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It is that time of life, midlife, menopause, and you aren't sleeping so well. Is melatonin the answer?

Menopause and midlife aging happen at about the same time for most women, but they aren't exactly the same. Menopause is when periods stop because there are not any more eggs to ovulate in the ovary. It's the last period, and it happens at about 50 years of age in most women. Midlife is a little harder to define, but it is that middle of your life from about 40 to 70, after you are young, but before you get old. Maybe it's really from 30 to 60. It depends on where you are as to what range you will embrace. I embrace the 40 to 70, but 30 to 60 is probably better.

We are about as strong and as smart, and I'm not saying wise, as we're ever going to be in normal biologic function at about 30. After that, we begin to age with decreasing muscle mass, bone density, and cognitive speed.

We are usually really great sleepers until midlife. Of course, there are some kids who are naturally short sleepers, and there are those people whose sleep rhythms don't let them really fit into their daily lives. They're night people, but they have to get to work at 7:30 in the morning, so their sleep is disrupted. There are the years of infants and young children that wake us up at night. There are years of jobs that shift hours. But left to our own devices, we are often pretty good sleepers until the middle of our lives.

It's a combination of anxiety, all things for which you're responsible, adolescents in their 20s, finances, juggling stuff keeps us awake. Aches and pains with aging and stiffness keep us awake. And then menopause with hot flushes keeps us awake.

Now, what is melatonin? Melatonin is a small molecule that was originally thought to be made just in the pineal gland in the brain. Its function originally was thought to help us set our circadian rhythm, our internal clock. Pineal melatonin is suppressed by bright light. And when lights get dim, melatonin rises because of its own natural daily rhythm and the lack of suppression by light and helps us signal sleep time. As we age, we make less and less melatonin and that's the midlife aging part.

Now, we know that melatonin isn't only made in the brain, and its function isn't only to help our clock give us daily rhythms. It's found in our gut and may help our gut bacteria have a rhythm, and it's found in the placenta and the ovary and it's an important antioxidant in the body. There is much more that can be said about it, but let's get back to menopause and melatonin.

So you're a midlife menopausal woman and you're having difficulty sleeping. You're having a hard time getting to sleep and your hot flushes wake you up. You're not so interested in taking estrogen hormones for your hot flushes, but you should be and you've read about melatonin. Does it work? Is it safe to take? Can you get addicted to it? Can you take it for a long time?

Does it work? An international group of researchers published a summary of what we know about this in the journal "Sleep Science." Several studies done around the world suggested that a three-milligram dose of melatonin before bed helped with sleep. Women were given melatonin or a placebo and asked about sleep, physical symptoms, hot flushes, and psychological symptoms, and these all got slightly better when people took melatonin over placebo.

Of course, getting better sleep can help with joint aches, psychological symptoms, and hot flushes, but melatonin does a lot of amazing stuff and maybe melatonin was helping.

It was safe with few side effects. Some women in both the placebo group and the melatonin group had side effects of sleepiness and nausea and vomiting and headache, but the incidence was not different in the two groups. People who took placebo and people who took melatonin had the same rate of side effects.

Is it safe to take for a long time? The answer is probably yes. It is not addictive in the traditional sense. There's no evidence that a low dose leads to higher dose usage. There's no evidence that higher doses over three milligrams is more effective. There's no evidence of withdrawal.

The main problem is that there's no control over what's actually in the bottle when you buy it at the grocery store or the health food store. You might be getting melatonin or you might not.

The NIH has a Center for Complementary and Alternative Medicine with a short page about melatonin. They note that a 2017 study tested 31 different melatonin supplements bought from the grocery store and pharmacies. For most of the pills in the melatonin bottle, the amount of melatonin didn't match what was on the label and there were other compounds in the bottle. The biggest concern was 25% of the bottles had serotonin in them, and serotonin is a regulated drug with side effects that can be harmful at low levels.

Melatonin is widely used in Europe as a sleep aid, and supplements are regulated in Germany. So they have to have what they say on the label in the bottle, and no other funny stuff. In the U.S., they could sweep up what's on the lab floor, stick it in a little capsule, and you'd be none the wiser, and no one's watching.

So what do you do if you want to take melatonin? It would be good to talk with your clinician and make sure you don't have any contraindications. They should know that you're planning to take it and it should be on your medication list.

Although the USP verified label on supplements is not a guarantee that you're getting what you think you're getting, it's a start. The USP label indicates that the product has been subject to voluntary testing and meets U.S. pharmacopeia convention standards, that's the USP part, meaning the product is accurately labeled and free of harmful substances. This does not mean that it's been tested by the FDA, but it's better than nothing.

Now, of course, melatonin is found throughout the plant kingdom, and a wonderful paper in the journal "Nutrients" from 2017 listed the melatonin contents of common foods. Some mushrooms have a lot of melatonin. Portobello mushrooms are the basic white and brown ones that you can get at the grocery store have a lot. Seeds and nuts have a lot of melatonin. And pistachios win the top melatonin prize in the nut family.

Sprouted seeds also have a lot of melatonin and sprouted lentils are at the top. I can see a dinner salad with sprouted lentils, mushrooms, and pistachios being perfect to help you sleep. Your gut will love it and you won't feel guilty. Both of those factors are important for a good night's sleep.

It turns out that roasted coffee beans have a lot of melatonin, and coffee has some, but coffee is defeating the purpose.

So there are a lot of reasons you may not be sleeping well in midlife. The American Academy of Sleep Medicine would suggest behavioral approaches, such as bright morning light and daily exercise, a bath before bedtime, and no coffee after noon, limit alcohol at night, and no screen time just before bed to suppress your melatonin.

Having said all that, international studies suggest that melatonin in low doses can be helpful for midlife women struggling to get to sleep. So sleep tight, and thanks for joining us on The Scope.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

My retirement was a slow, steady decline. Kind of like what menopause is, is a phased retirement. It's a slow retirement from your reproductive life. Phased retirement. That's what menopause is. Your Phase 1 is all about sex and babies and partnering or not partnering and being social. Then when it's over, phased reproductive retirement, that's menopause. You kind of slip into not being fertile and having more irregular periods. Then it's over. But it's really not over.

Menopause is the last period and the decline of hormones made by the ovaries. It happens at about 50 for most women, and it isn't usually an all of a sudden kind of thing. Unless the ovaries are removed surgically, the usual course is for periods to become a little irregular, then more irregular, and then stop over several years.

We talk a lot about bleeding in the "7 Domains of Health." It is bleeding too much or too little that brings us to care. It is menstrual blood that's a taboo, even just a little one when we talk about feminine hygiene products. It's bleeding to death that's the number one cause of maternal mortality around the world, and bleeding defines our reproductive life. And when it stops, it defines menopause. That's what the word means, end of menses, end of menstrual bleeding, the end of fertility, the end of child-bearing. Only your own heart beats.

In many cultures where menstrual blood is a bigger taboo, women might only assume a position of power in their community after their bleeding time is over.

There's a mistaken sense by some that women who are cycling having periods cannot be trusted with power as they're too emotional, but I'd say I've seen lots of guys get emotional, so it's not just a girl thing.

