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Quick definitions for menopause and hormonal balance

Menopause is just a point in time — the date on which you haven’t had a menstrual period for a year. Perimenopause is the period of hormonal fluctuation that leads up to menopause; it can last from five to 15 years or longer. Early menopause does occur for a tiny fraction of women, but the term is mostly used by women — not practitioners — when symptoms occur much earlier than "normal." Medical menopause is menopause brought about by medical treatment — typically hysterectomy or cancer treatment — and an incredible 25% of women enter menopause this way.

Hormonal balance is our normal state. When we have menopausal symptoms, we are suffering from hormonal imbalance — an abnormal state. About 80% of women today experience symptoms of hormonal imbalance — more than ever before — because of the extraordinary demands made on their bodies and the inadequate support provided.

Fortunately, nearly all women can find relief from the symptoms of perimenopause and menopause by restoring that balance — naturally and without drugs. And we’re here to show you how.

Why do women come to us with so many unanswered questions? Why do so many women feel dissatisfied with the answers they’re getting from conventional medicine?

The simple answer is that conventional medicine breaks everything down into separate parts that can be separately controlled — and that’s not how the female body works. As you explore our website and find the answers you need, keep in mind that every aspect of your life affects your health — and that no symptom or health problem can be viewed (or controlled) in isolation.

So here are the resources for you in this section of our website. Read on for the answers you seek, then give us a call if you would like additional guidance.

Perimenopause — the beginning of hormonal change

Up until relatively recently, conventional medicine has had little to offer women suffering from symptoms of hormonal change. Until a woman was deemed to be officially in menopause and could be prescribed synthetic hormone therapy, she was often told that her symptoms were all in her head. Even today, women struggling with hormonal imbalance are frequently sent home with a prescription for antidepressants, rather than being offered real solutions for a very real condition.

In integrative medical circles, there has long been recognition that a transitional period of time exists before menopause, which is different for each woman, when fluctuating hormones may cause her serious distress. Thankfully, conventional medicine has caught up and we now have an official name for this passage in medical textbooks: perimenopause — defined as a transition period that precedes menopause, as in "pre-menopause," which is symptomatic of hormonal imbalances and fluctuations in a woman’s body.

Symptoms of perimenopause can begin as early as 10–15 years before menses completely stop. Women in their late 30’s, 40’s and early 50’s may transition in and out of a perimenopausal state many times before they finally enter menopause. If you are currently experiencing symptoms such as irregular periods, heavy bleeding, hot flashes, sleep disruption, headaches, dry eyes, vaginal changes, hair loss, weight gain, loss of libido or extreme emotional distress, you may be relieved to know that these are all common signs of perimenopause.

Along with the more obvious changes listed above, many of my perimenopausal patients find their short-term memory impairment or a lack of focus to be very irksome. These cognitive effects of hormonal imbalance are frequently overlooked in mainstream discussions about perimenopause. Yet fuzzy thinking and an inability to multitask can definitely be traced to your physical state, as can increased anxiety, fatigue, depression and drastic mood swings. These symptoms are actually signals being thrown up by your body to make you stop in your tracks and take notice. Women often remark on the brain fog that comes over them after childbirth, affording them only the attention span to focus on their new baby. A similar phenomenon occurs with the hormonal fluctuations leading up to menopause — only this time the miasma of your hormones is telling you to stop and pay attention to yourself!

It may be reassuring to remember that a woman’s body is always in flux, always changing, and never more so than in the years that characterize puberty and perimenopause. In the same way you can be "pubescent" you can also be "perimenopausal." But these are just words, not a rigid definition of who you are, what your body is capable of, or who you are going to be.

During perimenopause, the ratio of estrogen to progesterone is frequently in a state of flux, which can manifest along with other symptoms as very heavy (and maybe even frightening) bleeding. In our culture, many women tend to be operating with an internal hormonal balance tipped toward the estrogen side of the scale. This tilt is often the result of a diet high in simple carbs and low in quality protein, a lack of essential nutrients and fats, and chronic exposure to environmental toxins and artificial hormones such as endocrine disruptors. Prolonged emotional and physical stress, which I define as anything that works against your state of balance, will also upset the hormonal applecart. In today’s fast-paced, disconnected, eat-and-run world, it is no surprise to me that younger and younger women are coming in to my practice with symptoms of hormonal imbalance and perimenopause.

