Midlife and Menopause A KAISER PERMANENTE GUIDEBOOK FOR WOMEN CONTENTS

2 THE MENOPAUSE TRANSITION: AN OVERVIEW

2 WHAT IS MENOPAUSE? 2 MORE ABOUT SYMPTOMS 4 , RADIATION TREATMENT, AND AFFECT MENOPAUSE 4 IMPORTANT SCREENING TESTS

6 SYMPTOM RELIEF AND TREATMENTS

6 SELF-CARE AND COMPLEMENTARY THERAPIES 10 THERAPY 13 OTHER

14 STAYING ACTIVE AND EATING WELL

17 SEXUALITY AND RELATIONSHIP HEALTH

18 RELATIONSHIP HEALTH 19 20 WHAT TO DO IF YOU’RE IN AN UNHEALTHY RELATIONSHIP

21 EMOTIONAL AND MENTAL HEALTH

21 COPING WITH 22 BOOST YOUR MEMORY

23 HEALTH RISKS AFTER MENOPAUSE

23 25 HEART DISEASE 28 CANCER Making good health choices in midlife can boost your well-being for years to come. Women can experience a range of health changes in the years before and after menopause. When you understand and prepare for this transition, you’ll move through it with more ease. You may also discover new ways to enhance your health.

Midlife and Menopause: A Kaiser Permanente Guidebook for Women is designed to give you: • A stage-by-stage summary of health changes most women experience. • Tips on lifestyle choices and complementary therapies to help you care for your body, emotions, mind, and relationships. • An overview of health challenges that can occur and self-tests to help you check your risks. • A summary of hormone replacement therapy and other medical treatments.

This guide brings together the expertise of Kaiser Permanente specialists in women’s medicine, health education, and complementary therapies.

We hope you’ll use this guidebook as you: • Make menopause and midlife health choices. • Create a care plan with your Kaiser Permanente doctor.

To learn more about women’s midlife health services: • Contact your local Kaiser Permanente Health Education Department or Center. • Go to kp.org/mydoctor. • Talk with your doctor.

Kaiser Permanente gives you the tools and information to help you make healthy choices throughout life.

Thank you for choosing Kaiser Permanente.

1 THE MENOPAUSE TRANSITION: AN OVERVIEW Today many women think of the health changes that come with midlife as natural and manageable. Your midlife years—before, during, and after menopause—can be a positive time, even if you face some health challenges.

ou’ll be better prepared for the During this time: own timeline. Some women stop Ymenopause transition if you are • Female and menstruating in their mid-40s, while knowledgeable about the health decrease. others continue into their mid-50s. changes to come. It’s also wise to • Menstrual periods become Postmenopause is the phase be aware of new risks you may face. shorter and lighter or longer that begins after a ’s final Each woman moves through midlife and heavier. The interval menstrual period. and menopause in her own unique between periods becomes MORE ABOUT SYMPTOMS way. Although some women have unpredictable. few problems as their bodies adjust Irregular Hormonal changes can also cause to hormonal changes, most deal Your menstrual patterns may change uncomfortable symptoms. Each with uncomfortable symptoms so that your bleeding is lighter or woman’s set of symptoms is unique. at times (see Table 1). For some, heavier and your cycles are longer or Usually, symptoms don’t all occur at serious health conditions may shorter. If you’re worried or uncertain the same time or continue nonstop develop. about your bleeding, keep track throughout perimenopause. Whether your midlife path is smooth of your periods and any spotting Symptoms you may experience or rough, it’s important to take or bleeding you have in between include hot flashes, vaginal dryness, excellent care of your health through for a few months. Talk about your urinary problems, mood changes, these years. You’ll feel better and be symptoms with your doctor. sleep problems, and difficulties with able to age more gracefully. Hot Flashes focus or concentration. Some or all WHAT IS MENOPAUSE? symptoms: Hot flashes are very common. You may get flushed or feel The term “menopause” is • May continue for 2 to 8 years. commonly used to mean the entire heat flowing through your face • Usually become milder after the and nearby areas. Usually the health transition women go through final . in the years before, during, and sensations last for a few minutes. after their last menstrual period. Women whose are removed Hot flashes that happen while () may enter perimeno- you’re sleeping are called night The medical terms for the phases of pause early, starting right after surgery. sweats. Sometimes this transition are perimenopause, can be strong enough to wake you menopause, and postmenopause. Menopause technically means a woman’s final menstrual period. up. To manage hot flashes: Perimenopause includes the When a full year has passed • Use natural remedies. See the years before your final menstrual since your last period, you’ve section Symptom Relief and period and the first year after it. completed menopause. On Treatments: Self-Care and This phase usually begins when average, menopause occurs around Complementary Therapies women are in their mid-40s but age 51. But every woman has her (page 6) for helpful tips. may start as early as age 35.

2 • Consider talking with your doctor • (PMS). • Avoid strenuous exercise in the about hormone treatments if you Symptoms may worsen or few hours before bedtime. have frequent, intense hot flashes start for the first time during • Check with your doctor on how that impact your ability to sleep, perimenopause. to manage medications and work, or enjoy life. See the section • Forgetfulness and concentration. mood changes that can affect Symptom Relief and Treatments: Learn more in the Emotional and your sleep. and Other Mental Health section (page 21). Learn more about sleep problems in Medications (pages 10–13) for Talk with your doctor or nurse the Relieve Menopause Symptoms more information. practitioner if you have ongoing Naturally section (page 6). Vaginal Dryness problems. Problems with Urination Your may feel itchy or Sleep Disorders () Leaking unexpectedly may irritated. Some women get Exactly why women’s sleep happen once in a while or so often more vaginal infections. Having patterns change in midlife isn’t that it interferes with your normal sex (intercourse) may be yet known. One factor may be activities. This can develop in uncomfortable or difficult. decreasing hormone levels. midlife and as people get older. Using a lubricant (water soluble You can find new strategies to Talk with your doctor about this or silicone type) can help relieve get the sleep you need to feel common problem. There’s no dryness, which results from well and stay healthy. Many of the need to feel embarrassed about it. decreasing estrogen levels. following tips will also support To help control leaking: Mood Changes your overall health: • Do pelvic floor muscle exercises It’s useful to know how hormonal • Cut back on or avoid foods and (also known as Kegels) daily changes may affect your mood, drinks that contain caffeine or to keep your bladder and emotions, and mind, even though alcohol, especially in the hours supporting tissues healthy. not all women experience this before bedtime. • Figure out what actions (like symptom. This phase of life may • Learn about foods that are most sneezing or laughing), situations, also bring positive changes, nourishing for midlife women. and foods/drinks are linked to including freedom from If needed, change your eating your urinary problems, and then risk and more time for yourself, habits to include these. make adjustments. your health, and meaningful • Get at least 30 minutes of Learn more about urinary relationships. aerobic exercise, like walking, problems (incontinence), Some women have problems with: most days of the week. Kegels, and other solutions • , , or • Choose activities you enjoy. and treatments in Sexuality and depression. These may worsen or Relationship Health: Urinary occur for the first time. Incontinence section (page 19).

3 HYSTERECTOMY, RADIATION (mammography) the United States. We strongly TREATMENT, AND For women who are not at high recommend you begin screening CHEMOTHERAPY AFFECT risk for breast cancer, these are the at age 50, unless you are at high MENOPAUSE most recent screening guidelines: risk. We usually recommend taking a fecal immunochemical test (FIT) Menopause symptoms can come on • Age 39 and younger. Routine every year. If you are at high risk, early and suddenly for women who mammogram screening is not we recommend colonoscopy rather have their ovaries removed with or recommended. without a hysterectomy (removal of than FIT. Talk to your doctor about • Age 40 to 49. Consider the the ). This sometimes happens the screening schedule that’s best risks and benefits of routine after a hysterectomy alone or with for you. mammogram screening before treatment for cancer with radiation Heart Disease deciding to have a mammogram. or chemotherapy. When only the By looking at your risk factors for • Age 50 to 74. Get a routine uterus is removed with hysterectomy, heart disease, we decide when mammogram screening every 1 menopause usually occurs normally. you should get baseline tests and to 2 years. Talk with your doctor about relief for how often we’ll repeat them. Most your symptoms. • Age 75 and older. Talk with women should have: your doctor about when to get You may benefit from estrogen • Blood pressure testing every 1 screened. therapy if you’re younger than to 2 years. age 50, develop symptoms after Cervical cancer (Pap and HPV tests) • Blood tests of cholesterol surgery, and have no medical From ages 21 to 65, have a Pap levels every 5 years beginning reason to avoid estrogen. We test every 3 years. Have HPV tests at age 40 (for who are recommend that you consider beginning at age 25. After age 65, otherwise healthy). stopping estrogen after age 50. most women no longer need a Pap Learn more about menopause and IMPORTANT SCREENING TESTS or HPV test. Talk with your doctor health risks by visiting: Ask your doctor about the screening about how often you should have • North American Menopause tests you need now and will need Pap/HPV tests. Society at menopause.org. through midlife to protect your Colon or colorectal cancer (FIT health. Also, talk with your doctor test or colonoscopy) • Women’s Health Initiative at whi.org. about your risks for conditions and Colorectal cancer is one of • kp.org/ diseases that can affect women the most common cancers in My Doctor Online at before and after menopause. mydoctor for information on women and heart disease, breast cancer, colorectal cancer, and osteoporosis.

