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SEX AFTER MENOPAUSE


Many women find that going through menopause does not impact their sex life. Some even find it
even more exciting than ever because they are no longer concerned about becoming pregnant. For
many women, though, some of the physiological effects of menopause does impact their enjoyment of
sex. It is important to understand that these effects can be treated, and sex after menopause can be
very fulfilling and enjoyable.
Symptoms of Menopause that Affect Sexual Enjoyment

During menopause, there are certain physiological changes that can interfere with the enjoyment of
sex. Due to loss of estrogen, these symptoms include:
*
Hot flashes that can occur at any time, causing discomfort and irritability
* Night sweats that interfere with a woman's sleep, thereby decreasing her desire for sex
* Vaginal dryness
* Loss of androgens (including testosterone) that can lower a woman's sex drive or libido

It is likewise important to note that a woman's desire for sex can be affected by other physical
changes related more to aging than to menopause. These changes may include:

* Decreased blood flow to the pelvis - ovaries no longer need as much nourishment, and the
reduced blood flow causes the vagina to become smaller and less elastic
* Walls of the vagina may become thin and tender, causing intercourse to be very painful
* Problems with urine leakage or increased urinary frequency due to weakening of pelvic muscle
support

Treatment

For both menopause-related symptoms, as well as symptoms of aging, there are steps you can take to
ensure an enjoyable sex life beyond menopause.

*
Healthy living - exercise and a healthy diet can make a difference in your overall sense of well-
being and dealing with some symptoms, like hot flashes
* Hormone Replacement Therapy - can reduce the incidences of hot flashes and night sweats, as
well as treating vaginal dryness
* Various over-the-counter and prescription medications and sex techniques (be sure to discuss
with your health care provider)
* Compensate for vaginal dryness through the use of over-the-counter water-based gel lubricants
(such as K-Y Jelly, Replens, or Astroglide) during intercourse
* Continued sexual activity can also help to prolong and maintain vaginal health

Do Seek Advice

Often, sexual problems that are easily treatable are dismissed by many women as just a part of aging.
If continued sexual fulfillment is important to you, be sure to discuss any problems you are
experiencing with your partner and your health care provider.

Many women find that sex after menopause can actually be more enjoyable and fulfilling than in
younger years. Find out what to expect and how to easily plan for some of the inevitable changes.
Menopause does not signal the end of female sexuality. In fact, many women find that intimacy is
enhanced in midlife.

Several years ago Judy Grant, a 52-year-old lawyer, realized she was no longer getting her period, her
vagina was drier than usual, and sexual arousal was taking longer. She began to worry that her sex
life would soon disappear.
She had heard that at menopause, women lose their interest in and ability to have sex. But since she
started using a little KY jelly to add lubrication and adjusted her expectations, she's found she enjoys
sex more than ever. She especially likes the extra time she and her husband spend stroking and
cuddling before they try to reach orgasm.

Like Judy, many women fear that menopause signals the end of their sexual desirability and pleasure.
This fear comes from stereotypes of the midlife and older woman as unattractive and asexual. In
addition, loss of the ability to bear children may become confused with loss of sexual desirability.
The reality is that the need for and capacity to have satisfying sexual relationships does not disappear
as a natural or irreversible part of aging in women or men. According to Paula Doress-Worters, co-
author of The New Ourselves, Growing Older and The New Our Bodies, Ourselves, "there is no reason
to think that women in midlife should necessarily have problems with sexuality."

Although menopause does bring physiologic changes that may slow down response time and affect
sexual activity in a variety of ways, 70%-80% of women do not experience a reduction in sexual
activity or satisfaction. And for those who do, there are safe, effective solutions.

How you perceive and deal with the changes can have a significant impact on your sexual health and
pleasure. Some women have a reawakening of sexual interest when they are no longer concerned
about getting pregnant and adult or older children require less time and attention. However, there is
tremendous individual variation in women's experiences.

Changes at Menopause That May Affect Sexuality

Physiologic changes at menopause can sometimes affect sexual activity and desire in some women.
Changes may occur in lubrication, the vaginal walls, arousal, orgasm, and sex drive that make sex less
comfortable and enjoyable.

Vaginal Dryness and Pain During Intercourse

The most common problem is vaginal dryness, although only about 20% of women experience it. The
vaginal walls may also become thinner and less flexible. Itching, burning, and occasional pain and
bleeding may occur during intercourse.

Over-the-counter water-based lubricants, such as Astroglide and KY jelly, can help with vaginal
dryness. Do not use petroleum-based lubricants such as Vaseline. They weaken the latex in condoms
and can cause vaginal infections. Vitamin E or moisturizers such as Replens can also help if used
regularly.

If lubricants and moisturizers are not sufficient, vaginal estrogen cream, rings, or tablets are generally
helpful.

Stimulation and Orgasm

Some women have fewer and less intense orgasms when they reach menopause. It may take more
time and stimulation to become aroused. For all women, having intercourse or masturbating regularly
can help increase sexual responsiveness and pleasure. They keep the muscles supporting the uterus,
vagina, and bladder in shape and increase lubrication. Kegel exercises, contractions of the pelvic
muscle near the vagina, can also help strengthen the vaginal muscles.

Sexual Desire

Loss of interest in sex, temporary or long-term, occurs in some women during and after menopause.
Possible causes include the following:

* Fatigue
* Stress
* Illness
* Relationship problems
* Psychological issues
* Medication side effects
* Hormonal changes
* Discomfort from the physical changes of menopause

Relationship problems tend to be the cause of decreased sexual desire only when there have been
ongoing difficulties in the relationship. These difficulties may be exacerbated by changes at
menopause. If this is the case, consider seeing a therapist who specializes in sexuality.

If the problem is hormonal, estrogen may help. However, its effect is generally on the physical
changes, such as vaginal dryness and pain during intercourse. No direct relationship has yet been
found between estrogen levels and desire to have sex.

One study in particular published in the journal Menopause in September/October 2000, found no
direct relationship between declining estrogen levels and desire to have sex. Rather, the researchers
found that hormonal levels, health, and social changes associated with aging, and the mental and
emotional effects of being recently menopausal probably work together to create changes in a
woman's sexual desire. Longer-term studies are needed to determine whether reduced estrogen
production affects a woman's sexual functioning as she gets farther from menopause.

A natural decrease in testosterone at menopause might play a role in sexual desire, although this
remains unproven. Testosterone is available in pills, injections, and creams, but side effects are a
major concern.

Increased Intimacy

The changes that take place in midlife can provide an opportunity to explore new and different sexual
experiences. Men also go through changes, such as needing more time and stimulation to become
aroused. The slower, more sensuous foreplay that often results is a welcome change for some women.

Increased focus on sensuality, intimacy, and communication can help a sexual relationship become
more rewarding than ever. There are many ways of expressing your love besides intercourse:

* Hugging, cuddling, kissing


* Touching, stroking, massage, sensual baths
* Manual stimulation
* Oral sex

Sexual relationships after menopause can indeed be satisfying if you are able to adapt to the changes
that occur.

A Note About Birth Control and Safe Sex

When you are having intercourse you need to continue using birth control until you have not had a
period for 12 months in a row. However, protection against sexually transmitted diseases, including
HIV/AIDS, remains a concern. Unless you are in a long-standing monogamous relationship, be sure to
use a male latex condom or female condom, and preferably with the spermicide nonoxynol-9.

RESOURCES:

National Institute on Aging


http://www.nih.gov/nia

The North American Menopause Society (NAMS)


http://www.menopause.org
It's possible to restore post-menopausal sex drive, but do women want to?

The Orange County Register


Apr. 9, 2004 08:00 PM
Women treat it like a dirty little secret. A "condition" they whisper to their physician, convinced they
are unusual, strange, dysfunctional.

They say they don't like sex anymore. They say they've lost interest since menopause.

Or maybe their husbands or partners can't perform because of prostate surgery or blood pressure
medication, and (is it possible?) they're relieved. Glad to have sex out of their lives.
So much for post-menopausal zest.

"Low desire is the most common complaint older women present at our clinic," says Dr. Jennifer
Berman, co-director of the Female Sexual Medicine Center at UCLA.

This, says the doctor, is a problem that can be solved. Women willing to talk about it can find a
solution, she believes.

She's not alone in assuming the embers are there, ready to flame if they're fanned.

Physicians, pharmaceutical companies and mainstream media are discovering that women's sexual
dysfunction at midlife is a hot topic. Drugstore shelves are filling up with herbal remedies designed to
spark love interest. A "female Viagra" is being developed. Clinics, such as the one at UCLA and
another planned at the University of California, Irvine, cater to the sexual changes of post-
reproductive women.

The problem is obvious. The solutions, if there are any, are not.

There are physical causes, such as hormonal imbalances and medications affecting sex drive and
stifling sexual urges, Berman says. Appropriate treatments, such as hormone replacements and other
medications, can make a difference, she says.

There are psychological causes such as cellulite-dimpled derrieres, age spots and wrinkles creating
self-image concerns, counselors say. Women who don't feel sexy don't act sexy or respond to sexual
overtures, they say. Therapists stress counseling to help women focus on their attractions, including
the experience that comes with age.

There are natural reasons, such as evolution to grandmotherhood, researchers say. Viagra-
emboldened senior studs are not "natural," they point out.

The truth is, no one has a magic pill for any of the causes.

While health professionals are trying to make sense of how and why sexual dysfunction occurs in
midlife, they're proposing some solutions.

Getting down to the basics If sexual desire lessens, a good physical examination is the first step,
according to Dr. Robert Butler, 76, and his wife, Myrna Lewis, 64, who co-authored the classic study
"Love and Sex After 60" in 1976. The book was updated last year. Butler is founder of the
International Longevity Center in New York.

Exercise and a healthy lifestyle are two ways to prolong sexual activity, Butler says.

Counseling women on relationships also is primary, Lewis says. She finds that many women who
complain of lack of arousal are locked in a sexual relationship that isn't working for a number of
reasons, from boredom to physical disabilities such as prostate surgery.

Lewis says many couples she counsels benefit from a growing maturity in their relationships. There is
a familiarity, an understanding of arousal techniques that come with time.

For women at any age, sex is all in the mind, says Newport Beach, Va.-based psychologist Pat Allen.
"She's got to feel good about it, got to have the right attitude," she says.

Having sex with a longtime partner can get boring, she says, if he stops paying attention to her turn-
ons.

And she suggests it's up to the women to change the atmosphere. Use your imagination, from sexy
underwear to stimulating videos. Whatever works.

"You've got to remember that we're the magnets, and you've got to think like a magnet," she says.
"What we forget is sex is an art form."

---

With aging and menopause, estrogen decreases, and some women experience a change in sexual
function. Estrogen decline may cause hot flashes and vaginal dryness that makes intercourse painful,
Berman says.

Low testosterone also can alter women's sexual response, she says. A drop in the male sex hormone,
which women also produce, is thought to diminish sexual interest. At this time, there are no approved
testosterone preparations for women, although clinical studies are under way, Berman says.

Berman will not say hormone replacement cures low desire, insisting there is no blanket solution for
everyone, but she adds, "There is a role for testosterone in post-menopausal women."

Not everyone agrees.

There is no good data showing testosterone really affects libido, says Dr. Vivian Dickerson, a UCI
Medical Center gynecologist and president-elect of the American College of Obstetricians and
Gynecologists.

She says there seems to be a short-term benefit for women whose testosterone drops as a result of
menopause, but no data indicating a long-term benefit.

Researchers are studying the role of testosterone in women's sex drive, but it may be causing nothing
more than the placebo effect, she says.

---

Women's sex drive is complex. It's tied to mood, body image, age, weight, "even how tired you are,"
Dickerson says. "All these things have tremendous impact on our sex drive at any age.

"Patients come to me and say, I don't want my husband to feel rejected, I don't want him to worry,
but he's not doing anything for me sexually," she says.

"What women want from sex varies but is usually more snuggling, kissing, holding."

Couples should go away for two weeks to a place where there are no children or grandchildren.

"You need plenty of time to be together," she says.

"You have to talk to each other. You have to create levels."

On level one, the couple can touch and kiss but no more.

"Once you do that, spend a day touching and kissing, you know the ground rules about what pleases
the other person. There's a freedom and communication," she says.

"I usually don't have to tell them when to go to level two."


The Butlers point out there is more to an intimate relationship than sexual intercourse.

"Outercourse" is the new psychological buzzword for intimacy without actual penetration. Touching,
holding hands, cuddling can be satisfying sexual activity for seniors when the man cannot achieve an
erection, they say.

---

Nature designed women to be more "forceful on the world stage" after menopause and naturally less
inclined to think about sex, says Dr. Leonard Shlain, author of "Sex, Time and Power: How Women's
Sexuality Shaped Human Evolution" (Viking, 2003).