In some cases, women in perimenopause may have low levels of progesterone in comparison to their estrogen levels. In other cases, the progesterone level is fine, but estrogen levels are too high. Another case we are seeing more frequently is where all three of the key hormones which flux during this time, estrogen, progesterone and testosterone, are too low. What’s most important to recognize is that each woman needs to be evaluated differently, preferably by a medical practitioner conversant in integrative or alternative medicine. More often than in the past I find conventional doctors are quite willing to discuss the reality of perimenopause, but natural, long-lasting solutions are still hard to come by. Most conventional practitioners don’t believe that people can change their lifestyle and eating habits. My response is that I know and have seen that they can. And I will tell you this: no woman needs to suffer with symptoms of hormonal balance, at perimenopause, menopause, or after menopause. You can feel better and you can start right now.

Being in perimenopause does not necessarily mean that you will follow an immediate and direct path to menopause. Some women go for years in this transitional state, whereas others sail through in just a few months. What does seem to influence the severity of symptoms is the weight of other burdens women may have placed on their bodies over the years. Poor nutrition, chronic stress, and a lack of daily exercise are three major amplifiers because they each play a significant role in the body’s ability to detoxify and maintain homeostasis. Lifestyle choices such as smoking or drinking to excess are likewise compounding factors.

Another hidden element of perimenopause is fear. Many women are terrified by the prospect of losing their biological fertility, just when stress and low testosterone may be zapping their libido. Our youth-obsessed culture has been extremely hard on aging women, but I have witnessed the dynamic transformation that takes place in my patients. The joys of life after menopause are many and great — you just have to learn how to manage the symptoms leading up to it!

After more than 20 years of helping women with their premenopausal issues, I understand firsthand women’s frustration with the way healthcare is often delivered. With projections indicating that for the first time in history our children’s life expectancy may be shorter than our own, the time is ripe to make some changes in the way we care for ourselves — changes that aren’t oriented toward drugs. I’ve found that a combination approach, one that takes into account all four corners of a woman’s foundation of health, provides the most relief. That’s why I created the Personal Program to give women the basic tools necessary to navigate the confusing waters of perimenopause: in short, optimal nutrition, hormonal balance, mindful exercise habits, and emotional support.

Hypothyroidism (low thyroid function) in women

The thyroid gland is a little winged gland in our necks that controls the rate of function for every cell and gland in the body, including growth, repair and metabolism. It’s fair to say that you can’t maintain optimal health unless your thyroid is working pretty well.

While the thyroid is vital to both genders, women have a greater tendency than men to suffer thyroid problems, especially hypo- (low) thyroid function. No one clearly knows why. It probably has to do with the interplay between our reproductive hormones - i.e., estrogen and progesterone - and our thyroid hormones. Many women experience underactive or hypothyroid issues during perimenopause, just as some do during adolescence or pregnancy, the two other stages in our lives of tremendous hormonal flux.

Since these are times of hormonal change, it makes sense that an imbalance in female hormones would strongly impact thyroid function. In fact, we often see hypothyroidism in our patients as part of a larger pattern of long-term hormonal imbalance.

Unfortunately, conventional medicine typically views the thyroid in isolation from the other systems of the body. And quite frankly, the success rate of conventional medical treatment for hypothyroidism is far from encouraging. In so many cases women with thyroid problems spiral steadily downward, feeling worse as the years go by and finding themselves on an ever-expanding list of medications.

I would encourage you instead to see the thyroid as an integral part of your overall health picture. In this section of our website we explore the main aspects of low thyroid function, hypothyroidism, and hyperthyroidism from a holistic perspective. What we find is that with this approach to thyroid health, we can often restore and then maintain healthy thyroid function in our patients.

Healthy bone function and peak bone mass

Bone loss is a natural, in fact vital process. Only bone loss (called resorption) can initiate healthy new bone formation (called deposition or formation). As with all things in nature, good bone health relies on a balance between this action and counter-action, like breathing out and breathing in.

New bone is strong, flexible with the ability to bear both compression (running, jumping) and tensile (flexing) pressure. Bones strengthen with use, just like muscle, all through your life. But at some point, bone loss gradually begins to outpace bone growth — when this begins happening is highly individual, but it can be as much as 20 years or more before menopause.