In our own culture and in the U.S., it's hard to know, because we're a multi-cultural society, what culture we are talking about. But women often fear menopause because it's a reflection of aging, and aging women are not always seen as attractive to the opposite sex. That usually means men, because attraction for men is often linked with potential fertility. Even if it isn't recognized as the focus of sex, but that's the underlying urge, is to make babies. So menopausal women who look older don't look fertile, and women spend a lot of time and money and makeup and surgery and stuff to make themselves look younger.

Kristen Hawkes at the University of Utah has proposed the Grandmother Hypothesis, that humans developed genetic differences from chimpanzees that had allowed them to live long after their menopause because they had language and mothers help their daughters become more successful mothers.

But menopause is the end of ovulation and predictable ovarian function, and the ovary still makes hormones, but just in smaller amounts. For some women, the abrupt cessation of ovarian function is associated with immediate symptoms like hot flushes and longer-term symptoms like vaginal dryness and urinary symptoms. These can vary significantly and affect the quality of life for women.

But women at menopause also complain of stiff and painful joints, like osteoarthritis, but these symptoms often get better with estrogen replacement, suggesting that these symptoms arise from lack of estrogen.

So while not all women experience some or any of these symptoms, they are troublesome. And then there's the sense that the brain isn't working as well as it did. Women, they have great brains. They remember stuff. They remember people. They remember names. They remember where they're supposed to be. They're multitaskers. And when that isn't working, we notice.

And for some women, their brain is more irritable. Lights are too bright. Sounds are too loud. Things set them off. All of this can be associated with hot flushes or with the sleeplessness that comes with hot flushes.

The ovary continues to make hormones in smaller and smaller amounts and not very predictably. Many women have a few symptoms, but some women experience hot flushes and difficulty sleeping and concentrating. And making sure that the brain works well was one of the top concerns of women coming to our Midlife Women's Clinic.

Today, in The Scope Studio, we're joined by Dr. Sarah Berga, and she has a special expertise in neuroendocrinology, how hormones affect the brain and how the brain affects hormones.

Dr. Jones: So what happens to the brain when it doesn't get estrogens anymore?

Dr. Berga: We've been studying that for quite a while. And one of the things is the neurons start to pull apart and start to shrivel.

Dr. Jones: Oh, no.

Dr. Berga: Yeah. And the disconnection actually means the brain works slower. You don't really see people losing their intelligence as much as they speak more slowly, they process information more slowly, and they do sometimes forget where their keys are.

Dr. Jones: Oh, that doesn't sound very good. So menopause happens midlife around 50 when already our brain is aging some. Many women are fearful about taking estrogen after menopause. They've heard all kinds of things. Can you help reassure me now that my brain is falling apart? Reassure me that it's going to be okay if it's not too late.

Dr. Berga: So the Women's Health Initiative really did put some scare out there for estrogens, and it's true that we need to use them judiciously and how they're used really does matter. So you want to get the right kind at the right time and the right dose, and that is actually something we can do now.

We can measure estradiol, the estrogen made by our ovaries. We can know if we're giving too much or too little, and we can also see using neuroimaging the effects of giving back the right amount of estradiol. So now we're pretty informed, and we can do this in a wiser way than we could before.

The best estrogen for us as humans is estradiol, and it needs to be in what we call a physiologic range. So it needs to be above 40 and probably below 100 picogram per ml, and that safe range seems to be safe for most everybody. In fact, if we use estradiol transdermally, there are studies showing that it actually reduces the risk of stroke and blood clots. So it is a matter of titration and using it wisely.

When people take products and they don't know what levels they're achieving or they don't even know what kind of estrogen they're getting, then it's a little hard to be reassuring.

Dr. Jones: Now, the next question, of course, for me is if women have a uterus and they're taking estrogen, they need to take a progestin, a different hormone, to help protect the uterus against building up too much of the estrogen. And progestins, we know, have effects on the brain too. What do we know about that?

Dr. Berga: So progestins aren't so happy for the brain. High doses of progestins actually make the brain a little sad and a little blue and a little darker in some ways. So we want to give the least necessary to protect the uterus, and we have some clever ways to do that.

One is the progestin-bearing IUDs, and they might be the right answer for many people, particularly people that are going through the transition. So they still might need birth control, but they might be sort of perimenopausal and having symptoms intermittently. We can give them the Mirena or some equivalent for the uterine protection and for birth control, but also add some estradiol on top of that, and then they can just smooth away menopause.

Dr. Jones: Oh, that's what we want. We just want a smooth menopause, particularly for the 50- to 65-year-old who's the woman who's having the most symptoms, who's got the most to lose by not having the brain that she wants, I think.

When I think about what the literature says about midlife, it suggests, and Freud was the worst one about this, that women have involutional melancholia, meaning when their ovaries quit working, they get sad. So let's debunk the myth that women at menopause go crazy, because, in fact, they don't.

That's an unfortunate thing that was prompted by Freud, who said that women suffer involutional melancholia as the ovary involutes meaning becomes menopausal, women go crazy, because, in fact, women don't.

For many women, it's actually a time of great emotional stability. Women are at their most depressed and anxious in their 30s and 40s. And that's not counting teens, because teens are having their own issues. But we're talking about women-women, not teen-women.

There's a time before menopause when the ovaries have stopped working, where hormones are on and off and on and off, the perimenopause. And that's a time for women who have been vulnerable to hormones going up and down. These are women who've had post-partum depression and they're women who've had PMS, that they might be more irritable, they might be more anxious, and they might be more depressed. But once menopause has happened, most women are not more depressed.

So late 50s and 60s women are often in the happiest time of their life, although there are good studies that show that women are more likely to experience grieving during this time because, as you can imagine, their parents and their friends are starting to die. But they don't get depressed and they don't necessarily get anxious just because of menopause. I think that's a myth that's way past time to getting debunked.

Now, I would say that women who are having a lot of hot flushes can be irritable or cranky. So the irritable and cranky brain, which we talked a little bit about when we talked to Dr. Berga can be associated with hot flushes themselves or the sleeplessness, because you all know that when you haven't slept for night after night, you get irritable and cranky.

Now, I may remember this misappropriately, however, Isak Dinesen was a famous writer and she was most famous for her book "Out of Africa," but she had a quote that went something like this: "Women when they are old enough to be done with the business of being women and can lose their strength must be the most powerful creatures in the world."

So, for me, I think that's the scope about women. Women get power after menopause. Women get power after midlife. Women get power after they stop being obsessed with how they look and whether they're sexy or not and having babies and raising their children. It's appropriate to be focused on that at the appropriate time of life, but when that's over and they can let loose their strength, must be the most powerful creatures in the world.

So thinking about the social domain . . . we talked a little bit about evolutionary domains and different societies and how menopausal women actually come into their own after they stop bleeding and having kids, but who runs the family reunions and who runs the PTAs and who runs the church groups and who runs all the small non-profits? It's usually post-menopausal women. They're the ones who get stuff done.

So post-menopausal women are really important for your family, your neighborhood, your society, your town. And I'm saying the country. So let's think about post-menopausal women as members of Congress or members of the Senate or in the White House. And they don't have to be post-menopausal. They could be pre-menopausal too.