Modern society short-circuits nature's plan with medicinal enhancements for sexual desire after
menopause, he says.

Shlain's controversial theory says women invented time when they recognized their natural hormonal
cycles.

They also equated menstruation with fertility, and a lack of menstruation with a natural shift away
from sexual interest.

Using various enhancements to tinker with nature "upsets the hormonal clocks originally instilled in
us," Shlain says. "This alters the course of nature."

There is a reason women stop menstruating, he says.

"By cutting off her ability to have children, nature lets women have the time and energy to help their
daughters raise children. This is a clever strategy on the part of nature," he says.

"Nature shuts us down as an act of mercy," psychologist Allen says.

"Why? Because there's no point in feeling sexual when the guys your age don't have much push. Why
do you suppose Demi Moore is with what's-his-face?" (That's Ashton Kutcher, for those who care.)

Aging women outnumber men 15 to 1, she says. "The men don't hold up, and those that do hold up
don't want a 50-year-old woman anyway, so too many women feel they have to give up sex."

A shutdown is natural, she says. "We're not supposed to be available to men because all the men are
supposed to be dead," she says.

UCI Medical Center's Dickerson points out that bodies change with menopause and that most people
are in denial about the effect of age on their sex drive. "We have to come to grips with aging," she
says.

How?

"I think we expect things to be the same with us always, but there are natural modulations of things
when time goes on.

"We can't see as well at 50 as we did at 20, yet we expect to have the same sex drive."
Enjoying Sex After Menopause: Expert Advice

How to enjoy sex after menopause


An article in the February 2004 issue of the Journal of the American Medical Association (JAMA)
contained a research study on sexual dysfunction that garnered extensive media coverage. The
findings may surprise you: 43% of women and 31% of men in the US suffer from sexual dysfunction.
Pretty large numbers. Significantly more people have sexual issues than Hollywood, fashion
magazines, and even many doctors lead us to believe.

Simply stated, sexual dysfunction is a common problem. Almost half of all American women struggle
with it. Viagra has come to the rescue of many aging men, but what about women? So far women
been left out in the cold.

However, there are some new herbal formulations that hold out the promise of improved sexual
stimulation and response for females. Many women have reported significant improvements in sexual
pleasure, both before and after menopause, with the use of these products. You could consider trying
one of these female sex stimulants to help improve your sex life.

The truth is that as women age and reach menopause, many women lose interest in sex. Their bodies
simply stop producing the same levels of sex hormones as they did when they were younger. As sex
hormone levels decline, so does desire. To make matters worse, many women develop vaginal
dryness, which can make sex painful.

At the same time, some men are losing their drive and ability to perform, so their female partners
may not even notice the drop in their own libido. But now that we know better -- and men are finding
help -- women should make an effort to get a piece of the action!

I've listed below four suggestions for increasing your sex drive, enhancing arousal, and combating
sexual problems after menopause. Give them a try and see if you notice a change for the better.

1.

Hormones: Why worry about hormones? Because scientists have begun to realize that menopause
devastates us hormonally. Women produce less and less testosterone, the "male" sex hormone, as
they age. By the age of 40, they have half as much testosterone as they did when they were 20.
Research has shown that a low testosterone level means lack of sexual desire. As if that weren't
enough, estrogen levels also decline by 80-90% during menopause. Low estrogen levels cause vaginal
dryness, which leads to painful intercourse, and diminished blood flow to the vagina, which interferes
with arousal and pleasure during sex.

This may be devastating to some women. Many doctors recommend hormone replacement
therapy (HRT) as a solution.

Taking estrogen can help rid you of all symptoms of menopause including moodiness, vaginal
dryness, and hot flashes. In addition, it may reduce the risk of cardiovascular disease, osteoporosis,
and some cancers. Testosterone therapy has been shown to enhance desire, induce feelings of well
being, and combat menopausal symptoms.
However, testosterone may produce unwanted side effects such as acne, increased risk of heart
disease and breast cancer. HRT is a serious treatment with many important factors figuring in. It
should be carefully considered with your doctor.

2.

Supplements: For many women, the real problem is not lack of sexual interest but a generally low
energy level. They work, manage the household, take care of the kids, husbands and parents, and at
the end of the day simply don't have the energy to engage in sexual activity. To give yourself an added
boost, try taking a nutritional supplement with ginseng or ginkgo. Both herbs have been taken for
hundreds of years as natural energy enhancers.

Supplements can also provide our bodies with the raw materials they need to perform better,
naturally.

For example Arginine, an amino acid that is found in nuts, meat, and dairy, enhances blood flow.
Taking a supplement with Arginine, ginseng, and ginkgo biloba can improve arousal by increasing the
flow of blood to the clitoris-vagina area during sexual activity, together with boosting energy levels.

Provestra is a herbal supplement that has proven to be specifically useful for enhancing sex drive,
libido and sexual response in women after menopause. You should consider trying this out for yourself.

3.

Diet: I have a friend who had a terrible time with menopause. She experienced huge emotional
swings, gained weight, and suffered debilitating hot flashes. After consulting an alternative medicine
doctor who advised her to eat lots of soy, she completely changed her diet. She became a vegetarian,
replaced meat with tofu and milk with soymilk, and added more fresh vegetables to her meals. Within
a few months she had lost weight, all her symptoms had disappeared, and her sex drive had improved
tremendously.

Studies show that one valuable resource for women is soy. Soybeans contain phytoestrogens, or
plant estrogens, that may help replace the estrogen that your body is naturally producing less of over
time. Japanese women, who eat a diet heavy in soy, have far lower levels of breast cancer and less
trouble with menopausal symptoms. A suggestion is to inject more soy into your diet and see what it
does for you.

In general, remember that you should eat a diet that is low in fat and high in fresh fruits and
vegetables.

4.

Physical problems: Vaginal dryness, a common problem after menopause, can be easily treated
with lubricants available at most drugstores and supermarkets. You'll need to apply the lubricant
every time you have sex. If you use condoms, avoid Vaseline or other oil-based lubricants as they
destroy the condom material. While there is a vast variety available, we specifically recommend these
special sex enhancement lubricants:

Water-based sexual lubricants


Silicone-based sexual lubricants

If you find that your vaginal walls have relaxed over time, as do many older women, there is
hope. A simple exercise, known as the Kegel exercise, can improve your muscle tone and help you to
enjoy sex more. Simply squeeze the muscles around your vagina as if you were trying to stop yourself
from urinating midstream. Contract these muscles for one minute, then release. Repeat at least 10
times, and increase the number of repetitions over time. You can do these exercises any time – while
you're working at a desk, while driving, or even when you're watching TV.
http://xnet.kp.org/permanentejournal/sum00pj/libido.html
Management of Libido Problems in Menopause
By Jeanne L. Leventhal, MD
Presented at the Conjoint Annual Meeting of the American Society for Reproductive Medicine and the
Canadian Fertility and Andrology Society 32nd Annual Postgraduate Program, Toronto, Canada,
September 25-26, 1999, and published as a course handout to participants.
Sexuality and Aging
Menopausal and postmenopausal women can experience decreases in both libido, orgasm, and
frequency of coitusmost commonly because of physiologic changes due to menopause, less commonly
due to depression or marital discord (Figure 1). The differential diagnosis in women who are seen for
sexual difficulties during the climacteric is challenging, especially when symptoms such as decline in
libido and/or persistent dyspareunia occur simultaneously with depression and marital discord.
Estrogen, with or without androgen, can ameliorate the physiologic changes of menopause affecting
sexuality. Depression can be treated with psychotherapy, with or without antidepressant drugs. Marital
discord is best treated with couples therapy. The marital difficulties can either be the cause or the
consequence of changes in sexual activity. In the latter case the marital discord resolves with the
return of regular coital activity.
The physiologic changes of menopause affecting sexual response are largely mediated by estrogen.
The most notable effect is on orgasmic response: Altered nerve function due to the hypoestrogenic
state of menopause may delay clitoral reaction time and result in slow or absent orgasmic response.
This effect, along with delayed or absent vaginal secretion, diminished orgasmic platform (ie,
decreased or absent congestion in the outer third of the vagina), and painful uterine contractions (in
some 60- to 70-year-old postmenopausal women) can further affect the sexual experience.1,2 The
psychological impact of these sexual changes is varied and can be very disturbing to women and to
their partners.
Although the ratio of dysthymia and depression is as high as 2:1 in women versus men, many of these
women are not treated for this depression and thus enter the menopausal years with untreated
depressive illness.3-5 Depression can itself cause decreased libido as well as marital problems and can
complicate any sexual problems arising from menopause. In addition, hot flushes and consequent
nonrestorative sleep can complicate all these clinical situations.
Medication and illness in the postmenopausal years can affect sexuality and can complicate existing
physiologic changes associated with menopause.6 The newer forms of antidepressant medication, ie,
selective serotonin reuptake inhibitors (SSRIs), may cause slowed or absent orgasm and can reduce or
eliminate libido in some women. Illness can decrease desire or simply make sexual activity
inadvisable, given illness-associated lack of energy or anatomic difficulties.7
In about one third of couples, male sexual dysfunction contributes to decreased frequency of coitus
(Figure 2); the remaining two thirds of couples are affected by physiologic factors of menopause
(Figure 3).8 The psychological aspects of aging are less a factor in decreased coital activity than the
physiologic effects of aging and the way couples adjust to those changes. Couples may choose to
include alternatives to genital-genital contact if the male partner is having erectile problems;
increased nonpenile stimulation may be helpful for women who have delayed response; and couples
may develop a more flexible attitude toward their sexuality.10
Sexual problems are numerous in the US population and increase with aging. The scientific literature
indicates, however, that sexual problems in elderly people are often anatomic or physiologic in
nature,11,12 whereas sexual problems in younger people tend to be more psychological and
sociocultural.13 Because of the complexity of sexual problems in postmenopausal women,
gynecologists and primary care physicians have a central role in expediting the differential diagnosis
and treatment (Figure 4).14,15
Clinical View of Sexual Functioning
Davidson16 divided sexual functioning into behavior and potency, whereas Sarrel and Whitehead8
divided sexual functioning into the desire phase, excitement phase, orgastic phases, and dyspareunia.
Both are useful ways to view sexual functioning when evaluating perimenopausal and postmenopausal
women. These classifications are shown in Table 1.9,16
Sex and Menopause: Studies on Etiology of Decreased Coitus
Sexual research on sexual functioning during the climacteric has been studied for 30 years. This
research has approached the issue from different points of view, including biologic, psychiatric,
anthropologic, and sociologic. The two main conclusions are that decreasing sexual activity in a
woman results in part from decreasing sexual functioning of her male partner and in part from
anatomic and physiologic changes associated with her menopause. The representative studies are
summarized in Table 2.17-25 The large majority of these studies found a decrease in coitus and sexual
interest of greater than 40% within a few years of the menopause.
Physiologic Changes at Menopause and Their Effect on Sexuality
Hormones affect sexual arousal through sensory perception, central as well as peripheral nerve
transmission and discharge, peripheral blood flow, and capacity to develop muscle tension.
Impairment of this mechanism can lead to diminished sexual responsiveness, dyspareunia, decreased
sexual activity, decline in sexual desire, and sexual aversion.
Decreasing estrogen affects the integrity of female reproductive tract tissues. Decreased vaginal
lubrication and atrophic vaginitis result in dyspareunia. Decreased blood flow to the reproductive
organs results in diminished vasocongestion. Progressive ischemia, thinning of the barrier layers of
skin and mucous membrane tissue, loss of subcutaneous fat, and a shrinking introitus are among
many changes which occur in the genital structures as a result of hypoestrogenemia. Extragenital
effects include loss of pelvic muscle tone, decreased intraurethral pressure, a smaller bladder, and
thinning of the mucous membrane lining of the bladder and urethra. These effects have been found to
be somewhat ameliorated by continuing sexual activity despite no estrogen replacement. Women who
were sexually active had less atrophy than those who were not.26 In general, the health of the vaginal
tissues decline in the absence of estrogen stimulation, despite sexual activity.
The physiology of the sexual response changes with prolonged hypoestrogenemia. These changes
include diminished and slowed clitoral reaction time, diminished or absent secretion by the Bartholin
glands, delayed or absent vaginal secretion, decreased vaginal length, and decreased transcervical
width as well as possible painful uterine contractions in women aged 60 years to 70 years. Lack of
estrogen decreases blood flow to the genitalia, and one study found a 50% increase in vulvar blood
flow measured ultrasonographically when estradiol treatment was initiated.27 Ovarian steroids affect
nerve cell growth, proliferation, transmission time, and rate of discharge along nerve fibers. A
hypoestrogenemic state results in altered nerve function. Possible clinical manifestations of change in
peripheral nerve function in postmenopausal women are numbness, itching, clothing intolerance,
increased 2-point discrimination threshold, paresthesia, loss of clitoral reaction sensation, and
decreased capacity for orgasm.28,29 Ovarian steroids can also affect neurotransmitters centrally,
although this topic is beyond the scope of this article.
All these changes affect desire, mainly through aversion. A postmenopausal patient's experiences of
persistent dyspareunia, postcoital bleeding, delayed or absent lubrication, and delayed or absent
orgasm affect her motivation for sexual intercourse. Pain can cause vaginismus, a conditioned
response to painful coitus. Lack of sexual relations due to physiologic change may then be further
complicated by the effect of this condition on the marital relationship. Decline in sexual relations may
cause a couple to respond or cope in ways that lead to further decline in coitus and further
deterioration of the marital relationship.
Testosterone and Libido
Androgen levels in postmenopausal women decline over time. The impact of this decline on libido
depends on the woman's inherent biologic sensitivity to testosterone, her sexual history, and many
other factors. Half of postmenopausal women continue to secrete appreciable amounts of testosterone
from their ovaries, whereas the other half of postmenopausal women have negligible ovarian
production of testosterone.30 In postmenopausal women who still secrete testosterone, testosterone
levels may be approximately 50% lower than in premenopausal, younger women.31 Postmenopausal
ovarian stromal tissue secretes testosterone but little to no androstenedione.32
The evidence that testosterone affects libido in women draws from clinical research on women who
have lost ovarian testosterone production.33,34 The best known of that research was done by Sherwin35,
who examined mood, memory, and libido before and after surgical oophorectomy in the absence of
preexisting depressive illness. With regard to testosterone and libido, Sherwin35 found that in surgically
menopausal women, women receiving estrogen-testosterone preparations reported higher levels of
sexual desire and arousal and higher frequency of sexual fantasies compared with women treated
postoperatively with estrogen alone or with placebo. Other research on replacement therapy in
postmenopausal women described use of estrogen versus estrogen-testosterone and found that libido
improved in the combined treatment group only.36-39 Evidence shows that to the degree loss of
testosterone affects libido in postmenopausal women, testosterone replacement can improve libidinal
functioning.40,41
Moreover, hormone replacement therapy itself can decrease libido through the effect of different forms
of estrogen on sex-hormone-binding globulin (SHBG).42 In this circumstance, estrogen replacement
stimulates production of SHBG and thus results in reduced levels of free estradiol and free
testosterone. These reductions can cause return of hot flushes and dyspareunia as well as decrease in
libido. The increase in SHBG can be ameliorated by prescribing a combined testosterone and estrogen
preparation, by changing to an estrogen preparation that does not stimulate SHBG as greatly, or by
prescribing testosterone along with the estrogen preparation the patient is already on.
Libido and the Psyche
Physiologic problems must always be treated despite presence of psychiatric illness, because these
two factors can have an indistinguishably intertwined impact on libido and coital activity. Dyspareunia-
related decrease in frequency of coitus can be the primary cause of marital problems and can present
as a marital problem when in fact physiologic problems of menopause are the cause of the change in
libido. Lack of libido due to low testosterone levels can induce the same type of marital conflict, a
circumstance that can in turn mislead physicians into diagnosing a psychological problem as the cause
of the lack of libido.
For depression or anxiety disorders to be the cause of decrease in libido, onset of the psychiatric
illness must be established and correlated with the onset of sexual symptoms. Depression and anxiety
in women may directly affect libido and sexual response through loss of desire and also may affect the
woman's sexual partner in that he stops initiating sexual relations. Libido can be affected by marital
stress as well as by accumulated anger between the couple. Both these factors should be taken into
account when evaluating decrease in libido.13 However, the chronicity of the coital problem and of the
libidinal problem is a critical aspect of determining the cause of decreasing libido and frequency of
coitus.
For depression or anxiety disorders to be the cause of decrease in libido, onset of the psychiatric
illness must be established and correlated with the onset of sexual symptoms. Many perimenopausal
and postmenopausal women have untreated dysthymia, a new episode of depression, or an untreated
anxiety disorder. Because of the high prevalence of these untreated psychiatric illnesses, the likelihood
of psychiatric comorbidity in postmenopausal women is high.43
Many types of medication used to treat psychiatric illness can lead to a decrease in libido or orgasm.
This issue will be reviewed in another article on the newer forms of antidepressant medication.
Because prevalence of depression and anxiety disorders is higher in women than in men and often
remains untreated, the probability of a comorbid psychiatric disorder developing in midlife patients is
high. Consequently, evaluation for problems of libido requires in-depth evaluation for depression and
anxiety as well as for marital discord.
Psychological barriers to continued sexual functioning can also exist. Women who did not find sex
pleasurable before menopause may look forward to ceasing sexual activity after menopause. Women
with problems in their marital relationships may have resentment toward their spouses, and
menopause may give these women permission to decline sex. Some women were raised to believe
that sexual relations end at a certain age, and altered body image due to atrophic changes can impact
libido. Consideration of these factors is necessary for understanding libido and the psyche.44 For
marital problems to be the cause of decrease in libido, the marital problems must precede the
decrease in libido and must be somewhat long-standing.
Cultural Issues
Cultural issues too can affect a woman's view of herself and thus can affect her psyche as well as her
libido. Societal attitudes toward sex in midlife affect behavior.12 A woman's value as a sexual person
increases or decreases postmenopausally according to the society in which she lives.12 In a Nigerian
study, most of the older women became sexually abstinent.21 In contrast, older women in almost 25%
of primitive societies were seen as less inhibited, became more sexually active, and were more
attractive to young men. Thus, societal context can substantially affect women's libido.21
Previous sexual functioning has also proved to be a predictor of future sexual functioning. Koster and
Garde45 examined sexual wellness in Danish women aged 40, 45, and 51 years by in-person interview
and by questionnaire and found that current frequency of sexual desire was highly correlated with
former sexual activity. An additional finding was that anticipation of declining desire predicted decline
in desire.
Sexual scripts may require people to adapt to the challenges of aging. Geriatric problems with health,
pulmonary function, cardiovascular function, and mobility may all affect a woman's ability to have
sexual relations.7 Degree of comfort with alternative modes of sexual interaction may also affect her
ability to have continued sexual relations.46
Summary
Coital and libidinal change can be singularly caused by anatomic and physiologic change associated
with the climactericby psychiatric illness, by marital discord, or by a combination of all these factors.
The ideal treatment for women in midlife is complete evaluation of the factors affecting sexuality and
use of a combined treatment approach to ameliorate these factors. Use of such an individualized
approach can enable the women in midlife to continue to have a satisfying sexual life, should they
choose to do so.
References
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Med 1991 Feb;7(1):41-61.
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31S-35S.
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Maturitas 1982 Apr;4(1):27-32.
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levels in perimenopausal women. Arch Sex Behav 1985 Oct;14(5):385-94.
20. McCoy NL, Davidson JM. A longitudinal study of the effects of menopause on sexuality. Maturitas
1985 Sep;7(3):203-10.
21. Bajulaiye O, Sarrel PM. A survey of perimenopausal symptoms in Nigeria. In: Notelovitz M, van
Keep PA, editors: The climacteric in perspective. Proceedings of the Fourth International Congress on
the Menopause, held at Lake Buena Vista, Florida, October 28-November 2, 1984. Lancaster, Boston:
MTP Press Limited; 1986. p. 161-75.
22. Hällström T. Mental disorder and sexuality in the climacteric: a study in psychiatric epidemiology.
Goteborg: Esselte studium; 1973. [Reports from the Psychiatric Research Centre, St. Jörgen's
Hospital; 6. Scandinavian University Books]
23. Keep PA van, Kellerhals JM. The impact of socio-cultural factors on symptom formation. Some
results of a study on ageing women in Switzerland. Psychother Psychosom 1974;23(1-6):251-63.
24. Hällström T. Sexuality in the climacteric. Clin Obstet Gynaecol 1977 Apr;4(1):227-39.
25. Hällström T, Samuelsson S. Changes in women's sexual desire in middle life: the longitudinal study
of women in Gothenburg. Arch Sex Behav 1990 Jun;19(3):259-68.
26. Masters WH, Johnson VE. Human sexual response. Boston: Little, Brown; 1966.
27. Sarrel PM. Progestogens and blood flow. In: Proceedings of the Consensus Development
Conference on Progestogens, Naples, 1988. Int Proc J 1989;1(101):226-71.
28. Rauramo L. Estrogens and psychic function. In: van Keep PA, Lauritzen C, editors. Ageing and
estrogens; workshop conference in Geneva, October 5-6, 1972. Sponsored by the International Health
Foundation, Geneva. Basel, New York: Karger 1973. [Frontiers of human research, v. 2]
29. Sarrel L, Sarrel P. Sexual turning points: the seven stages of adult sexuality. New York: MacMillan;
1984.
30. Lucisano A, Acampora MG, Russo N, Maniccia E, Montemurro A, Dell'Acqua S. Ovarian and
peripheral plasma levels of progestogens, androgens and oestrogens in postmenopausal women.
Maturitas 1984 Jul;6(1):45-53.
31. Botella-Llusia J, Orio-Bosch A, Sanchez-Garrido F, Tresquerres JAF. Testosterone and 17 beta-
oestradiol secretion of the human ovary. II. Normal postmenopausal women, postmenopausal women
with endometrial hyperplasia and postmenopausal women with adenocarcinoma of the endometrium.
Maturitas 1997 Jan;2(1);7-12.
32. Longcope C, Hunter R, Franz C. Steroid secretion by the postmenopausal ovary. Am J Obstet
Gynecol 1980;138:564-8.
33. Plouffe L Jr, Cohen DP. The role of androgens in menopausal hormone replacement therapy. In:
Lorrain J, Plouffe L Jr, Ravnikar V, Speroff L, Watts N, editors. Comprehensive management of
menopause. New York: Springer-Verlag; 1994. p. 297-308. [Clinical perspectives in obstetrics and
gynecology]
34. Sherwin BB. Impact of progestins on mood and cognition in women [abstract]. Presented at the:
North American Menopause Society, Chicago, IL, September 26-28, 1996.
35. Sherwin B. Changes in sexual behavior as a function of plasma sex steroid levels in post-
menopausal women. Maturitas 1985 Sep;7(3):225-33.
36. Cardozo L, Gibb DM, Tuck SM, Thom MH, Studd JW, Cooper DJ. The effects of subcutaneous
hormone implants during climacteric. Maturitas 1984 Mar;5(3):177-84.
37. Cardozo L, Gibb DM, Studd JW, Tuck SM, Thorn MH, Cooper DJ. The use of hormone implants for
climacteric symptoms. Am J Obstet Gynecol 1984 Feb 1;148(3):336-7.
38. Burger HG, Hailes J, Menelaus M, Nelson J, Hudson B, Balazs N. The management of persistent
menopausal symptoms with oestradiol-testosterone implants: clinical, lipid and hormonal results.
Maturitas 1984 Dec;6(4):351-8.
39. Burger H, Hailes J, Nelson J, Menelaus M. Effect of combined implants of oestradiol and
testosterone on libido in postmenopausal women. Br Med J (Clin Res Ed) 1987 Apr 11;294(6577):936-
7.
40. Graziottin A. Loss of libido in the postmenopause. Menopausal Med 2000 Spring;8(1):9-12.
41. Davis SR. Androgen treatment in women. Med J Aust 1999 Jun 7;170(11):545-9.
42. Nachtigall LE, Raju U, Banerjee S, Wan L, Levitz M. Serum estradiol-binding profiles in
postmenopausal women undergoing three common estrogen replacement therapies: associations with
sex hormone-binding globulin, estradiol, and estrone levels. Menopause 2000 Jul-Aug;7(4):243-50.
43. In: Jensvold MF, Halbreich U, Hamilton JA, editors. Psychopharmacology and women: sex, gender,
and hormones. Washington DC: American Psychiatric Press; 1996.
44. Barbach L. Sexuality through menopause and beyond. Menopause Manage 1996 Nov-Dec;5(5):18-
21. [Originally published in: The pause: positive approaches to menopause by Lonnie Barbach.
Copyright © Lonnie Barbach, 1993. Dutton Signet/Penguin Books.]
45. Koster A, Garde K. Sexual desire and menopausal development. A prospective study of Danish
women born in 1936. Maturitas 1993 Jan;16(1):49-60.
46. Bachmann GA. Sexual issues at menopause. Ann N Y Acad Sci 1990;592::87-94; discussion 123-
33.
www.menopause-remedy.org