4 Table 1. WHAT’S HAPPENING TO YOUR BODY?

Age Range Period Changes Symptoms Other Health Changes

Mid-30s to mid-40s • Lighter or heavier bleeding • Mood changes • Getting pregnant is still may occur during periods. • PMS (premenstrual possible but less likely. • Period cycles may be longer syndrome) • Get a blood pressure or shorter and less . • Hot flashes screening every 1–2 years. • Sleep pattern changes or • Begin blood cholesterol problems screening at age 40; get tested every 5 years. • From age 40 on, consider the risks/benefits of mammogram (breast cancer) screening. Talk with your doctor about what’s right for you.

Mid-40s to late 40s • Skipping periods may begin. • Mood swings, irritability, anxiety, • Continue heart health and • Periods may be as close depression, forgetfulness, breast cancer screenings (as together as every 3 weeks. difficulty concentrating above). • Other period changes • Hot flashes, racing heartbeat, continue. , joint and muscle aches • Breast discomfort, vaginal dryness, changes in • Weight gain, bloating • • Urinary problems • Hair loss or thinning

Late 40s to mid-50s • Periods become less frequent • Symptoms may increase (see • Get a mammogram screening and eventually stop completely. the symptoms above). every 1–2 years from age 50 • Ovaries produce much less to 74. estrogen for 6–8 months • Continue heart health prior to menopause (the final screenings (as above). period). • Most women complete menopause in this age range.

Mid-50s and beyond • Symptoms decrease or • Risks for heart disease and end for some women after osteoporosis increase for most menopause women. Talk with your doctor • Others have them for up to about your risks. 7 years • Continue heart health and • Less often, hot flashes and mammography screenings (as sleep problems continue for above). up to 12 years

5 SYMPTOM RELIEF AND TREATMENTS Many studies show that women have less discomfort during menopause when they make healthy choices, such as being active and eating well. Mind-body methods, including yoga and meditation practices, can also be helpful.

SELF-CARE AND • Talk with friends going through or bamboo is more comfortable COMPLEMENTARY THERAPIES menopause, or join a support group. than synthetic fabrics. Self-care and complementary therapies • Keep a journal. • Avoid sleeping pills. can benefit your life in ways that • Find a creative activity to enjoy. • Take a warm bath or shower at continue beyond menopause. You If you feel stressed during the day, bedtime. can use them whether or not you also take a few minutes or more to • Drink warm milk or chamomile decide to try hormone therapy. breathe and relax. Slowly breathe in tea before bedtime. Kaiser Permanente offers you and out, filling and then emptying the • Take an insomnia class at your many online classes and resources. lungs and belly. local Kaiser Permanente Health You can search kp.org/mydoctor To manage hot flashes: Education Center. for more information, podcasts, programs, and videos on many of • Drink cool beverages. To deal with mood changes and the topics covered in this section. • Wear layers of cotton clothing or anxiety: Relieve Common Menopause other natural fabrics. • Set aside 15 minutes every day Symptoms Naturally • Lose weight (if needed) to just for worrying. Think about the reduce the length of time you’ll things that make you anxious. To help ease all 3 of the most The rest of the day, let go of your common symptoms, hot flashes, have hot flashes. Losing even a small amount can help. worries. Writing down what’s on sleep problems, and mood changes: your mind may also help. • Keep the air around you cool, • Eat soy foods, such as tofu, tempeh, soy milk, or . • Consider cognitive behavioral using fans for air flow. therapy (CBT), a method of • triggers • Work towards 30 minutes of Track your . Find working with your thought patterns moderate physical activity, such as out what yours are and avoid them. to reduce negative emotions. CBT walking or swimming, on most days. Possible triggers include: can be done one-on-one with a • Practice yoga, meditation, (or ––Strong emotions therapist or in a group. A variety a similar mind-body method) ––Caffeine of Kaiser Permanente classes use CBT methods, including classes on regularly. ––Alcohol managing anxiety, depression, or • Take a stress management class. ––Spicy food anger. • Take time for yourself. ––Specific clothing To cope with stress: • Limit your use of caffeine and To relieve sleep problems: • Find ways to change or avoid alcohol, especially close to bedtime. • Sleep in a cool room with good stressful situations to lower your • Try supplements and herbs (see air circulation. anxiety. For example, if sitting in page 7). • Use all-cotton mattress pads and traffic causes you stress, plan to take bed linens, if possible. Cotton public transit or listen to an audio book or music while you’re in the car.

6 • Change the way you react. If Massage therapy uses healing You may have heard that bioidentical something unfair or upsetting touch to relieve pain, stimulate hormones (also called natural hormones) happens, choose to take a circulation, release tension, and are better than medical hormones. 5-minute break (outdoors, if reduce stress. However, no studies show that one possible) instead of getting stuck Supplements, Herbs, and Other hormone therapy type is safer or in frustration or anger. Over-the-Counter Products more effective than another. • Be prepared. Think of how you Some women are concerned about Compounded bioidentical want to respond to difficult the potential medical risks and side hormones are not approved by the situations that may come up. You’ll effects of hormone therapy. You FDA. Be sure to check with us before probably feel less overwhelmed. may instead decide to try herbs or using compounded bioidentical • Reward yourself after you’ve coped other dietary supplements to relieve hormones (“compounded” means with stress. Give yourself a treat, your symptoms (see Tables 2 and 3). that the hormone combination such as a bubble bath, a facial, Please review these important points is done by a “compounding” time with a good book, or a walk before using herbs and dietary pharmacy). Or seek advice from in the park. supplements: a practitioner who knows how to prescribe them. Mind-Body Methods • The Food and Drug Compounded hormones may be You can do some of these methods Administration (FDA) does not appropriate if you and your doctor on your own. For others, you’ll regulate herbs and dietary or another care practitioner decide need the support of a clinician or supplements. So it’s hard to that you need an unusual dose of certified instructor. Ask your local know for certain about the quality estrogen or progesterone. Kaiser Permanente Health Education of a product. Levels of active Department or Center about behavioral ingredients may vary between Some alternative hormone products health classes and other resources. similar herbal products or may combine different types of estrogen. not even be present. These may be called “tri‑est” or Prayer, meditation, and relaxation can “bi-est.” These products use a weak be practiced in many different forms. • Some herbs do not work well with other herbs, medications, form of estrogen. Yoga helps keep you strong and or over-the-counter drugs. Concerns about risks for breast cancer, flexible and may improve your Make sure to talk to your doctor , and heart disease apply to all responses to stress. or pharmacist if you’re taking forms and types of estrogen (except Humor can reduce stress-related medications and plan to start vaginal estrogen products used to treat chemicals in the body and boost herbs, or vice versa. vaginal dryness). your immune system’s ability to • Be aware that some products Read more in the Hormone Therapy resist disease. Watch a funny movie may contain contaminants from and Other Medications section and let yourself laugh. the production process. (pages 10–13). Aromatherapy is the therapeutic use • Herbs and supplements are To learn about various herbal of oils and extracts from plants, like sold over-the-counter. Kaiser products, search the Natural lavender, to promote relaxation and Permanente pharmacies Medicines database: kp.org/ help reduce a variety of symptoms. carry only herbs that studies naturaltherapy Visualization and guided imagery have shown to be potentially If you have questions or need more involves focusing on a mental image effective in treating specific information, talk with a pharmacist. or imagining you are in a peaceful medical conditions. place. This practice promotes Bioidentical (Natural) and relaxation. Alternative Hormones Music can influence body, mind, and emotions. Put on your favorite The term “bioidentical” describes music. Relax and enjoy. hormones that are chemically identical to those our bodies make. Acupuncture, clinical hypnosis, and The chemicals in bioidentical -based Stress Reduction hormones come from animals and are promising methods for relieving plants, including soy and yams. sleep and mood problems and other They’re available as pills, patches, menopause symptoms. creams, and sprays.