Bone health is influenced by many factors: family history, body frame size, diet, calcium intake, vitamin D levels, physical exercise, hormonal balance, stress, and lifestyle. And because bones are constantly regenerating, before and after menopause, every positive step you take to support their function will make a big difference — whenever you take them.

To get a better idea of how this works, let’s take a closer look at our bones.

Bones are complicated living tissue, not hard shells around soft marrow like soup bones. Bones are 35% latticed protein — an infrastructure known as the collagen matrix — and 65% mineralized collagen, which gives the bone its strength.

Bone health depends on the give-and-take process I described above, also called remodeling. During this process, bone cells called osteoclasts travel through bone tissue retrieving old bone and leaving small, jagged spaces behind. This triggers their counterparts, called osteoblasts, to come into these spaces and deposit new bone. About 5–10% of all our bone tissue is replaced — or turned over — in a year in this way. Osteoblasts cannot work properly without sufficient osteoclast activity, and new bone is stronger and — this is key — more flexible than old bone.

Exercise and physical stress naturally build new bone and speed the remodeling process, even when you’re older. That’s why you can lift progressively heavier weights in an exercise program — it’s not just muscle you’re building.

But no matter how much bone you make, you’ll still experience bone loss with age. The bell curve looks something like this: during puberty, when our body and skeleton are growing, bone formation outpaces bone loss. Between ages 20 and 30 most women have reached peak bone mass, but the age varies depending on race and lifestyle.

The concept of peak bone mass has been oversimplified. The accepted idea is that it’s like a retirement account — the more healthy bone you’ve accumulated by your mid-20’s, the more you’ll have to draw down as you get older. But peak bone mass can vary as much as 100% in women of the same age from different cultures. And peak bone mass seems to have minimal affect on fracture risk: for instance, Asian women have a lower bone mass than Western women but a lower fracture rate.

Differences in ethnicity, diet, exercise, onset of puberty, and lifestyle make peak bone mass a very individual characteristic, hard to quantify — and not a good measure of bone health.

At some point in your mid to late 30’s, bone resorption begins to outpace formation (by about 0.5–1.0% per year). After menopause this rate may accelerate to 1.0–5.0% with the dip in reproductive hormones. Within five years after menopause, when hormonal fluctuations settle down, bone loss evens out again to a gradual and perfectly normal decline of 1.0–1.5% per year.

So what differentiates normal and abnormal bone loss — and who’s really at risk for osteoporosis?

What is osteoporosis anyway?

If you have established osteoporosis (not just the risk of getting it), bone loss may accelerate over time to absorb up to one-third of your total bone mass. Over time whatever bone is left is thin and porous — it looks like ruined honeycomb — and fractures easily doing everyday things like walking and coughing.

Before 1994, to officially have osteoporosis, you actually had to break a bone as the result of minor impact or trauma. Since then, new bone-scanning technology has cast a wider net and allowed medicine to quantify the diagnosis. Osteoporosis is now defined as having a bone mineral density (BMD) that deviates more than 2.5 points below a standard. That standard is the average for a large sample of 20 to 29-year-olds. In short, you’re being compared to young women with supposedly peak bone density.

What is osteopenia?

As recently as the 1970’s, the diagnosis of osteopenia didn’t exist (my colleague, Dixie Mills, checked her textbooks from medical school just to be sure). Experts chose this term in the 1980’s to fit the women who didn’t quite have osteoporosis to motivate them to pay attention to bone health.

However, there was no medical basis for choosing this number and no studies to support everyone’s immediate assumption that a diagnosis of osteopenia meant you were headed for osteoporosis. No one seemed to notice — except of course the drug companies — that by this definition almost half of all post-menopausal women now had the new medical condition called osteopenia.

Because osteoporosis is progressive, the diagnosis of osteopenia can be very frightening — many women stop lifting heavy objects or engaging in physical exercise for fear of fractures. But in reality almost all women with osteopenia should be getting more exercise, not less!

Risk factors and causes of osteoporosis

A small percentage of women will get true osteoporosis. Osteoporosis occurs earlier and more severely in white women of Northern European descent who are small-boned and thin. And despite the claims made by the calcium supplement makers, the highest rate of osteoporosis is seen in cultures that eat the most dairy.