Menopause: Male Fretting


by Dr Robert Gamble
www.glycoshare.com

Posted Mar 30th 2007,


Read 105 times since then.
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(Go ahead; try saying it, “Fi-to-ster-ols”)
Menopause (definition): The almost inevitable fretting by husbands whereby they first anticipate (sometimes in sheer terror), the
looming specter of being “outside the affections of the marital bedroom” looking in…
Let’s concede the obvious. Menopause affects desire…and it can affect marriage.
That concern is as old as civilization. Even Roman husbands dreaded the onset of this problem associated with menopause. What
was it they said?
“Hic astabo tantisper hac forma et factis frustra?”
(Rough translation: “Am I to stand idle and unnoticed, so handsome and so heroic, all for nothing?”). Menopause does evoke
theatrics in men at times.
Of course, menopause is really a condition which develops in women usually between the ages of 45- 50. Menopause occurs
when an imbalance between estrogen and progesterone causes symptoms such as:
· the uncomfortable hot flashes,
· vaginal dryness,
· osteoporosis (reduction in bone density),
· loss of drive, and
· Fibrocystic growths.
There’s certainly much more to menopause than that of marital relations between spouses. Incidentally, the loss of drive occurs in
menopause when the hypothalamus (an endocrine gland) lessens marital desire due to reduction in the production of
progesterone.
Menopause: normal or abnormal condition?
Progesterone deficiency simply doesn’t exist in many cultures around the world. As a result, menopause is practically unknown
among such people. Why? The diets in those cultures are rich in certain nutrients found in fresh vegetables and legumes.
Those nutrients are called natural Phytosterols. Foods which are rich with such natural Phytosterols keep the body’s progesterone
capacity at the necessary levels. Menopause doesn’t develop in these women. They show no symptoms of menopause. They do
have strong marital desire, strong bones, no hot flashes…forcing the men to fret about other things besides menopause.
Progestins and Menopause
Of course, when we have a medical problem, it seems we immediately turn to some sort of drug to “fix it.” Progestins are
substances which are made to act like progesterone. So… voila! The problems of menopause are expected to disappear.
Anyone with a prescription of progestins to help them with the symptoms of menopause knows that “it just ain’t so.” Progestins
do not provide all of the same effects as progesterone and there is a substantial body of research concerned with their side effects.
Yes, some relief from menopause may take place but the side effects can be considerable.
I know, I know. “Nulla tam bona est fortuna de qua nihil possis queri.” (“No luck is that good that you can’t find something to
complain about.”).
Well, if you are looking for relief from menopause and tempted to take prescriptions, consider the side effects of progestins:
Acne Jaundice Depression Insomnia Nausea Tenderness Fluid retention Bleeding
Menopause and DHEA
Because the “mother hormone” – DHEA (dehydroepiandrosterone) – is used by our bodies to produce as many as 50 other
hormones, many use it to help regulate the estrogen – progesterone imbalance and to maintain good health.
Again, we have a problem like menopause, so we jump at the chance for a prescription. But, synthetic DHEA can result in liver
damage. On the other hand, almost all of the degenerative diseases out there, are accompanied by low DHEA levels. Synthetic
DHEA supplementation creates an imbalance with substances produced by our body, such as cortisol.
That imbalance creates further problems- such as low energy, Thyroid dysfunction, decreased immune function (see immune
system at http://www.glycoshare.com/), compromised sleeping habits, Muscular dysfunction and many other issues and
complications.
Wouldn’t it be better to simply take foods –or natural supplements – which contain Phytosterols to deal with menopause?
Menopause can be prevented or mitigated by the progesterone produced from natural Phytosterols. Why go to drugs for relief?
DHEA can be regulated by the progesterone produced by Phytosterols. Why, I say, do we run for drugs as our only choice?
Incidentally, Phytosterols can aid in other conditions besides relief of menopause and its symptoms:
1. Fat loss (Are you beginning to understand why dieting often doesn’t work?)
2. Bre*astCancer involves low levels of DHEA. Phytosterols help the body handle that issue and in turn, aids in combating
breastcancer. In fact, one study showed that of 5,186 women who developed breastcancer, all of them – 100%! – had a dramatic
fall in their DHEA levels up to 9 years earlier (R.D. Bulbrook, J.L. Hayward, C.C. Speir, “Relations Between Urinary Androgen
and Corticoid Eccretion and Subsequent BreastCancer.” Lancet. 2:395-398.) 1971.
3. PMS along with menopause (See my article on PMS and Phytosterols).
4. Depression
5. Diabetes (for help with diabetes see my articles “Diabetes: The $132 Billion
Dollar Pandemic” and “Diabetes: “So Far, So Good…”)
5. Stress
6. Prostate
7. Obesity
8. Arthritis
9. Many other diseases and conditions.
Phytosterols is a natural food substance which translates into hormonal action in the body. It is safe and it is almost a “menopause
prevention program” by itself…
Women need it for menopause. Persons using phytosterols don’t have to worry about side effects as they would with progestins
and synthetic DHEA.
However, as with any treatment, you should consult a health care professional, if you have concerns.
Perhaps a new “definition” for menopause can begin to emerge. Yes, let’s try that.
Menopause (New Definition): Menopause is no longer the disruption of the marital bedroom. Rather, it is replaced by the almost
inevitable glee experienced by husbands whereby they (sometimes quite “boyishly”) anticipate the constancy of your doting
attentiveness lavished upon them as they stand before you “idle and noticed, so handsome and so heroic. ”
Are you thrilled girls?
Finis
(I’m done.)
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www.merck.com
Menopause is the permanent end of menstrual periods and thus of fertility.
• For up to several years before and just after menopause, estrogen levels fluctuate widely, periods become irregular, and
symptoms (such as hot flashes) may occur.
• After menopause, bone density decreases.
• Menopause is usually obvious, but blood tests may be done to confirm it.
• Certain measures, including drugs, can lessen symptoms.
During the reproductive years, menstrual periods usually occur in approximately monthly cycles, with an egg released from the
ovary (ovulation) about 2 weeks after the first day of a period. For this cycle to occur regularly, the ovaries must produce enough
estrogen and progesterone (see Biology of the Female Reproductive System: Menstrual Cycle). Menopause occurs because, as
women age, the ovaries stop producing estrogen and progesterone. During the years before menopause, production of estrogen
and progesterone begins to decrease, and menstrual periods and ovulation occur less often. Eventually, menstrual periods and
ovulation end permanently, and pregnancy is no longer possible. A woman's last period can be identified only later, after she has
had no periods for at least 1 year. (Women who do not wish to become pregnant should use birth control until 1 year has passed
since their last menstrual period.)
A distinctive transitional period called perimenopause occurs during the years before and the 1 year after the last menstrual
period. How many years of perimenopause precede the last menstrual period varies greatly. During perimenopause, estrogen and
progesterone levels fluctuate widely. These fluctuations are thought to cause the menopausal symptoms experienced by many
women in their 40s.
In the United States, the average age for menopause is about 51. However, menopause may occur normally in women as young
as 40. Menopause is considered premature when it occurs before age 40 (see Menopause: Premature Menopause). Premature
menopause is also called premature ovarian failure.

Did You Know...


• Symptoms of menopause can start years
before menstrual periods end.
• The average age for menopause is about
51.
• Many symptoms thought to be related to
menopause—mood changes, depression,
irritability, anxiety, nervousness, insomnia,
loss of concentration, headache, and fatigue
—probably are not.

Symptoms
Perimenopause: During perimenopause, symptoms may be nonexistent, mild, moderate, or severe. Symptoms may last from 6
months to about 10 years.
Irregular menstrual periods may be the first symptom of perimenopause. Typically, periods occur more often, then less often,
but any pattern is possible. Periods may be shorter or longer, lighter or heavier. They may not occur for months, then become
regular again. In some women, periods occur regularly until menopause.
Hot flashes affect about three fourths of women and usually begin before periods stop. Most women have hot flashes for more
than 1 year, and up to one half of women have them for more than 5 years. What causes hot flashes in unknown. They may be
related to fluctuations in hormone levels and may be triggered by cigarette smoking, hot beverages, certain foods, alcohol, and
possibly caffeine. During a hot flash, blood vessels near the skin surface widen (dilate). As a result, blood flow increases, causing
the skin, especially on the head and neck, to become red and warm (flushed). Women feel warm or hot, and perspiration may be
profuse. Hot flashes are sometimes called hot flushes because of this warming effect. A hot flash lasts from 30 seconds to 5
minutes and may be followed by chills. Night sweats are hot flashes that occur at night.
Other symptoms that may occur around the time of menopause include mood changes, depression, irritability, anxiety,
nervousness, sleep disturbances (including insomnia), loss of concentration, headache, and fatigue. Many women experience
these symptoms during perimenopause and assume that menopause is the cause. However, evidence supporting a connection
between menopause and these symptoms is lacking. These symptoms are not directly related to the decreases in estrogen levels
that occur with menopause. And many other factors (such as aging itself or a disorder) could explain the symptoms.
Night sweats may disturb sleep, contributing to fatigue, irritability, loss of concentration, and mood changes. In such cases, these
symptoms may be indirectly (through night sweats) related to menopause. However, during menopause, sleep disturbances are
common even among women who do not have hot flashes. Midlife stresses (such as struggles with adolescents, concerns about
aging, caring for aging parents, and changes in marital relationship) may contribute to sleep disturbances. Thus, the relationship
between fatigue, irritability, loss of concentration, and mood changes seems less clear.
www.power-surge.com.

DEPRESSION

As many of us know, depression is a common complaint during menopause. I have spoken to hundreds
of women's health experts, physicians, medical journalists, authors, researchers who claim that
depression is "not a symptom" of peri or postmenopause. That the depression women suffer during
their menopausal years is more likely related to the aging process, or to the kids growing up and,
therefore, empty nest syndrome, or to changes in their marital relationship. I am not a doctor.
However, after having communicated with tens of thousands of women in various stages of
menopause, it would seem apparent that depression can be and is a very definite symptom of raging
hormone levels just as mood swings, anxiety and other psycholgical disorders are caused by an
imbalance of hormones.
There are numerous natural remedies for treating mild to moderate depression, such as St. John's
Wort You will find many listed on the Power Surge Recommendations page. I also suggest visiting
the Power Surge Depression forum to exchange experiences and ideas with other women suffering
from depression, whether it's menopause-related or depression that existed prior to the beginning of
perimenopause. I also highly recommend the transcripts of Stuart Shipko, M.D. -- a psychiatrist and
neurologist who has provided invaluable information about depression, anxiety, panic and the various
medications being used to treat these disorders and Psychotherapist, Dr. Lee Baer -- Dearest.
As many as 25 percent of all Americans will suffer from depression this year. And depression impairs
people's ability to function more than any other disease except heart disease. However, depression is
one of the most treatable illnesses known. Drug therapy and psychotherapy can help victims of
depression feel better, become more productive and improve their relationships.

Depression will strike up to 25 percent of all Americans this year, and many of them will fight the
disease with drugs like Prozac. One of the most widely prescribed drugs for depression, Prozac has
sales that top $1 billion annually. Prozac falls under a family of antidepressants developed in the late
1980s called the selective serotonin reuptake inhibitors (SSRIs). "SSRIs work by increasing the
availability of the neurotransmitters erotonin between the nerve cell endings in the brain. Enhancing
serotonergic neurotransmission usually results in improvement in the symptoms of depression," says
Lawrence R. Gulley, M.D., a psychiatrist affiliated with West Paces Medical Center, a Columbia affiliate
in Atlanta, Georgia. SSRIs including three relatively new drugs, Zoloft, Paxil and Effexor - help lift the
symptoms of depression quickly. Some SSRIs also help people whose depression is coupled with
anxiety.

If side effects do occur, they are usually minor. The SSRIs may make people feel "speedy" at first, and
a few people experience this feeling as a need to "get out of their skin." The drugs also may suppress
the appetite. These symptoms usually subside in several weeks. SSRIs may also lower sexual desire for
as long as the patient takes the drug.

Doctors recommend that most people should be on any antidepressant for a minimum of six months to
prevent a recurrence. In fact, although SSRIs are not addictive, many people taking them feel so much
better that they are hesitant to come off them.
34 Signs / Symptoms of Menopause
There's been a list of the "34 signs of menopause" circulating for years. The list originated with Judy
Bayliss' wonderful newsgroup, The Menopaus Listserv (That's Menopaus without the "e" at the end).
I've taken the liberty of adding my own Notes to the original list. You'll find hundreds of articles
pertaining to menopause symptoms, treatments and menopause / midlife-related health and emotional
issues including articles on midlife relationships, weight and fitness issues, intimacy, psychological
problems associated with menopause in Power Surge's, "Educate Your Body" extensive library.
I suggest you begin with the comprehensive article explaining what menopause is (by clicking this
link): in "An Introduction To Menopause: Signs, Symptoms and Treatments"
You'll find remedies for most of these symptoms on the Recommendations page.

