain your weight Age

Sedentary

Moderately Active

Active

31-50

1,800

2,000

2,200

51+

1,600

1,800

2,000-2,200

Sedentary: You regularly partake in typical day-to-day activities. Moderately active: You partake in day-to-day activities, plus you exercise equivalent to walking about 1.5 to 3 miles per day at a 3 to 4 mile per hour pace.

Active: You partake in day-to-day activities, plus you do activity equivalent to walking more than 3 miles per day at a 3 to 4 mile per hour pace.

Source: American Heart Association

What is the best diet for menopausal women?

By doing simple exercises and eating a healthy diet you should be able to watch the scales drop. But it’s a good idea to get some support to help you through the process. In the Women’s Healthy Lifestyle Project, a clinical trial of 535 healthy perimenopausal women, participants were assigned to lose 10 to 15 pounds. The first group received a structured lifestyle intervention program, consisting of a low-fat, 1,300-calorie per day diet and a physical

activity program of two to three miles of brisk walking most days. The second group was told to lose weight on their own. Researchers found that women in the intervention group either lost weight or remained at their baseline weight, whereas women left on their own gained, on average, 5 pounds. Some structure is helpful and sometimes necessary. “If women are committed to changing their diet and exercise patterns in ways that work for them, then they are much more likely to be successful over the long term,” says Pinkerton. Ease yourself into a healthy diet, then combine this with a healthy dose of exercise every day, and you should start to see the weight gain slow down or stop.

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DIET & EXERCISE

eol Toank tr

Follow these tried and tested expert tips, and soon you will look and feel fabulous!

Eat plenty of fruit and vegetables

Get moving

They’re high in vitamins, minerals, and ﬁber and low in calories.

Aim to do at least 30 minutes of moderate exercise most days of the week. If you can’t manage 30 minutes at a time, try three 10-minute sessions. Not only will this help keep off the weight, it will improve your cardiovascular ﬁtness too.

Switch to whole grains Unrefined whole grain foods contain fiber that will help you lower blood cholesterol and fill you up for longer.

Cut out high-fat protein

Try weight-bearing exercise

Choose lean cuts of skinless meat and poultry, and cook them without saturated or trans fats. Add spices for extra ﬂavor.

This strengthens bone structure and burns calories. Aim to ﬁt in a brisk walk three times a week or a quick game of tennis twice a week. Thirty minutes of brisk walking a day can lead to a 15-pound weight drop in a year.

Reduce your saturated fat intake

Enjoy yourself!

Switch to healthy fats such as olive oil, canola oil, and ﬂaxseed oil. Avoid frying foods. Instead, grill or bake whenever possible.

If you like your exercise routine, you’re less likely to quit. Find a class you enjoy at your local recreation center or train with a friend for added motivation.

Select low-fat dairy products

Think Active

When you reduce your fat intake with low-fat foods, watch out for hidden sugars, because these products often beef up the sugar content to add extra taste.

Build exercise in to your everyday life. Walk the dog, spend more time gardening, take the stairs, walk rather than drive when possible… The list is endless.

WEIGHT WISE

Follow these weight loss wisdoms and watch the pounds drop off!

Set and Record Targets: Set yourself a target weight in a sensible amount of time, say over six months. Break the amount into weekly short-term goals and aim to lose 1-2 pounds per week. Keep a daily weight loss diary. Record everything you eat and drink as well as your exercise and activity sessions. This will provide a clear indication of how you are doing from week to week. Sports experts agree that writing down

your goals and setting achievable targets is the most effective way to lose weight.

Plan Ahead: Write out and plan your meals in advance and stick to them. Plan three wellbalanced, nutritious meals per day containing about 450 calories each. Try to include some low-fat protein in every meal, which will help ward off hunger. Never miss breakfast and don't skip meals.

Snack Healthy: Make sure you have plenty of healthy snacks at hand to curb cravings and reduce ﬂuctuating blood sugar levels. Aim for about 100 calories per snack, and have three snacks a day: small portions of nuts such as almonds and walnuts or small packs of fruit salad or a whole fruit that you enjoy eating. Tubs of fat-free yogurt are a great low-fat protein source between meals. For those who crave crisp, crunchy snacks, make sure you always have mixed portions of vegetable crudités to dip into low-fat and fat-free dips.

DIET & EXERCISE

Surgical Solutions

When the weight ‘just won’t go,’ surgery may be a lifesaver for some women

lthough there is no causal link between menopause and obesity, there is an age-related link in that over 30% of American women older than 50 are obese. Because of the serious health risks associated with obesity such as heart disease, type 2 diabetes, stroke, and some cancers, bariatric surgery is seen as a lifesaver for some women.

Understanding Bariatric Surgery Bariatric surgery is a common term used to describe a variety of operations for treating severe obesity. It is not a form of cosmetic surgery. These operations are performed to make physical changes to the stomach and/or the small intestine in order to help you decrease the amount of food you eat. It is a proven method for long-term weight reduction and portion control among people who are exceedingly obese (BMI >40). A recent study of obese patients who

had undergone the procedure and then followed the lifestyle changes necessary for success suggests that bariatric surgery is a lifeline for those who had previously failed to lose weight. It was shown to result in complete remission of diabetes in up to 86% of severely obese patients with diabetes. It was shown to reduce the risk of death by nearly 30% in patients with severe obesity. It is not a simple, “quick fix” solution to a serious long-term weight problem. It requires commitment and lifestyle changes for successful weight loss and improved health.

Type of Weight Loss Surgery There are several types of bariatric surgery, which fall into two categories: Restrictive procedures: Adjustable gastric banding (LAP-BANDTM). These surgeries significantly reduce the size of the stomach, making you feel satisfied after eating less food, and you stay full longer.

Restrictive/malabsorptive procedures: Gastric bypass. These surgeries reduce the size of the stomach and shorten the small intestine, which are permanent changes to your anatomy. The smaller stomach also makes you feel satisfied and full after eating less food. In addition, the changes to the intestine reduce the amount of calories the body can absorb.

Be Prepared In making the decision, you and your doctor will need to consider many factors before determining if weight loss surgery is right for you. Ask yourself if you are up to the challenges you will face. First of all, you will be required to have a full medical examination. Your doctors will also perform a comprehensive psychological and behavioral assessment to make sure you will be able to look after yourself in a healthy way after surgery. Bariatric surgery will require you to visit your doctor regularly for follow-up appointments. If you choose the adjustable gastric band procedure, the surgeon will

When Michelle weighed 305 lbs, she thought she couldn’t afford the LAP-BAND® procedure. Then she found out insurance covered it and couldn’t afford to wait a day longer. The LAP-BAND® Adjustable Gastric Banding System is an affordable weight-loss procedure that can work.1,2 Being severely obese can be very costly. But getting weight-loss surgery doesn’t have to be. Did you know:

Michelle Lost 105 lbs. Results may vary.

• Most cases are covered by insurance • Following weight loss, health conditions like high blood pressure, type 2 diabetes and joint pain often improve 3,4 • There’s no stomach stapling 1 So if you want a procedure that’s often performed as an outpatient procedure1—talk to your doctor about LAP-BAND® today. Please read Important Safety Information adjacent to this page. LAP-BAND® is not for those who are pregnant, have autoimmune or organ diseases. Reoperations, removal and fatalities are rare. Band slippage, stomach injury, vomiting and heartburn may occur. 1. Directions for Use (DFU). LAP-BAND AP® Adjustable Gastric Banding System with OMNIFORM™ design. Allergan, Inc., Irvine, CA. 05/10. 2. O’Brien P, McPhail T, Chaston T, et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006;16:1032-1040. 3. O’Brien PE, Dixon J. LAP-BAND®: Outcomes and Results. J Laparoendosc Adv Surg Tech A. 2003;13(4):265-270. 4. Dixon J, O’Brien P, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008;299(3):316-323.

To find a free seminar near you visit seminarlapband.com.

IMPORTANT LAP-BAND® SYSTEM SAFETY INFORMATION

make any necessary adjustments to your band during these appointments. Because the surgery creates physical changes to your stomach (and intestine, if you elect to have a gastric bypass), the routine visits will ensure longterm weight loss success. Weight loss surgery is usually reserved for people who are seriously overweight, and therefore at a higher level of medical risk, and those who continue to have a long-

standing weight problem despite making numerous attempts to lose weight.

The Risk Factor Weight loss surgeries are major surgeries that involve risks and may lead to significant short-term and long-term health complications. The risks and complications vary according to the types of surgical procedure you elect to have and often depend on your age, level of excess weight, other existing health conditions, and how well you manage your health and your lifestyle. Problems associated with bariatric surgery can range from minor to lifethreatening. Complications may occur during, immediately after, or within weeks or several months after surgery. Additional surgery, re-admission to the hospital, medication, or nutritional supplements may be required. Health insurance may not cover some or any of the costs related to these unanticipated circumstances. If you choose to have the surgery, your surgeon will carefully explain the risks that are unique to you and specific to the type of operation you choose. Be sure to ask your surgeon all the questions you may have about risks and benefits of weight loss surgery before undergoing your procedure.

Be Committed Your success is dependent on your motivation and commitment to lifestyle changes. Your eating habits will have to change for you to lose weight and maintain your health. This will involve choosing healthy foods to eat, eating smaller portions, and taking daily nutritional supplements. Regular exercise (30 minutes a day, five times a week) is strongly encouraged for achieving and sustaining weight loss. Exercise preserves lean muscle tissue when losing weight rapidly after surgery and may also aid in suppressing your appetite. In addition, exercise may help reduce surgical complications, promote healing, and enhance recovery after surgery.