Other risk factors for osteoporosis include:

I would add that adrenal exhaustion is a major factor in my patients with osteoporosis. I often see women with several problems or comorbid conditions: inadequate nutrition, weak digestion, low metabolic rate (often as a result of chronic dieting), and adrenal fatigue. For these women, osteoporosis is a result, not an underlying cause, of other health conditions. Giving them a drug like Fosamax does nothing to fix the real problems.

Click here to learn more about how to prevent weak bones and what substances you should avoid.

Bone density, bone strength and the risk of fracture

When most women hear the word "osteoporosis"they think with a shudder of hip fractures, broken wrists, and the loss of height and spinal deformity characterized as the "dowager’s hump."We automatically assume, because we’ve been told, that low bone density is the first step to bone fractures.

But there is no hard evidence that bone density correlates with bone strength or flexibility — the two factors that prevent bone from fracturing under stress. In fact, bones can be dense (rich in calcium and hard) yet brittle — what matters more is the health of the collagen matrix, which keeps the mineralized bone supple and resilient.

The collagen matrix is a foundation of nutrients and minerals that allows the bone to expand, contract, and mend without breaking. Think of the difference between a living, breathing sand dollar and its ossified shell, or a slab of dried wood and a thinner piece that has been saturated in protective oils. While this is not an exact comparison, it may help you understand why a dense, hard covering can actually be more fragile than a thin but well-integrated whole — and why drugs like Fosamax and Actonel that treat only bone density do not necessarily prevent fractures.

Bone density test and osteoporosis screening

Unfortunately we can’t test bone health directly — we mostly look only at bone density. But it’s better than nothing, as long as you remember the limitations of the test.

When diagnosing osteopenia or osteoporosis, most doctors rely on a bone density test, usually dual-energy X-ray absorptiometry, or DEXA. There are other tests, including CT scans, dual photon asorptiometry (DPA) and ultrasound, but DEXA is by far the most prevalent. Click here for more information on bone density testing and its use in osteoporosis diagnosis.

Be sure when discussing your BMD results with your healthcare practitioner, remember to ask what standard you were evaluated against. Often simply normalizing for your age, race, or region will give you very different results. And be sure to get a copy of the results. This is your test and you should keep your own medical file.

Bone health and fractures

While fractures are frightening and can be incapacitating, the common perception that low bone density causes fractures is misleading. The simple reality is that falls cause fractures. The average age of a hip fracture for a woman is 79, and over 90% of hip fractures occur after a fall (not vice versa). Most falls are due to complicating factors, and low bone density is pretty far down on the list of risks. Click here for more information about osteoporosis and the risk of bone fractures.

Why has there been so much focus on bone density as a cause of fractures if the relationship is so weak? One answer is that we actually have a test for bone density. The other is that there is a product to sell — biphosphonates (such as Fosamax and Actonel) and HRT.

Drugs for osteopenia and osteoporosis

Research on HRT in the 1970’s showed that estrogen therapy (and later the combined estrogen plus progesterone therapy) helped inhibit bone loss for about seven years after menopause.

This news meant that prescriptions for HRT were written increasingly for the prevention of diseases like osteoporosis — not for relief — and as a result, women were put on hormone therapy whether or not they were experiencing symptoms of menopause. And the truth is that HRT does help bone density — at least in some women.

No wonder HRT was the most frequently prescribed drug in this country by 2001! A year later, when the WHI released its data on the real risks of HRT, this became a dubious practice.

Another fact women weren’t told is that once hormone therapy is discontinued, bone loss accelerates to reach its age-appropriate rate —

the nominal gains are "wiped out." Most HRT studies are rarely carried out for longer than a few years, at which point bone loss may have stabilized itself anyway. And there’s no indication that HRT therapy has any long-term effect on fracture risk in women over 75 — when most fractures occur. And there are no studies of the long-term effects on bone health of HRT therapy.

Fosamax charged into the osteoporosis market as HRT receded. Fosamax works by inhibiting bone resorption. Unfortunately that’s not as good as it may sound. Remember that bone function is a two-way street: if resorption is delayed, then so is formation — so no bone is lost, but no new bone is made.

