MENOPAUSE: WHEN YON LEAST EXPECT IT
No more incongruous time or place could be imagined, the night I was hit by the first bombshell of the battle with menopause. It was a Sunday evening. Snug inside a remarriage not yet a year old, I was sitting utterly still, reading, in a velvet-covered armchair. A pillow's throw away my husband was doing the same, while jazz lapped at our ears and snow curtained the window. Every so often we looked up and congratulated ourselves on staying home in this cocoon of comfort and safeness and love we had created.
Then the little grenade went off in my brain. A flash, a shock, a sudden surge of electrical current that whizzed through my head and left me feeling shaken, nervous, off-balance.
"What was that?" I must have mumbled.
"What?"
"Nothing."
But some powerful switch had been thrown. I tried to go back to reading. It was difficult to concentrate. When I looked down at the pages I had just finished, I realized the imprint of their content on my brain had washed out. I felt hot, then clammy. I tried lying down, but sleep could not soak up the agitation. My heart was racing, but from what? Complete repose? I felt, for perhaps the first time in my life since the age of thirteen, profoundly ill at ease inside my body.
In the months that followed, I sometimes felt outside my body. I was aware of spates of "static" in my brain and came to recognize the aura that preceded the first migraine-like headaches I'd ever had. Usually optimistic, I began having little bouts of blues. Then little crashes of fatigue. Having always counted on abundant energy, it was profoundly upsetting to find myself sometimes crawling home from a day of writing and falling into bed for a "nap," from which I had to drag myself up just to have dinner.
I was only forty-eight. And still menstruating. So this couldn't be "Change of Life," could it?
Besides, all these strange physical sensations were only background noise in what was otherwise a thrilling, adrenaline-pumping, mind-stretching period of creative redirection, in both my career and my new family life. I was traveling all over the country and the world and coming home to a husband and new adopted child, both of whom I adored, satisfied that another beloved daughter was already launched. So I took Scarlett's "fiddle-dee-dee" approach; I'd think about it tomorrow.
But tomorrow I began to notice something strange. For the first time since my early teens, when the sexual pilot light went on and I was warned not to want sex too much, I began to worry about not wanting it enough. Again, I had the sensation of standing outside my body and scolding it: "What's the matter with you why don't you act the way I feel anymore?"
I went to see my conservative, male gynecologist, known as a superb clinician but short on communication skills. He measured my hormone levels. I was very low on estrogen. I vaguely remembered my family doctor having mentioned in passing, when he'd rattled off the results of my annual physical in recent years, that my estrogen levels were getting lower and lower.
"Could I be a candidate for hormone replacement therapy?" I asked.
"Not yet." My gynecologist went strictly by the book. "You're not in menopause, because you're still menstruating. You have to be menstruation-free for a year before I can give you estrogen replacement."
"But this, um, effect on my sexual response" embarrassed, I fumbled for the words "couldn't that be because I need more estrogen, like a vitamin supplement?"
"It's nothing I can help you with. Decrease in sexual response is just a natural part of aging."
The curt clinician washed his hands of me. I left his office feeling as though I'd just been handed a one-way ticket to the Dumpster. Does this mean I can't be me anymore?
It was time for me to shop for another gynecologist. A recommendation sent me to see Patricia Allen, a vivacious woman in her forties and an attending physician at New York Hospital, who demands excellence of herself and discipline from her patients. She made it clear from the start that she does not accept passive patients or women who smoke, only those who are willing to participate actively in their own health care. That sounded reasonable. She spent a good twenty minutes before the physical exam taking a holistic history. The irregular periods, the erratic expanding and constricting of blood vessels that caused the static, and the mood swings indicated to her that I was in perimenopause. Then she said something startling:
"I believe in treating each patient as an individual. This perimenopausal period should be a transformation, so that a woman gets to becomephysically, emotionally, and spirituallythe best that she ever was." Imagine your run-of-the-mill male gynecologist harboring such a radical point of view!