Let's talk about stuff my mom never told me. I'd say my mom wasn't particularly great on finances. In fact, she used to borrow from my babysitting money at the end of the month because she didn't have enough in her food allowance from my dad. So I think she really didn't have a sense of where the money was, where the money wasn't, because my dad took care of that and gave her a monthly food allowance, which back in the late '50s and early '60s, that's actually the way a lot of times things went in this country. So my mom never told me about how to run my finances.

Now, having said that, when my mom died, I found that she had her finances in perfect order. So somewhere between the time that I left home and the time that she died, she became very smart about money. She knew exactly where to put it and she knew where it was and she knew where it wasn't and she knew where to protect some for herself and she knew where to protect some for kids.

So becoming smart about money in midlife becomes really important. Financial health is something that many women in their midlife start thinking about, and it's not the ovaries that are making you think about it now. In fact, more life is behind you than ahead of you, and your parents are dying, unfortunately, and friends. And so you start thinking about growing older and what you have to support you. A lot of women know where the money is or isn't and know what they need to do to secure their financial future. But around the country, more women don't know about their finances than do.

You can get help with this. There are a number of organizations that can help you if you don't have your own financial advisor. Even your own local United Way can put you in touch with free financial advisors that can help you think about your future. Do you have any Social Security? How much do you have? Do you really know how to live on a budget? Do you know how much Medicare is going to cost? And although you're not there yet, for ladies in this menopausal transition, you're going to be there soon and you've got maybe 15 years to get things tucked in. So get it tucked in.

Menopause often opens a window to women creatively and spiritually. Raising a family, raising a business can significantly suck the creativity out of you and be diverted appropriately to very important stuff, like kids and businesses and work. But now, it's your time to listen to your own heartbeat. It's time to connect with something bigger than yourself. It's time to become wise.

And most people, to become wise, you have to have lived a little before you can get the 30,000-foot view, unless, of course, you're the Dalai Lama and you've already had many, many previous lives. But for most of us who haven't had many previous lives, this is the only life we've got and this is the only life we know. And you have to live some before you can become wise.

Part of that wisdom is coming to a sense of what matters matter, and that becomes important when you think about your own spirituality.

We talked about brains with Dr. Berga, but my midlife brain and my friend's midlife brains, we always sit around and say, "Oh, gosh, my brain isn't what it used to be," or, "Oh, gosh, I forgot where I put my keys."

Women are acutely aware of what they can't do anymore. Usually, it's finding names and proper nouns and nouns. Because women are so verbal, they remembered a lot more than men did, and this is a fact that you can actually show in testing, that women's verbal memories are better than men. So when they start losing this verbal memory, they get nervous.

Women come to me and say, "I can't remember names anymore and I can't remember where my keys are. Do you think I'm getting dementia?" And I say, "No, but I want you to think about how to keep your brain healthy."

• Teach what you know how to do best. That's what we talked about what menopause is all about. What is it that you do best? And that's what language is for in our long lives. So teaching, whether it's a recipe or if it's gardening or whatever it might be, take the opportunity to teach what you do best. Teaching requires your brain to do more than doing.

• Learn something new. I'm learning a lot of new things because I only have maybe 10 more years of a really great brain. And this is the time, if you have time, to learn some new things.

• Keep your friends close. One of the biggest predictors of a great brain, a great intellect, into aging is friendships and smiling and optimistic outlook. So catch up with friends and family that you haven't seen for a while. Strengthen relationships that will sustain you as you get older. There are lots of women out there that you can just talk about menopause with. So chit-chat, complain, whine, laugh about all the things that you're whining and laughing about.

The best way to protect your brain against dementia is to keep physically active, eat your fruits and veggies, keep your blood sugar and blood pressure under control, and hang out there with your friends and laugh.

Bad news is that menopause happens, and for some women, they don't feel so good. The good news is that there are lots of safe options for hormone therapy. Talk to your clinician about your symptoms and concerns. And if they aren't up to date on hormones and menopause, see a specialist in menopause and hormones.

You can do slow. Some people do it fast. But wherever you do it, if you live long enough, it's going to get done. So how to deal with it, how to cope with it, how to be positive about it. I was really positive about it, so good for me. Hopefully, good for you.

So here you are, ladies. This is your time. This is midlife. This is menopause.

Faucet of blood off
My body is my own now
Only my heart beats

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This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

What is one thing that every woman on the planet has but nobody wants to talk about? It's periods, period. Actually, women talk about their periods a lot, but they don't use that word "menstruation." They don't say, "My menses has come," or they might say, "My period has come." But all over the world, in many cultures, people use other words. One study looked and found more than 5,000 different slang or euphemistic expressions or phrases for their periods.

What's my favorite? My favorite is the French who use les anglais ont débarqué, and that means "the English have landed." Now, that's quite a phrase for having your period come, and it tells you a lot about what the French think about the British.

We as mammals have a process of building up the uterus lining so that we can grow our babies inside. We are the only mammal, as humans, that actually sheds the lining in such an obvious way. The animals that we share our DNA with, and that's the higher primates, chimpanzees, gorillas, they usually don't bleed all that much unless they have a problem or a cancer, whereas humans, compared to all other species on the planet, bleed a fair bit, and they bleed when they're shedding the lining and getting ready to start a new menstrual cycle when they're not pregnant.

Now, this has been going on for millennia that we have been humans. However, thousands of years ago, women rarely had their periods because they rarely ovulated. When women were starving or breastfeeding, which we were most of the time when we were hunter-gatherers, we didn't have much periods. So we didn't bleed very much. But over the last couple hundred years, since the Industrial Revolution, we are mostly well fed. We don't breastfeed for four years.

Many of you know, who have periods, that you can modify your periods and make them lighter by using some contraceptive methods that are quite healthy. We know that women who use birth control pills have periods that are about 80% or half of their periods when they're not on birth control pills. And some IUDs have very light periods or no periods at all. Women may choose these methods specifically for the way they modify their periods. So periods can be lighter and less painful by using contraceptive methods.

Okay. We're going to get ready for this week's medical mystery. And my producer, Chloé, is here in the studio and she's going to give me a person and some symptoms, and I'm going to try to figure it out.

Chloé: So this person just stopped having her period.

Dr. Jones: Okay. And she's how old?

Chloé: Late 20s.

Dr. Jones: Late 20s. First of all, has she gained or lost a lot of weight?

Chloé: So she hasn't had any weight loss. She hasn't been pregnant. She's, for the most part, had pretty normal periods.

Dr. Jones: Okay. How about exercise? Is she an endurance athlete or an elite athlete?

Chloé: She's not Olympian, but let's say she keeps active maybe a few, three hours a week of physical activity a week. Not much.

Dr. Jones: Okay. Not really very much. Okay. I'm not worried about that. All right. Now, has she had any surgery on her cervix or her uterus that might have caused a blockage or anything?

Chloé: No. No major surgeries.

Dr. Jones: Okay. Tell me about her past medical history. Has she had any serious medical illnesses?

Chloé: I'm going to say that she doesn't know because she doesn't talk to her family. So no medical history—no family medical history. No.

Dr. Jones: How about for herself, though? Her own medical history. Any severe medical illnesses in her past?

Chloé: So she had cancer when she was a teenager around maybe 14, 13 years old. She did get treatment. She did get cured, and her period did stop for a little bit after that, but it's back to normal, or it was until it stopped.