Here is the list of: "The 34 Signs of Menopause:"


1. Hot flashes, flushes, night sweats and/or cold flashes, clammy feeling (related to increased
activity in the autonomic / sympathetic nervous system). Without becoming too, technical, messages
are sent to the hypothalmus because of declining estrogen production via neurons which result in
vasodilation -- widening of the lumen of blood vessels (lumen being the cavity of a tubular organ, i.e.,
the lumen of a blood vessel,) which, in turn, causes flushing or hot flashes. Tips for treating/minimizing
(and even avoiding) hot flashes: Power Surge's Menopause Survival Tips. Also, read the Power Surges
(hot flashes) Forum
2. Bouts of rapid heartbeat (related to increased activity in the autonomic / sympathetic nervous
system) Note: Along with rapid heartbeat (palpitations), women can experience skipped heartbeats,
irregular heartbeats. These are generally normal vasomotor responses experienced during menopause
- usually due to fluctuating hormone levels. However, if these problems continue, it's always a good
idea to be checked by your health care practitioner. An echocardiogram is a common procedure to tell
the doctor what he needs to know about your heart. If your health care practitioner doesn't suggest it,
ASK FOR IT! Read the Palpitations, Heart Issues, Hypertension Forum
3. Irritability. Note: Along with irritability, a host of "anger" problems can develop during
menopause. Just as a perimenopausal woman can find herself suddenly crying for no apparent reason
or provocation, so can she find herself reacting to given situations in an angrier manner than she
normally does. This anger can sometimes feel like "rage." Again, this is hormone-induced, but for some
women, the anger can become inappropriate and a woman can feel like she's out of control. There's
nothing wrong with seeking counselling to discuss these issues with a mental health professional. This
is a challenging time of life and some objective outside help can be tremendously useful in helping a
woman cope with all the emotions she's feeling. Remember, menopause isn't simply physical changes,
but emotional and spiritual changes as well. There's an excellent forum on the Power Surge Message
Board that deals with the issues of Anger / Mood Swings / Rage.
4. Mood swings, sudden tears. Note: Mood swings can include anything from mood shifts (happy
one moment, deprssed the next) to sudden bouts of crying when nothing overt has occurred to cause
the crying. Mood swings can and have been misdiagnosed as bipolar disorder because one can feel
such extremes of emotions due to hormone imbalance. Anxiety, depression, panic attacks and even
feelings of agoraphobia aren't uncommon during menopause. The panic attacks often can develop with
the onset of hot flashes. For some women, hot flashes can be severe and quite frightening.
5. Trouble sleeping through the night (with or without night sweats). Note: This can develop into
insomnia or just waking at 2 in the morning for an hour. Relaxation and breathing exercises can be
useful at this time -- many women may log onto the Power Surge message boards and are surprised to
find so many other women there in the middle of the night. More help on the Insomnia, Sleep
Disorders Forum
6. Irregular periods: shorter, lighter or heavier periods, flooding, and phantom periods. Note: A
phantom period is when you experience all the symptoms you're accustomed to having before you
menstruate -- but... no period comes. This is a common experience during perimenopause before a
woman's period actually stops.
7. Loss of libido (sex drive). Note: Not every woman loses her libido entirely during
perimenopause, although some may temporarily. Many women simply have a decreased interest in sex
- often it's simply because they generally don't feel well and sex is the last thing on their mind! Also,
bear in mind that there are many medications that can affect one's libido, including the anti-
depressants some women take to cope with the depression and anxiety associated with menopause to
anti-hypertensives.
8. Dry vagina (results in painful intercourse) Note: Click here for an excellent article about
vaginal dryness, sexuality and midlife relationships. Recommended: Sexual Issues/Libido Forum
9. Crashing fatigue. Note: I've never been able to determine if the "fatigue" associated with
perimenopause is a symptom in and of itself, or if it's a side effect of the cumulative symptoms and
general exhaustion (from them) many women experience. Take all the symptoms and "dump" them on
one person -- is it any wonder perimenopausal women are so fatigued? If you can, try to find time to
grab a nap. One of the things that helped my fatigue, and it's all chronicled in my personal odyssey to
find remedies, is the use of considerable amounts of soy isoflavones and protein, which I found in
Revival Soy. I can't say that it specifically targetted and relieved the crashing fatigue, but it helped so
many other symptoms and gave me a burst of energy, that I feel comfortable in attributing the fatigue
relief to Revival. There are various vitamins, such as those in the "B" family, that can help with fatigue
as well. Also, increased amounts of vitamin C. The Recommendations page lists numerous vita-
nutrients that can be useful in treating fatigue and other symptoms associated with perimenopause.
10. Anxiety, feeling ill at ease.Note: One of the biggest complaints during menopause. Read the
Anxiety/Stress Forum
11. Feelings of dread, apprehension, and doom (includes thoughts of death, picturing one's own
death). Note: It's possible that this can be a manifestation of depression associated with menopause,
or possibly feelings that come from going through daily discomfort through a difficult menopause
transition that can last anywhere from 3-12 years. A woman living under these circumstances can feel
totally overwhelmed and frightened by the physical, psychological and spiritual changes. When there
seems to be no reprieve from the suffering, for some it can leave them feeling drained wondering
when and IF they'll ever feel well again. It isn't unusual for women at this time of life to have thoughts
about dying. One phase of their life is coming to a close (not soon enough for many). There may be
apprehension and fear about moving on to the next phase of life and wondering whether things will get
better or worse. Helpful: The Panic Attacks / Disorder / Fear / Apprehension Forum
12. Difficulty concentrating, disorientation, & mental confusion. Note: Forgetfulness during
perimenopause is often referred to lightly and humorously as "brain fog" but it's not always funny.
Note: An excellent article, Menopause And The Mind. Also, visit the Memory Loss, Foggy
Thinking, Forgetfulness, Verbal Slips Forum
13. Disturbing memory lapses. Note: See #12,
14. Incontinence -- especially upon sneezing, laughing: urge incontinence (reflects a general loss of
smooth muscle tone).
15. Itchy, crawly skin (feeling of ants crawling under the skin, not just dry, itchy skin Note: the
feeling of ants crawling on your skin is called "formication") Visit the Your Skin: Dryness, Itching,
Vaginal Dryness, Disorders, Discomfort Forum
16. Aching, sore joints, muscles and tendons. (may include such problems as carpal tunnel
syndrome). Note: Osteoarthritis can develop during perimenopause - and those with existing arthritic
and/or rheumatic pain may find it's exacerbated during the menopausal transition. See the Joints
Aches and Pains/Arthrisitis Forum
17. Increased tension in muscles.
18. Breast tenderness. Note: Breast swelling, soreness, pain.
19. Headache change: increase or decrease. Note: Many women develop migraine headaches
during perimenopause. However, if one doesn't have a history of migraine headeaches, they're
generally a short-lived experience of perimenopause. Also see the Headaches, Migraine Forum
20. Gastrointestinal distress, indigestion, flatulence, gas pain, nausea. Note: For nausea, try
some ginger or, as I use, boiling hot water with a few teaspoons of lemon or lemon juice concentrate in
it. Many women also develop acid reflux (Gerd). For some, it can be an uncomfortable feeling of severe
burning sensations in the throat. If it persists, see your health care practitioner.
21. Sudden bouts of bloat. Note: Bloating, water retention are common complaints during
perimenopause. Also, Acid reflux and heartburn are very common during perimenopause. Treat them
as you would if you weren't going through menopause.
22. Depression (has a quality from other depression, the inability to cope is overwhelming, there is a
feeling of a loss of self. Natural hormone therapy, ameliorates the depression dramatically). Note:
There are various natural methods of treating depression. Read Power Surge's Menopause Survival
Tips. Also, many women using progestins or progesterone supplementation experience "depression" as
a side effect. Power Surge recommends only naturally compounded, bio-identical hormones. Naturally
compounded estrogen and progesterone supplementation doses can be individually adjusted to suit
each woman's needs. So, if a woman is experiencing depression from progesterone, the level of
progesterone supplementation can be reduced until the compounding pharmacist comes up with the
right blend. The combination of estrogen and progesterone is important in achieving the desired
results. Other remedies, such as St. John's Wort can be very effective in alleviating the depression
associated with menopause.
My personal experience was that my perimenopause-related depression was elliminated when I started
using Revival Soy Protein Revival is excellent for mood swings, but I was astonished by the impact it
had on the hormone-related "lows" I experienced before using it. Also recommended, The Depression
Forum
23. Exacerbation of any existing conditions. Note: Often, conditions women had prior to entering
perimenopause become exaggerated (worse) during the menopause transition.
24. Increase in allergies. Note: Many women who suffer from allergies develop worse allergies
during the menopausal years. Many women who've never had allergy or respiratory problems may
develop them for the first time. Many people don't realize that histamine levels are affected by
hormone levels. Women can develop wheezing, coughing and a host of respiratory problems. This
generally disappears as the hormones level out once a woman becomes menopausal.
25. Weight gain. (is often around the waist and thighs, resulting in "the disappearing waistline" and
changes in body shape.) A good read, Weight Gain and Fitness Issues
26. Hair loss or thinning, head or whole body, increase in facial hair. Note: There is often a loss of
pubic hair during menopause. Many women are more comfortable simply shaving their pubic area
instead of having patches of hair.
27. Dizziness, light-headedness, episodes of loss of balance. Note: Although common
complaints during menopause, I always recommend anyone suffering from dizziness, dysequilibrium
have her blood pressure checked just to be on the safe side. However, women can experience these
symptoms during perimenopause without having hypertension.
28. Changes in body odor. Note: I wouldn't be too concerned about this one. It can happen, but in
13 years of running Power Surge, I've heard of relatively few cases of developing body odor during
menopause.
29. Electric shock sensation under the skin & in the head ("take the feeling of a rubber band
snapping against the skin, multiply it (exponentially, sometimes) radiate it & put it in the layer of
tissues between skin & muscle & sometimes a precursor to a hot flash.") Note: Those buzzing
sensations, as though you've put your finger into a live electrical socket, can be frightening. They're all
part of the hormones, nerve endings and electrical waves running through our bodies when our
hormones are constantly fluctuating. Many women experience this during perimenopause, but it
eventually passes.
30. Tingling in the extremities (can also be a symptom of B-12 deficiency, diabetes, or from an
alteration in the flexibility of blood vessels in the extremities.)
31. Gum problems, increased bleeding.
32. Burning tongue
33. Osteoporosis (after several years)
34. Brittle fingernails, which peel & break easily.
Some additional signs from Dearest:
• Dry skin / skin changes
• Internal shaking / tremor-like feelings. Read the Internal Shaking Forum
• Acne and other skin eruptions
• Itching wildly and erratic rashes
• Shoulder pain / joints / arthritis development or flare up in preexisting conditions
• "Heart pain" - a feeling of pain in the area of the heart (if persistent, get checked by
your health care practitioner)
• Acid reflux / heartburn / difficulty digesting certain foods
Some of the 34 signs may also be symptoms of one of the following:
• Hypothyroidism
• Diabetes
• Depression with another etiology