Finding a Reputable Weight Loss Surgeon Finding a reputable weight loss surgeon can increase your chance of having a successful operation, a good recovery, and satisfactory progress toward your weight loss goal. Some factors to consider when selecting a surgeon include: the surgeon’s qualifications and number of successful operations he or she has performed, where you live, what type of health insurance you have, and your current physical condition. The American Society for Metabolic and Bariatric Surgery (ASMBS) can help you and your PCP locate a weight loss surgeon.

Indications: The LAP-BAND® System is indicated for use in weight reduction for severely obese patients with a Body Mass Index (BMI) of at least 40 or a BMI of at least 35 with one or more severe comorbid conditions, or those who are 100 lbs. or more over their estimated ideal weight. Contraindications: The LAP-BAND® System is not recommended for non-adult patients, patients with conditions that may make them poor surgical candidates or increase the risk of poor results (e.g., inflammatory or cardiopulmonary diseases, GI conditions, symptoms or family history of autoimmune disease, cirrhosis), who are unwilling or unable to comply with the required dietary restrictions, who have alcohol or drug addictions, or who currently are or may be pregnant. Warnings: The LAP-BAND® System is a long-term implant. Explant and replacement surgery may be required. Patients who become pregnant or severely ill, or who require more extensive nutrition may require deflation of their bands. Anti-inflammatory agents, such as aspirin, should be used with caution and may contribute to an increased risk of band erosion. Adverse Events: Placement of the LAP-BAND® System is major surgery and, as with any surgery, death can occur. Possible complications include the risks associated with the medications and methods used during surgery, the risks associated with any surgical procedure, and the patient’s ability to tolerate a foreign object implanted in the body. Band slippage, erosion and deflation, reflux, obstruction of the stomach, dilation of the esophagus, infection, or nausea and vomiting may occur. Reoperation may be required. Rapid weight loss may result in complications that may require additional surgery. Deflation of the band may alleviate excessively rapid weight loss or esophageal dilation. Important: For full safety information please visit www.lapband.com, talk with your doctor, or call Allergan Product Support at 1-800-624-4261.

CAUTION: Rx only.

Apples Pears When we gain midlife weight, we do so differently depending on our body shape. There are two classic problem-body shapes: the Apple, where excess weight is carried around the middle, and the Pear, where weight tends to gather more around the hips. Sound familiar? Well, we can’t change what we were born with, but with a little tailored exercise we can make the most of what we’ve got

Which Body Sh Shape e Are You? APPLE ✔

✔

You have a large bust, a heavy waistline, and a problem tummy – your waist, hip, and bust measurements are pretty much the same. You are likely to have a relatively small backside and perhaps find jeans hard to fit because of this. You tend to lose weight from your arms and legs first, but find it difficult to shift it from your midriff.

PEAR

✔

You tend to gain most weight on the lower half of your body.

✔

You tend to lose weight from your bust and waist first, but find it difficult to shift it from your hips and backside.

Walk the Walk Before starting your moves, you need to achieve a 30-minute cardio fat burn. We suggest power walk interval training to start, then increase the intensity of your power walk as you improve. This can be done outdoors with a good pair of training shoes and a watch, or on a treadmill at the gym.

Power Walk Interval Training Power walking is walking briskly as though you were about to break out into a jog. Keep your arms tight to your side and controlled and walk right through your foot from heel to toe. Breathing should be controlled and even; you should never feel completely out of breath. Begin by walking slowly for three minutes to warm up. Then pick up the pace to a moderate intensity for two minutes; and if you can pick up the pace, go a further two-minute blast. That is your first cycle. Repeat for two minutes at low intensity, followed by two minutes at moderate intensity and then a two-minute high-intensity blast. Increase the length of the moderate-

and high-intensity blasts as you improve. For maximum results, repeat the 30-minute session at least five times per week.

THE MOVES APPLE MOVES PROBLEM AREAS: Waist - Stomach - Bust 1. Waist Nipper = The Plank 2. Tummy Tuck = Ball Hip Lift 3. Bust Booster = Curl & Press

PEAR MOVES PROBLEM AREAS: Stomach - Thighs - Bottom 1. Tummy Tuck = Ball Hip Lift 2. Thigh Firmer = Stability Ball Leg Curls 3. Bottom Blaster = Step & Squeeze

Begin with three sets of 10 reps for each move, increasing the reps as you improve.

DIET & EXERCISE

The Plank

WAIST NIPPER

Lie facedown with your forearms resting on the ﬂoor. Your elbows should be under your shoulders and bent 90 degrees. Push off your elbows, lifting your body off the ﬂoor, so your torso is supported on your elbows and forearms and your body forms a straight line from your head to your heels. Keep your navel pulled toward your spine and your head in line with your spine. Hold for 10 to 15 seconds. Then lower to starting position.

Ball Hip Lift

TUMMY TUCK

Lie on your back with your arms at your sides and hook the ball with your knees so it’s nestled between your heels and your hamstrings. Contract your abs and lift the ball off the ﬂoor, rolling your hips up and drawing your knees toward your chest. Keep your navel pulled toward your spine throughout the move. Pause, then slowly lower back to the starting position.

Curl & Press

BUST BOOSTER

Sit on a chair (preferably one without arms), feet ﬂat on the ﬂoor. Hold a dumbbell in each hand, arms extended down to your sides and palms facing out. Keeping your upper body stable, bend your elbows and curl the weights up toward your shoulders. Immediately rotate your wrists so your palms are facing out in front of you and press the weights above your head. Pause. Then reverse the move, lowering the weights to your shoulders, rotating your palms in toward your body, and lowering the weights back down to your sides.

Stability Ball Leg Curls

THIGH FIRMER

Lie on your back on the floor. Extend your legs and place your heels on the top of the ball. Rest your arms on the floor by your sides, palms down. Press your heels into the ball and lift your rear off the floor a few inches. Bend your knees, using your heels to pull the ball toward your rear, so your feet end up flat on the ball. Pause, then extend your legs back to the starting position.

Step & Squeeze

BOTTOM BLASTER

Stand about a foot away from a step with your feet about hip-width apart. Place your hands on your hips. Step forward with your left foot, placing it on the center of the step. All in one move, straighten your left leg, lift your right foot off the ﬂoor, squeeze your buttocks, and extend your right leg behind you. Hold, then reverse the motion. Repeat with the opposite leg. Alternate legs until you complete a full set with each leg.

SMART Super Food Q&A ‘Eat smart’ is the new message from Changes nutritionists. If you could get all the nutrients you need from a vitamin pill, you’d take it, right? We asked our experts to answer readers’ nutrition questions; and although it’s unfair to single out a few ingredients for all the credit, some foods are multitasking wonders. Here’s what the experts recommend

I am a recently converted vegetarian. I avoid dairy products and fish but need a high-protein vegetarian substitute other than tofu. Any ideas? (Maryanne, 47, Illinois)

Beans, beans, and more beans! Dried cooked beans such as kidney, navy, garbanzo, pinto, and more “top the nutrition honors list,” says Linda Antinoro, R.D., a senior nutritionist at the Brigham and Women’s Hospital in Boston.

And for good reason: “Beans are a good source of vegetable protein and make an excellent meat replacement.” They are also high in heart-healthy fiber (beneficial for digestion and constipation) and valuable sources of foliate – a B vitamin that may reduce your risk of heart disease. TRY: A nutritious bean salad with tomatoes, cucumber, and onion and a delicious low-fat vinaigrette dressing. Or a heartwarming chili bean hot pot packed with a selection of colorful beans and vegetables.

My husband says he will go crazy if I ask him again where I left my keys. What food could I eat more of to improve my memory? (Tricia, 51, Maryland)

The best way to counteract any postmenopausal memory loss is to binge on berries. “Their deep purple color is more than a fashion statement,” says Mary Ellen Camire, Ph.D., a professor in the Food Science Department at the University of Maine in Orono.

DIET & EXERCISE

I am in the high-risk group for osteoporosis. What super food should I be filling my shopping cart with? (Debbie, 49, Wisconsin)

A Q

I stopped eating eggs a while ago because of the high cholesterol content, but I do miss them. Are they all bad? (Helen, 50, Boston)

A In fact, she notes, “Rats fed on diets high in blueberries showed improved brain function, with older rats behaving more like their younger counterparts [versus] those who didn’t get the fruit.” Human studies have also shown that fruit may improve memory in postmenopausal women. TRY: Sprinkling a handful of berries on your morning cereal. Whiz in a blender with yogurt to make a delicious smoothie, or simply enjoy them as a hunger-busting snack.

No, eggs are back on! “Nutritionists are far more concerned these days with saturated fat,” says Susan Mitchell, Ph.D., a dietitian in private practice in Orlando, Fla., “and eggs are relatively low in saturated fat. Plus, eggs are an excellent choice for the protein punch they pack in less than 100 calories.” “Protein is important,” adds Mitchell, “because it helps maintain muscle mass, which tends to decline in the postmenopausal years. It also helps keep hair glossy and healthy looking.” TRY: Egg white omelets. For a super low-fat protein kick, add fresh herbs, curd cheese, or chopped tomatoes. Eggs Florentine with wilted spinach is a superb weekend brunch idea, and who can resist a simple soft-boiled or poached egg?

Well, as you are in the market, we are going to suggest two: milk and greens. “The milk message is clear,” says Connie M. Weaver, Ph.D., who heads the Department of Foods & Nutrition at Purdue University in Lafayette, Ind. “Drink at least 3 cups of non-fat or low-fat milk daily to help maintain bone density.” Weaver, one of the country’s leading experts on calcium, touts milk’s other advantages as well. “Evidence shows protection against insulin resistance, diabetes, and hypertension.” When nutritionists list their favorite foods for menopausal women (in fact, all women!), dark leafy greens are always high on the list. “High-in-foliate dark greens like spinach, kale, and collards can help lower levels of homocysteine – an amino acid linked to heart disease. High levels of homocysteine may also put your body’s collagen at risk,” says Antinoro, the Boston nutritionist. In terms of bone health, this is serious, she adds. “Scientists speculate that collagen, a protein that contributes to bone strength, may be weakened by homocysteine, increasing the risk of fractures in the postmenopausal years.” TRY: “Skinny” lattes, fruit smoothies made with non-fat milk. Or for a real treat, dreamy hot chocolate made with 70% cocoa. Three more smart options: a delicious Asian stir-fry made with dark green leaves, green vegetable lasagna made with whole wheat pasta sheets, or spinach and ricotta tortellini.