7 Table 2. SUPPLEMENTS AND HERBS WITH PROVEN EFFECTIVENESS

Name Symptom Relief Notes on Use and Study Data

S-equol (soy Provides general symptom relief • Use recommendations for breast derivative in a form most cancer survivors are not available. women can use)

Ginseng () Improves mood and overall well-being • Many types are available. • Research has not proven what types are most effective.

St John’s wort Improves mild (but not major) • Don’t use for longer than 2 years. symptoms of depression • Side effects include stomach upset, tiredness, and extra sensitivity to sunlight. • This alters the absorption and effectiveness of other medications and supplements. • Don’t use with anticlotting drugs or prescription .

Valerian Improves sleep quality and relieves insomnia

ERr 731 (rhubarb, Rheum May reduce hot flashes • 1 small, brief study produced positive rhaponticum, root extract) results.

Flaxseed May reduce hot flashes and night • 1 small study produced positive sweats in women with mild symptoms results; another study found no benefit.

Maca (Lepidium meyenii) Provides general symptom relief • 4 small studies produced positive results.

Relizen Provides general symptom relief (flower pollen extract)

Progesterone cream May reduce hot flashes • The effects are mild and unpredictable. • Don’t use to replace prescription progesterone if taking prescription estrogen.

Soy () Lowers heart disease risk (cholesterol) • Studies show mixed results for hot and may reduce hot flashes flash relief. • Don’t consume more than 25 grams per day. Overconsumption may be unsafe. • Use recommendations for breast cancer survivors are not available.

8 Table 3. SUPPLEMENTS AND HERBS WITH NO PROVEN EFFECTIVENESS

Name Claimed Symptom Relief Notes on Use and Study Data

Black cohosh Provides general symptom relief • A large study showed no benefits. • There are no known risks for taking this herb.

DHEA (hormone) Improves well-being • Kaiser Permanente does not recommend this supplement. • Marketing effectiveness claims go far beyond available study data. • DHEA changes into estrogen and in the body. • Side effects include acne, voice deepening, liver problems, and a possible decrease of “good” cholesterol. • High-dose usage is linked to heart disease risk in women.

Dong quai Relieves hot flashes • Kaiser Permanente studied this traditional Chinese medicine (TCM) herb and found no effectiveness for hot flashes. TCM doctors say they use dong quai with other herbs to improve women’s health. • Risks include blood clotting issues. Women with blood clotting or fibroid problems should not use it.

Evening primrose oil Relieves hot flashes • Studies show no evidence of effectiveness. • Side effects include nausea and diarrhea. • Risks include blood clotting problems, immune system problems, and inflammation.

Kava Reduces anxiety, increases relaxation, • The FDA recommends against use and improves sleep due to potential liver damage. • This may cause mild euphoria and relaxation, similar to the effects of alcoholic drinks. • Kava is potentially addictive.

Red clover Relieves hot flashes • Studies show no evidence of (isoflavone source) effectiveness.

9 HORMONE THERAPY patches, creams, and sprays. If hormone formulation is done by a Menopause symptoms seriously progesterone (progestin) is also “compounding” pharmacy.) affect the lives of some women. prescribed, it can be given alone Testosterone is sometimes You may have tried to cope by or combined with estrogen in the combined with estrogen in HT using dietary changes, exercise, same prescription. and taken in pill or cream form. and other self-care methods Local HT. Hormones are applied You may think of testosterone as and complementary therapies. directly to certain areas of the a male hormone, but women also However, if you continue to have body such as the vagina, to relieve produce it in their ovaries and severe symptoms, you may want to specific menopausal symptoms, adrenal glands. consider hormone therapy (HT) or including vaginal dryness and pain With aging, or if your ovaries are other medications. during sex. Local HT is available in removed, the body produces less Along with relief from many creams, tablets, and rings. Although testosterone. This may lower your menopause symptoms like hot vaginal estrogen can usually be sexual desire and energy levels. flashes and vaginal dryness, some used safely, women who have had Taking testosterone sometimes women feel better in general and breast cancer or blood clots should helps with these symptoms but also have improved skin quality while talk with their doctor before using it has negative side effects and risks. in any form. taking HT. Oral testosterone: How Hormones Affect Your Body HT replaces hormones your • Reduces “good” cholesterol (HDL). body no longer makes as their Estrogen is a hormone made by • May increase blood pressure levels decline during menopause. your ovaries. It affects many areas and risks of heart disease and The most common type of HT of your body, including the , breast cancer. combines the female hormones uterus, vagina, skin, , liver, estrogen and progesterone. arteries, and brain. Your estrogen • May cause hair loss, facial hair growth, acne, and emotional Estrogen is taken with levels drop during the menopause changes such as irritability progesterone to help prevent transition, although your ovaries and aggression. Rare side . If you’ve had a continue to produce it. effects include hoarseness, hysterectomy and no longer have Progesterone levels increase each voice deepening, and a uterus, you can use estrogen month during your fertile years, enlargement. therapy (ET) alone. when the releases an . Only one FDA-approved oral If you choose to take HT, we This hormone protects the lining testosterone-estrogen is recommend using the lowest of the uterus. If you have a uterus currently available. It’s approved for possible dose for the shortest and want to use HT, you should menopausal symptom treatment but time needed to relieve your take progesterone along with not for low . Oral testosterone symptoms—ideally for less than estrogen to prevent an increased hasn’t been thoroughly studied in 5 years. Once you stop HT, many risk of uterine cancer. women. Some studies show only of the benefits disappear quickly, Medroxyprogesterone (Provera) is mild positive effects. but so do the risks. the form of progesterone usually Testosterone cream is made in Types of HT prescribed. Other pill types are available. Progesterone made compounding pharmacies as well Hormone therapy is available in from yams and soy (micronized as Kaiser Permanente pharmacies. 2 main forms, either “systemic” progesterone or Prometrium) Side effects are the same as oral or “local.” is sometimes called natural testosterone, though testosterone Systemic HT. Hormones are progesterone. To protect your given through the skin as a cream released in your bloodstream. They uterine lining, it’s important is less likely to affect cholesterol affect the organs and tissues to take a precise dose of levels. There is no long-term safety throughout the body to help progesterone. You can’t be sure information or data on breast relieve a range of menopausal you’re getting the correct dose cancer risk with testosterone cream. symptoms, such as hot flashes. if you use over-the-counter or Benefits of HT This type of HT is available in “compounded” progesterone. When taken short-term (for 5 years many forms, including pills, skin (Compounded means that the or less) at the lowest possible dose,

10 HT can provide several benefits. • Women who start HT after age • Women who have not had their These include: 60 are at slightly higher risk for uterus removed should take • Reducing the amount and heart attack. progesterone with estrogen. severity of hot flashes. • Women without a uterus who Blood clots • Helping with sleep problems. take estrogen only (ET) and start • Taking estrogen and HT within 10 years of completing • Relieving vaginal dryness and progesterone in pill form (orally) menopause have lower risk of soreness. is linked to risk for blood clots coronary artery calcification in the legs and lungs, which can • Reducing breast tenderness (associated with heart disease). be life-threatening. and irregular bleeding. Breast cancer • Risk of blood clots is significantly • Preventing bladder-related • Breast cancer risk is higher in lower for the and problems, such as frequent women ages 50 to 59 who take some types of progesterone. urinary tract infections, urges to HT for longer than 5 years, and urinate, and urine leaks. • Risk increases with prolonged risk increases gradually with sitting (or other inactive periods), • Preventing loss and additional years of use. such as air travel. Do leg lowering the risk of hip, spine, • Women who use HT are more exercises when sitting for long and wrist fractures. likely to develop dense breast periods. It may be helpful to • Slowing the loss of collagen in tissue. This makes mammograms stop HT for 1 to 2 weeks before the skin, which puts the stretch harder to read, which could lead a long plane flight, road trip, or in skin and muscle. to more breast biopsies and period of bed rest. Get advice Risks of HT delay breast cancer diagnosis. from your doctor or another The risks of taking HT are related • Women ages 50 to 59 without clinician on when to restart HT. to your age, when you started a uterus have no increased risk Stroke it, and how long you take it (see of breast cancer within 10 years • Beginning HT or ET after age Table 4). Short-term use in early of beginning ET. Risk is likely to 60, or more than 10 years after menopause is less risky than increase slightly if ET is taken for completing menopause, is likely starting HT later in menopause. longer than 10 years. to increase stroke risk. Heart disease Uterine cancer • Continuing to take hormones • Women ages 50 to 59 who use • Estrogen taken alone increases after age 60 also appears to HT have no increased risk of uterine cancer risk (except in raise risk. heart disease. women without a uterus). Memory loss • Current research is inconclusive on whether HT improves or decreases memory loss and . • One study found increased dementia rates in women who started HT between the ages of 65 and 79. Side Effects of HT Side effects of HT include: • Irregular • Swollen or tender breasts • Headaches, nausea, or bloating • Leg cramps • Vaginal discharge (continued)

