Women's Moods

Women's Moods, by Deborah Sichel and Jeanne Watson Driscoll, ISBN 0-688-14898-0

This book is written by a psychiatrist and a nurse/psychotherapist who founded a women's mental health center that incorporates into their basic treatment philosophy an understanding of how hormonal influences affect our mental wellness. Aside from a few quibbles, mostly things that have to do with the fact that the book was published a number of years ago now, we think it's a tremendously sound and useful resource for us all. We're going to summarize and discuss a lot of it here, but we're still just skimming the top of the varied information presented. This review does not encompass everything of value in the book; this is merely intended to help you decide whether or not and how it might be useful for you as you explore strategies for dealing with surgical menopause.

Overall, the material in the book is excellent: content-rich, physiologically sound, simple enough for a non-professional to follow but not a simplistic "pop science" sales pitch. There's real content to take away from this book.

Their premise is that estrogen and its related ovarian hormones have profound effects upon brain function. We've more or less reviewed that basic physiologic information in a previous discussion here, so we're going to assume you've already read that. Go ahead and read it now if you haven't. But beyond that relationship, Sichel and Driscoll go further into how hormonal imbalances have a lasting effect on brain function.

According to these authors, low-level and intermittent brain dysfunction induced by hormonal imbalances, stressful episodes, and genetic susceptibility are often unrecognized heralds of more serious brain dysfunction, episodes of which may later be brought out by more serious hormonal imbalance. Although a lot of their material speaks to hormonal imbalances of puberty and menstruation setting the stage for pathological levels of postpartum depression or other brain dysfunctions (worsening of OCD, bipolar disorders, etc), they also acknowledge that the hormonal dip of menopause can be a similar trigger. In other words, our experiences of hormone balance (or lack thereof) earlier in life leaves us more susceptible to dysfunctional brain episodes whenever we undergo another hormonal uproar, of which menopause is clearly a significant example.

I'm going to give a lengthy quote here of content that goes into some detail on this imprinting (or as they call it, "dysregulating") process because I feel it has real applicability to our situation when we experience sudden-onset surgical menopause:

You've been held up at knifepoint and your heart raced, your mouth became dry, and your stomach churned. You may wonder how all that happened so quickly. Your response to stress is a lightning-fast yet highly complex cascade of chemical and biological events in your brain and body.

A nucleus in your old brain [that is, closer to your brain stem, the more primitive part of your brain] called the locus ceruleus is the brain's main depot for the neurotransmitter norepinephrine. Norepinephrine activates serotonin and cortisol-releasing hormone from structures in the limbic brain, and prompts the pituitary gland to release adenocorticotropic hormone (ACTH) into the bloodstream. ACTH tells the adrenal glands, which sit atop the kidneys, to secrete cortisol and adrenaline, the body's stress hormones, which in turn send your heart pumping, your stomach churning, and so on. As complicated as this may sound, amazingly the entire circuit is activated within milliseconds. 

Every part of this stress circuit (what's called the hypothalamus-pituitary-adrenal circuit or HPA) is pumping to biochemically enable you to respond. You are now primed to meet the crisis. 

When the robbery is over, you may be left without your wallet, but your body will remain on alert for a while. Eventually your heart rate will slow, your breathing will return to normal, and you will feel relieved. Your brain, however, will continue to stay “armed” for a few days in response to the event. You may find that you startle easily or feel a bit anxious for a time, but ultimately your body will reregulate and resume normal functioning. 

The brain has intrinsic mechanisms for switching off the stress response and allowing recovery to take place. Once the original threat is gone, adrenaline and cortisol tell the pituitary and the limbic brain (in particular the hippocampus) to stop secreting ACTH and other stress hormones. When this occurs, the locus ceruleus replenishes the depleted norepinephrine, serotonin normalizes, cortisol drops, and the HPA circuit quiets. The hyperalert state settles because the brain has biochemical mechanisms to bring it back into balance. This chemical ability to “switch off” is vital. Yet in women's brains estrogen and progesterone appear to delay the ability to switch off the stress response. 

Although traumatic, fortunately the robbery doesn't limit your life and you go on without further repercussions. You cope because you have some power over your destiny. The act of willingly surrendering your wallet was a key factor in surviving the attack, and that provides you with a sense of control. 

But the repetition of difficult life stressors such as these can chemically “load” the brain. For instance, suppose now that you're seventeen and your best friend is killed in a car accident. The same stress reaction that occurred during the robbery cascades through your body, but this time your anxiety persists. 

It's not as easy for your cortex to process this event as it did the robbery; your brain is unable to switch off your stress-hormone response. Serotonin levels become depleted, and your HPA circuit, taking on a life of its own, goes into overdrive and stimulates the overproduction of stress hormones from the adrenal gland. As a result, no matter what you do, your cortex cannot calm the primitive limbic responses as easily as it did before. You begin to have symptoms of chemical dysregulation: difficulty sleeping, loss of appetite, problems concentrating. 

Four months later you are still not feeling yourself. You eat poorly and have lost fifteen pounds. Your sleep is disturbed, you are easily irritated, and you find that it is harder to get going in the morning. It looks and sounds as though you are in a major depression. Because the onset of these feelings coincides with the death of your friend, you tell yourself that in time you will feel better and your symptoms will settle on their own.