DIET & EXERCISE

The good news is that nuts are very satisfying; and because they contain protein, they will keep hunger at bay.

I have developed an abnormal heart rhythm and need to be extra cautious about my heart health. What food should I be eating more of? (Miriam, 53, San Diego)

Stock up on salmon or mackerel – or any other fish that is rich in essential omega-3 fatty acids. “These deep-water fish can make your blood less sticky, preventing blood clots,” says Mary Felando, R.D., of the Heart Institute at Cedars-Sinai Medical Center in Los Angeles. “Studies also find that these anti-inflammatory fats can help prevent abnormal heart rhythms, an increasing threat as women age.” Aim for two servings a week – each serving about the size of the palm of your hand. And don’t shun canned salmon. Because it’s processed with the bones, it provides an excellent source of calcium. TRY: Salmon fish cakes (go to the Changes website for a great recipe) or healthy salmon fish pie with a sweet potato or butternut squash topping. Alternatively, why not try a delicious salmon and arugula sandwich on rye, with a watercress and crème fraiche dressing?

I often get cravings for savory snacks in the evenings. What can I replace my salted chips and popcorn with? (Maria, 50, Alberta)

You are right to look for a replacement to these high-risk snacks. Both are high in fat and sodium and will increase your risk of high blood pressure and heart disease. “Go nuts for nuts instead,” suggests Felando. “Talk about nutrition in a nutshell. Not only are they high in vitamin E, which helps to lower bad cholesterol, but nuts are packed with heart-healthy omega-3 fatty acids, fiber, and calcium.” Don’t limit yourself to one nut variety, however. Choose wal-

nuts for omega-3 fatty acids, and choose almonds for calcium, vitamin E, and fiber. Brazil nuts are a great source of selenium, magnesium, and thiamine. Stick to a handful of nuts at a time, though, as they are high in calories because of their high fat content. The good news is that they are very satisfying; and because they contain protein, they will keep hunger at bay. TRY: Unsalted mixed nuts. Put a selection of these super nuts into small portioncontrolled handy bags ready to grab when the snack attack happens. Sprinkle nuts onto your cereal or into stir-fries or Thai food. Peanut butter on whole wheat bread is, of course, a firm favorite!

Bosom Buddies

Good friends Jo and Sally talk frankly with our Changes experts about their breast cancer fears and understandings

POSTMENOPAUSE

JO: Doesn’t estrogen encourage breast cell growth? So surely after menopause the chance of breast cancer is reduced?

JO: My mother believed that breast discomfort is a normal part of womanhood and we shouldn’t give it too much thought. CHANGES: Breast discomfort is an indicator that something might be wrong. We should all be wearing good fitted bras, and extra-support sports bras when we exercise, to reduce the discomfort of everyday living. But beyond that, breast pain is very common during perimenopause and is often the first sign of approaching menopause, even before a skipped period or mild hot flashes. As you might expect, fluctuating hormone levels are thought to trigger this perimenopausal breast discomfort. For most women the tenderness and lumpiness will subside after menopause. –Nancy Elliott, M.D., director of the Montclair Breast Center in Montclair, N.J.

SALLY: My boobs have really started to droop, and it’s uncomfortable in bed. Is this because I’m approaching menopause? CHANGES: The mammary glands in your breasts usually shrink after menopause. And this may be beginning to happen now. For some women fat replaces the glands and causes this very common sagging. Short of surgery there isn’t much we can do to fix this, although strength training exercises such as pushups might help reduce the sagging. This sagging can cause discomfort especially at night when we don’t tend to wear any support. Try a light cotton or sports bra at night to alleviate the discomfort. –Rebecca F. Nachamine, M.D., practicing gynecologist in New York City.

CHANGES: Despite the drop in estrogen, breast cancer rates rise with age. At age 50, one in 50 women will develop breast cancer. At age 80, one in 80 women will develop breast cancer. The good news is that postmenopausal cancers grow more slowly than premenopausal breast cancers, making them less dangerous. –Milicia Kay, R.N., nurse coordinator at the Josephine Ford Cancer Center in East Bloomfield, Mich.

SALLY: I read that hormone therapy can increase the risk of breast cancer. CHANGES: Using hormone therapy, especially estrogen plus progestogen, has been found to have a slight association with an increase in breast cancer risk. The Women’s Health Initiative, a large government-funded study, found that using one combination hormone product (Prempro) increased risk to 38 cases per 10,000 women per year versus 30 cases per 10,000 women per year with no hormone therapy.

POSTMENOPAUSE

JO: Isn’t there a wonderful new blood test for breast cancer?

SALLY: So an annual mammogram is the best way forward? JO: So how do we decide? CHANGES: Each case is unique, and all women should talk in depth to their healthcare provider about what is the right option for them. If you are in a high-risk group your options will be different. For example, a woman with a family history of breast cancer is in a very different position from a woman with no family history. Changes and the North American Menopause Society recommend that if hormone therapy is the best option for you, you should take the lowest possible dose for the shortest possible time.

CHANGES: For most of us, yes, an annual mammogram is a good diagnostic tool, along with regular self-exams. However, if you are a breast cancer survivor, have a strong family history of cancer, or have the BRCA1 and BRCA2 cancer genes, consider having a breast MRI or an ultrasound in addition to your mammogram. MRIs, while more expensive, can detect cancers as tiny as a lentil, even in women with dense breasts. If you are high risk you should have an MRI every three years. If you find a lump, it needs follow-up even if the mammogram is negative. –Nancy Elliott, M.D., director of the Montclair Breast Center in Montclair, N.J.

CHANGES: Keri Sweeten, a boardcertified gynecologist and fellow of the American College of Obstetricians and Gynecologists, recently incorporated the Provista Life Science BT Test®, a blood test for the detection of breast cancer, into her patient care practice. Sweeten noted a case where a 44-year-old patient called to schedule her annual mammogram, and in advance of the mammogram Sweeten ordered the BT Test. When her patient’s BT Score® came back high, indicating an increased likelihood of the presence of breast cancer, she changed the order for her patient’s routine screening mammogram to a diagnostic bilateral mammogram. A diagnostic mammogram is an enhanced radiology procedure that increases the number and angles of breast imaging views with increased magnification of those views. Using this procedure, the radiologist was able to locate a deep, very small clustering of suspicious-looking cells in the patient’s left breast. A biopsy was recommended and performed, and the subsequent pathologist’s report came back with a confirmed diagnosis of cancer. Surgery was scheduled two weeks later, and the cancerous growth was removed. Without the BT Test the advanced mammogram probably wouldn’t have been recommended and the early detection of cancerous cells may not have happened. This is an isolated case and is very expensive; as always, each case must be considered on its merits for advanced radiology.

Visionary Thinking If you are wondering why your eyes are dry, itchy, or things are getting a little more blurred around the edge recently, the answer might just be those crazy hormones again!

y the time she reached menopause, Lynn Adams was fully prepared for hot flashes and night sweats. What she didn’t expect were the changes that affected her eyes. “I felt like I had sand in my eyes every hour of the day,” says the 53-year-old from Atlanta, Ga. “One minute they were burning and irritated; the next they were feeling terribly tired.” For Adams, eye discomfort was the most unpleasant of her menopause symptoms. Known as dry eye syndrome, it’s a common, yet annoying, condition that often surfaces in perimenopausal and postmenopausal women. But, while it can cause a lot of discomfort, it rarely threatens sight. So what exactly happens in dry eye syndrome? Tear production decreases naturally with age, but around menopause this can be exacerbated by hormonal changes (particularly falling androgen levels), which subtly increase

inflammation in the eye. Because the lacrimal gland, known as the tear gland, isn’t producing suﬃcient tears to keep the conjunctiva and cornea covered, the eyes dry out and become irritated. Then they suddenly produce a large amount of tears to compensate, explains Stephen Pflugfelder, M.D., professor of ophthalmology at Baylor College of Medicine in Houston, Texas. You may experience dry eye as an overly watery eye, or you may feel stinging, burning, scratchiness, and the feeling that there’s something in your eye. Occasionally, environmental factors such as low humidity or winds can worsen symptoms. Hormone receptors have been identified in many parts of the eye, and it is known that the quantity of tears produced is lower in postmenopausal women. In America, 3.2 million women are affected with dry eye syndrome. Luckily, some simple changes can help. Craig Skolnick, M.D.,

POSTMENOPAUSE

Go ahead, chat on. T O P I C : B O N E H E A LT H

OSTEOPOROSIS AWA R E N E S S

www.nof.org

E D U C AT I O N

A DVO C AC Y

R E SE A RCH

POSTMENOPAUSE

Boost Your Eye Health About three-quarters of all vision loss is preventable or correctible, says the National Eye Institute’s Janine Smith, M.D. Healthy lifestyle changes, along with regular eye screenings and early treatment, can make a difference in quality of life.

an ophthalmologist at Bascom Palmer Eye Institute in Palm Beach, Fla., recommends: ➤ Avoid sitting close to air blowing from fans and air conditioning vents. ➤ Use a humidifier, particularly during the winter months when indoor air is drier. ➤ When using a computer, make sure you blink often and take frequent breaks. Keep your computer screen at or below eye level so your eyes don’t have to open quite so wide to see the screen; that way they’ll be less likely to dry out.