11 Side effects may go away after specific risks and benefits. You what’s needed to help you feel you’ve taken HT for a while. Talk can also discuss other options for better. In our treatment method, to your doctor or other main managing your symptoms. Learn we adjust your hormone therapy practitioner about side effects as much as you can about your based on your symptoms. How you that bother you or go on too long. choices before starting HT. feel is most important, not the level Adjustments to your medication Hormone therapy should be of hormones in your blood. may help you feel better. individualized to meet each When Should You Stop If you start hormone therapy during woman’s needs. If you decide to Taking HT? early menopause, you may continue use HT, tell your doctor about your HT-related risks start to increase to have monthly periods. You may symptoms and health status at every after 5 years of treatment. We also have irregular bleeding. Please appointment. HT doses can be recommend trying to stop HT see your doctor if this happens. adjusted or stopped, as needed. after 4 to 5 years. Some women Deciding about HT Hormone Testing decide to continue longer Each woman is unique. Only you We don’t recommend saliva to control their menopausal know how severe or distressing or blood testing to check your symptoms. Their estrogen dose your menopause symptoms are. In hormone levels. Your levels should be reduced to the lowest making your decision, consider both change daily, even during level that provides relief. Vaginal your quality of life and the potential menopause. If you are several estrogen products can be used as risks of HT. years past your last period, your long as needed. Talk with your doctor or other hormone levels will test low. We usually recommend slowly care practitioner about your Testing does not help us decide reducing your HT over 2 to 3 months. This gives your body time

12 TABLE 4. HORMONE THERAPY HEALTH RISKS

Condition Health Risks Risk Details

Heart disease • No increased risk at ages 50 to 59 Women without a uterus who take estrogen only (ET) and • Small increased risk with starting start therapy within 10 years of completing menopause HT at ages 60 and older have a lower risk of coronary artery calcification (associated with heart disease).

Breast cancer • Increased risk if HT taken longer Women without a uterus have no increased risk within than 5 years at ages 50 to 59 10 years of starting ET, but risk increases with taking ET • Dense breast tissue may develop for more than 10 years. and affect breast cancer diagnosis

Uterine cancer • Increased risk if taking estrogen only, Women with a uterus should take progesterone with except in women without a uterus estrogen.

Blood clots • Increased risk if taking oral (pill) Prolonged sitting (or other inactivity), such as during air estrogen with progesterone travel, increases risk. Get advice from your doctor about • Lower risk for estrogen patch or stopping and restarting HT when you plan to travel. some types of progesterone

Stroke • Increased risk from HT or ET Starting HT or ET after age 60, or more than 10 years after completing menopause, increases risk. Continuing HT or ET after age 60 also increases risk.

to adjust. There is no one best way These medications are called was developed to to stop HT. As you reduce your SSRIs/SSNRIs (selective serotonin prevent seizures and is prescribed HT, continue taking progesterone [norepinephrine] reuptake inhibitors). for chronic pain. It can also if you are taking estrogen by pill If you are experiencing troubling improve sleep and decrease hot or skin-absorption form (a patch). mood changes, read more in the flashes and night sweats. If you’ve had a hysterectomy, you Emotional and Mental Health and daytime sleepiness are side may be taking estrogen only (ET). section (page 21). effects for some women. Vaginal estrogen creams, tablets, Talk with your doctor about which or rings can be used for vaginal antidepressants may be helpful in dryness and pain during sex. alleviating menopause symptoms, as OTHER MEDICATIONS well as other potential benefits and Antidepressants side effects of these medications. Although prescription anti- Other Prescription Medications depressants were developed to is a medication that treat depression and anxiety, lowers blood pressure and comes we’ve learned that specific in patch and pill form. It relieves antidepressants reduce some hot flashes and night sweats for menopause symptoms, including some women. Low doses often hot flashes and night sweats. They don’t cause side effects. It can can be an effective alternative to be taken by women without high HT in very low doses with few or blood pressure. Dry mouth is a no negative side effects. side effect for some women.

13 STAYING ACTIVE AND EATING WELL While the benefits of exercise and nutrition are well known, women in midlife have even more reasons to stay active and eat well.

etting regular physical activity . After menopause, • Walk in beautiful places or Gand eating healthy during your body weight may shift— on different routes. Try local menopause help you sleep better, usually moving toward the hiking trails. lift your mood, and benefit your stomach and midsection. You may • Listen to music or audio books overall well-being. Your risk for also lose muscle, which supports while you exercise. osteoporosis (bone loss), heart bones and joints and keeps your • Focus on how good it feels to disease, and breast cancer may also body looking firm. Exercise can be active. be reduced by your healthy choices. strengthen and tone your muscles. Always exercise in a safe place with STAYING ACTIVE It’s Never Too Late to Start good lighting. If you have pain, For women, midlife may be the most Even if you haven’t been exercising, choose a different activity. Try water important time of life to be active. start getting active now. It can make aerobics or swimming. a big difference in your health and Healthy weight. Your metabolism, For more information about well-being for the rest of your life. the rate your body burns calories, exercise, visit your local Kaiser naturally decreases as you age. Start where you are. Gradually Permanente Health Education But regular exercise reverses this. increase how long, how often, Department or Center. It boosts your metabolism and is and how hard you exercise. Work EATING WELL one of the best things you can do toward 30 minutes of moderate for your health. You burn calories physical activity on most days. Good nutrition lowers your risk while exercising and for several Make sure some of your exercise for common diseases in women, hours afterward. is weight bearing, to help keep including heart disease, cancer, bone loss, , stroke, and . Bone strength. After menopause, your bones strong. Include weight Studies on women’s nutrition women’s bones lose density, so lifting for the upper body. recommend these guidelines. they aren’t as strong. This is a Keep it fun. Mix up your activities major cause of fractures in older to strengthen different body parts Eat vegetables and fruits. They women. These injuries make older and avoid boredom. Try these ideas are naturally low in , delicious, women less mobile, and their to stay interested and motivated: and nourishing. Eat a variety of fruits and vegetables every day. quality of life worsens. • Use a fitness device, app, or They should fill half your plate. The best way to maintain bone pedometer (step counter) to set strength is with weight-bearing goals and track your progress. Eat more whole grains and other exercise, like walking or dance • Exercise with a friend. high-fiber foods.Whole-grain aerobics. breads, whole grains (such as brown • Start a neighborhood walking rice), and cereals add vitamins and Balance and fall prevention. club or a lunchtime walking fiber to your diet. Other foods high Yoga, tai chi, and similar forms of group at work. in fiber include oats, bran, beans, exercise can improve balance and and prunes. make falls less likely.

