John Lee MD
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Menopause Chapter Excerpts

WHAT YOUR DOCTOR MAY NOT TELL YOU ABOUT MENOPAUSE

The breakthrough book on natural progesterone.
by John R. Lee, M.D. and Virginia Hopkins

CHAPTER ONE
The Crux of the Matter: Menopausal Politics and Women’s Hormone Cycles

Not so long ago, menopause was a word you did not say out loud in public, and you had to go to a medical library to find a book on the subject. Go into a typical bookstore these days and you’ll find literally dozens of titles on menopause. They range from praising the wonders of estrogen and hormone replacement therapy to personal stories of the ups and downs some women experience during the “change of life,” and there are now many other books written on the subject of natural hormones. What was once a taboo subject has become a mainstay of talk shows and women’s magazine articles.

Menopausal Politics

With 30 million menopausal women in North America and some 20 million baby boomer women in menopause or on the brink of it, it’s no wonder this is a major topic of discussion. What is a wonder is how we have managed to make menopause, a perfectly natural part of a woman’s life cycle, into a disease. It has only just dawned on us that menstruation, pregnancy, and childbirth are not diseases; now we need to realize that menopause is not a disease despite millions in advertising dollars spent by drug companies to convince us otherwise. The pharmaceutical companies have not failed to notice the huge population of premenopausal women in the pipeline, a financial gold mine in the making. Premarin, a form of hormone replacement therapy made from pregnant mare’s urine by the Wyeth-Ayerst company, was one of the top-selling prescription medicines in the United States until the 2002 Women’s Health Initiative (WHI) study showed that PremPro (a combination of Premarin and a progestin) increased the risk of breast cancer, strokes, and gallbladder disease. Although Premarin/Prempro generated more than $2 billion in sales in 2001 and represented 22 percent of Wyeth's pharmaceutical sales, more recently, sales of Premarin/Prempro have declined about 25 percent.

In 1995, when I first wrote this book, I stated, “A large percentage of advertising and research dollars are spent trying to convince women that estrogen will cure everything from heart disease to Alzheimer’s, but there is scant evidence for any of these claims and reams of evidence that synthetic estrogens are highly toxic and carcinogenic.” Now the WHI has proven me correct on this, and many millions of women are searching for a safe alternative to PremPro. In truth, it’s not so much the estrogens per se that are toxic and carcinogenic, it’s estrogens used in excess, and with progestins instead of natural progesterone. But you will learn a lot more about this as you read further.

The good news is that women have become guarded and skeptical about having new drugs pushed on them. After being told that DES, a hormone that was supposed to guard against miscarriages, was safe, hundreds of thousands of women discovered the hard way that it caused cancer in their children. Women were told that Valium was a safe and effective remedy for depression and anxiety, only to find out that it was addictive. Then their physicians tried to convince them that once they had reached menopause they should automatically go on hormone replacement therapy featuring synthetic estrogens and progestins, only to find it was increasing their risk of deadly diseases rather than saving them from the aging process. It is telling that only 10 to 15 percent of menopausal women chose to use conventional HRT despite intense pressure from doctors and the media. The real tragedy is that many thousands of women have undoubtedly died or been permanently harmed because they used HRT, when the natural forms of these hormones, used wisely and in moderation, could have been, and still could be of very real benefit. In the chapters that follow, we will look more closely at how estrogen and progesterone work in a woman’s body and the politics of pushing drugs to women.

What is Menopause?

Strictly speaking, menopause is the cessation of menses, the end of menstrual cycles. The unpleasant “symptoms” of menopause that some women suffer, such as hot flashes, vaginal dryness, and mood swings, are peculiar to industrialized cultures and, as far as I can tell, they are virtually unknown in agrarian cultures. In native cultures menopause tends to be a cause for quiet celebration, a time when a woman has completed her childbearing years and is moving into a deeper level of self-discovery and spiritual awareness. She is becoming a wise old woman. In these cultures menopausal women are looked up to and revered. They are sought out for advice and their opinions are heavily weighed in the decision-making process of the community. How strange that sounds to us! We know menopause as a death knell, the end of a woman’s sexuality, a descent into a dried-up and painful old age of arthritis and osteoporosis. How did this experience of menopause come to be? I believe it’s a combination of poor diet, unhealthy lifestyle, environmental pollutants, cultural attitudes, the incorrect use of synthetic hormones, and advertising. But first, let’s look at what happens in a woman’s body as menopause approaches.

Chapter 2 - The Rise and Fall of Hormones During the Menstrual Cycle

In a normal menstrual cycle, every 26 to 28 days the ovaries, which hold a woman’s eggs, receive a hormonal signal from the brain that it’s time to get some eggs ready to be fertilized. Anywhere from a few to a few hundred eggs begin to mature inside sacs called follicles. After 10 to 12 days one egg has moved to the outer surface of the ovary and the follicle bursts, releasing the egg into the fallopian tube for its journey to the uterus.

As the egg is ripening in the ovary, the uterus is ripening in preparation for the possibility of growing a fetus. The uterine lining thickens and becomes engorged with blood that will nourish the growing embryo. If no fertilized egg implants itself in the uterus, it sheds its lining. This shedding is the blood of menstruation. Then the cycle begins again, with the signal from the brain telling the ovary to ripen an egg.