Protect Your Sight Not all eye conditions are as benign as dry eye syndrome. Some, such as macular degeneration and glaucoma, can lead to vision loss or even blindness. And this issue is particularly relevant for women, who are nearly three times more likely than men to lose their sight. Worldwide, studies show that women make up twothirds of those who are blind. But you can protect your vision with

good eye care and some healthy lifestyle changes. “Women reaching menopause should have a complete eye exam,” says Janine Smith, M.D., deputy clinical director of the National Eye Institute in Bethesda, Md. “You can’t take your eye health for granted, just like you can’t take any other part of your body for granted.”

The Aging Eye While dry eye may have a hormonal basis, other eye conditions related to aging are simply the result of, well, age. Many of us reach midlife already using glasses or contacts to see objects far away. But as we age, the lens of the eye, which helps focus images, loses its flexibility. This results in presbyopia, diﬃculty in seeing objects up close. The solution may be reading glasses or bifocals, or possibly one of the newer laser surgeries that may give you back your pre-forties vision, at least for a while. Floaters – those shadowy squiggles and dots that drift into your field of vision – also increase as we age. They’re the result of changes in vitreous gel, liquid inside the eye that helps give it its shape. You usually don’t need to worry about

STOP SMOKING. The chemicals in cigarette smoke travel in the blood to every cell in the body and can cause eye damage in addition to other problems. For example, studies ﬁnd that about one-third of macular degeneration cases may be caused by smoking. LOSE WEIGHT. A healthy diet and regular exercise appear to reduce the risk of serious eye disease. Manage your weight to reduce the risk of diabetes, which is a major risk factor for cataracts, glaucoma, and a nerve-destroying condition called diabetic neuropathy. EAT AN APPLE A DAY. Several studies suggest diets rich in fruits and vegetables may reduce the risk of cataracts and macular degeneration by providing valuable antioxidants to prevent age-related damage. Vitamin supplements may be necessary if you ﬁnd it hard to increase your level of antioxidants. SHADE OUT THE SUN. Too much sun exposure can lead to cataracts and macular degeneration, says Smith. Look for sunglasses that block 90% to 100% of both UVA and UVB light.

POSTMENOPAUSE

MANAGING

DRY EYE

Eyedrops. Over-the-counter artiﬁcial tears may be helpful, but they’re likely to only ease symptoms. Make sure you choose a product speciﬁcally designed for dry eyes, not just to get the redness out.

floaters, says Skolnick. They’re just the outlines of debris drifting along in the liquid. However, if they suddenly increase, see an eye specialist immediately. They could be a sign of a detached or detaching retina. Then there are the big guns of aging eyes: cataracts, macular degeneration, and glaucoma – leading causes of blindness and vision loss in older Americans. Cataracts, or a clouding of the lens in the eye, used to be the primary thief of eyesight in the elderly. Today, however, a simple, outpatient procedure to remove the cloudy lens and replace it with an artificial lens is one of the most commonly performed surgical procedures in the country. Your risk of cataracts increases with age, sun exposure, smoking, diabetes, steroid use, or a family history of cataracts. Some studies show that estrogen users have fewer cataracts. Age-related macular degeneration, or

AMD, destroys the cells in the macula, the part of the eye responsible for central vision. It can begin in middle age, with the risk increasing as you get older. As a woman, your risk of AMD is higher than a man’s. It’s also higher if you’re white, smoke, or have a family history of the disease. Glaucoma is usually caused by increased pressure from the buildup of fluid in the eye, which can slowly damage the optic nerve. You are at risk if you are over 60, African American, Mexican American, have a family history of the disease, have ever had an eye injury, have diabetes, or have taken steroids. If caught early, glaucoma can be kept under control with drugs, preventing vision loss. Regular eye exams are very important, says Skolnick. Early detection, along with lifestyle changes (See “Boost Your Eye Health” on page 61), will help ensure your eyes remain in optimum condition as long as possible.

Anti-inflammatories. If over-the-counter drops don’t work, the prescription eye drop drug cyclosporine (Restasis®) could be the next step. Restasis dampens the eye inﬂammation that leads to irritation and tearing. Punctal plugs. These tiny silicone plugs block the drain that normally allows tears to ﬂow down the nose. If the plugs fall out, your healthcare provider may decide to cauterize the drains to permanently close them. Corticosteroids. Studies show corticosteroid eye drops provide some symptomatic relief. They may have adverse effects, though, so they’re not suitable for long-term use.

Statuesque Strong bones, unlike strong teeth and healthy hair, are often ignored until it’s too late and we have literally started to fall to pieces. Don’t let this happen to you; act now for healthy, strong bones

he National Osteoporosis Foundation estimates that 8 million women are affected by osteoporosis, and those women who have experienced menopause are more likely to be affected because women lose up to 20% of their bone mass in the five to seven years after menopause. But osteoporosis is an avoidable disease, so act now to prevent the effects of weakening bones. We tend to think the bones we have in our twenties are the same as the ones we have in our fifties. They’re not. Bones are constantly being remodeled throughout our lifetime to maintain their strength. So how does the process work? Special cells called osteoclasts break down old bone tissue and remove it. Then bone-building cells, known as osteoblasts, replace that tissue with healthy new bone. When you’re young, the bone-building cells work faster than the bone-destroying cells, and your bones grow larger and denser. This continues until about age 30, when women reach their peak bone mass. From then on, bones gradually lose their strength. Your risk of osteoporosis will depend on your peak bone density and your rate of bone loss.

Helpful Hormones

Maintaining Strong Bones

It’s not just age that determines bone health. Bone remodeling is regulated by several hormones, particularly estrogen. During perimenopause, women lose 2% of bone density each year because of decreasing estrogen levels. This loss continues until a few years after menopause, at which point bone loss will slow to 1% a year. While the rapid loss of bone around menopause puts women at greater risk of osteoporosis and makes menopause a good time to get serious about preserving bone, it doesn’t mean you have to rush into treatment, says Bruce Ettinger, M.D., an osteoporosis specialist at the University of California, San Francisco. Osteoporosis, or the fracturing it causes, isn’t an immediate risk for women during the menopause transition, he says. “Relax about osteoporosis – that’s the message I would give to healthy women at the time of menopause,” says Ettinger. “Women at the age of 50 or 55 who are generally healthy have a very low risk of having a fracture in the next five to 10 years.” Instead, now is a time of prevention. That means finding out if you’re at high risk for osteoporosis and discussing a bone-healthy lifestyle with your healthcare provider.

The most important strategy for preventing osteoporosis is making sure you get enough calcium, says Michael McClung, M.D., director of the Oregon Osteoporosis Center in Portland. Calcium deficiency speeds the rate of bone loss, he notes, and studies find calcium supplementation can slow the rate of bone loss in women with low dietary intake of the mineral. Ideally, premenopausal women should aim for 1,000 milligrams a day of elemental calcium, while perimenopausal and postmenopausal women should try to get 1,200 milligrams a day. Try to obtain your daily calcium from your diet rather than supplements, says McClung, because your body can better absorb the mineral from food sources. It’s easy enough: Three servings a day of dairy products like milk and cheese, or calcium-fortified foods like some orange juices, will do it. If you can’t get enough calcium from food (maybe you’re lactose intolerant), consider a supplement. You may need only about 600 milligrams extra a day, says Felicia Cosman, M.D., an osteoporosis specialist and the medical director of the Clinical Research Center at Helen

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If you drink milk fortiﬁed with vitamin D or spend at least 15 minutes a day in the sun with your arms, hands, and face exposed and not covered in sunscreen, you may be getting what you need. Hayes Hospital in West Haverstraw, N.Y. And don’t forget vitamin D, the socalled sunshine vitamin. Without it, your body can’t absorb calcium. If you drink milk fortified with vitamin D or spend at least 15 minutes a day in the sun with your arms, hands, and face exposed and not covered in sunscreen, you may be getting what you need. Vitamin D deficiency is especially prevalent in older women in the North, where the winter is dark. If you’re over 50, aim for at least 400 IU a day of vitamin D; if you’re 70 or older, increase that to at least 600 IU. A cup of milk contains about 100 IU. Because your body has a harder time manufacturing vitamin D, even as your need for it increases, you may need to supplement, says McClung. Most calcium supplements and multivitamins contain enough vitamin D to meet your needs.

Understanding

Your Risk Healthy women with no risk factors for osteoporosis don’t need bone screenings until age 65, according to most guidelines, including those of the National Osteoporosis Foundation. If you have an increased risk of osteoporosis, you may need to start screening sooner. Numerous factors can increase your osteoporosis fracture risk, including:

» Low bone-mineral density » Previous fracture (other than skull, facial bone, ankle, ﬁnger, or toe) as an adult

» History of previous hip fracture in a parent

» Being small and thin (less than 127 pounds)

» Smoking and drinking too much alcohol

» Calcium or vitamin deﬁciency

» Use of certain bone-robbing prescription medications (such as steroids for more than three months)

» Increased risk of falls (e.g.,

from poor balance, dizziness from medications, etc.)

Work It, Baby! In addition to proper nutrition, exercise is critical when it comes to strong bones, says Cosman. Bone is like muscle, she explains, responding to the stress of exercise by growing stronger. Studies find that inactivity increases the rate of bone loss and that exercising can slow that loss. Not just any exercise will do, however. Building bone requires exercise that forces your skeleton to carry your body’s weight. Brisk walking, jogging, and aerobics will do the trick; swimming and biking won’t. Strength training is also important, Cosman says, because it builds bone and lowers your fracture risk by helping you keep

your balance and reducing your chance of falling. But if you stop exercising, she warns, you’ll lose both the muscle you built up and the bone. Before you begin any exercise program, check with your healthcare provider to discuss the type that’s best for you. Other measures to prevent osteoporosis include: quitting smoking, as studies find that smoking doubles the risk of osteoporosis; keeping alcohol consumption to a moderate level; and limiting your consumption of salt, caffeine, and protein, all of which may deplete calcium.