14 Check montereybayaquarium.org/ catfish, almonds, soy products, Making Time for Exercise seafoodwatch to learn more about and green, leafy vegetables. Take Look for ways to be more active sustainable, low-mercury seafood. supplements if you need them to throughout the day. It’s best to Limit high-fat foods. Sticking with meet your daily recommendation. be physically active for at least low-fat foods will help control your Calcium and 30 minutes on most days. weight, keep your heart healthy, supplements are available in • Take the stairs instead of the and reduce your risk of cancer. Kaiser Permanente pharmacies. elevator. Avoid saturated in meats and See the Health Risks After whole-fat dairy products, and Menopause: Osteoporosis section • Take short walks, or do hydrogenated fats in margarines, (page 23) for more information stretches during lunch or cookies, crackers, chips, and fried about calcium and vitamin D. work breaks. foods. Use small amounts of olive Go easy on salt and sodium. • Walk or bike when doing or canola oil (monounsaturated Eating too much sodium, found errands. fats), or a zero-calorie nonstick in salty foods, may cause loss • Fit in mini-workouts throughout spray, when cooking. of calcium in your urine and the day. Lift light weights Limit or skip alcoholic drinks. increased blood pressure. Healthy first thing in the morning, Alcohol can increase some adults should eat no more than or workout to a short online hormones in your body, especially 2,000 mg (less than a teaspoon of video in the evening. estrogen. This can increase your table salt) a day. Women with high • Plan longer workouts and breast cancer risk. Limit yourself blood pressure may need to limit active events, such as hikes to one drink (5 ounces of wine, their sodium even further. Check or longer bike rides, on 12 ounces of beer, or 1.5 ounces with your doctor. weekends when you have of hard liquor) per day (or less) to Include soy foods. Foods made more time. minimize your risk. Alcohol adds from soybeans, including tofu, Benefits of Regular Physical calories and can cause weight gain. tempeh, roasted soy nuts, soy Activity Some studies show that moderate milk, or isolated soy protein, are • Lower your risk for use of specific types of alcohol high in . They may osteoporosis, heart disease, may lower heart disease risk. help reduce hot flashes. They’re and cancer Eat foods rich in calcium and also low in fat and can add variety to your diet. • Help manage arthritis pain vitamin D. Calcium and vitamin D can help reduce the risk of • Boost your immune system osteoporosis (bone loss). The • Raise your self-confidence recommended daily intake of and self-esteem calcium is 1,000 mg for women • Help you feel both energetic ages 19 to 49 and 1,200 mg for and relaxed women 50 and over. Vitamin D • Improve your sleep recommendations are a subject of heated debate. Total daily • Lift your mood intake of vitamin D (at least 1,000 IU/day), preferably vitamin D3, Eat more fish.Fish is rich in is recommended for all pre- or nutrients that protect against heart postmenopausal women and men disease. Two to 3 fish-based meals aged 50 or older. per week along with a low-fat diet will benefit your health. Be aware It’s best to get calcium and that many types of fish contain traces vitamins from dietary source. of mercury. Don’t consume high Good sources include low-fat quantities of these fish. Low-mercury dairy products, such as yogurt, fish include shrimp, canned light cheese, and milk. Each serving tuna (not albacore), salmon, flounder, contains about 300 mg. Other tilapia, pollock, and catfish. sources include salmon, sardines,

15 How to Start Eating Healthier • Remove fat from meat before Instead of trying to change eating. Have fish at least once everything at once, make small a week. Limit butter, cream, changes in your eating habits. dressings, and sauces. Here are ways to get started and • Broil or bake instead of frying. things to look out for. Use sprays and nonstick pans. • Add 1 fruit or vegetable to any • Snack healthy with fruits, of your meals or as a snack until vegetables, nuts, yogurt, you have reached 5 servings cottage cheese, whole-grain a day. Add a handful of bread, or low-fat crackers. blueberries or another favorite • Don’t shop for groceries when fruit to your cereal or yogurt. you’re hungry. Make a list • Be aware of portion sizes: ahead of time that focuses on ––A whole piece of fruit is 1 healthier foods. serving. • When eating out, beware of large ––A green salad with lettuce portions and added calories. and about a cup of Order salad dressings, sauces, vegetables, like cucumbers and gravies on the side so you and tomatoes, is 2 servings. can decide how much to put on your food. Consider sharing ––A half cup of rice or pasta or entrées or ask for half portions. half a bagel is 1 serving of grain. • Read food labels to avoid hydrogenated fats, or trans fats. ––One cup of milk or yogurt or 2 slices of cheese is a serving of dairy. For more information about healthy eating, contact: ––A serving of meat is about the size of the palm of your • American Dietetic Association: hand. Try skinless chicken or eatright.org lean red meat, like tenderloin • United States Department of or bottom round. Agriculture: choosemyplate.gov

A Word on Women and Weight As women get older, they experience an increase in body fat and a decrease in the rate they burn calories. Unchecked, this is a recipe for weight gain. Extra weight raises risks of developing heart disease, hypertension, diabetes, and problems like low back and knee pain. For people who are overweight, small weight losses—just 8 to 10 pounds—can significantly improve diabetes, high blood pressure, and other medical conditions. Also, studies show that women who lose 10 or more pounds during menopause stop having hot flashes sooner. If weight is a struggle for you, don’t lose hope. We have classes and other resources to help. Visit kp.org/mydoctor/healthyweight.

16 SEXUALITY AND RELATIONSHIP HEALTH Sexuality includes the desire for both physical and emotional closeness and the need to feel and to give affection or pleasure. Your interest in sex can last your entire life.

any women have questions suggestions in this guide. Talk Spend more time in foreplay. Mabout their sexual health, with your physician about your Learn about your body and what such as: questions and concerns. makes you feel sexually excited, • Am I having enough sex? Will You Have Less Interest and communicate this to your partner. Women’s desire is usually • Am I having too much sex? in Sex? increased through physical • My partner seems to want it all the Your interest in sex can change for touching and lovemaking, which time, and I’m just not in the mood. many reasons, including: also increases . Is something wrong with me? • Pain during intercourse due to Use a nonhormonal vaginal The truth is that there is no “normal” vaginal dryness. This is related to lubricant or moisturizer for lower levels of estrogen. Vaginal for all women. Some women want vaginal dryness. You can get moisturizers and lubricants can to have sex weekly, some monthly, these without a prescription. help relieve this problem. and some rarely or not at all. A Lubricants are water or silicone woman’s experience of her sexuality • Emotional changes, major life based and must be used every can change significantly as she goes events, stress, depression, or time you have intercourse. You through her life’s stages, including fatigue. apply moisturizers 2 or 3 times a the transition to menopause. • Perimenopausal symptoms, week and may also use a lubricant Will You Lose Your Desire? including hot flashes, irritability, for intercourse. Avoid petroleum Your sexual desire depends on or sleep problems. jelly and other creams or lotions many factors, including your • Partner’s changing sexual that aren’t made for vaginal emotional makeup, physical abilities or interest. moisturizing. They can cause vaginal infections. health, social and cultural • Serious illness or surgery. background, and hormone levels. Exercise. Physical activity can • Lack of time with your partner In midlife and after menopause, increase blood flow to the vagina or problems in the relationship. your hormone levels gradually and also boost your body image. • Boredom with your . decrease. Your sexual desire and Enjoy sex in the morning or arousal from sexual stimulation • Weight gain or loss, or poor afternoon when you have more may also decrease. body image. energy, rather than at night when Your desire can also be affected • Side effects of medications. you and your partner are tired. if having intercourse becomes • Alcohol or drug use. Make dates with your partner. painful or if you’re bothered by • Lack of a partner. Take a walk, go out for dinner and menopausal symptoms, such as a movie, or just relax and talk. Self-Care Tips hot flashes, insomnia, or irritability. Nourishing emotional intimacy Most symptoms can be managed You can overcome sexual and closeness is important for with self-care and complementary challenges and enjoy a fulfilling strengthening sexual intimacy. or medical therapies. See the sex life by trying these tips.

17 decrease in testosterone may mean • Practice squeezing these that desire also decreases. Sometimes muscles while keeping your adding testosterone to your hormone stomach and buttocks relaxed. therapy is helpful (see page 10). • Squeeze your pelvic floor muscles Consider vaginal estrogen. For and hold for 3 seconds; then relax some women, estrogen cream for 10 seconds. This is 1 Kegel. applied in and around the vaginal • Do 10 Kegel exercises in each set. opening increases blood flow, • Start with 1 set 3 to 4 times a muscle tone, and lubrication and week, holding for 3 seconds. decreases pain with intercourse. Gradually build up to 3 sets every Other options are an estrogen-filled day, holding each squeeze for 6 to (Estring) or a tablet. 8 seconds. Pelvic Floor Muscle Exercises You can do Kegels anywhere (Kegels) and anytime. No one will know Kegel exercises strengthen your except you. pelvic floor muscles, which can RELATIONSHIP HEALTH improve your sexual function and help prevent frequent urges to The quality of your intimate urinate and incontinence (urine relationship affects your health. leaks). All women should do Kegels. If you’re in a difficult or abusive relationship, you’re under chronic Follow these steps: stress that can contribute to a Don’t give up on sex. Instead of • Practice stopping your urine wide range of physical or mental waiting until you feel desire, let stream and then restarting it. health problems. Relationships yourself be willing. You may not Feel the muscles around your that are loving, respectful, and start out being “in the mood,” but urethra and anus squeezing and safe improve immune function and most women can get in the mood. relaxing. After you have felt how overall health. You can prepare yourself, get your pelvic floor muscles work, help from a supportive partner, don’t do this again; it can make it and keep your communication difficult to empty your bladder. open. Staying sexually active with your partner or by self-stimulation increases blood flow to the vagina and helps maintain elasticity and moisture, decreases discomfort, and brings many other benefits. Explore erotic books and videos to see if they enhance sex for you and your partner. Masturbate (self-stimulate). Many people find a pleasurable way to release sexual tension. Others enjoy it to explore and learn what arouses them and brings the most pleasure. Ask about testosterone. The ovaries produce small amounts of testosterone, the “desire” hormone in both men and women. With aging, a