Dr. Jones: I have a very strong suspicion here, and here's how it goes. When periods stop, we think about outflow track, something having damaged the uterus or the cervix. That didn't happen to her.

We think about weight gain and weight loss or a lot of exercise. Elite athletes or endurance athletes can interrupt the process of getting ovulating, and she doesn't have that.

The biggest thing is she had chemotherapy for a cancer, which she's cured for, but we know that chemotherapy can damage the number of eggs that she has. And even though she got her periods back, she probably still didn't have that many eggs left. Now, she's run out.

I think she has premature ovarian failure. Her ovaries have run out of eggs, not at 50 when most women do, but early. What we're going to do is going to get a blood test. It's pretty simple. I'm going to get an FSH level, follicle-stimulating hormone. If it comes back elevated, meaning she doesn't have any eggs left, then we're going to talk about where do we go from here to help her with her estrogens and help her have a baby someday.

"Do I have enough pads for my next period?" "Where have I stashed them?" "Do I have them in my purse?" "Do I have them in the house?"

Women have a lot of periods, and there's a whole industry that's been built up around this. There are methods that women use to control their menstrual flow or manage it. So menstrual products are a huge billion-dollar industry, but why do we always show commercials for women having their periods or women in these tight white pants when that's our ultimate fear? I think that we should be more real that this is a perfectly natural phenomenon.

And can you afford them? That's the financial aspect. The fact that you have to buy these products, and they can be pretty difficult. Not having the equipment, not having the protection can be pretty frustrating. Financially, not being able to afford your products can be very difficult. And there have been some movements around the country to try to make products for women who are homeless. When we think about women not being able to afford food, they certainly won't be able to afford their menstrual products. So being able to afford menstrual products is an important thing.

Polly Wiessner is a professor in anthropology at the University of Utah and at Arizona State who spent some time in two very different cultures. She's going to help us unwind some issues about periods in other countries.

Dr. Jones: Now, Polly, it's important for us to think about how long you've been following these cultures. Some people go for a two-week little trip to try to see stuff, but you've been following these cultures you're going to be talking about for how long?

Prof. Wiessner: I've worked with the Kalahari Bushmen for over 40 years and with the Enga of highland Papua New Guinea for 30 years, so a lot of experience.

Dr. Jones: Right. So you've seen a lot.

Prof. Wiessner: Yeah. One could say that human beings, culturally, what they elaborate on the most is food, sex, and things related to body fluids. So you have an enormous amount of variation. But I'll talk about menstruation in the two societies where I work, which have really diametrically opposite views. But in most cases, with menstrual blood in many societies, it is assumed that men have to be careful about it.

So, in the Bushmen, there's a lot of ritual around a girl's first menstruation. Menstruation is supposed to show the transition to adulthood. It's supposed to promote health, fertility, and so on. When she's finished menstruating . . . and she has to go through all these taboos with food, with not touching the ground, not seeing the sun, which is scorching and drying. When she's finished, she gets a ritual bath and then her face is painted with red okra so she looks beautiful, and she's showered with gifts and beads.

And come out and really praised in all possible ways. But after that, there are very few beliefs about menstrual blood, except a woman who is menstruating cannot touch a man's hunting equipment or go near a hunter because it's believed to interfere with his hunting success.

Dr. Jones: How about the Enga? How about the people in New Guinea?

Prof. Wiessner: Oh, the Enga, it's just opposite. They believe that female menstrual blood contaminates men, and if men have contact with menstrual blood, or if men take food cooked by a menstruating woman, they will decline in strength, get weak, and their wits will be greatly diminished. And so that's why they have men's and women's houses.

In the women's houses, you have a room where men can go in the front and a place where women sleep at the back. When they menstruate, they have to retire and sit in the pig stalls, and then they go out at night or when they're not likely to see people.

However, as you know, women tend to menstruate at the same time, so I think sometimes they have a lot of fun together because they don't have to do much work in that time. They get some rest. Then when they come out, however, in some parts of Enga, the women, to dispose of their menstrual wastes, go to the forest and they do all sorts of rituals that will promote their husbands' prowess in warfare, hunting success, success in exchange. So they are able to use their menstrual blood to benefit men if they handle the aspect of staying away and contamination properly.

You see, the beliefs are very different, but they always have some beliefs of how menstrual blood can affect men and beliefs about menstrual blood promoting fertility, the health, everything, the beauty of women.

Most women would say they feel different before their period is coming. This may be very difficult emotionally because they may be angry. They may be frustrated because they have pain and they lose time from work. Maybe they're more irritable or they're not sleeping as well.

Adolescents who don't understand it, who can barely control their emotions anyway, may get particularly difficult during their period. And I've seen a number of patients who are developmentally delayed for whom having a period is frightening. Blood is frightening, and the emotional changes lead them to be uncontrollable in their family environment, and their parents may actually bring them to me to stop their periods.

Premenstrual syndrome is common, and it is troublesome for women and the people who live with them. Recognizing that you have this and you have a predictable emotional pattern in the week before your period is very important.

• Identify why you're feeling irritable or depressed
• Understand what helps you feel better
• Eat well
• Get exercise
• There are medications that can help with premenstrual dysphoric disorder, or PMDD

Another emotional response to the menses, to the period, is for people who try desperately to become pregnant, and the sign that the period is coming is a sign that they have not succeeded. Women who've been through an enormous input of time and effort and physical trouble by doing an IVF cycle, understanding that their in vitro fertilization process has not worked, because their period has come, can bring a profound sense of failure and depression.

For many women, even though their periods can be frustrating, no matter what their periods might be and what their social and cultural norms may be, their period is a reminder monthly that they are female, that they are fertile. And all around the world, having your period is a reminder of this incredible gift that we have to be able to have children.

Many women say, "This is part of what every woman does on the planet. It ties me to my mother and to my daughter." It's something we share. It's part of the biological rhythm of life. And it's a rather profound rhythm, this monthly lunar rhythm. So it makes us often feel like we're part of something much bigger, and isn't that the very core of spirituality?

But where do you find and keep your spiritual home when you live in a body you don't believe in? For women or men who are going to be trans men, the period is a reminder that this is a body they don't love. This is a future and a foundation that they don't share. So every woman is going to have a very unique and special relationship with her periods.

So the spiritual domain is a powerful one because, certainly, many faiths tell us how we should feel about our periods, but we should feel the way that we feel about our own bodies.

I don't want our listeners to think, men and women, that because women have periods that actually closes down their life and they bleed to death and things are awful, because, in fact, women do their whole lives bleeding. So there's a great song, "Anything you can do, I can do better," and anything you can do, I can do bleeding. Women carrying on their lives while they're doing this menstrual thing and you don't know.

So, ladies, let's think about three things that are good for you during your period.

1. When blood comes out, that bright red comes from iron. Iron is important supplement in your diet. Most women actually don't eat enough iron, and you can get iron through meat. If you're not a meat-eater, you can take it through leafy vegetables. And if you're having difficulty with both of those, then adding a supplement that has some iron can be useful to keep your iron up, particularly if you have heavy periods.