But when they do subside and your brain has finally been able to switch off the stress response, it is not without cost to you. Your brain's biology has probably changed. The nerve cells activated by the stress of your friend's death may now be sensitized by complex factors affecting their genetic coding, so that they learn to function as if stress were present all the time. 

Therefore, when another traumatic event occurs, even if it is not as severe as your friend's death, your HPA circuit may become more easily disturbed because it has already “learned” how to do so. A changed biology is now part of who you are. 

[several more illustrative examples cut] 

The series of stressful events we have proposed has loaded, strained, and eventually changed your brain's mood pathways. Ultimately this sensitization becomes so profound that a normal female event such as the premenstrual period can easily trigger the biochemical disruption that leads to depression. The result: You bring a chemically altered brain into your adult years and are at risk for mood and anxiety problems throughout your reproductive life.

The lessons here for us are twofold. First of all, some of the response we show to the sudden onset of surgical menopause is the result of our genetic makeup plus all of our preceding life events that may have carried out this brain "training" that can set the stage for the hormonal disruptions of menopause to have a strong effect on our brain function. Because of that, they will also influence how we deal emotionally with the physiological aftermath of the stresses and hormonal changes we encounter. And secondly, being in this state of hormonally-triggered disability further establishes it in our brains and makes it harder to recover on our own, to the point where we may need more help than simply restoring hormonal balance in order to get back out of the situation.

The book spends quite a bit of time going through the various standard psychiatric diagnoses and reviews what they look like and how their presentation may be affected by hormones. The chapter is titled “What I'm feeling has a name?” and I think that's an important statement about recognition that they are making: women are encouraged by society and medical practitioners to minimize their symptoms, accept them as “just their lot in life” or “something you'll get over” and this prevents us from recognizing mood disorders as a problem and as something we can get help for. While noting that diagnosis is the job of the mental health practitioner (and we've discussed in that referenced previous post how the very disorder we're experiencing can obscure our ability to recognize that we are ill), they go on to say:

When we listen to women's accounts of their lives, we want to know whether they've experienced these symptoms because that helps us to pinpoint the onset of the disturbance. To ascertain if our patients have a special vulnerability to hormonal change, we look for:

• evidence of puberty-related depression
• evidence of premenstrual depressive symptoms
• an adverse response to oral contraceptives
• depression or anxiety while taking fertility-enhancing drugs
• signs of illness during pregnancy, including mood changes in the first few weeks
• changes in demeanor in the last few weeks of pregnancy
• problems in the delivery or the baby's health that could contribute to mood changes later
• obsessional thoughts of harming the baby
• changes in disposition before and after taking hormone-replacement therapy

We can make use of this knowledge preoperatively, when we know we are facing surgical menopause. If we have experienced these elements of possibly hormone-related problems earlier in life, there is some risk that the hormonal events of surgical menopause may be more challenging to our brain stability than they would be for another individual without hormonal instability in their past. This doesn't mean that we are going to go nuts in menopause; it may mean that we will need some extra support and preparation to face the challenges that this transition places on our whole body and in particular on our brains.

We frequently have conversations on our discussion forums about post traumatic stress syndrome and resolving trauma, but this book ties up that package even more neatly:

Stress and depression are highly interrelated. In Chapter 3 we saw how traumatic life events can permanently alter the brain's delicate mood pathways. In fact, research from laboratories all over the world have found that at least half the people who suffer from depressive disturbances also have disruptions in their stress-hormone levels. This has led to the theory that depression is one way in which the brain responds to stress. 

Traumatic events evoke the stress response—that complex cascade of cortisol and other hormones—in your brain and body. In fact, when the emotions are powerful and prolonged, the stress response can overwhelm your brain's self-regulatory capacity, which is usually able to counter it. Cortisol levels remain high, and for reasons that we don't yet understand, they don't shut off.

Now, we dislike the oversimplistic term (and concept) of "crashing" as our response to ovarian loss and hormone depletion. This book uses the model of an earthquake to describe a dysregulating event, and we think this concept is a great one because it better deals with the complexity of the situation over time:

An earthquake is a perfect analogy to describe what is happening in our patients' lives. Earthquakes occur when the internal pressures on a weakened subterranean fault line become overwhelmed. To relieve the intense pressure, the fault line gives way with great force and the earthquake erupts, breaking through the earth's surface and creating chaos and destruction above. When all has settled, the fault line shifts into a new position, vulnerable to the pressures of the rock adjacent to it and in a state of altered quiescence, while the cycle of pressure builds again. 

Our basic brain biochemistry can be equated with the fault line beneath the earth's crust. As the surface of the earth above the fault line appears intact, so, too, do women, as they often portray themselves as feeling "fine" even if their brains are suffering from overloading and strain. Eventually the burdens of stressful life and/or hormonal events can disrupt this delicate balance of brain biochemistry (just as the pressures created by geophysical forces affect the geologic fault line) and an emotional earthquake occurs.