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Breaking the Silence: Getting Screened There’s a reason osteoporosis is called the “silent disease,” says Charles Kahn, M.D., a rheumatologist at Memorial Regional Hospital in Hollywood, Fla. “Most patients don’t get any pain. They never know they have it.” Until, that is, they fracture a wrist or hip. Other osteoporosis signals include chronic back pain or a loss of more than 1.5 inches in height – both signs of vertebral fractures. Thus, regular screenings are vital beginning at age 65 or earlier if you are at high risk of the disease (See “Understanding Your Risk” on page 66). The most common and most accurate form of bone mineral density testing is dual energy X-ray absorptiometry (DXA). DXA produces a T-score, a measure of how your bone density differs from that of a healthy young person of the same gender. The normal range is above -1. If your T-score is below -2.5, you’re diagnosed with osteoporosis. The problem with T-scores is they don’t tell the whole story, says McClung. They can vary from individual to individual, and age also plays a part. “The bone density value itself tells us almost nothing about the fracture risk,” says McClung. “You may want to ask your provider to put your T-score into context by providing a sense of your overall risk of fracture, before starting any drug therapy,” suggests Cosman. The World Health Organization has recently announced a new system to

You may want to ask your provider to put your T-score into context by providing a sense of your overall risk of fracture, before starting any drug therapy.

Stay Safe Prevent accidental falls in the home with these suggestions from the National Institute on Aging:

replace T-scores; it will analyze risk in the context of a woman’s general health, explains Ettinger. “This is going to make it easier to make decisions about when it’s right to treat,” he says. The National Osteoporosis Foundation will provide an analysis of when treatments should and should not be used.

Treating Osteoporosis If you have osteoporosis, there are lots of medical options, all of which require long-term use to prevent bone loss returning. “Regardless of what medication you’re taking, you need to make sure you’re getting adequate calcium and vitamin D to maximize their effectiveness,” Kahn warns.

» Make sure you can see and

hear well. Use your glasses or a hearing aid if needed.

» Ask your doctor if any of the drugs you are taking can make you dizzy or unsteady on your feet.

» Use a cane or walker if your walking is unsteady.

Wear rubber-soled and low-heeled shoes.

» Make sure all the rugs and

carpeting in your house are ﬁrmly attached to the ﬂoor, or don’t use them.

» Keep your rooms well lit and the ﬂoor free of clutter.

» Use nightlights.

I wanted to stop my bone loss.

If you have osteoporosis, like me, calcium-rich foods, vitamin D, and exercise can help. But they may not be enough to keep your bones strong. So ask your doctor if once-monthly BONIVA can help you do more. BONIVA is a prescription medication to treat and prevent postmenopausal osteoporosis. Ask your doctor if BONIVA is right for you.

“Eat plenty of calcium-rich foods like yogurt, spinach, and cheese.”

Important Safety Information: You should not take BONIVA if you have certain problems with your esophagus (the tube that connects your mouth and stomach), low blood calcium, cannot sit or stand for at least 60 minutes, have severe kidney disease, or are allergic to BONIVA. Stop taking BONIVA and tell your doctor right away if you experience difficult or painful swallowing, chest pain, or severe or continuing heartburn, as these may be signs of serious upper digestive problems. Follow the dosing instructions for once-monthly BONIVA carefully to lower the chance of these events occurring. Side effects may include diarrhea, pain in the arms or legs, or upset stomach. Tell your doctor and dentist about all the medicines you take. Tell them if you develop jaw problems (especially following a dental procedure) or severe bone, joint, and/or muscle pain. Your doctor may also recommend a calcium and vitamin D supplement. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. Please read Patient Information on the next page.

Enroll today. Call 1-866-571-6893 or visit BONIVAfreetrial.com and try BONIVA free.

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IMPORTANT FACTS ABOUT BONIVA (bon-EE-va) ibandronate sodium 150-mg tablet What is BONIVA?

BONIVA, a bisphosphonate, is a prescription medicine used to treat and prevent osteoporosis in postmenopausal women, characterized by weakening of the bone. Taken once a month in tablet form, BONIVA may stop and reverse bone loss in most women. It has been clinically proven to help build and maintain bone density, which can help reduce fractures.

What is the most important information about BONIVA? BONIVA may cause serious problems in the stomach and the esophagus (the tube that connects your mouth and stomach) such as trouble swallowing, heartburn, and ulcers. Who should not take BONIVA?

Before you start BONIVA.

Do not take BONIVA if you:

Tell your health care provider if you:

• have abnormalities with your esophagus, such as restriction or difficulty swallowing • have low blood calcium (hypocalcemia) • cannot sit or stand for at least 60 minutes • have kidneys that work very poorly • are allergic to BONIVA or any of its ingredients See Patient Information for complete list.

• are pregnant or plan to become pregnant • are breast-feeding • have trouble swallowing or other problems with your esophagus • have kidney problems • are planning a dental procedure such as tooth extraction Tell your health care provider and dentist about all medications you’re taking, including vitamins, antacids, and supplements.

How should you take BONIVA?

You must take BONIVA exactly as instructed by your health care provider. • Take first thing in the morning, on the same day each month.

• If you miss a monthly dose and your next scheduled BONIVA day is more than 7 days away, take one BONIVA 150 mg tablet in the morning following the day that you remember. Do not take two 150 mg tablets within the same week. If your scheduled BONIVA day is only 1 to 7 days away, wait until your next scheduled BONIVA day to take your tablet. Then return to taking one BONIVA 150 mg tablet every month in the morning of your chosen day, according to your original schedule. If you are not sure what to do if you miss a dose, contact your health care provider, who will be able to advise you.

• After you take BONIVA, remain standing or sitting for at least 60 minutes before you eat, drink, lie down, or take any other oral medications, including calcium, vitamins, and antacids. Some medicines can stop BONIVA from getting to your bones. • If you take too much BONIVA, drink a full glass of milk and call your local poison control center or emergency room right away. Do not make yourself vomit. Do not lie down. What are the possible side effects of BONIVA?

Stop taking BONIVA and call your health care provider right away if you have pain or trouble swallowing, chest pain, or very bad heartburn or heartburn that does not get better. Follow dosing instructions carefully to decrease the risk of these effects. BONIVA may cause:

Common side effects are:

Less common side effects are:

• Pain or trouble swallowing • Heartburn • Ulcers in stomach or esophagus

• Diarrhea • Pain in extremities (arms or legs) • Upset stomach

• Short-term, mild flu-like symptoms, which usually improve after the first dose

Rarely, patients have reported allergic and skin reactions. Contact your health care provider if you develop any symptoms of an allergic reaction including skin rash (with or without blisters), hives, wheezing, or swelling of the face, lips, tongue, or throat. Get medical help right away if you have trouble breathing, swallowing, or feel light-headed. Rarely, patients have reported severe bone, joint, and/or muscle pain starting within one day to several months after beginning to take oral bisphosphonate drugs. Contact your health care provider if you develop these symptoms after starting BONIVA. Rarely, patients have reported serious jaw problems associated with delayed healing and infection, often following dental procedures such as tooth extraction. If you experience jaw problems, contact your health care provider and dentist. This summary is not a complete list of side effects. For a complete list, consult your health care provider or pharmacist. Want to know more? This summary is not everything you need to know about BONIVA. It does not take the place of talking with your health care provider about your condition or treatment. For more complete information, talk to your health care provider or pharmacist. Visit myboniva.com or call 1-888-MyBONIVA for the complete Prescribing Information, which includes the Patient Information.

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• Swallow whole (do not chew or suck) with a full glass (6 to 8 oz) of plain water (not sparkling or mineral). Do not take with tea, coffee, juice, or milk.

Join the MyBONIVA® Program for Sally’s Tips, plus one month of BONIVA free!

“What’s my secret? My healthcare provider gave me a copy of Changes!”

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• Sally Field’s tips on managing your osteoporosis and building stronger bones.

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• One month of BONIVA free*.

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MyBONIVA is a free program that gives you tips from Sally, ideas, and support to help manage your osteoporosis. You’ll get:

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*You must be 18 years of age or older to join MyBONIVA. The free trial offer is limited to one per patient. MyBONIVA is a registered trademark of Roche Therapeutics Inc.

*Subject to a shipping & handling cost of $29.95 per carton of 30 magazines.

POSTMENOPAUSE

m o o r t s Re

d e r u Ass , the phrase n e m o w l a s u a p eno For some postm g” is no joke in h g u la lf e s y m “I nearly wet

ncontinence, the persistent involuntary leaking of urine, is more common around, and particularly after, menopause; but it’s a condition that can pop up, unannounced, regardless of your menopause status. Urinary incontinence has many causes, including pregnancy and childbirth. But menopause and the natural effects of aging also play a role. So what’s the menopause link? Estrogen? Maybe or maybe not. Prior to menopause, estrogen helps increase blood flow to your urogenital tract (the vagina and the urethra – the tube extending from the bladder to the outside), which helps keep muscles and tissue toned and flexible.

Estrogen levels become consistently low in postmenopausal women, and the linings of the urethra, bladder, and vagina become thinner and weaker. But then, as you age, the bladder muscle also weakens; the bladder simply can’t hold as much as it once did. It is estimated that among midlife women, about 5% suffer severe incontinence, while 60% suffer mild incontinence. So aging is certainly a factor, but not all postmenopausal women experience incontinence, says G. Willy Davila, M.D., who heads the urogynecology and reconstructive pelvic surgery section at Cleveland Clinic Florida in Weston, Fla. Three main types of urinary inconti-

nence affect women: ➤ STRESS INCONTINENCE When you leak urine during a cough, sneeze, laugh, or physical activity ➤ URGE INCONTINENCE When you feel the sudden and intense urge to urinate, even shortly after emptying your bladder ➤ MIXED INCONTINENCE This is a combination of stress and urge incontinence Even with so many women between ages 45 and 64 being affected by urinary incontinence, very few seek evaluation

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The most effective approach teams the woman with a healthcare provider and a continence educator (typically a nurse) for coaching and personal support. and treatment. Often it’s due to embarrassment, or because many women believe that incontinence is a normal aspect of aging and can’t be treated. Treatment can be very successful – from simple interventions such as treating a persistent cough, or taking antibiotics for a urinary tract infection, to doing regular Kegel exercises and biofeedback, to taking daily medicine or even having surgery. The most effective approach teams the woman with a healthcare provider and a continence educator (typically a nurse) for coaching and personal support.