Evista (raloxifene) is a selective estrogen receptor modulator similar to tamoxifen. It is increasingly prescribed to women with or at risk for osteoporosis. Developers claim it reduces fractures without the risks of HRT. Side effects include increased hot flashes, leg cramps, flu-like symptoms, blood clots and peripheral edema. These symptoms of inflammation are obviously not good for you. Studies are currently underway looking at this drug’s potential to prevent breast cancer.

Osteoporosis prevention and hormones

Before menopause, it’s important to promote your body’s natural hormonal balance so bone growth stays consistent. After menopause, your body has many natural mechanisms to boost estrogen levels and maintain bone health.

One is to store a little extra weight (that’s one of the reasons that recent weight gain is so stubborn). Estrogen is made and stored in fat cells, so keeping a few more around is actually good for your bones. This is one case where thin is not better!

Testosterone, a potent steroid hormone, increases muscle mass, which in turn helps build bone density. After menopause, testosterone can be one of the substances your body converts into estrogen. (Click here for a diagram of how hormones are made in your body.) When you exercise, your body releases testosterone — just one of the reasons physical activity is a natural antidote to bone loss.

But what about women who don’t make enough hormones naturally?

Osteoporosis, irregular periods, and hysterectomy

Much of the information on estrogen and bone loss comes from women who’ve undergone a full hysterectomy and received HRT therapy in their 20’s and early 30’s — the stage at which they are supposed to be maximizing bone density.

Teenagers and young women who’ve experienced hormonal deficiencies characterized by frequent amenorrhea due to malnutrition, eating disorders, over-exercising, or other factors are at a greater risk for osteoporosis for the same reason.

These women just haven’t had the steady supply of sex hormones to store up a good base of bone to age with. If any of these factors sound familiar, talk to your practitioner about your risk of osteoporosis and the usefulness of a pursuing a course of bioidentical hormone therapy that includes the proper balance of estrogen, progesterone, and testosterone.

And keep in mind that a risk is just that — a risk — not your destiny. Instead of worrying so much about bone loss, most women would benefit by focusing more on natural steps to improving bone health.

Calcium and bone health

Healthy bones store about 99% of the body’s calcium; the rest is used throughout the body for other vital functions. Bones also house about 85% of the body’s phosphorous and 50% of the body’s total sodium and magnesium.

Calcium is one of the most important minerals in the body, not only for bone health but for other physiological functions, including nerve transmission, blood clotting, muscle growth and contraction, heart function, hormone function, and metabolism.

But calcium makes you work for it. It requires a lot of digestive teamwork, including the presence of stomach acid, a whole alphabet of vitamins, magnesium, other essential minerals, and a well-functioning GI tract to deliver calcium’s many benefits. If you have deficiencies anywhere along the line, it won’t matter how much calcium you eat, your body will take it (and whatever other minerals it needs) from your bones. This usually shows up first in non-vital areas like your teeth, hair, and nails.

To test how easily your calcium supplement breaks down in a healthy stomach, put it in a glass of vinegar and stir occasionally. It should dissolve completely in twelve hours.

Bones release calcium by upping the rate of resorption. Whatever doesn’t get used gets excreted through the kidneys — this is why doctors test your urine for calcium as one marker of bone loss. In Chinese medicine the bones are said to be ruled by the kidneys, so interlocked are their functions.

But increasing calcium is not the answer: too much is as problematic as too little, causing other difficulties, like kidney stones, gallstones and hypercalcemia. Our American diets have plenty of available calcium and we still have osteoporosis — what many of us lack is the ability to successfully use the calcium we get.

If you have GI issues, including IBS or celiac disease, you can’t absorb the calcium you need from your food. Older women often lack the digestive acids necessary to break down calcium. Ironically, women are told that antacids like TUMS are good calcium supplements — but antacids oppose the very stomach acid (hydrochloric acid) needed for calcium absorption. Protonics, like Nexium, have the same problem.

Nutrition and calcium absorption

Vitamin D is crucial to moving calcium from the small intestine into the bloodstream, in conjunction with stomach acids and other vitamins. In one study up to 30–40% of older patients with hip fractures had a vitamin D deficiency or insufficiency. Maybe the real health risk for bone fractures is vitamin D deficiency, not low bone density! (For more information on the importance of vitamin D, see our article.)