A significant portion of the book details clinical examples of these "earthquakes" at different significant hormonal milestones in women's lives. One of these is obviously menopause. Predictably, the authors deal primarily with natural menopause—that remains, of course, the overwhelmingly more common experience. In relating clinical stories to do with menopause, much of their attention is thus devoted to recognition of the transition. And I have to say that this section and their background on HRT use in meno is one of the weakest—because it is so dated—aspects of their whole discussion. Their material predates the Women's Health Initiative study and only represents the very beginning of the present period of interest and research into human-identical HRTs and route-related effects.

More seriously and misleadingly, however, they also talk about "tolerating" use of specific hormones as an on/off function. That is, you either "tolerate" the hormone or you do not. This misses what has come to seem most critical in hormone balance: it is not the hormones themselves, for which we all have demonstrated needs, but rather the amount we have in our systems, our remaining unmet needs, and how a given HRT fulfills that need, that determine the reactions we observe when we take a given HRT at a given dose. This distinction is much more useful for us in functional terms than simply writing off an unpleasant response as a demonstration that we cannot use that hormone. Because of this conceptual lack in this book, we found the chapters on menopause and hormonal manipulations particularly outdated and unhelpful in terms of guidance. But then, this book is not about hormonal balance; it's about brain function and how hormonal disruptions affect it.

We did find interesting and worthwhile in those chapters the authors' discussion of how it's necessary to support both brain chemistry and hormonal needs in the process of diagnosis. In particular, they try to make a point of providing for both in search of chemical stability before making any effort to reach a psychiatric diagnosis. This, we think, speaks to our concerns when we grow frustrated with caregivers who seem to feel that once we've been given an HRT prescription, any HRT prescription, any further difficulties we experience must be due to the fact that we're depressed or just not "adapting well" to the idea of our surgical menopausal state. The authors' stance is rather in contradiction to that premise, saying that you can only diagnose underlying disorders once the immediate chemical disruptions are stabilized. Do we hear a resounding "duh!"?

So how can we use this book to help us deal with our own problems in surgical menopause? First of all, understanding the physiology, understanding their earthquake model and the idea that if we have had past experiences of hormonal disruption that have challenged our equilibrium (like postpartum depressions) or a family history of similar problems, we are more liable to experience a rocky time at menopause, gives us a validation and encouragement to see this as something that can be dealt with. Not only does it exist (we're not "just" crazy!), but there are ways to deal with it.

Further, if we have a surgeon or other health professional who is dealing with our hormone balance needs by handing us an SSRI and telling us to see a shrink, we have two choices. We can look for another doctor and continue trying the d-i-y approach of seeking primary hormone balance as the solution to our problems. If we are truly having an "earthquake," this may take some time, but we may be able to persevere in waiting out our brain's slow adaption and relaxation.

Or, we can choose to support our brains as well as the rest of our bodies and look for a psychiatric practitioner or therapist who is able to deal with the complex interplay of brain and hormonal chemistry and guide us through the earthquake into the search for better stability. From what we've learned in this book, we think that those who are at high risk, because of family history or their own previous experience, might well be better served by this latter approach. As in all things, however, the choice of this professional and their expertise in dealing with this sort of practice model is important: not all mental health professionals are comfortable with this or capable of working with the hormonal interplay.

So is there a lesser level of intervention for those of us who just want to bootstrap our own way through this experience? 

Yes. The other significant portion of the book involves detailing the rest of their treatment plan, the plan that they use in conjunction with drugs and therapy and the one they set up as long term maintenance for those who are no longer in active treatment. They refer to it as the "NURSE" program in an acronym based on its components:

• Nourishment and Needs: refers to eating a sound diet for health, that meets but does not exceed needs. We've discussed elsewhere how our needs and metabolism change in menopause and how important changing our dietary makeup may be in preventing menopausal weight gain. The specific dietary recommendations in the book are, alas, somewhat outdated; we recommend instead the references linked to from our bookmark account with the tag "diet" for more current information. Also in this category would come the very important nutrients—zinc, magnesium, B vitamins—that are required for HRT metabolism. This can all have significant brain impact and a certain percentage of negative HRT experiences are due not to the HRT itself but to an underlying deficit of these nutrients.
• Understanding: This is the informational component, one of the cornerstones of what we're trying to do with the Survivor's Guide. We need to know what's going on in our bodies and brains in order to best care for them and to recognize what is happening with them in surgical menopause. Sometimes this understanding requires a therapist's assistance to figure out; for many of us, self-education is adequate. But we are equipping ourselves for a healthier menopause when we understand what is going on in our bodies.
• Rest and Relaxation: In this section, the authors acknowledge the importance of sleep for good health and the way that sleep and daily hormonal cycling play into acquiring good quality rest. We know insomnia in various forms can be stimulated by hormonal imbalance, and this underscores how important unraveling those imbalances to restore good sleep, not just medicating to overwhelm our insomnia, is a key to healthy rest. They also speak to the importance of various stress-reducing techniques, such as meditation, visualization, and mindfulness, in restoring proper cognitive function after it has been disrupted and to protect it from further disruption. Developing a long range plan for relaxation is an important component of their long-term prevention strategy.
• Spirituality: as used here refers not just to religion, but to

  any experiences that help you to feel uplifted and joyful. Relationships, solitude, appreciation of nature, creative endeavors, music, keeping a journal or other reflective practices, and belief in God/Goddess or a higher power can all nourish the soul.