18 URINARY INCONTINENCE surgery. Kegels usually help • Avoid coffee, tea, and other If you have urinary incontinence improve or cure this type of drinks that contain caffeine, since (urine leaks), it may help to know incontinence. these overstimulate the bladder. that you’re not alone. Millions • Overactive bladder means Drink other fluids as you normally of people have this problem. that the need to urinate comes would, as you need them to Usually incontinence can be on too quickly to have time to keep your body healthy. managed or cured. Temporary get to the bathroom. This is a • Practice double-voiding. incontinence can be caused by common problem, and there Empty your bladder as much water pills (diuretics) and other is not always an obvious cause. as possible, relax for a minute common medications. Other It can be caused by bladder (or stand up and sit down causes include constipation, infection, fibroids and other again), and then try to empty bladder infections, stones in the tumors that may press on the your bladder again. Leaning urinary tract, and long-term bed bladder, Parkinson’s disease, forward while sitting can also rest. When these underlying and nerve-related disorders like be helpful. problems are corrected, multiple sclerosis or stroke. • Use a schedule. For example, incontinence is cured. • Overflow incontinence go to the bathroom every 3 to There are 3 types of ongoing happens when the bladder 4 hours during the day, whether (chronic) incontinence: can’t empty completely and you have an urge to or not. This • means small amounts of urine leak may help you regain control. that small amounts of urine leak continuously. • Ask your doctor or nurse out during exercise, coughing, Self-Care Tips practitioner about the laughing, sneezing, or other • Keep doing the things you like Successful Bladder Control movements that squeeze the to do. If needed, you can buy video or class, if interested. bladder. Women are most absorbent pads or briefs in Your practitioner can also refer likely to get this type, though pharmacies and supermarkets. you to a pelvic floor physical men may have it after prostate therapist.

19 WHAT TO DO IF YOU’RE IN AN If you are being hurt by your National Domestic Violence Hotline UNHEALTHY RELATIONSHIP partner, it is not ok. You deserve to ndvh.org If your safety is at risk, here’s how be safe and healthy. For toll‑free, 1-800-799-SAFE (7233) or you can protect yourself: 24-hour support in safety planning, 1-800-787-3224 (TTY for housing options, legal advice, and hearing or speech impaired) • Develop a safety plan. local referrals, call: • Prepare an emergency kit for a situation where you have to leave suddenly (keys, QUIZ: ARE YOU IN A QUIZ: ARE YOU IN AN money, legal and important HEALTHY RELATIONSHIP? UNHEALTHY RELATIONSHIP? documents, medicine, etc.). Is my partner willing to Does my partner call me • Talk to someone you trust communicate openly when names or humiliate me? about what’s going on. there are problems? m yes m no • Let your doctor know about m yes m no your situation. Does my partner control • In addition to getting safe, Does my partner give me where I go, who I talk to, and reduce the effects of stress space to spend time with how I spend my money? through exercise, meditation, other people? m yes m no yoga, or other strategies that m yes m no work for you. Has my partner threatened Is my partner kind and to hurt me? • Call 911 if you are in supportive? immediate danger. m yes m no m yes m no Has my partner forced me to If you answered yes to these have sex against my will? questions, it is likely that you m m are in a healthy relationship. yes no Studies show that this kind of If you answered yes to any of relationship leads to better these questions, your health physical and mental health and safety may be in danger. and longer life.

20 EMOTIONAL AND MENTAL HEALTH As you go through the menopause transition, you may face many physical, mental, and emotional changes. These changes may be greater than any you’ve experienced since .

or many women, menopause work as an alternative to hormone • Persistent sadness Fand midlife are a wake-up call. therapy for some women, relieving • Loss of interest in activities you Some of the changes that come symptoms like hot flashes and usually enjoy with the menopause transition mood problems. Talk with your • Decreased interest in sex can be challenging. But as you doctor if you’re interested in gain an understanding of your learning more about this option. • Ongoing tiredness or trouble concentrating needs and learn to meet them, Know When to Seek Professional your well-being can increase. As Help • Strong feelings of guilt, a result, you may discover how to worthlessness, or helplessness live a healthier, more fulfilling life. Although you can often take steps to improve your mental • Trouble sleeping Common emotional and mental and emotional states on your • Restlessness changes during perimenopause own, sometimes you may need • Change in appetite (the time before and the year assistance. Clinical depression • Suicidal thoughts or plans after your final menstrual period) is much more than just feeling include: sad. Seek out professional help If your’re thinking of harming • Difficulty sleeping if you’ve been depressed for 2 yourself, call 911 or go to the nearest hostpital. You can • Tiredness weeks or longer and have had several of the following symptoms: also call the Suicide Hotline: • Mood swings 800-SUICIDE (800-784-2433). • Irritability • Depression • Anxiety • Trouble concentrating • Forgetfulness • Worsening premenstrual syndrome (PMS) COPING WITH DEPRESSION Can Antidepressants Help with Menopause Symptoms? Antidepressants are prescription medications for treating depression. They can also help with irritability, anxiety, insomnia, and moodiness. Specific antidepressants also

21 Self-Care Tips For more information on BOOST YOUR MEMORY You can help balance your mood managing your mental health during Gaps in short-term memory changes and other menopausal menopause, try these resources: are common as we age. symptoms by making good health • Office on Women’s Health— They’re rarely signs of a serious choices. See on Staying Active Menopause: womenshealth. condition like Alzheimer’s and Eating Well (page 14) and gov/menopause/menopause- disease. Try these tips to help Relieve Common Menopause mental-health you remember things: Symptoms Naturally (page 6). • National Institute of Mental • Repeat a new name or Health—Women and Mental other information as soon as Health: nimh.nih.gov/health/ you get it. Write it down if topics/women-and-mental- possible. health • Make lists and post them where you’ll easily see them—on your refrigerator, computer screen, or calendar. • If you often misplace your keys or other items, keep them with your wallet. • Use several senses to remember. Write down the information, look at it, and say it to yourself.

22 HEALTH RISKS AFTER MENOPAUSE Know your risks for 3 conditions that women are more likely to develop after menopause.

OSTEOPOROSIS more than 3 cups of coffee a day, you feel dizzy or light-headed. Osteoporosis is a condition that limit salt intake to under 2,000 mg Blood pressure medications causes bones to become weak per day (less than 1 teaspoon), and sometimes cause dizziness. and brittle. This increases the risk drink only small amounts of alcohol. • Keep your house well lit to of fractures. • Consider medications. If you’re avoid bumping into things. The risk of fractures for women in diagnosed with osteoporosis • Use rugs with nonslip backing in their 50s is generally low, but they or you’ve had a fracture, your your home and avoid throw rugs. doctor may recommend taking can have very high bone loss in the • Keep floors and hallways clear bisphosphonates or other 5 to 7 years after menopause (the of boxes, papers, clothing, and medications, such as SERMs final menstrual period). Half of all electrical cords. (selective women older than age 50 fracture • Install handrails and nonslip their hip, wrist, spine, or other bone modulators). Studies show that hormone therapy can decrease mats in your bath and next to due to osteoporosis. By following your toilet. the prevention guidelines, you can osteoporosis risk. But because keep your bones strong through of other risks related to hormone • Make sure you can easily reach menopause and beyond. therapy, we don’t use it to treat all kitchen items. women who don’t need hormones • Avoid standing on chairs, step Help Prevent Osteoporosis with to manage menopause symptoms. These Self-Care Tips stools, or ladders. Prevent Falls • Take calcium and vitamin D daily. To help keep bones strong: Many women fall and break a Know the Warning Signs of • Use calcium citrate rather than bone at some point in their lives. Osteoporosis calcium carbonate as your Use these tips from recent studies • Loss of height calcium supplement if you take to help prevent falls: a proton pump inhibitor (such • Unexplained • Maintain your balance, strength, as Prilosec, Protonix, Prevacid, • Kyphosis or dowager’s hump or Nexium). and coordination (try walking, gentle yoga, tai chi, or swimming). (curving of the upper back) • Do weight-bearing activities • Wear low-heeled shoes with • Fracture from a fall or bump like walking to help maintain from standing height or lower bone mass. Aim for at least 30 nonslip soles. • minutes most days of the week. • Use a cane if you walk unsteadily. Frequent fractures • Cut down on caffeine, salt, and • Get your vision checked Bone Mineral Density (BMD) Test alcohol. All 3 of these can reduce regularly, and wear glasses or This test uses small amounts of bone strength by causing loss contacts if needed. radiation or sound waves to measure of calcium in the urine. Experts • Review your medicines with your bone density. The results help us recommend that women drink no doctor. Let your doctor know if know how much bone mass