Talk About Your Symptoms Rebecca Kightlinger, D.O., an assistant professor of obstetrics and gynecology at the University of Virginia in Charlottesville, says that up to half of her postmenopausal patients leak urine. She notes, “If I didn’t ask, many of them wouldn’t bring it up, because they think it’s normal.” Incontinence isn’t normal. And it can have

a major impact on your quality of life, from curtailing leisure activities and wardrobe choices to snuﬃng out your sex life. Yet studies find that less than half of women ages 45 to 64 with urinary incontinence seek evaluation and treatment.

Getting Treatment When determining how to treat your condition, your healthcare provider will first consider the type of incontinence you have. Not all treatments are appropriate for every type. Most experts recommend trying the least invasive, non-medical options before opting for medication or surgery.

Best for … … All Types of Incontinence Behavioral therapies. These include Kegel exercises to strengthen and condition pelvic floor muscles and bladder training to lengthen the time between voiding and to control urination urges.

CASE STUDY When Brenda Strong, 61, from Tampa, Fla., was forced to decline an invitation to her local golf invitational, she realized it was time to do something about her bladder control problems. “It happened gradually with leakage, but it had gotten to the point of embarrassment for me, and the thought of spending 18 holes without being close to a bathroom caused me anxiety. I couldn’t handle the thought of embarrassing myself in front of all my friends and the members of the club,” Strong remembers. But it wasn’t until an appointment with her physician that she realized there were lifestyle changes that she could make to lessen the

frequency of her urges to use the bathroom and the resulting urine leakage. Strong started a program of Kegel exercises to strengthen her pelvic floor, and the avid golfer also started swimming at her local pool three times a week to trim down her tummy. “After about six weeks of adjusting my exercise routine, by adding three days of swimming along with starting up my weekly golfing schedule again, I started to lose weight,” she says. “With the added strength of my pelvic muscles, I felt more confident about spending time away from the bathroom without embarrassing myself.”

a Proof 1

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… Stress Incontinence Injectable implants. Collagen is injected into the tissue surrounding the opening of the urethra, adding bulk and helping to close it. Surgery. Surgical techniques, some using “slings” or tape-like material, can prevent further sagging of pelvic structures. Support and plug devices. These are inserted into the vagina or the urethra to stop urine leakage. These also have good results for mixed incontinence.

… Urge Incontinence Medication. Options include oxybutynin (Ditropan®, Oxytrol®), tolterodine (Detrol®), darifenacin (Enablex®), solifenacin (Vesicare®), and trospium

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Patient Information VESIcare® – (VES-ih-care) (solifenacin succinate) Read the Patient Information that comes with VESIcare before you start taking it and each time you get a refill. There may be new information. This leaflet does not take the place of talking with your doctor or other healthcare professional about your condition or treatment. Only your doctor or healthcare professional can determine if treatment with VESIcare is right for you. What is VESIcare? VESIcare is a prescription medicine used in adults to treat the following symptoms due to a condition called overactive bladder: • Having to go to the bathroom too often, also called “urinary frequency” • Having a strong need to go to the bathroom right away, also called “urgency” • Leaking or wetting accidents, also called “urinary incontinence” VESIcare has not been studied in children. What is overactive bladder? Overactive bladder occurs when you cannot control your bladder contractions. When these muscle contractions happen too often or cannot be controlled you can get symptoms of overactive bladder, which are urinary frequency, urinary urgency, and urinary incontinence (leakage). Who should NOT take VESIcare? Do not take VESIcare if you: • Are not able to empty your bladder (also called “urinary retention”) • Have delayed or slow emptying of your stomach (also called “gastric retention”) • Have an eye problem called “uncontrolled narrow-angle glaucoma” • Are allergic to VESIcare or any of its ingredients. See the end of this leaflet for a complete list of ingredients What should I tell my doctor before starting VESIcare? Before starting VESIcare tell your doctor or healthcare professional about all of your medical conditions including if you: • Have any stomach or intestinal problems or problems with constipation • Have trouble emptying your bladder or you have a weak urine stream • Have an eye problem called narrow-angle glaucoma • Have liver problems • Have kidney problems • Are pregnant or trying to become pregnant (It is not known if VESIcare can harm your unborn baby) • Are breastfeeding (It is not known if VESIcare passes into breast milk and if it can harm your baby. You should decide whether to breastfeed or take VESIcare, but not both) Before starting on VESIcare, tell your doctor about all the medicines you take including prescription and nonprescription medicines, vitamins, and herbal supplements. While taking VESIcare, tell your doctor or healthcare professional about all changes in the medicines you are taking including prescription and nonprescription medicines, vitamins and herbal supplements. VESIcare and other medicines may affect each other. How should I take VESIcare? Take VESIcare exactly as prescribed. Your doctor will prescribe the dose that is right for you. Your doctor may prescribe the lowest dose if you have certain medical conditions such as liver or kidney problems. • You should take one VESIcare tablet once a day • You should take VESIcare with liquid and swallow the tablet whole • You can take VESIcare with or without food • If you miss a dose of VESIcare, begin taking VESIcare again the next day. Do not take 2 doses of VESIcare the same day • If you take too much VESIcare or overdose, call your local Poison Control Center or emergency room right away What are the possible side effects with VESIcare? VESIcare may cause allergic reactions that may be serious. Symptoms of a serious allergic reaction may include swelling of the face, lips, throat or tongue. If you experience these symptoms, you should stop taking VESIcare and get emergency medical help right away. The most common side effects with VESIcare are: • Blurred vision. Use caution while driving or doing dangerous activities until you know how VESIcare affects you • Dry mouth • Constipation. Call your doctor if you get severe stomach area (abdominal) pain or become constipated for 3 or more days • Heat prostration. Heat prostration (due to decreased sweating) can occur when drugs, such as VESIcare, are used in a hot environment Tell your doctor if you have any side effects that bother you or that do not go away. These are not all the side effects with VESIcare. For more information, ask your doctor, healthcare professional or pharmacist. How should I store VESIcare? • Keep VESIcare and all other medications out of the reach of children • Store VESIcare at room temperature, 50° to 86°F (15° to 30°C). Keep the bottle closed • Safely dispose of VESIcare that is out of date or that you no longer need General information about VESIcare Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets. Do not use VESIcare for a condition for which it was not prescribed. Do not give VESIcare to other people, even if they have the same symptoms you have. It may harm them. This leaflet summarizes the most important information about VESIcare. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about VESIcare that is written for health professionals. You can also call (800) 727-7003 toll free, or visit www.VESIcare.com What are the ingredients in VESIcare? Active ingredient: solifenacin succinate Inactive ingredients: lactose monohydrate, corn starch, hypromellose 2910, magnesium stearate, talc, polyethylene glycol 8000 and titanium dioxide with yellow ferric oxide (5 mg VESIcare tablet) or red ferric oxide (10 mg VESIcare tablet) Rx Only Manufactured by: Astellas Pharma Technologies, Inc. Norman, Oklahoma 73072 Marketed and Distributed by: Astellas Pharma US, Inc. Deerfield, Illinois 60015-2548 Marketed by: GlaxoSmithKline Research Triangle Park North Carolina 27709

(Sanctura®) to calm an overactive bladder and topical estrogen therapy to help restore blood flow to the urethra and vagina, and to strengthen the tissue lining. Electrical stimulation devices. These direct a painless, mild electrical current to the urogenital area to strengthen the muscles around the urethra. These devices can also be used for stress incontinence. “Women need to understand that incontinence symptoms are common and can be treated,” says Lindsey A. Kerr, M.D., co-director of the Pelvic Care and Continence Center at the University of Utah in Salt Lake City. “They don’t have to accept them, and there are solutions other than wearing pads to stay dry.”

Kegel Exercises: Get Them Right Studies ﬁnd that Kegel exercises, which aim to strengthen pelvic ﬂoor muscles, can be more effective than medication in treating urge incontinence, because they address the cause of the problem, not the symptoms. But there’s a catch. You need to learn to do them properly, do them regularly, and keep doing them, says Ivy Alexander, Ph.D., a women’s health expert at Yale University School of Nursing and a Changes medical advisor. Here’s how:

» Identify the correct muscle groups to strengthen. Try to stop the urine stream while you’re urinating. Those are the correct muscle groups, the ones you want to work on. (But don’t try Kegels while you’re urinating. It could cause irregular voiding patterns.)

» Try the strongest contraction you can manage and count to

10, then relax. And go slow, says Alexander. “Quickies” won’t make muscles stronger. Each time you contract, hold for increasing lengths of time until you can hold for 10 seconds.

» Try ﬁve sets of contractions and releases twice a day. Increase to 10 sets twice a day, then 10 sets three times daily.

» Schedule Kegels every day. You can practice the contractions throughout your day – waiting in line at the store, on the bus, at your desk – no one needs to know. Challenge yourself by coughing or clearing your throat while performing the exercise. You’ll be laughing without fear of leaks in no time! Still ﬁnding it difﬁcult? You can view Kegel instructions and diagrams on the American Physical Therapy Association website at www.apta.org (type “Kegel” into the search engine).

Always running to the bathroom? Maybe your internal plumbing isn’t working like it should. This checklist can help you talk to your doctor about it. When I go out, I always make sure there’s a bathroom nearby.