2. You should take care of yourself. This is a time that's very personal to you. If it means that you need some time out and you need a little quiet time, if you have really crampy periods, give yourself a break already and take some time for yourself. If that means going for a walk, it turns out that exercise makes period cramps not so bad. So go for a walk. Take some time for yourself.

3. You should celebrate yourself. Every woman on the planet has periods. It's not such a bad thing. It could be bad, but it's not necessarily a bad thing. Celebrate this as a sign of your femininity. It's a sign of potential fertility, even if you don't want children, and it is a sign of your overall physical health. It means that you're young. You're not an old lady. You're not a little kid. You're a real live woman and good on you.

Sad when it shows up
Happy when it stops or not
Red can rule our lives

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Hot flashes, they are hard to describe and women experience them differently, and it's been a really long, hot summer. But what if that summer lasted 15 years?

All women who live long enough and it really isn't all that long, just to about 51, will have their ovaries stop working. When that happens, estrogen levels fall. And about 85 percent of women who make that transition from ovaries on to ovaries off will experience hot flashes.

The baby boomers, formerly the largest generation in the U.S., now replaced by the millennials, are aging and 6,000 women in the U.S. enter menopause each day. By the year 2020, coming right up, about 50 million women in the U.S. will be post-menopausal, one-third of all women in the U.S.

The two signature symptoms of estrogen withdrawl are hot flashes and vaginal dryness, and both are treated pretty well by estrogen. Many women are not distressed by these symptoms and good for them.

But AARP, formerly the American Association of Retired Persons—but as not all members are retired, they are just AARP—anyway, AARP did a menopause survey of their female members between 60 and 69, and 72 percent said that menopausal symptoms interfered with their lives and eight percent said it interfered a great deal.

Now, these women were actually about 10 years from their menopause. And when their ovaries stopped working 10 years ago and they're still having symptoms, 20 percent said that they had vaginal dryness, 24 percent had hot flashes, and 23 percent night sweats. Of course, some had all three symptoms and some had none.

Women with severe hot flashes typically experience them for seven to 15 years, and 15 percent of women with severe hot flashes experience them for more than 15 years. Now, what in the brain makes this hot flash happen? Do only women get them?

Recently, some very cool research on hot flashes was done in mice, and they found that the KISS1 neurons, kiss isn't that cool, KISS1 neurons that are part of the brain that make up the ovaries and testes work, so these KISS1 neurons make the ovaries and testes work, actually have their feet on the ground in the part of the brain that controls temperature.

These KISS1 neurons in mice work the same way that those neurons work in humans. Activating KISS1 neurons initiated a fast rise in the mouse's skin temperature followed by a drop in core body temperature. The same symptoms occurred in male and female mice. Removing the female mouse's ovaries made this temperature swing worse. We know that men that had their testes removed or who take medication for prostate cancer that makes the testes stop working can have hot flashes.

Now, we don't know if the mice who experienced these changes in their body temperature experienced distress, but some other studies suggest that they seek out cooler places in their cages. We don't know if they have spikes in anxiety or irritability, or if they're having hot flashes and they're getting angry, but that would be an interesting experiment to do.

Hot flashes at menopause may have more complex neuron functions than just KISS1, and about 15 percent of normal women never have hot flashes with menopause. So it's complicated. But understanding some of the brain's mechanisms might help us to think about new therapies.

Now, back to that survey from AARP, 46% of the women surveyed said that they had never discussed menopause with a health care provider, and only 1 in 12 had been referred to a menopause specialist. So what's the takeaway from all these numbers?

One, most women who experience menopause will have hot flashes.

Two, most women who experience hot flashes will tolerate them.

Three, most women with hot flashes will find that their flashes decrease in a couple of years. That sounds like a long time to me in a long, hot summer with hot nights.

Four, about one in eight women will have significant distress from their hot flashes and they'll go on for a long time. For 50 million women who will be post-menopausal in 2020, one in eight of 50 million is a lot of women.

Five, women who bring to their experience of menopause all the physical, social, cultural, environmental, emotional, financial, and spiritual experiences. In other words, hot flashes can be wrapped up in all of the seven domains of women's health.

Six, there are quite a few options other than estrogen, which works best, for managing hot flashes, and most clinicians don't know about all of the options.

Seven, if you are suffering from hot flashes that seem to go on and on and on, the longest summer ever, talk to your clinician. Ask them what is their training in menopause and ask what they know about different options. If you try some of the options they offer and you're not getting better, or if you don't like the side effects of the options, you should seek out a menopause specialist.

Eight and last, many specialists called reproductive endocrinologists have training in menopause. And some physicians, primary care providers and OB/GYN's have a special interest in understanding menopause and caring for women who are having difficulties. Some clinicians have made it their special interest in their practice. It could be a search, but your doctor probably knows where you can get help.

At University of Utah Health, you can use our app for finding a doctor who has an interest in treating menopause symptoms. That will get you started. The most important thing is that we're learning more and developing and understanding new options. So no big sweat, and thanks for joining us on The Scope.

updated: November 12, 2020
originally published: September 6, 2018

Dr. Jones: For some women, menopause is tough. We have this hormone thing going on, but we're also aging, and our joints hurt. And our teens are trouble, and that makes us cranky. So what are the options and therapy for the menopausal transition? This is Dr. Kirtly Jones from obstetrics and gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Although hot flashes are the signature symptom of menopause, there are a number of other physical and emotional symptoms that are common for women in their 50s. Insomnia, anxiety, joint aches, and headaches come to mind. Some of these are clearly related to the loss of estrogens, but some are not so clearly related to hormones. Whatever we think the biological cause might be, women don't feel well.

How do we take the women as a whole person and not just the sum of her symptoms? And what are some of the options? Today in The Scope studio we're talking with Dr. Lisa Taylor-Swanson. She's an assistant professor in the College of Nursing and an expert in acupuncture. Lisa, thank you for joining us to help us think this through.

So give us some thoughts about the care of women in menopausal transition thinking about all of these symptoms. You know, women certainly can wander their way through the traditional health care system. They can get estrogen for their hot flashes, they can get a triptan for their migraine, they can get sleeping pills for their insomnia, they can get Ibuprofen for their joints, they can get Prozac for their anxiety. But women don't want to think of themselves like that. They don't see themselves siloed in so many pill prescriptions. So what do we do?

Dr. Taylor-Swanson: That's something I've thought a lot about. And I know as a clinician practicing traditional East Asian medicine including acupuncture and Chinese herbal medicine, I've always been drawn to thinking about the whole person. And in that tradition the way we diagnose, for example, a hot flash in woman A would really depend on how her sleep is, her bowels, her mood, and depending upon compared to say woman B who has no problem sleeping but does have hypertension, I would use different acu-points and different herbal prescriptions to treat the same, say primary concern of hot flashes, because we have to understand the whole person.

So that whole person view is literally at the theoretical foundation of East Asian medicine. And that's why I study that. It's really very interesting.

Dr. Jones: So I would say coming from the church of Harvard medicine, that although I want to know about a woman's hypertension and the way her bowels work, the dose that I would give for her hot flashes would be more just to her hot flashes and not to her guts I'd say?