Estrogen (from estrus, meaning “heat” or “fertility”) is the dominant hormone for the first week or so after menstruation, stimulating the buildup of tissue and blood in the uterus as the ovarian follicles simultaneously begin their development of the egg. Around the time of ovulation, estrogen causes changes in the vaginal mucus, making it more tolerant of male penetration during sexual activity and more hospitable to sperm. At this phase in the menstrual cycle, the vaginal mucus tends to somewhat resemble uncooked egg whites. Watching for this change in mucus combined with a rise in body temperature is one of the best nonlaboratory methods for identifying the time of ovulation.

About twelve days after the beginning of the previous menstruation, the rising estrogen level peaks and then tapers off just as the follicle matures and just before ovulation. After ovulation the now-empty follicle becomes the corpus luteum (so named because of its appearance as a small yellow body on the surface of the ovary). The corpus luteum is the site of progesterone production, which dominates the second half of the menstrual month, reaching a peak of about 20 milligrams (mg) per day.

Progesterone production during this phase of the cycle, along with estrogen, leads to a refinement and “ripening” of tissue and blood in the uterus. Progesterone also contributes to the changes in the vaginal mucus seen at the time of ovulation. The rise of progesterone at the time of ovulation causes a rise of body temperature of about one degree Fahrenheit, a finding often used to indicate ovulation.

If pregnancy does not occur within 10 to 12 days after ovulation, estrogen and progesterone levels fall abruptly, triggering menstruation, and the cycle begins anew. If pregnancy occurs, progesterone production increases and the shedding of the lining of the uterus is prevented, thus preserving the developing embryo. As pregnancy progresses, progesterone production is taken over by the placenta and its secretion increases gradually to levels of 300 to 400 milligrams per day during the third trimester.

Premenopause

A woman’s hormone balance can begin to shift at anywhere from her mid-thirties to her late forties, depending on a variety of factors such as heredity, environment, how early or late she began menstruating, whether she had children and if so at what age and how many, and her lifestyle. Was she exhausted trying to juggle career and family? Was she eating junk food, caffeine, sugar, and alcohol or whole grains, fresh vegetables, and fruits? Has she taken vitamins? Has she lived in the city or country? Was she exposed to toxins in the workplace? Hormone balance is intimately connected to stress levels, nutrition, and the environmental toxins encountered daily. We will discuss all of these factors more thoroughly in the chapters to come.

The ability of the follicles to mature an egg and release it may begin “sputtering,” so to speak, a decade before actual menopause, creating menstrual cycles in which a woman does not ovulate, called anovulatory cycles. If she isn’t ovulating, she isn’t producing progesterone from the ovaries and she may begin experiencing menopausal symptoms such as weight gain, water retention, and mood swings. Menstrual cycles can continue even without the progesterone, however, so most women aren’t aware that the lack of progesterone is causing their symptoms. I call this phase premenopause. I will be discussing premenopause symptoms in more detail in Chapter ***, and have also written an entire book on the subject called What Your Doctor May Not Tell You About Premenopause. The phase right around the time of menopause, when hormones and brain signals to the ovaries are fluctuating, is called perimenopause.

It used to be true that the majority of women began menopause in their mid-forties to early fifties. In the last generation, however, things appear to have changed. Women now may have anovulatory periods starting in their early thirties and yet do not experience cessation of periods (menopause) until their fifties. During this time, the ovaries continue to produce estrogen sufficient for regular or irregular shedding, creating what I term “estrogen dominance,” which will be discussed in detail throughout the book.

Some women may go for years with irregular cycles and slowly wind down, or may just suddenly stop menstruating one month and never menstruate again. They may be overwhelmed with unpleasant symptoms or hardly notice what has happened other than not having to worry about birth control or tampons every month. How menopause is experienced is as individual and unique as each human being.

During the many months of anovulatory periods, estrogen production may become erratic, with surges of inappropriately high levels alternating with irregular low levels. Periods of vaginal bleeding may become erratic, some much heavier than others. When estrogen surges, women undergoing these changes may notice breast swelling and tenderness, mood swings, sleep disturbance, water retention, and a tendency to put on weight. These may be the symptoms of estrogen dominance caused mainly by lack of ovulation and thereby lack of progesterone while their estrogen levels are still in the “normal” range. Their doctors may check their estradiol levels and their FSH and LH levels, but rarely does it dawn on them that their patients’ progesterone levels are too low. In taking the usual blood tests, the doctor may find the estrogen normal that day or even a bit on the low side and FSH levels a bit too high. On another day the estrogen might be elevated and FSH levels normal. If the former is found, the doctor may even prescribe some estrogen on the theory that the patient is nearing true menopause. The woman usually finds that this does not help her and often makes things worse

More often, the doctor ascribes her complaints to emotional causes or simply some defect of Mother Nature that women must endure. In later chapters, I will discuss this phenomenon in more detail. For the present, we will merely say that a rising percentage of women are experiencing premenopausal woes that are related to their hormones. The details concerning environmental toxins, nutritional factors, stress, adrenal hormones, exercise, and weight will be found in the chapters ahead.