YES

Once I get the sudden urge to go, I can’t wait. I wear pads sometimes because I worry I might accidentally leak. I’ve had enough, and I’m ready to do something about my urges and leaks. If you answered “Yes” to any of these, tear out this checklist and talk to your doctor about your results. Only your doctor can determine if you have overactive bladder. Once-daily VESIcare is proven to treat overactive bladder with symptoms of frequent urges and leaks.* That’s because it can help control your bladder muscle, day and night. So ask your doctor about taking care with VESIcare. *Results may vary. USE AND DOSE

VESIcare is for overactive bladder with symptoms of urgency, frequency, and leakage. The recommended dose of VESIcare is 5 mg once daily. If the 5-mg dose is well tolerated, your doctor may increase the dose to 10 mg once daily.

Clip here, tear out, and pipe up to your doctor.

IMPORTANT SAFETY INFORMATION

VESIcare is not for everyone. If you have certain stomach or glaucoma problems, or trouble emptying your bladder, do not take VESIcare. VESIcare may cause allergic reactions that may be serious. If you experience swelling of the face, lips, throat or tongue, stop taking VESIcare and get emergency help. Tell your doctor right away if you have severe abdominal pain, or become constipated for three or more days. VESIcare may cause blurred vision, so use caution while driving or doing unsafe tasks. Common side effects are dry mouth, constipation, and indigestion. Please see Important Patient Information on the following page.

First 30-day prescription Take care with free† at vesicare.com, or call (800) 403-6565. Subject to eligibility. Restrictions may apply.

†

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

SEXUALITY

SEX

AND THE

NITTY

GRITTY Samantha Jones’ sex drive may not have been affected by menopause, but for most postmenopausal women it takes a little more than an apple martini to get in the mood. However, there may be more to it than menopause. Our experts look at how you can turn from ‘cooled off’ to cougar!

aving been single for seven years, 56-year-old Sara Thomas* wasn’t too concerned about having sex anymore. But the reality of falling estrogen levels hit when she met her second husband. “It was the beginning of a rela-

tionship so, of course, we wanted to be together all the time,” she says. “But that wasn’t possible. It wasn’t that I wasn’t interested; it was just too painful to consider.” This experience isn’t unusual, says Susan Kellogg-Spadt, Ph.D., CRNP, director of sexual medicine at the Pelvic and

Sexual Health Institute of Philadelphia. “The three most common complaints I hear from middle-aged women about sex are lack of desire, diﬃculty in arousal and response, and painful intercourse.” But, she says, women don’t have to let these issues hold them back.

Sex and the Sixties Sex drive slowly declines with age in both sexes, but everyone has a unique experience. Some notice a decline in desire, and others have no change at all. Research shows, however, that women are two to three times more likely than men to be affected by a low sex drive, especially when they are in long-standing relationships. So what’s menopause got to do with it? The relationship between menopause and sexual desire is complex and still under study. Reduced estrogen levels can contribute to hot flashes and night sweats, robbing a woman of restful sleep and reducing her interest in sex. “With less estrogen, the walls of the vagina become thinner and lose their elasticity, and vaginal secretions diminish,” explains Mary Jane Minkin, M.D., an obstetrician/gynecologist and clinical professor of medicine at Yale Medical School. Translation: dryness, irritation, and pain. Also, loss of estrogen results in an increase in vaginal pH, changing the healthy acidic environment to an alkaline one that is more susceptible to vaginal infection. This condition, known as atrophic vaginitis, affects an estimated four in 10 postmenopausal women. This not only can make sex painful, but it can increase your risk of sexually transmitted diseases. Fragile vaginal tissues are prone to injury, tearing,

and bleeding during sexual intercourse or even during a pelvic examination. At the same time, the ovaries’ production of another hormone – testosterone – lessens with aging, possibly decreasing desire. Women experiencing induced menopause caused by removal of both ovaries or by chemotherapy have an accelerated decrease in estrogen and testosterone levels, causing more severe problems than in women having natural menopause.

The Good News Although hormonal changes may play a significant role in any loss of libido, the Massachusetts Women’s Health Study, which surveyed 2,569 middle-aged women, found a woman’s menopausal status has a lesser impact on her sexual functioning than other aspects of middle age. So consider the following before chalking up your loss of libido to hormones: Your sexual history. If you used to want sex every night, you’ll still be more interested in lovemaking than a woman who has never had much interest in sex. Occasionally, however, women may have an increased interest in sex at perimenopause possibly due to changes in the ratio of estrogen and androgens. Your relationship. “If there’s tension in your relationship, for whatever reason, it’s going to affect what goes on in the bedroom,” says Minkin.

Health issues. If you’ve had breast surgery or a hysterectomy, you may feel less secure in your identity as a woman and be reluctant to initiate sex, or your partner may be concerned and protective. Stress. “Maybe you’ve got kids or grandkids in the house, and you think you can’t have sex, or you’re worried about putting your parents in a nursing home – all of these things impede your sex life,” says Minkin. Insomnia. Whether it was a hot flash at 2 a.m. or your husband’s lumberjack-like snoring, irritability from lack of sleep can be a block to sex, says Minkin. Prescription drugs. “There’s a lot of press about how certain medications affect erectile dysfunction in men, but there’s little understanding about how they affect sexual function in women,” says Ivy Alexander, Ph.D., an associate professor of nursing at Yale. One theory is that anything that dries out mucous membranes – such as allergy medications or antidepressants – will also dry out the vagina. Self-esteem. If you feel unattractive and undesirable, you can create a self-fulfilling prophecy when it’s time to undress in front of your partner. Your partner’s attitude toward sex. Whether your partner is disinterested in sex, has a sexual dysfunction, or is reaping the rewards of Viagra®, his attitude can affect your sexual function and satisfaction as well. Often, a partner’s sexual issues need addressing also.

SEXUALITY

America Reveals Its Sexual Secrets In the most comprehensive survey since the Kinsey Report in 1953, we have a contemporary picture of what really goes on in the bedrooms of Americans between the ages of 14 and 94. This representative, internet-based study of nearly 6,000 Americans shows us a “snapshot” of the country’s sexual behaviors, condom & contraceptive use, and sexual health. Interestingly, it seems that people over 40 are having varied and satisfying sexual experiences, but are perhaps not so great at condom use, reports the research team from Indiana University.

Variety Seems to Be the Spice of Life The ﬁndings of the survey are very interesting in terms of the sexual behavior of older Americans. The report suggests that while vaginal intercourse is still the most common sexual behavior, many “sexual events” do not involve intercourse and include only partnered masturbation or oral sex. It also suggests that many older adults continue to have active sex lives, with a range of different behaviors and partner types. For example, between the ages of 60 and 69, 38% of men and 25% of women indicated they had been given oral sex by a partner of the opposite sex in the past year. Vaginal intercourse is still the most common sexual act among adult men and women, but many people have sexual events that do not include intercourse. The next most common sexual repertoires consisted of giving and receiving oral sex with vaginal intercourse, and giving and receiving oral sex along with partnered masturbation and vaginal intercourse. The results suggest that women

may still be faking it. About 85% of men reported that their partner had an orgasm during their most recent sexual event, but only 64% of women reported having had an orgasm the last time they had sex. Men were more likely to orgasm when sex included vaginal intercourse, but for women, variety appeared to be important, as they were signiﬁcantly more likely to orgasm if they gave oral sex, received oral sex, had vaginal intercourse, or received anal sex. Both men and women were more likely to orgasm if they engaged in a greater number of sexual behaviors.

Get This Of the five basic acts identified – penile/vaginal intercourse, solo masturbation, mutual masturbation, oral sex, and anal sex – more than 6% of men aged 25 to 29 claimed to have engaged in all five during their last sexual event. For women, 16% aged 18 to 24 engaged in four or five of the five basic acts the last time they had sex, as did 8% of women aged 50 to 59. Go girl!

Safer Sex, Please, Ladies In terms of sexual health, probably one of the survey’s most important ﬁndings is that condoms are used in only one in four acts of vaginal intercourse, and in one in three acts of vaginal intercourse among singles. The researchers suggest that efforts to promote condom use among sexually active individuals should remain a public health priority.

The main findings for condom use are:

» Condoms are used twice as often among casual sexual partners than among relationship partners across all age groups.

» Adults over 40 have the lowest rate of condom use; the highest rates of use were among 14- to 17-year-olds.

» Condom use is higher among black and Hispanic Americans than among other racial groups.

» Adults using a condom were just as likely to rate sexual intercourse positively in terms of arousal, pleasure, and orgasm than when having intercourse without one. The authors say the United States faces significant challenges in terms of the population’s sexual and reproductive health, particularly regarding the impact of HIV, high rates of other sexually transmitted infections, and high numbers of unplanned pregnancies. This large survey is one of the most comprehensive studies of U.S. sexual behavior and condom use in almost two decades. Its findings are important for all age groups, but it is interesting to note the high level and variety of sexual activity of older Americans. However, it should be noted that, unlike Kinsey’s research, the findings are not based on in-depth interviews but on self-response surveys via the internet and therefore may be less reliable. However, those responses may have been more candid.