Dr. Taylor-Swanson: Absolutely. And that's exactly not how East Asian medicine is practiced. And so those symptoms really inform one another, and then, of course, we look at the tongue and feel the pulse as well to have additional signs that we look at.

Dr. Jones: Look at the tongue?

Dr. Taylor-Swanson: Yeah, absolutely. Top and bottom.

Dr. Jones: Okay, ladies you're going to have to wash your mouth out and brush your teeth before you go.

Dr. Taylor-Swanson: But don't brush your tongue.

Dr. Jones: Don't brush your tongue, okay, okay. So what are some of the options in the field of alternative and complementary medicine that women might choose to pursue? I know women are already making these choices, because when they come to see me, they've got bottles of supplements. They've got dong quai. They've got some Chinese herbal medicines, I say I don't know that they . . . these Chinese herbal medicines may not actually have estrogen in them, so I'm always worried about what they're taking with these bags that they're going through.

But I can't stop them. You know, and I probably shouldn't, and I shouldn't negate their efforts to make themselves feel better through options other than my office. So what should we be thinking about and what are the choices?

Dr. Taylor-Swanson: There are many choices. Definitely, acupuncture is one to consider again for the whole person perspective. And what's interesting is that not only kind of clinically or intuitively we can imagine, say if someone receives acupuncture and her hot flashes are better, and then her sleep is a little better, and then her moods a little better that makes sense certainly.

But the fascinating thing as a researcher is that we have basic science, types of data that demonstrate how that happens. So we have changes in our serotonin production and re-uptake. We have changes in our muscles, changes in the connective tissue around the muscles, other changes in the central nervous system, peripheral nervous system changes, etc. And those all happen simultaneously. And so I think it's fascinating to consider. I know you asked what are the various options. But one is acupuncture, and that we know all those symptoms are affected simultaneously and we know more about why.

There's other good options too. There's definitely Ayurvedic medicine, traditional medicine from India that treats the whole person much in the same sort of way. Definitely massage therapy can be helpful for those joint aches and pains, and it's very relaxing and might help a woman sleep better. Reiki healing touch. I mean there are so many options nowadays, and most of them have been investigated to try to find out really do they work. But I think another really important message for our listeners is that acupuncture I can say for sure is safe. It doesn't hurt. It's very relaxing.

Dr. Jones: It doesn't hurt.

Dr. Taylor-Swanson: I know, right? Who would think that?

Dr. Jones: Well, I'm not needle phobic, and you mentioned that you started as an acupuncturist. I'm not needle phobic, but I know perfectly well when I have needles put in my skin, because I'm also a seamstress, so I poke myself with little needles and it's usually my finger, the most sensitive place to poke. But it hurts.

Dr. Taylor-Swanson: So these are different. One they're tiny. They're literally the size of about two hairs, 40 gauge, 36 gauge, for those of you clinicians out in the audience. And they're solid and the interesting thing is blind acupuncturist several hundred years ago figured out if they had a tube around the acupuncture needle, one, to help them locate the points and be safe clinicians because they couldn't see, but two, it was less painful.

So the Japanese tradition of acupuncture and that we've pretty much adopted in the U.S. is to use these guide tubes. So first the patient will feel the pressure of the tube, and what's happening is it sets up those little [node receptors 00:06:21], so they perceive pressure, and then you pop in the needle and you hardly even notice it for the most part.

Dr. Jones: Kind of like when you're giving a horse a shot, if you slap them three times on their skin and then you give them a shot, they don't feel a shot. Okay, okay. Well, I'm feeling better already. I'm feeling more calm about having needles put in my skin.

Dr. Taylor-Swanson: Most people do fall asleep. Or they go to this . . . a colleague of mine calls it acu land. And you just kind of drift off to this really mellow, quiet, relaxing place. Usually, the clinician will turn the lights down and have some nice music, and you're cozy with the needles in place. So it's really a very surprisingly comfortable experience.

Dr. Jones: Well, it sounds like it's a total time out from your week experience. It's not just hopping up on a table and getting poked a couple places. You're actually having some little time out. I can't say . . . well, sometimes the doctor's office, I get to look at magazines I would never ever buy at the store, but if people in the doctor's office are upset, I kind of, you know, while I'm waiting and wanting to say I'm not in a clinic and, you know, I'm just having a quiet time. But other people's moods while I'm waiting affect me. When I get in the room as much as I love my doctors, there's this third patient in the room called the computer that seems to get all my doctor's attention.

Dr. Taylor-Swanson: Well, and I think for women going through the menopausal transition and for midlife women overall there's this sandwich generation phenomenon where often women are working, taking care of kids, like you said in your intro, taking care of parents sometimes, and so to have that little time out just an hour once a week, once every couple weeks it can make a world of difference.

Dr. Jones: Well and when we talked before the interview, we talked about the fact that in medicine sometimes we silo women's symptoms so they get this for this problem, and this for that problem, and that prescription for that. But you talked about the spider web. Can you talk a little bit about that?

Dr. Taylor-Swanson: Absolutely. It's my favorite metaphor for how, again the theory and also the intervention of acupuncture in East Asian medicine works. If you were to imagine a woman as a spider web and say for example, that spider web includes her symptoms, it includes all of her body systems, so the endocrine system, all of your hormones, your digestive system, etc. And also includes your social life, so caring for kids, your friends, your church, your work, etc.

And so if there's a tug on one end of the web, say you're caring for an aged parent and she or he falls, then that's going to affect your whole spider web, your whole person. It's not just that, "Oh, gosh I have to schedule my time differently." But you're probably going to be worrying, and [perseverating 00:09:03], and scheduling appointments, and not sleeping as well.

So I think to really consider a woman as her whole self, not only all of the symptoms, it's great that science is moving that way. We talk about symptom clusters now instead of only a single symptom. But it's a real whole person phenomenon that includes her social life, her work life, her body as well, and not only the symptoms.

Dr. Jones: Well, we're just making you the poster child of our Seven Domains of Health. Because here, The Scope radio we believe in the seven domains, meaning there are many parts of us that have to be well for us to feel well. But I like the Native American, particularly Navajo tradition of the Spider Woman who weaves the web of life into this sense of wholeness. So who should a woman go to if she wants this particular approach?

Dr. Taylor-Swanson: Well, the good news is nowadays acupuncture is regulated by state departments of health in all but just a handful of states in the country, so you can just go to the website for your local Department of Health, look up an acupuncturist in your area. They're absolutely going to be board certified nationally, and they're absolutely going to have a master's degree. They might also have a doctoral degree either in acupuncture or something else. So you can be confident they'll be well trained and properly licensed.

Dr. Jones: Do you go and see if they're a good fit, or do you ask your friends because some might be really good for sports therapy and joint problems, but they don't get women.

Dr. Taylor-Swanson: Right. Well, and modern life definitely most of my patients when I practiced in Tacoma, Washington, where I just moved from most of my patients were either referred from their primary care or other specialty care practitioners or from their friends, and that's always a good way to find an acupuncturist. And modern life most acupuncturist have websites too. So you can check the web and get a sense of who they are from their website.

Dr. Jones: And see if they put midlife women transition kind of stuff.

Dr. Taylor-Swanson: Yeah.