23 QUIZ: ARE YOU AT RISK FOR Do you smoke? Do you exercise less that 3 OSTEOPOROSIS? m yes m no 30-minute periods per week? m m Do you have a family history of and moderate to heavy yes no osteoporosis? alcohol drinking can damage the Exercise, expecially weight-bearing m yes m no bones. Smoking also decreases activities, strengthens bones. As with many other conditions, estrogen levels, which leads to Is your diet low in calcium? more bone loss (osteoporosis). having this disorder in your family m yes m no history can mean you are more Smoking is the number 1 likely to get it. This is especially true preventable heart disease risk Getting at least 1,200 mg per day if your mother had a hip fracture. factor for women. of calcium, through food and/or supplements, slows bone loss. Have you had a bone fracture Are you Caucasian or Asian? after the age of 50? m yes m no Are you taking steroid medications or medications m m yes no Caucasian and Asian women are for treatment of hyperactive Women who have fractured more likely to have fractures and disease, blood clots, or a bone as an may have develop osteoporosis because seizures? their bone density is lower than weaker bones, which raises their m yes m no risk for osteoporosis. Don’t count women in other ethnic groups. fractures of the fingers, toes, and Did you experience menopause Steroid medications can cause facial bones. early (before age 40) due to bone loss, raising your risk for natural causes, surgical removal osteoporosis. Inhaled steroids Do you weigh less than 127 have less effect on this risk. pounds or have a BMI (body of your ovaries, or radiation or mass index) less than 21? chemotherapy treatment? If you answered yes to any of these questions, you may be m m m yes m no yes no at greater risk than normal Studies show that risk of Women who go through early for osteoporosis. The more osteoporosis is higher in women menopause are at higher risk questions you answered yes to, with these characteristics. because their estrogen levels are the greater your risk. Talk to lower for longer. your doctor at your next visit.

you’ve lost and whether your bones more than 7 years can lead to thigh disease, cholesterol, or the risk have become weak, thin, or porous. bone breaks in rare cases. Damage of blood clots. All women should have a BMD test to the jawbone occurs rarely, in less • Have no effect on the uterus, if they are 65 or older. Higher-risk than 1 per 1,000. It is usually related breast, or the risk of breast cancer. women, including those who’ve had to injectable bisphosphonates • Do not help with hot flashes, a fracture after age 50, may need a that are given to patients to treat vaginal dryness, or other BMD test sooner. Talk to your doctor. certain cancers. In almost all cases, symptoms of menopause. Medications for Osteoporosis the benefit of reduced fracture risk far outweighs the medication risks. • Sometimes upset the stomach and Bisphosphonates (Fosamax and Check with your doctor for the latest need to be taken as instructed. Actonel) are drugs for preventing information. • Should be taken with calcium and treating osteoporosis and and vitamin D. other bone diseases. They work Bisphosphonates: inside bone cells to reduce bone • Increase total body bone density, Use these tips to avoid stomach breakdown. These drugs don’t including in the spine and hip. upset: have the same risks or benefits as • Reduce the risk of fractures by • Take medication with a full hormones. New research suggests about half. glass of water when you first that taking bisphosphonates for get up in the morning. • Have no effect on heart

24 • Don’t lie down, eat, drink, or take any other medication for at least 30 minutes (ideally 90 minutes) after taking bisphosphonates. This helps your body to fully absorb the medication to provide full benefit to your bones. • Don’t break pills in half. If you forget to take your medication in the morning, don’t take it later in the day. Skip it, and take the usual dose the next morning. If you have side effects, tell your doctor. (Evista) stops the effect of estrogen on the breasts but does not affect the uterus or vagina. Other effects of raloxifene include: • Lowers spine fracture risk. • Decreases risk of breast cancer tumors that are sensitive to estrogen. HEART DISEASE other facts you should know about • Doesn’t cause bleeding in the heart disease: uterus or require progesterone use. Did you know that heart disease • Five times more women die of • Doesn’t increase uterine kills more women in our country heart disease than of breast cancer. cancer risk. than any form of cancer, stroke, domestic violence, or AIDS? • One in 4 women dies within a • Is about half as effective as year of having a heart attack, estrogen at increasing bone Many women don’t recognize the compared to 1 in 5 men. density. early signs of heart disease. Some tests and procedures—including • More women than men suffer • Shouldn’t be used by women the exercise stress test and stress a second heart attack within with blood clot problems ECG (electrocardiogram)—may be 5 years of their first. (studies show an additional 7 less accurate in women than in men. cases of blood clots per 1,000 • African American women are women) or an increased risk for Heart disease is serious. Know the nearly a third more likely than heart attack or stroke. facts, symptoms, and risk factors. Caucasian women to die of You can save your life with awareness, coronary heart disease. • Slightly increases incidence of education, and prevention. death due to stroke. • Women with diabetes are more Heart Disease Kills More than 2 and a half times more • Can cause hot flashes. American Women Than Men likely than other women to die • Does not reduce vaginal Every Year of coronary heart disease. dryness or other symptoms of You’re at higher risk for heart menopause. Only half of women in the United States are aware that heart disease disease if you: Raloxifene’s long-term effects are is the number 1 cause of death • Smoke. still being studied. among women. Your chance of • Have diabetes. For more information, visit the developing coronary heart disease National Osteoporosis Foundation is 2 to 3 times higher after you • Don’t get regular exercise. at nof.org. complete menopause. Here are • Have high cholesterol.

25 QUIZ: ARE YOU AT RISK FOR Do you have diabetes? it’s best to have a total blood HEART DISEASE? m yes m no cholesterol level lower than 200 mg/ dL. Levels 240 mg/dL and over are Do you smoke? Women with diabetes have considered high blood cholesterol. m yes m no twice the risk of developing But even levels in the borderline- heart disease. Smoking is the number one high category (200 to 239 mg/dL) preventable heart disease risk Do you eat a diet that is high can increase heart disease risk, factor for women. in saturated fat? depending on your ratio of HDL Do you have a family history m yes m no cholesterol to LDL cholesterol. of heart disease? A high-fat diet can increase the Are you overweight? m yes m no risk of heart disease. m yes m no A family history of heart disease is Do you have uncontrolled People who are 30 percent an important risk factor for heart high blood pressure? overweight or more are at greater disease. Did your father or brother m yes m no risk of heart disease. have heart disease before age 55? Did your mother or sister have High blood pressure (equal to or If you answered yes to any of heart disease before age 65? greater than 140/90) can increase these questions, you may be the risk of heart disease. at greater than normal risk Are you physically inactive? for heart disease. The more Is your HDL (good) cholesterol m yes m no questions you answered yes less than 50 mg/dL, or is your to, the greater your risk. Talk People who are inactive have LDL (bad) cholesterol over to your physician at your next nearly twice the risk of heart 130 mg/dL? disease. We recommend 30 medical visit. m m minutes of moderate physicical yes no activity, like walking, most days of The higher your total blood the week. cholesterol level, the higher your heart disease risk. For all adults,