Magnesium increases calcium absorption from the blood into the bone. Dairy products contain little magnesium and alcohol depletes it. Ironically, too much calcium blocks the absorption of magnesium, leading to a deficiency characterized by hair loss, muscle cramps, irritability, trembling, and disorientation.

A good balance between calcium and phosphorous (about 5:1) is crucial to bone strength, but too much phosphorous depletes calcium. Soda and red meat — two staples of the American diet — are full of this mineral, so much so that now some sodas have extra calcium to counteract the deleterious effect of drinking so much phosphorous.

Trace minerals like boron, selenium, copper, silicon, manganese, and zinc are also important in supporting the healthy balance that makes bone. For an in-depth explanation of all this and more, I encourage you to read Annemarie Colbin’s wonderful book, Food and Our Bones.

Good calcium digestion is dependent on a lot of other factors too, but I’ll cover only two other substances here because of their prescription use in osteoporosis treatment: calcitonin and parathyroid hormone. The former is secreted by the thyroid gland, the latter by the parathyroid gland.

Calcitonin stabilizes high levels of calcium by inhibiting osteoclast activity (the agents in bone resorption). It’s now available as a prescription nasal spray but is most effective in women who have osteoporosis as a result of corticosteroid use. It causes nasal irritation, headache and joint pain.

Parathyroid hormone (PTH) is normally triggered by high levels of phosphorous in the blood with corresponding low levels of calcium. Daily injections seem to stimulate bone formation and are being used to treat women with severe osteoporosis. High doses of the medication caused bone cancer in rats so treatment is not recommended for more than two years.

Osteoporosis and inflammation

An emerging area of study is the relationship between bone loss and blood acidity. It has been known for a while that vegetarians and women eating a low-protein diet have a lower rate of bone loss. What hasn’t been understood is why.

New studies are showing that high levels of the pro-inflammatory blood acid called homocysteine double the risk of osteoporosis-related fractures. It has also been linked to other inflammatory conditions like heart attack, stroke, and Alzheimer’s disease.

A recent report published recently in the New England Journal of Medicine asserted that elevated homocysteine levels inhibit new bone formation by interrupting the cross-linking of collagen fibers in bone tissue. It’s also possible that the body tries to neutralize acidic blood serum (i.e., low pH) by releasing more bone calcium. Homocysteine levels can also be stabilized by taking a vitamin supplement with folic acid, B12, and B6.

Be aware that a minority of the population can’t convert folic acid due to a genetic factor. If your homocysteine levels remain high even after a few weeks of B supplementation, you may want to ask your practitioner about adding a more bioavailable form of folate called 5-methyl-tetrahydrofolate to your diet.

Other foods that cause blood acidity are refined carbohydrates and simple sugars — yet another reason to minimize these unhealthy foods in your diet.

So, if we know that all this and more go into the proper balance of bone formation and resorption — and one function can’t thrive without the other — why is mainstream medicine so skewed to the side of drugs for osteoporosis?

The Women to Women approach

Your bones, including your hair, teeth and nails, are mirrors of what you put into your body and the balance in your life. At Women to Women, we encourage our patients to try a combination approach to preventing and treating osteoporosis that begins with optimal nutrition. In short, this means:

I recently saw a patient in her 50’s who had first come to me two years ago with a diagnosis of osteoporosis — she was 2.7 standard deviations below the norm. But her real problem was the "superwoman syndrome": adrenal exhaustion from over-work, neglected nutrition, and putting herself last. I told her she could overcome her osteoporosis if she worked at it. And she has — her latest BMD shows her above the norm.

Solid bones need support

In the end, osteoporosis is only as frightening as the power we give it. With some attention to your diet, a medical-grade supplement, and a few healthy lifestyle changes, most women can prevent, treat, even reverse bone loss without drugs and their side effects.

In Chinese medicine, osteoporosis is considered a physical manifestation of not feeling supported in life. Ask yourself if there is a relationship there to how you feel in your life.

Our youth-obsessed culture tends to undermine our self-esteem as we age rather than celebrate what we have learned and accomplished. As we continue on the amazing journey of life, maybe we can begin to see that time will actually make us stronger if we let it. And with the right support, our bones will help carry the load.