Dr. Jones: Well, we're waiting for you to hang out your shingle now that you're here in town and for you continue your research in the area of midlife women now that you're here at this College of Nursing. And we're here because getting old isn't for sissies. And 50 isn't even old. Many of us want to take an approach to our midlife concerns that helps our body and our mind. And we're grateful for Lisa for coming to help us think about it. And thanks everybody for listening on The Scope.

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Interviewer: Is hormonal therapy a good treatment option for menopause symptoms? Dr. Kirtly Jones, what's your advice?

Dr. Jones: For the two main symptoms of menopause, hot flashes and dryness, estrogen is the best therapy. The new North American Menopause Society guidelines outline the importance of individualizing therapy for each woman, looking at the options, discussing the symptoms, and the patient's own biology.

There are few, if any, absolute contraindications to hormonal therapy. It's all a risk/benefit discussion. Be prepared for your visit with your doctor. What are your symptoms? How much do they bother you? What is your medical history, and what are your fears and concerns and hopes? Coming prepared will help you and your clinician focus on your needs.

updated: June 11, 2021
originally published: June 19, 2019

Dr. Jones: What's new in the treatment for menopausal symptoms? This is Dr. Kirtly Jones from obstetrics and gynecology at University of Utah Health Care, and this is The Scope.

Announcer: Covering all aspects of Women's Health, this is the seven domains of women's health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Before the 1960's there wasn't much for the treatment of menopausal symptoms. In the 1970's we found out that women who took just estrogen, had a greater risk of uterine cancer and women and physicians were hesitant to prescribe. In the 1980's and 90's we learned about all the benefits of estrogen and added progestin to protect the uterus, and lots of women took hormones for menopausal symptoms. In 2000, the results of the women's health initiative suggested that women over 60 who took hormones had a higher risk of breast cancer and heart disease. You should be asking yourself what does "higher" mean? For Scope listeners, and prescriptions dropped off.

The North American Menopause Society's older guidelines suggested that the lowest dose of hormones for the shortest period of time, should be offered. And many clinicians only offered for hormonal therapy for five years, but now we have new guidelines informed by research from the past ten years. So what is new now?

What's new isn't really new to those of us who've practiced menopausal medicine. What's new is that the decision to take hormonal therapy for menopausal symptoms or non-hormonal therapy for menopausal symptoms is a conversation that takes more than just a few minutes in your clinicians office. The clinician must be informed about the real numbers involving risks and benefits of hormone therapy and they must have the time to talk to the patient about her symptoms, her options in therapy, her benefits and her risks. And because menopause symptoms change over time, the conversation should happen every year. Most women can safely use hormones if they want and hormones shouldn't be discontinued just because of a women's age. It's an individual risk/benefit analysis.

So this is what often happens. "My period stopped and I'm having terrible hot flashes". The clinician says, "Just wait, they'll go away soon." Well, that's not necessarily true, hot flashes persist for an average of 7.4 years. Some women will feel better in several months but the majority of women with troublesome hot flashes will have them for years.

Another, "I'm only 55 and my bone density shows that I have thin bones. What should I do?" Well here's a prescription for a medicine that will block bone thinning. No, it isn't hormone." Well, drugs like bisphosphonates do decrease bone thinning but they have their own risks and benefits and for young women, meaning within ten years of menopause, estrogen might be a good choice. And estrogens are FDA approved for the prevention of bone thinning. Estrogens have the benefits of protecting bones, treating hot flashes and vaginal thinning that causes pain with intercourse.

For the two main symptoms of menopause, hot flashes and vaginal dryness, estrogen is the best therapy. The new "North American Menopause Society's Guidelines" outline the importance of individualizing therapy for each woman. Looking at the options, discussing the symptoms and the patient's own biology. There are few if any absolute contraindications to hormonal therapy. It's all risk/benefit discussion. If the risks are small and the benefits for the woman is great, than the options should be open. The first ten years after menopause, the last period, are the years when the benefits are the greatest and women who had early menopause for whatever reason might have significant benefits of taking hormones for longer.

Dr. Joanne Pinkerton, who's the executive director of the North American Menopause Society and is the lead author of the new guidelines said, in an interview, "We want to remove the fear of using menopausal hormone therapy for healthy women under 60 and within ten years of menopause and make sure the benefits and the risks are discussed with women in an appropriate way."

What should you do if you're significantly troubled by menopausal symptoms? For those of you who are just getting started, if you're babies about menopause, there is a lot of not very scientific information out there on the web. Be careful and if you need menopause basics go to menopause.org/forwomen. For those Scope listeners who are data driven, you can go the website for the North American Menopause Society which is menopause.org and look at their treatment guidelines and clinical care recommendations. They are free for non-members, and there are guidelines on menopause therapy, treatment of vaginal thinning and non-hormonal treatments for menopause that actually work and which ones don't work.

If your clinician isn't a specialist in menopause, these guidelines are available to them too. Be prepared for your visit for with your doctor. What are your symptoms? How much do they bother you? What is your medical history? And what are your fears and concerns and hopes? Clinician time can be limited, but if your questions aren't answered or you need more time, make another visit. But coming prepared will help you and your clinician focus on your needs. For the many main symptoms of menopause, there are lots of options, and there is something that will work for everyone. You can feel better, and being informed is a really great start.

Announcer: TheScopeRadio.com is the University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Dr. Jones: Listen up, this is for ladies only. Gentlemen, kids, adolescents, go listen to stuff that is just for you. We're going to talk to ladies about vaginal dryness and pain after menopause. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Utah Healthcare and this is The Scope. Guys, change the channel. Ladies, plug in your earphones.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: There are many reasons why women are less interested in an intimate sexual relationship with intercourse after menopause, but one of the most common is that sex hurts. Menopause marks the end of significant production of estrogen by the ovaries. Estrogen production is linked to egg production, so it's a pretty good thing that we stop being fertile when we get to our 50s.

One of the prime targets of estrogen is the uterus, and after menopause the uterus gets smaller and the lining gets thinner and that's a good thing. That means there's less bleeding and cramping, in fact, if it goes as it should, no bleeding and cramping. However, the uterus is just part of the reproductive tract. Reproductive tract starts at the beginning of the vagina and those tissues get thin as well and sometimes they become very thin. They stop making as much fluids and the lining of the vagina can be painful and even bleed with intercourse. It only has to hurt a couple times and then women aren't so interested anymore. So what can be done about this?

First, how common is this? In a study reported in a menopause journal, 4,200 post menopausal women from Sweden, Finland, the U.K., Canada and the U.S. were surveyed about their symptoms and their knowledge. Thirty-four percent of Canadian women experienced symptoms with vaginal thinning and 43% of women in the U.S. noted symptoms, and two-thirds of them noted that the symptoms were severe and had a significant affect on their quality of life. That's a lot of ladies.

Fifty-one percent of American women didn't know that there was a local treatment for this problem, and 63% of women with symptoms had never been treated, but 67 of those who were treated had an improvement in their symptoms.

So what treatments are out there? Well, first, there's ordinary over the counter lubricants, slippery stuff. For some women, that's enough and it is safe and inexpensive. It's made by the same material that doctors use to make an internal exam more comfortable for women.