• Have high blood pressure. If you have one or more of these and blood vessels. Pregnant and • Have a parent or sibling with risk factors, you could be at higher postmenopausal women should be heart disease or who had a heart risk for heart disease. Be aware of extra careful about monitoring and attack under age 55 (male) or the warning signs of a heart attack. controlling their blood pressure. under age 65 (female). Heart Health Self-Care Tips Take time for yourself. Find ways to • Are overweight. Although you may have some risk relax and reduce everyday stress. Take a walk, listen to music, or soak • Have a personal history of heart factors you can’t change, there are in a bubble bath. Talk to someone disease, stroke, or blood vessel many positive steps you can take. about how you feel. Friends are disease in the legs. Lower high cholesterol. High good medicine. • Are older than age 55. cholesterol levels in your blood Know the Warning Signs But these aren’t the only factors. make it easier for cholesterol to build Your risk also increases if you: up in your artery walls. This leads to Women often seek help for heart heart attack or stroke. A low-fat diet, attacks later than men do. This may • Don’t see your doctor as weight loss, and exercise can lower be because women’s heart attack recommended. cholesterol levels. Take cholesterol- symptoms are often different than the • Don’t give your own medical lowering medication if your doctor well-known symptoms of chest or arm and health needs the same recommends it. pain. Here are the warning signs that a attention you give to others. Reduce high blood pressure. woman may be having a heart attack. • Think of heart disease as a High blood pressure puts strain on man’s disease. the heart and damages the heart

26 Common signs: Does Hormone Therapy Help doctor for more information. See • Uncomfortable pressure, fullness, Prevent Heart Disease? Symptom Relief and Treatments: squeezing, or pain in the center The Women’s Health Initiative Hormone Therapy and Other of the chest lasting more than a study found that women older Medications on (pages 10–13). few minutes than age 60 or who are already Contact your local Kaiser • Pain spreading to the at high risk for heart attack or Permanente Health Education shoulders, neck, or arms stroke and start taking combined Center for health information, hormone therapy (HT) may further programs, and other resources. • Chest discomfort with light- increase their risk of heart attack headedness, fainting, sweating, Other resources for heart health or stroke. For these women, nausea, or shortness of breath include: starting hormones does not • Shortness of breath and prevent heart disease. • WomenHeart: The National difficulty breathing Coalition for Women with Heart Some studies suggest that starting Disease: womenheart.org Less common signs: HT closer to menopause (the last • Abnormal chest, stomach, or menstrual period) may help keep • American Heart Association: abdominal pain blood vessels healthy and prevent heart.org • Unexplained anxiety, weakness, heart attack. But researchers • National Heart, Lung, and Blood or fatigue don’t know whether this is a long- Institute (NHLBI): nhlbi.nih.gov lasting effect or if heart attack • , cold sweats, or • California Smokers’ Helpline: risk may increase in women who paleness 1-800-NO-BUTTS use HT long-term. Small studies (1-800-662-8887) • Nausea or dizziness suggest that transdermal estrogen • Feeling very sick, in an (patches, creams, or gels applied unfamiliar way to the skin) may be safer than pills. If you experience any of these The U.S. Preventive Services Task symptoms, call 911 or go to the Force recommends against the nearest hospital. use of HT for the prevention of heart disease. Check with your

27 BREAST CANCER discharge, redness, or another Breast cancer is the most common change in your breast tissue, call form of cancer in women, after your doctor immediately. Most nonmelanoma skin cancer. lumps are not cancer, but you should Although breast cancer can’t be always have them checked. Breast prevented, it can often be treated cancer screening options include: effectively if caught early through • Mammography. This special regular screening. X-ray exam of the breast can Most breast symptoms are not show tumors that are too small related to breast cancer, which to be felt. Kaiser Permanente usually has no symptoms. However, recommends a schedule of if you have symptoms such as a regular mammograms based on new lump in your breast, nipple your age and risk. • Clinical breast exam. This is an examination by your doctor. QUIZ: ARE YOU AT RISK FOR Did you start your menstrual • Magnetic resonance imaging BREAST CANCER? period early (before age 12) or (MRI). This scan of the breast Do you have a family history of have your final menstrual period takes a long time, can result breast cancer? (menopause) after age 50? in many false positives, and m m has not been proven to save m yes m no yes no lives. For these reasons, it is Early menstrual periods or late Having a first-degree relative recommended only for women menopause may indicate that (a mother, sister, or daughter) at very high risk for breast cancer. who was diagnosed with breast your body has been exposed to How Often Should You Have cancer increases your risk. A higher than average amounts of Breast Cancer Screenings? small number of women who estrogen. This may place you at have 2 or more relatives on the higher risk for breast cancer. Kaiser Permanente’s breast cancer same side of the family who have Have you never given birth, or screening recommendation for had breast cancer before age 50 was your first pregnancy after you will depend on your age and may have a genetic risk. Ask your you were 30 years old? risk factors. You may need more frequent screening if your or your physician for more information if m yes m no this applies to you. family’s health history means that Many studies have shown that you’re at higher risk. Look at the Do you have a personal history early pregnancy protects against high-risk list below, and talk with of breast cancer? breast cancer. Women who your doctor about how often you m yes m no haven’t had children or had their should get a mammogram. Keep in A woman who has had breast first after age 30 mind that many women who are not cancer is more likely to develop have not received the protective at high risk also get breast cancer. breast cancer again. effects of early pregnancy. Average-risk screening Have you had a breast If you answered yes to any of guidelines these questions, you may be biopsy that was benign “Average risk” refers to women at greater risk than normal (noncancerous) but reported who do not have a personal for breast cancer. The more that you had atypical history of breast cancer or family questions you answered yes, hyperplasia or lobular history of a mother, sister, or the greater your risk. Talk to carcinoma in situ (LCIS)? daughter with breast cancer. Most your doctor at your next visit. m yes m no women are at average risk. If so, you may be at higher risk Doctors’ recommendations of developing breast cancer at may vary slightly for breast some point in your life. cancer screening. They include mammography and clinical breast

28 If you’re high risk, you should have taking ET for up to 7 years and annual exams and discuss your possibly longer. Using ET for screening schedule with your doctor. longer may increase risk, though If your ethnicity is Ashkenazi this hasn’t been confirmed yet. Jewish and you have a family Talk with your doctor about your history of breast and/or ovarian specific risks and benefits of using cancer or if any men in your family any type of hormone therapy. See have had breast cancer, discuss the section Symptom Relief and this with your doctor or nurse Treatments: Hormone Therapy and practitioner. After reviewing your Other Medications on (pages 10–13). history, your care practitioner may What Effects Do SERMs Have on recommend genetic counseling Breast Cancer? and possible testing for a breast cancer gene . and raloxifene are selective estrogen receptor Self-Care Tips modulators (SERMs) that are There isn’t much solid research approved by the U.S. Food and on whether what we eat affects Drug Administration for use in breast cancer. We do know being preventing breast cancer in women overweight increases breast at high risk. These drugs also cancer risk. If you’re overweight, help prevent osteoporosis (see losing weight may lower your risk. Health Risks After Menopause: exam. Check with your doctor Osteoporosis on pages 23–25). about how often you should See the Staying Active and Eating They don’t relieve hot flashes or be screened for breast cancer. Well section (page 14). Also, follow other menopausal symptoms. Studies show it’s important for these suggestions: No information on the long-term women between the ages of 50 • Eat fewer high-fat foods and effects of these drugs is available and 74 to have a mammogram especially avoid saturated fats. at this time. every 1 to 2 years. • Move to a more plant-based For more information, check out High-risk screening guidelines diet that includes vegetables, these resources: “High risk” refers to a woman who fruits, whole grains, soy foods, • American Cancer Society: has one or more of these risk factors: flaxseed, and fish. cancer.org • Previous breast cancer • Maintain a healthy weight. • Limit alcohol to one drink a day • Susan G. Komen organization: • A breast biopsy showing an komen.org irregularity, such as atypical or less. ductal hyperplasia (ADH) or Does Hormone Therapy Increase lobal carcinoma in situ (LCIS) Your Risk of Breast Cancer? • A mother, daughter, or sister Combined hormone therapy (first-degree relative) with (HT) contains estrogen and breast cancer progesterone, which appears to • An aunt, niece, grandmother, or increase your breast cancer risk granddaughter (second-degree if used longer than 4 to 5 years. relative) who had breast cancer Although the risk is small at first, • A first- or second-degree it increases the longer a woman relative who had takes HT. • A known BRCA gene mutation Women on hormone therapy in either herself or her close who have had a hysterectomy family members take estrogen alone (ET). Studies have shown no increase in the risk • Chest of breast cancer among women

29 This information is not intended to diagnose health problems or to take the place of medical advice or care you receive from your physician or another health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. ©2008, The Permanente Medical Group, Inc. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names All rights reserved. Regional Health Education. 98139 (Revised 5/17) RL 8.9 listed are for easy identification only. Some photos may include models and not actual patients.