• Exercise: We've discussed the importance of exercise for regaining post-op physical endurance and strength, weight control, bone health, and metabolic risks. But exercise has also been demonstrated, over and over, to have a positive effect on brain chemistry and relief of depression. It is turning out to be one of the single most important facets of healthy living.

Now if you've read along and are thinking "gee, none of that is really very radical," then you're right. As a treatment approach, it's the sort of vanilla "take care of yourself" stuff we get in different forms from a variety of sources. But, hey, it works. It really works for real physiological reasons. And it's as important for maintaining brain health in menopause as drugs like SSRIs or other antidepressants can be. Just because these are not strange and exotic measures, that does not lessen their potency. Even alone, for those who cannot or choose not to use hormones to deal with surgical menopause, they are a cornerstone of coping strategies. These are real tools and have real effects. Healthy living makes you healthier—who'd have thought?

There's obviously a great deal of information in this book. We've found it very interesting in the development of this topic from a direction different from the more purely hormonal one we usually discuss. Much of our focus has been on the disruptions of imbalanced hormones and the stress of the surgical menopausal transition and the effects these have on our brain and body, with the implicit understanding that if these hormones are brought back to a more functionally-appropriate level, other signs of this disruption will be self-correcting and alleviated by hormonal balance. But this book's focus on mental illness brings the suggestion that just making hormones "right" may not be enough to reverse a situation of illness, and that ultimate wellness may additionally require specific assistance to the brain to enhance healing.

This takes our discussions a needed step further and casts light on those situations where even rough balance seems especially slow and difficult to achieve and maintain. We've talked about stress in general, but this brings it home and provides the insight into some of the ways stress and hormones really fit into the whole picture: not only do our stressed adrenal glands have trouble managing our hormone burdens, but our brains are so dysregulated by stress that we cannot make good use of even the hormones we have. And it provides important validation and encouragement, when hormones simply are not moving the situation along well, for reaching out to another variety of approach in enhancing recovery and wellness.

Menopausal brain chemistry and SSRI antidepressants

Content warning: this article mentions depression and suicide. If you feel it would impair your current wellbeing to read about these topics, please skip this discussion.

Elsewhere on this website we discuss the use of SSRI antidepressants as a non-hormonal remedy for some symptoms of menopause. This offends some because it seems to suggest that menopause is an illness that must be treated with drugs. It offends others who are offered antidepressants in lieu, they feel, of properly balancing their hrts. Yet others aren't offered any help with the brain impacts of sudden surgical menopause by doctors who don't feel that hormonal deficiencies cause any symptoms other than hot flashes, and their doctors simply refer them to psychiatric practitioners for "failure to adjust" to the implications of their surgery. But there are real and valid ways that SSRIs may be used in menopausal brain disruptions, and that's what we're going to take a look at right now.

Selective Serotonin Reuptake Inhibitors (SSRIs) are drugs that work to enhance the amount of a hormone called serotonin in our brains. Serotonin is one of a class of chemicals in the brain called neurotransmitters. Others include dopamine, acetylcholine, norepinephrine. They chemically link one brain cell with another, and create the chemical context for consciousness, including thought and mood. In other words, thought does not occur without neurotransmission. Serotonin is particularly involved with transmissions involving mood, behavior, and emotional balance.

Women typically have more of this chemical than men (you can digress a considerable ways following this through to sex roles, thought patterns, etc, but that is beyond the scope of this particular discussion). Suicide victims have lower levels of serotonin upon autopsy, and portions of the brain that control judgement, balance, and mood show higher-than-normal numbers of serotonin receptors. Suicide is, of course, the ultimate brain disruption, in which an ailing brain seeks its own destruction.

Serotonin is made up of a protein called tryptophan. Estrogen promotes tryptophan availability in the brain and it also increases the general availability of serotonin. It helps regulate orderly firing of neurons (nerve cells) and enhances glutamate activity, which accelerates neurotranmission times. All of these things contribute to orderly and prompt brain function, hence mood and behavior stability.

When estrogen levels fluctuate or drop, the availability of seratonin and the ability of communications to pass from one cell to another decline. This literally disrupts our basic ability, on a cellular level, to carry out the physical process of thinking in a smooth and timely fashion.

Progesterone functions by exerting the brakes in this process: it limits estrogen receptor activity within the brain. At proper levels, this is a positive function. The "hyper" state of estrogen excess (up to and including seizures) demonstrates how serious the lack of progesterone can be to balanced brain function. In excess, however, it slows and disrupts brain activity in ways we call "depression." The two hormones must be present in the right proportions or optimal brain communications (hence, thought and mood) will be disrupted.

I am going to quote a couple paragraphs from Women's Moods by Sichel and Driscoll here because I think they capture this pretty well:

Usually when a part of your body is in distress, you become aware of it through the symptoms of pain, discomfort, fever, and malaise. If you have bronchitis, you cough, wheeze, and suffer chest pains. If you have a urinary-tract infection, you feel burning when you urinate and must do so frequently. These symptoms force you to take care of the problem beause they are uncomfortable. Indeed, they send you straight to your health-care provider, where you will receive medication that targets the biological cause. 