Second and most importantly, probably, is estrogen. Estrogen can be applied locally to the vagina twice a week in the form of pills or creams and this is very effective for the majority of women. There are many different ways to apply this local estrogen to the vagina. The dose is tiny and a recent study of half a million women in the Kaiser Healthcare system were studied to see if vaginal estrogens increased the risk of uterine cancer. They compared women who filled prescriptions for vaginal estrogens with women who didn't and the rates of uterine cancer were no different.

Women with a history of breast cancer are never supposed to use estrogens and they suffer, but there's no evidence that low dose estrogens increased the risk of breast cancer. Vaginal estrogen for women who've had breast cancer is controversial, but vaginal estrogen therapy's been used for decades for post menopausal vaginal thinning and pain with a terrific safety profile.

Third, DHEA, this is a weak adrenal male hormone that can be placed in the vagina and that can increase vaginal thickness and decrease pain. The trade name is Prasterone.

Fourth, Ospemifene, the brand name is Osphena. This is a pill that can be taken orally that isn't exactly an estrogen, but it does increase the thickness of the vagina and decrease pain.

So, why don't women get treated? I think we're in sort of a "don't ask, don't tell" situation here. Post menopausal women may not bring up the subject of pain within sex and doctors don't ask, but if there's evidence that sex is part of healthy aging, then doctors should ask and they should know the safety and effectiveness of treatments and, ladies, you should speak up. Sex doesn't have to be painful.

Now you can unplug your earphones and thanks for joining us on The Scope.

Announcer: TheScopeRadio.com is University of Utah Health Sciences radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Dr. Kirtly Parker Jones: I'm too hot, I'm too cold, wait, I'm just right. That's Goldilocks doing menopause. Menopause happens at about 50, but aging happens too. What are symptoms due to menopause and what are symptoms due to aging? This is Dr. Kirtly Parker Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care and this is menopause and this is The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Kirtly Parker Jones: Why do women have a menopause? How is menopause different from aging? One, what do women and female orcas, killer whales, but I don't like that term very much, and pilot whales share, that almost no other mammals have? Well they share a long life after their baby making days are over, and they share language, and their kids take a really long time to grow up. Chimpanzees, with whom we share 98% of our genes die just a few years after their menopause. But humans and female orcas may live 45 years after their menopause.
Some famous evolutionary anthropologists think that the grandmother theory explains this. The grandmother theory suggests that having a grandmother helps the daughter be a better mother. More grandchildren survive. You need language to teach and humans have language, orcas have language, chimpanzees, not so much. So having a grand old lady around helps the tribe survive and run the PTA and the nonprofits and the family reunions. Postmenopausal women are the civilizing force of society.
Female orcas run the pack and teach their children and grandchildren how to hunt and their boys, like Italian boys, seem to take forever before they leave home, in fact, they never leave home. Orcas aren't sexually mature until their mid teens, later for males, and they aren't very good hunters until then as well. Sound familiar?
So, two, why isn't it so good for the tribe for women to die right after baby making is over? Well we talked about that. Grandmothers help the moms be better mothers. So why don't we make babies until we're 80? Men can. I think all of you who have had children can answer that one. Children who give birth very late in life are more likely to die before their adolescents can stand on their own emotional and financial feet. And pregnancy is really hard on the heart.
So, three, how is menopause different from aging? Well the ovary starts losing eggs before we are even born and we see peak fertility in the 20s. Fertility declines in the 30s and plummets in the 40s and is rare in the 50s. They average age for menopause in American women of all races is about 50, 51 for Caucasian women and the range is 40 to 61. The menopause is your last natural period. The ovary ages and the eggs aren't so fertile as they get older and periods aren't so predictable.
There is this time, before the menopause, when periods are less regular and some are skipped, this is the perimenopause and it has an average of about four years. Sorry ladies, I'm too hot, I'm too cold, oh, wait, I'm just right, that's kind of the perimenopause.
So looking at competitive athletes, it's rare to see them at the top of their game after 35. This is aging; the hearts, lungs, connective tissue, brain, bone density are at their peak in their 20s and start declining in the 30s. Women at 50 may complain about their memory, their wrinkles, their joints and their hot flashes, but only hot flashes is specifically linked to the decline in ovarian function. Of course, if you're having 25 hot flashes a day, it's hard to sleep and focus on things.
So what are the common menopause symptoms? Hot flashes and vaginal dryness, but not all women have them, 15% of Caucasian women will not experience hot flashes, Asian women have fewer, African American women have a few more, not everybody has them. But if you have a lot of hot flashes, how long will they last? Here's the bad news. An average of eight years. This is Dr. Kirtly Jones and thank you for joining us on The Scope.

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Dr. Kirtly Parker Jones: Taking estrogen after menopause. Does it solve all the problems of postmenopausal women? Or does it poison you and give you cancer? For the past 60 years women have been hearing both of these points of view. So what do we know today? I'm Dr. Kirtly Parker Jones, professor of OB/GYN at University of Utah Health Care, and this is The Scope.

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Dr. Kirtly Parker Jones: In the 1950s and '60s, women were told that postmenopausal estrogen would make them feminine forever. In the '70s they were told it would give them uterine cancer. In the '80s and '90s we were told that it would keep our hearts healthy, our bones strong and help our hot flashes and sex lives. But we needed to add another hormone, progestin, if we had a uterus, to protect us against uterine cancer. In 2000 we were told that it would increase the risk of heart disease, breast cancer, blood clots and strokes, so we shouldn't take it, or at least for just a short time.
This pill is good, this pill is bad, this pill is just right; Goldilocks does menopause. Put on your thinking cap and get ready to do the numbers.
One, since 1976 almost 250,000, that's a big number, a quarter of a million, nurses have been recruited into the nurses health study, to follow women as they age and see what contributes to health and what to illness. Hormone replacement was associated with a healthier heart, better bones, less colon cancer, more blood clots and more breast cancer. Women starting hormones by choice were in their early 50s. In the women who elected to take estrogen there was 1 fewer heart attacks per 1000 women per year, 1 fewer bone fractures, 1 fewer colon cancers, there was 1 more breast cancer per 1000 women per year and 1 more blood clot per 1000 women per year.
In the mid '90s about 10,000 women, a big number, who were mostly healthy and on average 62 years of age, were randomized taking estrogen and progestins every day and they didn't know what they were taking, nor did their doctors, or placebo. They were followed for about 5 years. The results were the same except there was 1 more heart disease per 1000 per year in the hormone group, instead of 1 less. But the women were older. And there were no extra deaths in women who took estrogen or who didn't.
So what is Goldilocks to do? If Goldilocks is having trouble with some hot flashes, night sweats or vaginal dryness and she doesn't have a contraindication to estrogens, like breast cancer or blood clots, she should do what makes her feel better. Estrogens and progestins to protect the uterus is associated with 3 to 4 more bad things per 1000 women per year, and 3 to 4 more good things per 1000 women per year, so it comes out about equal. And for women with estrogen related symptoms, their quality of life is a lot better. But estrogens after menopause will not make Goldilocks thinner, or fatter, or more likely to look like Suzanne Somers, who's had a lot of help, will not solve global warming or congressional bad behavior, but she will feel better and be able to sleep well and think more clearly about these problems.
This is Dr. Kirtly Jones and thanks for joining us on The Scope.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.