SEXUALITY

Fifty, Feisty & Fearless! And that’s not all: Recent research shows that those in their ﬁfties (and up) are healthier, happier, and feel more fabulous than any previous generation. The ‘carpe diem’ generation!

ou are, as they say, “only as old as you feel,” and if you have passed your 50th birthday, that’s a lot younger than you actually are! Researchers recently found that if you are in your fifties, you are likely to feel on average 12 years younger – those in their forties felt only six years younger. These “young at hearts” benefit from good friends, owning a pet, younger outlooks, and enjoy good sex and healthy lifestyles. The growing number of single women in their fifties (known as ‘swifties’) report enjoying going out to nightclubs, jetting off to exotic locations, and tweeting and Facebooking their experiences on the internet. It also seems that the fashion, style, beauty, and makeup gap is closing in, with 26% of women sharing outfit and style tastes with their daughters. In another recent study of 340,000

Americans over 50, scientists asked how we were feeling, and the answer: “Much better than when we were younger, thank you very much.” Scientists found that 50-plus women are more confident, less stressed, more empowered, and embracing a time of life where they can enjoy themselves again. They have cash and know how to spend it wisely – well, mostly, anyway – and they are enjoying new experiences now that they are free from the responsibilities of child rearing and homemaking. Further research has confirmed that 50 is a second coming of age for travelers, particularly women who wish to travel far and wide, and often “the road less traveled.” Women are looking for challenging and exciting experiences, and are more adventurous and active than previous generations. And if you’re not 50 yet? Well, at least you’ve got something to look forward to!

RESTASIS® (cyclosporine ophthalmic emulsion) 0.05% Sterile, Preservative-Free INDICATIONS AND USAGE RESTASIS® ophthalmic emulsion is indicated to increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca. Increased tear production was not seen in patients currently taking topical anti-inflammatory drugs or using punctal plugs. CONTRAINDICATIONS RESTASIS® is contraindicated in patients with active ocular infections and in patients with known or suspected hypersensitivity to any of the ingredients in the formulation. WARNING RESTASIS® ophthalmic emulsion has not been studied in patients with a history of herpes keratitis. PRECAUTIONS General: For ophthalmic use only. Information for Patients The emulsion from one individual single-use vial is to be used immediately after opening for administration to one or both eyes, and the remaining contents should be discarded immediately after administration. Do not allow the tip of the vial to touch the eye or any surface, as this may contaminate the emulsion. RESTASIS® should not be administered while wearing contact lenses. Patients with decreased tear production typically should not wear contact lenses. If contact lenses are worn, they should be removed prior to the administration of the emulsion. Lenses may be reinserted 15 minutes following administration of RESTASIS® ophthalmic emulsion. Carcinogenesis, Mutagenesis, and Impairment of Fertility Systemic carcinogenicity studies were carried out in male and female mice and rats. In the 78-week oral (diet) mouse study, at doses of 1, 4, and 16 mg/kg/day, evidence of a statistically significant trend was found for lymphocytic lymphomas in females, and the incidence of hepatocellular carcinomas in mid-dose males significantly exceeded the control value. In the 24-month oral (diet) rat study, conducted at 0.5, 2, and 8 mg/kg/day, pancreatic islet cell adenomas significantly exceeded the control rate in the low dose level. The hepatocellular carcinomas and pancreatic islet cell adenomas were not dose related. The low doses in mice and rats are approximately 1000 and 500 times greater, respectively, than the daily human dose of one drop (28 µL) of 0.05% RESTASIS® BID into each eye of a 60 kg person (0.001 mg/kg/day), assuming that the entire dose is absorbed. Cyclosporine has not been found mutagenic/genotoxic in the Ames Test, the V79-HGPRT Test, the micronucleus test in mice and Chinese hamsters, the chromosome-aberration tests in Chinese hamster bonemarrow, the mouse dominant lethal assay, and the DNA-repair test in sperm from treated mice. A study analyzing sister chromatid exchange (SCE) induction by cyclosporine using human lymphocytes in vitro gave indication of a positive effect (i.e., induction of SCE). No impairment in fertility was demonstrated in studies in male and female rats receiving oral doses of cyclosporine up to 15 mg/kg/day (approximately 15,000 times the human daily dose of 0.001 mg/kg/day) for 9 weeks (male) and 2 weeks (female) prior to mating. Pregnancy-Teratogenic Effects Pregnancy category C.

Teratogenic Effects: No evidence of teratogenicity was observed in rats or rabbits receiving oral doses of cyclosporine up to 300 mg/kg/day during organogenesis. These doses in rats and rabbits are approximately 300,000 times greater than the daily human dose of one drop (28 µL) 0.05% RESTASIS® BID into each eye of a 60 kg person (0.001 mg/kg/day), assuming that the entire dose is absorbed. Non-Teratogenic Effects: Adverse effects were seen in reproduction studies in rats and rabbits only at dose levels toxic to dams. At toxic doses (rats at 30 mg/kg/day and rabbits at 100 mg/kg/day), cyclosporine oral solution, USP, was embryo- and fetotoxic as indicated by increased pre- and postnatal mortality and reduced fetal weight together with related skeletal retardations. These doses are 30,000 and 100,000 times greater, respectively than the daily human dose of one-drop (28 µL) of 0.05% RESTASIS® BID into each eye of a 60 kg person (0.001 mg/kg/day), assuming that the entire dose is absorbed. No evidence of embryofetal toxicity was observed in rats or rabbits receiving cyclosporine at oral doses up to 17 mg/kg/day or 30 mg/kg/day, respectively, during organogenesis. These doses in rats and rabbits are approximately 17,000 and 30,000 times greater, respectively, than the daily human dose. Offspring of rats receiving a 45 mg/kg/day oral dose of cyclosporine from Day 15 of pregnancy until Day 21 post partum, a maternally toxic level, exhibited an increase in postnatal mortality; this dose is 45,000 times greater than the daily human topical dose, 0.001 mg/kg/day, assuming that the entire dose is absorbed. No adverse events were observed at oral doses up to 15 mg/kg/day (15,000 times greater than the daily human dose). There are no adequate and well-controlled studies of RESTASIS® in pregnant women. RESTASIS® should be administered to a pregnant woman only if clearly needed. Nursing Mothers Cyclosporine is known to be excreted in human milk following systemic administration but excretion in human milk after topical treatment has not been investigated. Although blood concentrations are undetectable after topical administration of RESTASIS® ophthalmic emulsion, caution should be exercised when RESTASIS® is administered to a nursing woman. Pediatric Use The safety and efficacy of RESTASIS® ophthalmic emulsion have not been established in pediatric patients below the age of 16. Geriatric Use No overall difference in safety or effectiveness has been observed between elderly and younger patients. ADVERSE REACTIONS The most common adverse event following the use of RESTASIS® was ocular burning (17%). Other events reported in 1% to 5% of patients included conjunctival hyperemia, discharge, epiphora, eye pain, foreign body sensation, pruritus, stinging, and visual disturbance (most often blurring). Rx Only

Fill a RESTASIS® Ophthalmic Emulsion prescription and we’ll send you a check for $20! It’s easy to get your $20 rebate for RESTASIS® Ophthalmic Emulsion. Just fill out this information and mail. Follow these 3 steps: 1. Have your prescription for RESTASIS® filled at your pharmacy. 2. Circle your out-of-pocket purchase price on the receipt. 3. Mail this certificate, along with your original pharmacy receipt (proof of purchase), to Allergan RESTASIS® Ophthalmic Emulsion $20 Rebate Program, P.O. Box 6513, West Caldwell, NJ 07007. ❑ Enroll me in the My Tears, My Rewards ® Program to save more! ❑ I am not a patient enrolled in Medicare, Medicaid, any similar federal or state healthcare program, or a resident of Massachusetts.

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For more information, please visit our Web site, www.restasis29.com.

RESTASIS Rebate Terms and Conditions: To receive a rebate for the amount of your prescription co-pay (up to $20), enclose this certificate and the ORIGINAL pharmacy receipt in an envelope and mail to Allergan RESTASIS® Ophthalmic Emulsion $20 Rebate Program, P.O. Box 6513, West Caldwell, NJ 07007. Please allow 8 weeks for receipt of rebate check. Receipts prior to March 31, 2010 will not be accepted. One rebate per consumer. Duplicates will not be accepted. See rebate certificate for expiration date. Eligibility: Offer not valid for prescriptions reimbursed or paid under Medicare, Medicaid, or any similar federal or state healthcare program including any state medical or pharmaceutical assistance programs. Void in the following state(s) if any third-party payer reimburses you or pays for any part of the prescription price: Massachusetts. Offer void where prohibited by law, taxed, or restricted. Amount of rebate not to exceed $20 or co-pay, whichever is less. This certificate may not be reproduced and must accompany your request for a rebate. Offer good only for one prescription of RESTASIS® Ophthalmic Emulsion and only in the USA and Puerto Rico. Allergan, Inc. reserves the right to rescind, revoke, and amend this offer without notice. You are responsible for reporting receipt of a rebate to any private insurer that pays for, or reimburses you for, any part of the prescription filled, using this certificate. ®

marks owned by Allergan, Inc. Please allow 8 weeks for delivery of your rebate check.

APC77DY10

Certificate expires 12/31/2011

Available by prescription only.

Why aren’t artiﬁcial tears enough for me?

Alison Tendler MD,

They provide temporary relief. If your type of Chronic Dry Eye causes inﬂammation which decreases your ability to make tears, use RESTASIS®. I do.

RESTASIS® User, Eye Doctor

RESTASIS® Ophthalmic Emulsion helps increase your eyes’ natural ability to produce tears, which may be reduced by inﬂammation due to Chronic Dry Eye. RESTASIS® did not increase tear production in patients using anti-inﬂammatory eye drops or tear duct plugs. Important Safety Information: RESTASIS® Ophthalmic Emulsion should not be used by patients with active eye infections and has not been studied in patients with a history of herpes viral infections of the eye. RESTASIS® should not be used while wearing contact lenses. If contact lenses are worn, they should be removed prior to use. The most common side effect is a temporary burning sensation. Other side effects include eye redness, discharge, watery eyes, eye pain, foreign body sensation, itching, stinging, and blurred vision. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. Please see next page for important product information.

Go to restasis29.com, or call 1-866-311-2412 for a free kit. Find out more about a $20 rebate offer! See next page for details. Dr Tendler is an actual patient and is compensated for appearing in this advertisement.

Leader in Dry Eye Care