But have you ever thought about the signals your brain gives to show it is in distress? Most people are unaware of what their brains tell them regarding the state of its internal functioning. Yet responding to signals tht your brain is in trouble is one of the first lines of defense in mood and anxiety disturbances. This, too, should send you to your mental-health care provider, seeking relief and treatment. 

How does your brain tell you that it is hurting? Brain tissue itself does not feel pain, so there is no simple way to know. Yet a brain in distress does produce a range of symptoms. Like my patient Sarah, you may experience these as the emotions of fear, anger, sorrow, or depression. Or they may manifest themselves physically, as chest tightness and heart-rate changes, nausea and vomiting, abdominal pain and diarrhea, sleep and appetite disturbances, lethargy, frequent urination, muscle tension, and general aches and pains. 

These symptoms are some of the ways that the brain tells you it is overloaded. In fact, a simple way of understanding depressive or anxiety disorders is to think of them as the brain's slowing down in response to being biochemically overburdened.

In other words, hormone disturbances disrupt brain function, causing symptoms related to impaired brain activities. Now, this isn't news, but it focuses on where we're going with this.

We all would prefer to support our brains with proper levels of the needed hormones. This is a primary mechanism that is intellectually satisfying to us, not to mention that it is served by using hormones to meet other goals throughout our bodies.

But sometimes we can't reach that goal of delivering the right amount of the right hormones to the right parts of our brains right away. In fact, that can be made more difficult by the very brain disruption we're suffering. We are, for the most part, unable in any fundamental way to distinguish our chemical brain function from our conceptualization of "self" and "reality." This is, in the very worst cases, why we need psychiatrists: the more our thinking is disrupted, the less able we are to tell that it is.

This is where the use of SSRI antidepressants can come into it. They are not "feel good" pills that place a bandaid over the hurt and hide it. Instead, they act by various mechanisms to directly alter the availability and functioning of these same brain chemicals we've been discussing. The drugs of this class use a variety of methods to prevent the breakdown of serotonin, thus extending the supply in ways that are independent of estrogen function. By restabilizing our brain chemicals, they can thus give us the functional stability to continue working for a primary (hormone-related) solution and they can relieve some of the other physical effects of brain "pain." Like the crutches that allow us to regain some mobility and re-normalize our lives while a broken leg heals in a cast, so an antidepressant can provide us the tools to move on while a "broken" brain is resting and healing.

In current medical practice, there's a fine line between antidepressants as a brush-off and antidepressants as a critical tool. I appreciate that they are often used in the former capacity and by unqualified practitioners. That does not in any way negate their value in the latter case nor in qualified professional hands. Healing may of necessity come in stages. We should reach for as much healing as we can get by whatever tools we may have available, and use those enhanced resources to then turn our attentions to more preferable long term solutions. We would not continue walking on a broken leg, insisting that it heal completely on its own at night when we are asleep. We similarly should not fear doing everything we can to promote the healing of our brain.

We're not saying antidepressants are for everyone. We'll just ask each of you to look in the mirror and ask yourself: am I doing as much for my brain as I am for the rest of my body? We snicker at jokes about how men think with their genitalia, but are we not just as guilty when we give our vaginas more respect and help than our brains?

Strong Women, Strong Bones

Strong Women, Strong Bones by Miriam E. Nelson, Ph.D. ISBN 0-399-52656-0

Right up front we're going to say that this is a great book. We've spent a fair amount of time researching and studying up on osteoporosis, and we still learned things from this book. Nelson, who is an associate professor of nutrition and the director of the Center for Physical Fitness at Tufts University, is clearly gifted with a teacher's ability to take a complex subject and break it down to graspable elementals.

We're not going to give you the content of the book, but we will tell you a little bit about why you should read it if you're in menopause, irrespective of your hormonal status and personal risk factors. To begin with, as she points out, one in three women develop osteoporosis and more women die of its complications every year than are killed by, say, breast cancer. This really is a life or death matter, and if you're sitting with two of your women friends, the odds are substantial that it's your life or death we're talking about.

Anyone who reads this website and our discussion forums should realize pretty quickly that we feel that understanding the mechanism behind things helps us figure out what to do. So we were gratified to see an excellent discussion of how bone is made and how hormones and what happens to them with menopause impact this process. In very simple terms, our bodies use calcium to tune our systemic acid/base balance, and any time that's off, we scavenge a bit of bone for the calcium it contains. That is the fundamental reason why we never get "ahead" with bone maintenance: we need to consume a steady supply to keep up. And did you know that not only does estrogen affect the bone-building cells themselves, but our ability to absorb the calcium we eat from our intestines? And that stress, which causes our cortisol (the stress hormone) to rise, also can harm our bones by directly limiting those estrogenic effects? If you've read other stuff on this site about how cortisol and our ovarian hormones intersect in actions, this may slot neatly into that knowledge because, yes, it's all inter-related.

How much difference does menopause really make? Nelson says:

Without estrogen to contain them, the bone-dissolving osteoclasts increase their activity by about 20 percent; the osteoclasts don't increase to match. The net effect is loss of bone. Menopausal women typically lose 1 to 3 percent of their bone mass annually, and some lose as much as 5 percent.