Power Surge Treatments


And Recommendations
Midlife is a time of awakening, but not always a gentle one! By the time most women are 40-something (give
or take a few years), they find themselves being introduced to an unfamiliar body, one many of them describe
as "betraying them." As the transitional years progress, they will become more familiar with that body than
ever before in their lives. The idea is to make it work for, not against, you.
In order to alleviate the symptoms of menopause, women need to become more educated about the options
available for treating their symptoms. Many of the popular multi-vitamins, with their minimum daily requirements,
sufficed when women were younger, but as we age, women (and men) need more than the minimum doses of
vitamins, minerals, anti-oxidants and amino acids. I was shocked to see that one of the most widely advertised
formulas for women to "solve all your menopause problems with one tablet per day" -- Estroven -- contains only 30
IU's (int'l units) of vitamin E, and only 150 mg. calcium. Even their extra-strength formula contains 30 IU's of vitamin E
per day and 200 mg. of calcium. It's a known fact that in order to keep their bones strong, perimenopausal women
require 1250 mg. of calcium per day - postmenopausal women -- 1500 mg. daily. Menopausal women are advised to
take 600 - 800 IU's of vitamin E daily (Power Surge recommends taking 'E' in 3 doses of 200 IU's each). Read more
about vitamin E below. In addition, any formula or multi-vitamin not containing at least 400 mcg. of folic acid (folate)
is not what you want to be taking. Folic acid is essential for heart health. If you are taking one of these multiple
vitamins, it would be wise to take supplements of the essential vitamins for women in menopause.
The vita-nutrients listed here are for your reference. Not everything here needs to be taken as a separate
supplement. Many are included, and in very substantial doses, in the Active Women's Multi-vitamin, the most
comprehensive multi-vitamin I've ever seen for women -- containing far more of what midlife, peri and
postmenopausal women need than products such as Estroven.
The purpose of these recommendations is to provide remedies for peri and postmenopause. Power Surge
recommends using only products that meet the highest standards of quality. The vitamins, minerals and herbs
recommended here are by manufacturers whose products meet those standards. Only you can determine what you
need to treat your specific issues. All of the vita-nutrients, vitamins, minerals, herbs, et al, listed here have been hand-
selected for women in menopause and can be obtained via:
• Bellevue Pharmacy, co-owned by Pharmaceutical Consultant, Pete Hueseman, R.Ph, PD, Power Surge's
Ask The Pharmacist for 13 years.
• Physician's Labs, Medical Director, Aaron Tabor, M.D., Founder of Revival Soy Protein. Dr. Tabor has for
10 years been Power Surge's, Ask The Soy Expert.
Educate yourself. Read as much as you can before using anything, even aspirin. Try as much as you can until you
find the right "mix!" If you're using any prescription or even OTC (over the counter) medication(s), before adding
herbs and even certain vitamins, it's important to check with your healthcare professional to be sure there are no
contraindications. Remember, just because something says "natural," that doesn't mean it can't cause toxicity and
other health issues. Also, if you're adding new herbs, try smaller doses at first to see how you react. Some people
have adverse reactions to certain herbs. If you're taking any medication, be sure to check with your health care
practitioner because certain herbs should not be taken with certain medication. There are references below for
various herbs and medications.
Finally, remember that just because a certain dose of something, even as natural as a vitamin, works great, MORE is
NOT always BETTER. In fact, MORE can often be downright dangerous!
Please read the Power Surge disclaimer.

Doctor-Formulated Revival® Soy Protein® (one shake or bar per day): The importance of soy isoflavones as a
natural food supplement to menopausal women's diets cannot be stressed enough. I've used soy for 25 years in
various modalities. Revival was developed by mainstream medical doctors and is the #1 doctor-recommended soy
isoflavone product for peri and postmenopausal women who can't or don't choose to take hormones. It is a powerful
natural food supplement, made from the heart of the whole soybean where the highest concentration of isoflavones
are found. It is made from Non-GMO soybeans (non-genetically modified - while over 90% of the soy products on the
market are made from genetically modified soybeans), that eliminates hot flashes, night sweats, mood swings, vaginal
dryness, fatigue, and many other uncomfortable symptoms associated with PMS, perimenopause and
postmenopause. It also provides heart and bone protection, lowers cholesterol levels and provides breast cancer
protection.
Studies have shown that it's the combination of the soy protein and large doses of isoflavones that are most effective
in reducing menopausal symptoms and providing heart and bone health. Most of us aren't likely to eat one pound of
tofu or drink SIX of most soy shakes on the market if we can get the same amount of isoflavones in one serving of
Revival®. Most people don't eat raw tofu. However, once you cook it, according to the National Food Review Board,
cooking destroys 93% of the phytochemicals / nutrients. Read more about my, and thousand of other
womens', experiences with Revival.

Bioidentical, Naturally Compounded Hormones -- If you are currently on or considering the use of Hormone
Replacement Therapy (HRT) and, especially after the Women's Health Initiative Study (WHI) showed that synthetic
estrogen and progestins are more a risk than a benefit, you might want to look into naturally compounded, plant-
derived, bioidentical hormones -- just like those produced by your own body. Compounding is preparing medicines
tailored to patients’ individual needs. Compounding is the preparation, mixing, assembling, packaging, or labeling of a
drug as the result of a practitioner’s prescription drug order based on the pharmacist-patient-prescriber relationship.
Compounding offers patients their choice of drug, strength, dosage form, excipients, or lack of and can be decided on
a case-by-case basis. This process allows for medical treatments that otherwise might not be possible. With an
individualized approach to bioidentical hormone therapy, you can know exactly what your hormone levels are,
compare the benefits vs. risks of all possible therapies, and choose the ideal replacement protocol to bring your
hormones back to their proper balance. If your doctor is willing to prescribe conventional HRT, s/he should be more
than willing to prescribe natural, bioidentical hormones. Read about Your Hormones. There are transcripts in the
Library with doctors, medical journalists, women's health experts and pharmacists who recommend only natural, bio
identical hormones. Read the transcript(s) of Pete Hueseman, R.Ph., P.D. You can ask individual questions of our
natural hormone expert, Pete Hueseman, R.Ph., P.D. / Ask The Pharmacists. Additional contact info is provided on
the Resources page.

Conventional Hormone Replacement Therapy (HRT): For information about the more commercial brands of HRT,
Power Surge has provided a list of the most commonly used commercial brands and doses of HRT. Power
Surge has never endorsed the use of synthetic hormones.
PRO-GEST® BODY CREAM by Emerita): An OTC (over the counter) transdermal natural progesterone
cream (2 oz.). Read instructions for application. Just as menopausal women's bodies lose estrogen, they also lose
progesterone. Should you or your healthcare practitioner feel you may benefit from a stronger dose of natural
progesterone cream, you can discuss your hormone issues with Pete Hueseman, R.Ph, R.D., formerly with College
Pharmacy, is co-owner of Bellevue Pharmacy. Pete compounds natural, bio-identical hormones. Natural
progesterone is touted as a remedy for menopausal issues, such as hot flashes, insomnia, anxiety, vaginal dryness,
bones, thinning hair, et al. Some women experience adverse side effects, such as depression, irritability and/or
anxiety while using natural progesterone (in any modality), but as with everything else, playing with doses may
erradicate those side effects. In addition, OTC natural progesterone creams, although they may eliminate the early
symptoms associated with perimenopause, once a woman's estrogen levels decline, they find they need to add
supplemental natural estogen. The transcripts of Pete Hueseman, R.Ph.,P.D. and Dr. John Lee, provide useful
information about natural progesterone.

NATURAL PHYTOESTROGEN CREAM by PROGEST® (Emerita): An OTC (over the counter) transdermal
natural phytoestrogen cream (2 oz.). Phytoestrogens are nature's answer to balancing the female system. Plant
compounds that are structurally similar to estrogen, phytoestrogens can help balance the powerful and sometimes
harmful effects of too much or too little estrogen. Available in an easy-to-use cream, our Phytoestrogen Cream works
with the natural rhythms of your body. Progest/Emerita natural phytoestrogen cream contains Dong Quai (Angelica
sinensis), Licorice (Glycyrrhiza glabra), Chaste Tree Berry (Vitex agnus-castus), Black Cohosh (Cimicifuga
racemosa) and Red Clover (Trifolium pratense). These phytoestrogen-containing herbs are combined with other
natural ingredients:
• Aloe Vera Gel: for its healing and soothing properties.
• Ginseng (Panax ginseng): shown to help alleviate dry skin and reduce wrinkles.
• Vitamin E (Tocopheryl Acetate): a natural antioxidant, known for its moisturizing and absorption enhancing
properties.
• Black Walnut Leaf: a natural anti-microbial agent.
• Jojoba: used for its moisturizing properties.
• Evening Primrose Oil: long used for its healing and soothing properties.
Emerita® Phytoestrogen Body Cream contains no estrogen, mineral oil, petroleum or animal products and has not
been tested on animals. Read more about phytoestrogens here.
If you have any questions about Natural Phytoestrogen Cream, Ask Power Surge's Consulting Pharmacist, Pete
Hueseman, R.Ph, R.D.

Alura™ - For Building Intimacy: Sexual desire and response are frequently diminished during
perimenopause due to the fluctuation and decline of hormones, but one's intimate relationships can be enhanced with
various remedies. According to JAMA, the Journal of the American Medical Association, more than 40% of American
women experience some sort of sexual dissatisfaction and sexual issues frequently become more apparent when
perimenopause sets in. For more information about obtaining Alura™, E.mail one of our consulting pharmacists,
Bellevue Pharmacy. In May, 2001, Oprah's Magazine, "O", touted ALURA™ as a pleasure-heightening, sensation-
enhancing cream. Read more about Midlife Sexuality and Relationships.

Zestra® - For Increasing Female Sexual Arousal: Zestra® is widely recognized by Women's Health
Professionals as the "Scientific Gold Standard" for increasing female sexual arousal, pleasure and satisfaction.
Zestra® is a patented blend of two botanical oils and two botanical extracts specifically designed to increase female
sexual sensation, arousal, pleasure, and satisfaction when topically applied to the female genitalia. The all-natural
ingredients naturally stimulate the body's own sensory nerve conduction, heightening sexual sensation and pleasure.
For more information about obtaining Zestra®, E.mail one of our consulting pharmacists at Bellevue Pharmacy.
Read more about Midlife Sexuality and Relationships.

Active Women's Multi Tab (90 tablets):


Also available in bottles of 180 tablets.
In Power Surge's 15th year online, I've always been searching for the "perfect" multi-vitamin suitable for the needs of
peri and postmenopausal women. Power Surge's favorite multi-vitamin, which I call the kitchen sink because it
contains excellent doses of not only the most important vita-nutrients midlife women need, but anti-oxidants, minerals
and herbs helpful to women in peri or postmenopause. The Active Women's Multi also contains effective doses of
some of the most useful herbs for menopausal symptoms.
Some of the ingredients: Folic Acid, 800 mcg., B-6, 125 mg., 400 mg. calcium plus the 400 IU of Vitamin D required
to help calcium be absorbed by the body, 400 mg. magnesium and 200 mcg. selenium, boron, biotin, inositol (a
natural emulsifier Power Surge has recommended for years which is excellent for lowering cholesterol), choline, GLA
(gamma linolenic acid), camomille, chasteberry, black cohosh, dong quai and numerous vita-nutrients NOT found in
even the most well known multi-vitamins. There's no added sugar, salt, yeast, wheat, corn, preservatives, artificial
colors or flavors. See all the ingredients for yourself!

Aspirin: One aspirin tablet per day (325 mg., 1/2 a regular adult dose) as a natural anti-coagulant. Antiplatelet
therapy reduces the risk of any serious vascular event by about one quarter; risk of non-fatal heart attack by one
third, non-fatal stroke by one quarter, and vascular death by one sixth. If heart attack (or stroke) symptoms occur,
take one aspirin immediately as its anti-coagulant effects can mean the difference between life and death.

Folate/Folic Acid (400-800 mcg. per day): The supplement folate has a much stronger and more
associations with depression and mental disorders. Numerous studies have found a correlation between low folate
levels and higher rates of depression (although most data is from European/caucasion populations). There are even
studies tying folate deficiency treatment to the lifting of depression, increasing serotonin levels, and the effectiveness
of drugs like Prozac. Important for heart health. You can take folic acid separately, or you can get 800 mcg. in the
Active Women's Multi

Flaxseed / Linseed (organically grown): I've been using Bob's Red Mill Flaxseed for years (which I grind in a
coffee grinder), but you can also buy it as ground Flaxseed Meal.
Flax is good for your heart, for maintaining healthy cholesterol and triglyceride levels, one of the "good fats" our
bodies need, has anti-carcinogenic properties to protect us from various forms of cancer. It has so many good effects
on our body which is why I include flaxseed near the the top of my list because I believe it to be one of the singularly
most important things everyone should use daily. Flaxseeds contain lignans which are anti-viral, anti-fungal, anti-
bacterial and anti-cancer. Only 2% of the lignans found in flaxseeds ends up in flax oil. Flaxseed contains
phytoestrogens and lignans which are essential plant estrogens. Phytoestrogens are different from estrogens
because phytoestrogens do not stimulate the growth of cancerous cells and they help prevent breast cancer.
Phytoestrogens also relieve some of the minor symptoms such as hot flashes, anxiety and irritability. Flaxseed is an
excellent source of fiber and especially Omega 3 Fatty Acids. A 2 tablespoon serving provides 2400 mg of Omega 3.

Flax Oil Softgels: You can also use Flax Oil or Linseed oil as a substitute. It must be cold pressed-unrefined,
contain 1000 mg. organic virgin flaxseed oil (rich source of phytoestrogens); linolenic acid (omega 3); oleic acid
(omega 9); linoleic acid (omega 6) - very rich in omega 3 essential fatty acids (fish oils). Essential fatty acids must be
taken in the diet as the body can not make them. Flax seed oil is rich in ( GLA ) gamma. Linolenic acid used by many
for PMS and breast tenderness. You can also use ground flaxseed or flaxseed meal added to your food to provide the
same results. For years, I have been using 1-2 heaping tbsp. of flaxseed every day.