Dr. Allen posited that the impact of low estrogen on me, as on many women, was emotional. Of the several hundred patients who consult her about managing their menopause, quite a few mention feeling depressed although they have no rational reason to be. She also took seriously my distress over changes in libido. She asked if there was a history of osteoporosis in my family, which brought to mind memories of my mother suffering in her seventies as she sat on her powdery bones.
All in all, Dr. Allen felt I was a good candidate for hormone therapy, but she drove a strict bargain with her patients. Estrogen by itself carries a known increase in the risk of cancer of the endometriumthe lining of the uterus which is sloughed during menstrual periods. So she also prescribed a progestin* (synthetic progesterone), reportedly a protection against that risk. Also, I would have to agree to have an endometrial biopsy several months later to detect any changes in the tissue. She urged me to have a bone density evaluation done ($250), as well as a mammogram. This complete diagnostic workup cost $800, much of which was reimbursable by health insurance. It was costly, but it turned out to be part of an investment in long-term health and productivity that has more than paid for itselfand one I would recommend for all women who can afford it.
I filled the standardized prescription for 0.625 mg of Premarin (estrogen made from pregnant mares' urine, from which it derives its unforgettable name) and 10 mg tablets of Provera, the progesterone that stimulates the sloughing of the uterine lining. This is an approximation of the two hormones that the body produces naturally in the reproductive years.
After only a month, the estrogen had rekindled sexual desire, stopped the surges of static and dips of fatigue, and chased away the blues. But the Provera was another matter. It brought on unbelievable physical and emotional symptoms that I'd never experienced before. After a year of the combined hormones, my body seemed to be at war with itself for half of every month. My energy was flagging, and resistance to minor infections was falling. I felt as if I were racing my motor. So I stopped taking hormones cold turkey.
Dr. Allen agreed it was a good idea to take a break and see how the body responded. If nothing else, she said, going off hormones often serves to remind women why they started taking them in the first place.
For the first two months off hormones I felt marvelous; the bloating disappeared, as did the induced periods, and the terrible cramps and tension and sleeplessness that had begun to accompany them. I even got my waist back. Then, a crash. All the perimenopausal phenomena returned with exaggerated force. Now the static became full-fledged hot flashes and night sweats that interrupted sleep and left me limp by morning. I went back to my estrogen pills.
Within days the "blue-meanie" moods lifted. I was able to write for 12 hours straight on deadline and remain calm and reasonable under crisis. Within a few weeks all the other complaints were gone. I was staggered by the potency of the female hormone.
But the impact of the progesterone was also intensified. On day fifteen, when I had to add the Provera pills to my regimen, I felt by afternoon as if I had a terrible hangover. This chemically induced state was not to be subdued by aspirin or a walk in the park. It only worsened as the day wore on, bringing with it a racing heart, irritability, waves of sadness, and difficulty concentrating. And to top it off, the hot flashes came back! Cramps introduced pain for a week at a time. By night I couldn't go to sleep without a glass of wine, and even then was awakened by a racing heartbeat and sweating. Won't I ever be me anymore?
It didn't require a ten-year clinical trial and double-blind study to guess what was going on. Taking synthetic progesterone with the estrogen for half of each month was like pushing down the gas pedal and putting on the brakes at the same time, and it had left my body confused and worn out.
Clinicians I later interviewed relayed common side effects reported by patients who were taking the drug: "Whenever I take Provera, I have migraines, bloating, breast tenderness, the blues. I feel awful and want to die."
No wonder only 15 percent of American women in menopause are using hormone therapy. (There's an interesting deviation between the two coasts; in the Northeast it's five to 10 percent of the menopausal population, while in California, citadel of youth and vanity, it's closer to 30 percent.) The numbers are even lower in Great Britain, where only nine percent of women with menopausal symptoms are on hormone replacement therapy. Dr. Marc Deitch, medical director of Wyeth-Ayerst, the cash cow of the pharmaceutical giant American Home Products, which introduced Premarin fifty years ago, acknowledges that the average length of time women continue on estrogen replacement is only nine months. An estimated one third of those given prescriptions for hormones never even fill them, and two thirds of those who start out with the combination simply drop the progesterone after about a year.
*3\221\2*
Womens health