That doesn't sound like a terrifically high number, but when you think about a loss of 3 percent over just three years, that's nearly 1/10 of your total bone gone. And because bone strength depends upon the structure of the bone, not just its total weight, that represents a huge loss of the ability to survive the wear and tear of daily life.

After some introductory material presenting the basics on osteoporosis, most of the book is on specifics. She discusses risks and how to evaluate your own personal risk degree based on both history and lifestyle, including a surprising number of other medications you might be taking. She explains testing and how often and when we should be tested. She also includes instructions on how to test yourself for one critical aspect of bone preservation: balance and your ability to avoid falling. Think you don't have any problems with this? Try her tests and be surprised—we were.

This book was printed in 2000, which means it was written a year or two before that. While most of the material it contains is perfectly pertinent and up to date, there are a few areas where current research and medical thinking has moved on. Her section on calcium is excellent in terms of discussing food sources, supplements and the need for vitamin D to be able to utilize calcium. But her recommendations for vitamin D amounts are looking a bit outdated. Today doctors tend to focus on around 2000 IU for daily intake, varying according to sun exposure (an outdoor gal in Florida isn't going to have quite as high a need as a desk jockey in Alaska, and we almost all need a bit more in the winter than summer). That aside, her material on things like interactions (how bad is that soft drink for you really?) goes a long way towards giving us solid information on what happens to the calcium we eat and how to make best use of it. And for those who don't really want to take supplements, she provides tools and guidelines on how to maximize and calculate dietary calcium intake so you can get a clear picture of where you are and how to get to where you should be.

A large part of her book is devoted to exercise and why it's critical to both preserving and restoring our bones. According to her, it takes either the shock action of impact or the stress of strong muscles pulling against bones to provide the stimulus for our bodies to maintain bone strength. She divides the necessary components of a bone maintenance program into three elements: weight-bearing aerobics, strength, and balance. In each section, she provides ranges of activities appropriate for those anywhere from strong-boned to osteoporotic.

In terms of weight-bearing, this can be anything from jumping (recommended for non-osteoporotic women) to brisk walking (for those with already diminished density). She is clear that only exercises that transmit action through our spine and hips are effective--bicycles, rowing, swimming: these kinds of things may provide cardiovascular fitness but they do not affect bones. She is equally clear that while gentle walking is better than none at all, it fails to provide enough challenge to bones to create significant density improvement.

Strength training is the most likely to actually boost density. This is not just opinion on the author's part--she's participated in research that demonstrates greatest density gain when this is included in a bone maintenance program. As with each of the three workout segments, she gives specific exercises and directions on weights to begin with and how to step them up over time. That's right: we have to keep challenging our bodies over time. To involve the proper amount of stress, exercises must be difficult enough that the muscle groups involved can perform only eight repetitions before becoming fatigued. Just as aerobic training that doesn't work us hard enough to raise our heart rate isn't of use, so strength conditioning doesn't work unless it's also hard work.

The third portion of her workout focuses on balance. Here, the intention is bone-protective through reducing our risks for falls. If our sense of balance is well-developed and the muscles we need to maintain our balance are prepared to undertake the task, we are less likely to damage our weakened bones by falling. Those who are not suffering from bone loss yet may scoff at the need for this, but her point is that bone loss is part of our expected aging experience and making balance tactics ingrained early means they are in place to automatically protect us when we do come to need them.

This book also goes into the range of medications available to treat or prevent osteoporosis. Unfortunately, this is the other main area where the book is dated. Written before WHI and increasingly conservative attitudes amongst doctors towards prescribing hrt, she is a little more casual about estrogen use for maintaining bone density than is the norm today. While osteoporosis continues to be an FDA-recognized reason for prescribing estrogen, many doctors feel that the breast cancer risks, although lower than overall osteoporosis risks, are adequately compelling that they do not wish to be liable for prescribing hrts for bone maintenance. Nonetheless, the major medical consensus groups all stop short of denying that osteoporosis treatment or prevention are acceptable reasons to continue taking hrt.

While the book does spend some time favorably commenting on bisphosphonates, which are specifically used to treat osteoporosis, she is writing before the recent publicity, still not widely distributed within the medical community, of the risk of jaw osteonecrosis and atypical fractures as side effects of the bisphosphonates, even when administered in oral form. This risk has caused some questioning of the strategy of "fossilizing" bones, suggesting that treating density rather than actual bone strength restoration is treating the test rather than the patient. It's outside our purpose here to open up the arguments around bisphosphonates and the influence of pharmaceutical company economics on health care decisions, but more information on these topics can be found in our bookmarks account with the tag "osteoporosis."

Despite the concerns we have about these dated sections (and for which updated information is readily available online), we would still say that this is the best reference on the topic we have found to date, both highly readable and eminently practical.

The three estrogens: estradiol, estrone, estriol

There are three common forms of the hormone we call "estrogen" (and many many lesser variations and subvarieties). Understanding what each one is and does can be helpful in deciding which one(s) to supplement with when planning HRT.

Estradiol is the major estrogen produced by ovaries and is the strongest (the most effect for the least quantity) form. Estradiol is the "active" estrogen—the one that is capable of the fullest range of estrogen effects because it is the one that actually goes out there in our tissues and sockets into estrogen receptors and causes estrogen effects. In addition to being made by ovaries, it can also be produced by conversion from a number of precursors in the adrenal glands. It requires certain nutrients at specific levels to be metabolized properly, and it requires certain other factors to be present to determine which metabolites (some of which are considered more desirable than others) it is broken down into.