Max EPA, Omega-3 fish oil, 1000 mg: Max EPA is extracted from fish body oils at low temperature without
the use of harsh solvents. DHA and EPA are important omega-3 fatty acids.

Vitamin E: 200 IU's (Int'l Units), (3-4 per day providing you don't have hypertension). Vitamin E has been
shown to be excellent for menopausal symptoms, such as hot flashes, night sweats, heart health, palpitations (don't
forget your magnesium (500 mg at a shot). Vitamin E is fat soluble and must be taken with food to be properly
absorbed. The best regimen is to take one capsule with each of your three meals a day. You can take a 4th one dose
of 200 IU's, totalling 800 IU's a day, with an apple or fruit before bedtime. Also, d-alpha tocopherol, or natural vitamin
E, is recommended over dl-alpha-tocopherol, the commonly sold synthetic version. Power Surge recommends taking
no more than 200 IU of vitamin E at a time. Click here to read an important "Caution" about Vitamin E

Melatonin (3 mg.): taken occasionally for insomnia. 3 mg. Melatonin is a natural hormone produced by the
brain's pineal gland. It begins to decline sharply at adolescence, then again at about age 40. Older adults produce
only half as much as children. Melatonin can ease insomnia, especially in older adults. Animal studies suggest it may
strengthen the immune system and fight cancer. Remember that Melatonin, like DHEA, is a "hormone." albeit natural,
and should be used as recommended. Can be very helpful for sleep problems.

Niacin No-Flush (B-3): 60 mg. Improvement in cholesterol profile by reducing total cholesterol and LDL and
raising HDL. Niacin No-Flush is recommended as high doses (75 mg or more) of niacin can cause side effects. The
most common side effect is called "niacin flush," which is a burning, tingling sensation in the face and chest, and red
or "flushed" skin. Niacin plays an important role in ridding the body of toxic and harmful chemicals. It also helps the
body make various sex and stress-related hormones in the adrenal glands and other parts of the body. Niacin is
effective in improving circulation and reducing cholesterol levels in the blood, aiding in atherosclerosis, diabetes,
osteoarthritis, cataracts and burns. Niacin needs can be partially met by eating foods containing protein because the
human body is able to convert tryptophan, an amino acid, into niacin. Our No-Flush Niacin will not cause the flush
that is commonly associated with niacin use. It is derived from the finest Inositol Hexanicotinate available.
Caution: Because of the potential for side effects and interactions with medications, dietary supplements should be
taken only under the supervision of a knowledgeable healthcare provider.
Boron (12-18 mg. per day): is a trace mineral which helps metabolize calcium and magnesium. Because of this
close association between the three minerals, boron deficiency can negatively affect bone and joint function. Included
in Power Surge's Active Women's Multi

Borage Oil (1000 mg.): is a trace mineral which helps metabolize calcium and magnesium. Because of this
close association between the three minerals, boron deficiency can negatively affect bone and joint function.

Vitamin B-6: (100 mg) 3x per day. Excellent natural diuretic as it aids in the removal of excess fluid of
premenstrual and menopausal women. Works well as an anti-depressant. Necessary for the synthesis and
breakdown of amino acids, the building blocks of protein. Aids in fat and carbohydrate metabolism and in the
formation of antibodies. Maintains the central nervous system promotes healthy skin. Reduces muscle spasms, leg
cramps, hand numbness, nausea & stiffness of hands and helps maintain a proper balance of sodium & phosphorous
in the body.

Vitamin B complex: For energy, depression, general nervous system. Essential for the maintenance of
healthy nervous tissue. The B vitamins play a role in energy metabolism in the body.

Magnesium (500 mg - 1,000 mg. per day): Recommended: 500 mg. of magnesium daily as needed for
palpitations or migraines (500 mg. at a pop), even for anxiety and depression. Magnesium, a much under-rated
mineral, has finally come into its own as one of the most beneficial minerals you can add to your diet. I once heard a
nutritionist say, "If it spasms, give it magnesium," which is why magesium is excellent for palpitations and migraines
and could be helpful to those who experience internal shaking. Magnesium is also known as the "anti-stress mineral"
and has been known to help improve depression, promote cardiovascular health and keep teeth whiter. Magnesium
may be helpful with menopause, mood swings and PMS symptoms. A study performed involving 32 women found
that magnesium taken from day 15 of the menstrual cycle to the onset of menstrual flow could significantly improve
premenstrual changes in mood. Studies of large populations have shown that the more magnesium people take in,
the lower their blood pressures. This is partially due to magnesium. I recommend magnesium on Power Surge for
things like migraines and palpitations. It's a very underrated mineral. Magnesium is extremely effective in lowering the
blood pressure. It may reduce palpitations, strokes and heart attacks. It can decrease migraine headaches and
increase the effects of a low sodium diet. The amount would be about 800 mg a day and you can obtain it in fresh
fruits and vegetables. You will find 400 mg. daily in the recommended dose of Power Surge's Active Women's Multi

Calcium, Magnesium Citrates, Vitamin D and Boron: Calcium and magnesium combined. Calcium,
magnesium and vitamin D and Boron in one supplement. These are also included in the Active Woman's Multi.

Calcium and Vitamin D (200 IU): My Cal-Mag-Vitamin D combo contains calcium, magnesium and vitamin D
(200 IU). Vitamin D is essential for the proper absorption of calcium. Vitamin D deficiency in postmenopausal
women adds to osteoporosis risk. Regarding calcium, perimenopausal women require 1,250 mg. and
postmenopausal women, 1,500 mg. per day to retain bone mass and provide bone strength and protection from
osteoporosis. Magnesium is necessary for the absorption of calcium by the cells and is essential for proper nerve,
heart and muscle function. It also plays a role in the transmission of hormones and is required for over 300 enzyme
reactions. It is so important to our health and well being that there has been a proposal to add it to our water supply.
Between 50-60% of all the magnesium in your body can be found in your bones. As for vitamin D, a study by The
National Institute on Aging has found that postmenopausal women with too little vitamin D in their diets have an
increased risk of hip fracture. The Active Women's Multi contains 400 mg. of calcium and 400 IU's of vitamin D
required for proper absorption of calcium.
Inositol: (650 mg): In the "B" vitamin family, I'm never without this in my home. I've taken this for years on an "as
needed" basis - Discovered it 25 years ago when Dr. Robert Atkins called it "nature's own tranquilizer". I take 3 -
650 mg. capsules every morning -- yes, three capsules -- and have taken up to 4 when I'm very stressed. Also
necessary for the formation of lecithin; aids in the breakdown of fats, helps reduce blood cholesterol, and helps
prevent thinning hair.
Vitamin C: Anywhere from 1,000 up to 10,000 mg. per day. Vitamin C is an excellent anti-oxidant and serves
as powerful protection against cancer as it wards off cancer cells. It's excellent for the skin. It's a water soluble
vitamin. Therefore, it passes through your body when you void and taking even 10,000 mg. of vitamin C isn't harmful.
In some cases, it may cause some acidity and heartburn. Those who experience these side effects might try Ester C,
a buffered form of vitamin C.

Selenium -- Selenium (recommended 200 mcg. per day): Selenium is an anti-oxidant and anti-cancer mineral.
Selenium and vitamin E facilitate each other's absorption, so take them together. Vitamin C may interfere with the
absorption of some forms of selenium so take them separately. Avoid doses above 400 mcg. per day. Selenium is
excellent for heart health. The Active Women's Multi has 200 mcg. of selenium in it.

Co Q10 - Coenzyme Q-10 capsules (50 mg): 2 per day. Another anti-oxidant against free radicals (the
garbage in our society.. pollutants, preservatives, etc.) said to improve energy utilization and keep the body's
functions running "in tune" and excellent for maintaining heart health. Not only is CoQ10 an excellent antioxidant, but
it is also required for making energy in cells. No Co Q10 in a cell and it can’t produce energy aerobically. No CoQ10
in a heart cell and that cell can’t work at all. The more heart cells that can’t work, the worse off you are. Co Q10 levels
start to decline by the age or 35 or even sooner in some individuals. 300 or more grams a day and more have been
used in some cases to restore good health. It is a major nutrient that has been investigated with favorable results in
many research studies.

DHEA (25 mg. per day): DHEA is manufactured in and secreted by the adrenal glands, is called a master
hormone, or mother of hormones in that it 'gives birth' or is converted to all other steroid hormones and active
metabolites including estrogen in women and testosterone in men. It is these metabolites of DHEA that maintain and
improve health, and the body knows how to use DHEA to get what it needs for optimum health. DHEA floods the body
while we're young and has various and powerful beneficial effects on the human system. Also, research indicates that
high levels of the hormone in the bloodstream appear to extend lifespan, block the formation of fat cells (even when
food intake is increased), increase the body's ability to transform food into energy and burns off excess fat, and inhibit
the enzyme responsible for activating chemical carcinogens. DHEA production peaks between the twenties and
declines as we age. As we enter our thirties, production of DHEA begins to ebb. At 50, most people secrete only 30%
of what they produced when they were young, and its deficiency increases the risk of breast cancer in women and
heart attacks in men, as well as many age-related disorders. Read more about DHEA.

Soy Lecithin granules (1-3 Tbsp in juice per day): A natural emulsifier, excellent for lowering cholesterol and
source of soy. I was weaned on lecithin by a very nutrition-conscious mother. I learned early on to look at labels. If
you check every cake and candy bar you purchase, you'll find that lecithin is included "as a natural emulsifier."
Lecithin goes into your blood stream, and the granules attach themselves to the fat in your arteries and absorb it.
That's how she explained it. When she entered menopause, her cholesterol shot up to 400. My mother is 91 years
old today, has never taken any cholesterol medication and has used SOY lecithin granules for over 40 years, 2
heaping tablespoons per day in juice. Now you know why I'm a believer. I don't fall for every herb that becomes
trendy. I follow the tried and true. They must be adding lecithin to the cakes and candy we eat for a reason. Dare I
say one of them is because of the inferior lard/fats they use in preparing them?

Garlic or odorless garlic tablets: 300 mg. tablet. Immune System/Circulatory System. Used in all lung ailments,
for high and low blood pressure, parasites, fungal and bacterial infections, headaches and nervous disorders.
Classification: Aromatic herb. Warm energy. Excellent source of chromium, phosphorus, selenium and thiamine.
Garlic, a member of the family that includes onions, leeks, and shallots, is native to Europe and Central Asia. An old
Welsh saying goes, "Eat leeks in March and wild garlic in May, And all the year after physicians may play." Olympic
athletes in ancient Greece chewed a clove at the start of a competition, believing it increased their stamina. Garlic's
strong odor is due mostly to a sulfide called allicin. Garlic is a source of selenium, which must be present in the body
for proper immune response and which acts as an antioxidant in combination with vitamin E. Garlic is one of the
most important foods we can eat. It has a positive effect on every function of our bodies.
Pantethene (500 mg.): Pantethene and

Pantothenic acid --a little known fact I learned from Dr. Robert Atkins is that panthethine and pantothenic acid
are excellent aids for lowering cholesterol. Participates in the release of energy from carbohydrates, fats and
protein, aids in the utilization of vitamins, improves the body's resistance to stress. Helps in cell building and the
development of the central nervous system. Helps the adrenal glands, fights infections by building antibodies.
L-Taurine (500 mg., 1-2 tablets per day): A specialized amino acid which is an ion and pH buffer in the heart,
skeletal muscles and central nervous system -- good for the anxiety of menopause. Taurine is also a potent
antioxidant and antitoxin, and in these roles is particularly important to the liver and immune system.

L-Tyrosine (500 mg., 1 tablet per day): Tyrosine has been found to play a role in controlling depression.
Possible uses of tyrosine may be to control appetite and fatigue. It is also suggested that tyrosine may help with
allergies and headaches. This amino acid aids in the production of melanin (pigment of the skin and hair) and in the
production of the adrenal, thyroid, and pituitary glands.