Estrone is considered a weaker form of estrogen. It is typically produced by special belly fat cells, and is the major estrogenic form found in naturally-menopausal women who are not taking HRT. It is not directly active in as many tissues was estradiol is, but can be readily converted by to estradiol for actual use. Because of this, it is considered by biochemists to more properly be thought of as an estradiol precursor (although the conversion can go both ways, meaning that estrone can also be considered a breakdown or even a storage form of estrogen). It is sometimes considered "safer" than estradiol by virtue of its weakness, but since larger quantities are required to get the same effects as a smaller quantity of estradiol as well as the fact that it is normally converted to estradiol when that form is needed, other sources consider it no more or less safe than estradiol.

Estriol is a metabolic waste product of estradiol metabolism that can still have some effects upon a limited number of estrogen receptors. It is formed in the liver and is 8% as potent as estradiol and 14% as potent as estrone. Once estriol is bound to an estrogen receptor, it blocks the stronger estradiol from acting there. Thus it is considered to have both estrogenic and antiestrogenic actions. There is also some evidence that, because it is so weak and blocks the stronger forms, estriol can be considered to have "anti-cancer" action. To take it in quantities adequate to have effects comparable to estradiol (that is, to occupy as many receptors as a needs-meeting level of estradiol), however, the risk rises to the same level with estriol as with estradiol. A particular breakdown product of estriol, 16-hydroxyestrone, is elevated in women receiving oral estriol and is associated with an increased risk of breast and cervical cancers. Estriol has also been implicated as a source of interference in lab tests for estradiol, leading to "clinically significant" testing errors. It is believed to have special efficacy for genitourinary tissues and skin generally, but that is poorly studied and results of existing research are not conclusive.

Which ones must I supplement?

This is a matter of some controversy amongst different professionals. We can start by acknowledging that there is no agreement on this, no research that says one or another is the right choice for everyone. In fact, we feel that the idea of "one right choice" is just about backwards anywhere in the context of menopausal needs.

Some folks feel that because our bodies had some percentage of all three major estrogens at some stage during our fertile life or some broad averaged out body of menopausal women typically have some other percentage of these hormones, that this represents a goal of sorts: just put everything back to that level and life will be swell. As we've tried to suggest on the matter of testing, however, what is expressed when you measure and average a whole population of women is not necessarily right for any single one of them when she's taken as an individual. We all come from different genetic backgrounds, have had different life events that have shaped our physical health and hormone exposure, and so we will continue into menopause with individual needs and capabilities. These can differ a lot from one woman to the next.

But there is also a more fundamental problem with this notion that all estrogens must be supplemented, and that's the fact that in our bodies we rely on converting one to another depending upon what's needed when. When we have a few unfilled receptors and a need for some activity on that front, we can grab up a bit of estrone, do a little biochemical slight of hand and send some fully active estradiol on its way, ready for action. When we have more estradiol kicking around in our system than we have work for it to do, we can reverse this process and downgrade it to estrone, which isn't very active and can just lounge about waiting in the unemployment line without disrupting much. When we're done with our estrogens, we metabolize them further into waste products like estriol and many others, and they gradually make their various ways out of our body.

This is our normal mechanism for handling estrogens and the capability to do so doesn't end at menopause. What does change, however, is our supply of estrogen. We don't have all that fresh estradiol flooding into our system from our ovaries, being routed to all those fertility support needs. Instead, we've geared down into post-fertile maintenance mode, with only a slow, steady trickle of estrogen to meet our basic, nonfertile needs. We don't have a surplus of estrogen so most of our estradiol is out at work in receptors, not sloshing around to be captured with testing. All that shows up now is that unemployment line grade of estrogen, our estrone, and there's not all that much of it, either. But this does not reflect a change in our needs: it's instead reflective of our situation. We still have our same old capability of inter-converting our estrogens to their needed use (whatever that capability was—some of us are better than others at the basic mechanisms and at some times we're better equipped than others with the necessary chemical co-factors like vitamins and other nutrients). So whether we put in estradiol or estrone, we're probably going to be turning our HRT to the form we need it.

And if we're putting in estriol, we're not providing for those estradiol needs, directly or indirectly. Estriol is a breakdown product, estrogen on its way out of the body. Estriol can still carry out a few actions, remember, so it does make the estradiol we make seem to go a little further. But it's not in itself a convertable contributor to estradiol, and for women who can't make enough estradiol to meet their needs for that hormone form, estriol is not going to be an effective HRT in itself. It's a dilutant, not a participant. And we'll be making it for ourselves anyway, from however much estradiol we eventually metabolize into that breakdown product.

Balancing various estrogen forms

Why do some women seem to do best on all of one or on a blend, then? That comes down to more subtle things to do with the dynamic of how their bodies handle these forms. For some women, the conversion to estrone doesn't seem to be difficult but the conversion back to estradiol may not go well. They can handle a (relative) lot of estradiol and may need a ready supply of it circulating most of the time. Other women are the opposite: too much estradiol around makes them unbearably jangly but the weaker estrone doesn't bother them and they seem to be able to make as much use of it as they need to. It seems as though some women find the accommodation to menopause, especially when it happens as rapidly as surgical meno, disruptive to their hormone handling mechanisms and they need to settle in and de-stress before they can handle these active/stored form conversions smoothly. For them, beginning with estradiol may meet their needs best.

Remember: there are no "right" answers for which estrogen(s) you might need. The right answer in choosing an HRT is getting the ones that meet your own body's needs in a way that fulfills your menopausal wellness goals. It can take some time to feel your way to the right estrogen(s) for your body's capabilities, and those capabilities may change with time. Especially in the first postop year, what works to get hormones into your body may not be the HRT you'll need or want to stay on longer term.

So don't be fooled by someone insisting that this or that HRT approach is more "natural" than another. Just because something can be measured in a population of women doesn't mean it'll suit any one woman. Just because your friend does better on an HRT that contains all estradiol doesn't mean that your body mightn't be happiest on all estrone or perhaps a combination. Just because your doctor wants you to use estriol to lower your estradiol exposure doesn't mean that you'll have none in your system. Understanding that this is a fluid situation is, yeah, a little more challenging, but in the end the answers it provides can be a lot more useful in troubleshooting why your HRT is working the way it is for you.

Menopause is not a disease

It's awfully easy to get so caught up in going to the doctor and juggling HRT prescriptions and worrying about testing and feeling as though we're falling apart that we lose track of the fact that menopause is, after all, a normal and natural life stage. The fact that it tends not be valued very highly in our society notwithstanding, it's something that has been our destiny all our lives. The fact that we may have entered this state early or voluntarily as a tradeoff to be rid of some pressing health problem notwithstanding, here we are.

One thing that pains us when we read women's reactions and problems they're having dealing with their menopausal needs is when their understandable frustration boils over into statements like "I don't want to be taking these drugs all of my life. I want something that's natural." Okay, now there's nothing altogether wrong with that idea. In fact, we'd have to agree with that sentiment. But the rub is in how they apply it: to turn their backs on HRT and claim it's all an evil plot of the Big Pharmaceuticals to turn their lives into a disease.

Now we're not great fans of the way the business practices of Big Pharmco play out for the hapless consumer, but this situation also carries just a bit of cutting off one's nose to spite their face. We'd like to suggest a different way of thinking about menopause and our hormone needs that provides a better framework for understanding what we're doing.

Hormones are not drugs

It's easy to lose sight of this, when we have to go to the doctor and plead for HRTs, get a prescription, and take it to the pharmacy just as if it were a drug. But it's not. HRT is a supplement; it's just more of something our bodies already and naturally make. Used at its best, HRT just makes up the difference between what we can make and what we need to be healthy and feel good.

Drugs interfere with normal bodily processes and impose other effects (and, often, side effects: negative effects caused by this interference with a normal process). Hormones are necessary for our bodies to carry out normal processes and the undersirable effects we sometimes see with them are either those of an imbalance between our needs and our supply, or are effects of the dynamics of putting them into our bodies.

So if they are so normal and healthy and swell for us, why can't we just buy them at the store like vitamins and other health supplements? Well, because they are such powerful agents that it's possible to gravely injure ourselves with them. Used without understanding of their role and characteristics, hormones are just too dangerous for amateurs to mess around with. We mean you, our reader right this minute, no insult here, but we have to say that a great many women have no understanding of how their bodies function. Thanks to advertising and the helpful intent of friends, we're also subject to a great deal of inappropriate and misguided advice.

Unfortunately, the serious implications of hormone misuse mean that we need an educated and experienced partner in determining how best to use them. And because of the way our health care systems are set up, that has fallen to, for the most part, not health and wellness practitioners but medical practitioners: professionals whose expertise is in diagnosing and treating illness. And because their focus is on illness, not wellness, that casts our endeavors in a whole diferent light.

A doctor is trained to see symptoms and diseases, not to enhance a state of wellness. When we take our shopping basket of menopausal symptoms to a doctor, he must, by the professional standards under which he practices, see these as a form of illness. If we are lucky in our choice of partners, he is able to recognize these symptoms as representing a deficiency and he may prescribe HRT. If not, we will leave with another shopping basket of prescriptions for diseases representing each symptom and a referral to a shrink.

But that's the problem of mismatch, the problem of systems, the problem of bureaucratic administration; it's not our fault. We're not sick and we don't need drugs when we're having problems dealing with menopause gracefully. All we need is some help getting the available supply of a needed material our own bodies would make on their own if we still had ovaries restored to levels that let us meet our basic functional needs.

Few people would suggest that it's more "natural" to do without food nutrients we haven't grown ourselves but need to buy from the supermarket; few people would suggest that a diabetic or someone who is hypothyroid should "get over" their need for the lift-sustaining hormones they lack. HRTs are not drugs; they're just a way to replace a normal part of us that we agreed to displace in order to fight an illness through surgery. Menopause is not a disease.

Table of contents by topic

Update: This content has been moved so it's easier to find. You can follow this link to get there now. From anywhere on the site, you can also use the link at the top of the page, just under the title header.