L-Carnitine (500 mg.): L-Carnitine is excellent for weight-loss and maintenance. No risky chemicals, just
natural amino acids. L-carnitine is absolutely necessary for the transport of long chain fatty acids into the
mitochondria, the metabolic furnaces of the cells. Fatty acids are the major sources for production of energy in
the heart and skeletal muscles, structures that are particularly vulnerable to L-carnitine deficiency. A number of L-
carnitine deficiency states have now been identified, several of which are genetic in origin.
Genistein and Daidzein: Soy isoflavones are a type of phytoestrogen which have the ability to bind to estrogen
receptor (ER) sites inside the human body. Daidzein is an isoflavone which undergoes change when it contacts
intestinal bacteria in animals to form equol, a non-steroidal estrogen that can also bind with ER sites. Genistein and
equol can have anti-estrogenic properties when estrogen levels are high (PMS) by competing with enogenous
estrogen. Since equol is approximately .2% the strength of estradiol, estrogenic reception will decrease even though
all the receptors are engaged. If estrogen levels are low, as is often the case with menopausal women, they can have
mild pro-estrogenic effects, engaging many receptors which otherwise would have no estrogen reception at all.
Because these isoflavones have such properties, they are known as adaptogens. The fact that genistein and equol
can lower estrogen levels in premenopausal women complements the action of progesterone cream in alleviating
estrogen dominance. Also, because genistein and equol are mildly pro-estrogenic in menopausal women, they again
complement the action of the progesterone cream by providing a natural syngergy to alleviate the menopausal
deprivation of progesterone and estrogen. Genistein and Daidzein can be taken along with Revival®. Advisory:
There is not as much data available on the "pill" form of soy isoflavones as there is on "soy protein powders
combined with soy isoflavones." Most of the studies done on the benefits of soy isoflavones have been done utilizing
the above combination. The FDA's approval of SOY for heart and bone health was the result of studies done on soy
protein powder and isoflavones.

St. John's Wort: 0.3% hypericin (300 mg); helps improve mild to moderate depression, which is
commonly complained about during peri and postmenopause. St. John's Wort is used for the treatment of mild
depression. It seems to act as a mild ( MAO ) monoamine oxidase inhibitor. MAO inhibitors are used worldwide as
antidepressants. SJW has been used and researched (documented studies) successfully for hundreds of years in
other countries and is often touted as nature's Prozac. I used to use it occasionally for perimenopause-related
depression and even anxiety. Read the transcripts of Dr. Steven Bratman, author of Beat Depression With St.
John's Wort. Caution:1) If you're using SJW regularly, you can develop photosensitization, an increased sun
sensitivity that results in severe sunburn, especially those with fair skin. Take proper precautions when using large
quantities of this herb. 2) Depression can be a life threatening illness. If you feel you are depressed you must be
evaluated by a health care professional. Those taking St. Johns Wort should avoid tyramine containing foods, such
as aged cheese, beer, wine, etc. 3) St Johns Wort should not be taken with any prescription antidepressants.

Niacin No-Flush (B-3): 60 mg. Improvement in cholesterol profile by reducing total cholesterol and LDL and
raising HDL. Niacin No-Flush is recommended as high doses (75 mg or more) of niacin can cause side effects. The
most common side effect is called "niacin flush," which is a burning, tingling sensation in the face and chest, and red
or "flushed" skin. Niacin plays an important role in ridding the body of toxic and harmful chemicals. It also helps the
body make various sex and stress-related hormones in the adrenal glands and other parts of the body. Niacin is
effective in improving circulation and reducing cholesterol levels in the blood, aiding in atherosclerosis, diabetes,
osteoarthritis, cataracts and burns. Niacin needs can be partially met by eating foods containing protein because the
human body is able to convert tryptophan, an amino acid, into niacin. Our No-Flush Niacin will not cause the flush
that is commonly associated with niacin use. It is derived from the finest Inositol Hexanicotinate available.
Caution: Because of the potential for side effects and interactions with medications, dietary supplements should be
taken only under the supervision of a knowledgeable healthcare provider.

Glusosamine Sulfate: A nutrient for connective tissue and joint integrity. Glucosamine is a building block for
the connective tissues and other cementing materials that pack the cells together. You can use Glucosamine /
Chondroitin Sulfate Plus together for rheumatic, arthritic, joint pain. Read the transcript of Dr. Jason
Theodosakis, pioneer of Glucosamine and Chondroitin Sulfate.
MSM (Methylsulfonylmethane -- 1000 mg.): Methylsulfonylmethane (MSM) is an organic source of sulfur,
one of the major building blocks of glycosaminoglycans. It is an organic sulfur naturally found within connective
tissues and joint cartilage. Glycosaminoglycans are key structural components in cartilage and play an important role
in the maintenance of joint cartilage and in aiding bone aches and pains, arthritis and other bone/joint
conditions.
Kava Kava (60-150 mg. as needed): Herb for anxiety, usually prescribed in doses of 150-200 mg., one must be
VERY careful not to overdo this one. Caution: Kava kava has been found to cause liver problems if taken in large
doses. If you have been taking kava on a daily basis for more than four weeks, consult your doctor, who may
recommend routine blood tests to check your liver. Also, if you're using prescription sedatives, anti-depressants or
tranquilizers, always consult your health care provider before taking this herb. Avoid kava altogether if you have a
liver disease, such as hepatitis or cirrhosis, or if you regularly take drugs with known adverse effects on the liver, such
as acetaminophen. Women who are pregnant or breast-feeding should not take kava. Don't take kava if you have
Parkinson's disease; it can aggravate symptoms. Avoid drinking alcohol while taking kava.

Evening Primrose Oil (EPO): 500 mg. softgel. Excellent for hot flashes, breast tenderness, other menopausal
and PMS symptoms. A rich source of gamma-linolenic acid (GLA), is suggested for a number of women's conditions,
including PMS, menopausal symptoms and dysmenorrhea. Other doses and sizes of EPO available.

Ginkgo Biloba: 60 mg., 60 tablets. Also available in 120 tablets. It's great... when you remember to take it!
Improves circulation to cold hands and feet and to treat depression. Is helpful for menopausal "brain fog." Ginkgo
biloba is well known in the United States and Europe for its ability to improve memory, although its ability to alleviate
depression is not as widely recognized. It is believed that ginkgo exerts both its memory and mood enhancing effects
by increasing microcirculation to the brain and improving the brain's ability to metabolize its primary fuel source,
glucose. The smallest blood vessels in the body, known as microcapillaries, are the first to experience the ill effects of
a decreased oxygen supply. Ginkgo stimulates the release of substances within the cell wall that enable the
microcapillaries to relax. This results in increased blood flow and improved oxygen delivery. In addition, studies
demonstrate that ginkgo exerts a direct effect on mental alertness by modifying the frequency of brain waves. Studies
using an EEG to monitor brain waves showed that ginkgo increased the brain waves associated with alertness (alpha
rhythms) and decreased the brain waves associated with lack of attention (theta rhythms). Ginkgo has a considerable
track record for safety and appears to be well tolerated. Ginkgo may be particularly beneficial for people who are just
beginning to experience a decline in their cognitive function.
Be sure, as with all other herbs, it's 24% "standardized." 60 - 120 mg per day. Caution: Ginkgo Biloba, can increase
the effects of prescription blood thinners by increasing the risk of excess bleeding. If you're using an anti-coagulant,
consult your health care provider before using this herb.
Chasteberry (Vitex): Chaste tree berry extract is a source of phytoestrogens, and a popular herb among women
who need extra support during premenstrual and menstrual cycles.† Chaste Berry Extract is particularly beneficial for
premenstrual stress syndrome.

Valerian Root: Can be useful in treating anxiety and in some cases, insomnia common among
perimenopause and PMS symptoms. Valerian is used extensively in Europe as a mild sleep aid. Several clinical
studies on humans have shown it to safely relieve occasional insomnia. One drawback, it smells awful, so it's
advisable to take in capsule form (that doesn't smell too great either), but it works well for many.

Black cohosh: a hormone precursor which some find it excellent for treating menopausal symptoms like hot
flashes and depression. Black cohosh is said to relieve vasomotor symptoms and depression. Black Cohosh
(Cimicifuga racemosa) has been valued by many societies, including the American Indians, for its nutritional support
of the female reproductive system. It was also made into a poultice and applied to snake bites; hence it is sometimes
known as snakeroot. Modern natural health enthusiasts, like those of the past, use it to nourish the female system,
helpful for hot flashes, hormone balancer, nerves, spasms. Black Cohosh is fairly well studied in Germany, where it is
used to treat hot flashes. Experiments have shown that the herb has substances that bind to estrogen receptors in
animal models and lower LH (a hormone which is elevated in menopause) in both animals and humans. Remifemin is
a popular brand. There are other good standardized brands of black cohosh which provide the same effects at a
lower cost. Caution: Black cohosh can cause lowered blood pressure when taken at high doses.
Dong Quai: For menopausal and menstrual difficulties. Dong quai contains phytoestrogens, or plant estrogens.
Phytoestrogens have been shown to be helpful in relieving hot flashes. Dong Quai (Angelica sinensis) helps promote
the body's use of, and response to, available estrogen. Dong Quai is available as a tincture that can be added to a
little warm or cold water. Most of us need about 30 drops of tincture three times a day. Dong Quai is also available as
thin slices of cured root. One/16th of a slice of root once a day is about right for most women. The root can be
chewed or brewed into tea. (Dong Quai is also available in powder form. The quality and potency of the powder
varies greatly, and may not be adequate). Dong quai is included in the Active Women's Multi.
Black Currant: Active ingredient is Linoleic acid, (GLA) gama Linolenic acid and alpha Linoleic acid. In Europe the
leaves were used as a diuretic,and as a gargle for sore throat. The berries were made into a drink for colds and flu.
The oil is generally used today. Black currant seed oil is a rich source of essential fatty acids. These are converted in
the body to prostaglandin, which is necessary for fighting infection. Many women find this oil reduces breast
tenderness associated with PMS. Black currant, like evening primrose oil is often included in women's PMS and
menopause formulas. It can also be used as a tea. My favorite is the London Tea Company's Black Currant Bracer.
Licorice Root: Licorice, an estrogen-balancing herb especially for chronic stress. 250 mg. three times a day, 30 to
60 drops tincture three times a day, or 1 cup of tea three times a day Caution: Do not use if you have high blood
pressure.

Hawthorn: From the hawthorn berries, the active ingredients vitexin-2"rhamoside has been known since the
Middle Ages, used in China, Europe and America for heart and circulatory disorders. Hawthorn dilates blood vessels
and improves circulation. Has been used in combination with Ginko biloba to improve post menopausal memory loss.
Studies of its effectiveness in this area are lacking. Caution: Self-treatment for heart disease is a bad idea. If you
have or suspect that you have heart disease, or if you are using any heart medication, it's imperative that you consult
a health care professional before taking hawthorn.
Chamomile: A relaxant for the nervous system and menopause-related anxiety. Probably the most popular herb in
Europe where it has been used for centuries. Generally taken as a tea for its calming effects. Also useful as a
sleeping aid and may reduce uterine cramps. Helpful also for the common cold and flu to insomnia, diarrhea,
menstrual cramps, nerves, and drug withdrawal. Chamomile is popular as a late night herbal tea, sold around the
world in grocery health food stores. Chamomile contains the amino acid tryptophan. The plant also contains
flavonoids. Also useful for relaxation are Hops and passion flower. I have a cup of peppermint tea every night to
"settle" myself down. Caution: Those with hay fever may experience a mild allergic reaction.

Feverfew: Believed to prevent and treat migraines, arthritis and allergies. Dilates peripheral bloods vessels
helping high blood pressure. Used for migraine headaches, menstrual discomforts and digestive disorders.Caution:
Feverfew can interfere with blood clotting when taken internally.

Cranberry (concentrate): Is excellent in preventing and soothing urinary tract infections/inflammations


which are more common during menopause.
Ginger: Can be helpful in reducing the nausea assocatied with perimenopause and PMS. Another anti-nausea
solution is drinking hot water with lots of lemon.

Ginseng - Korean (Panax): Energy, longevity, age spots, nerve tonic. Ginseng, Korean (Panax) is the most
widely used and studied ginseng in the world. As an adaptogen herb, it is believed to help balance the body. Ginseng
(Panax ginseng) is supposed to slow aging, increase mental and physical capacity, increase sexual performance, and
boost immunity. The three major species are American, Siberian, and Korean. Each species has its own chemical
properties. For instance, Siberian ginseng is of a different genus from the other two ginsengs, but it possesses many
of the qualities of Korean ginseng. Siberian ginseng is an adaptogen, although perhaps more mild than Korean
ginseng. Siberian ginseng is the least expensive of the three ginsengs. Wild American ginseng is a true ginseng. It is
the most expensive of the three ginsengs. Caution: With all the hype about benefits ginseng provides, not many
mention that it has the potential to elevate blood pressure, especially in those predisposed to hypertension. In
addition, Ginseng, can increase sugar levels, which can be dangerous to diabetics. supposed to slow aging, increase
mental and physical capacity, increase sexual performance, and boost immunity. Therefore, it should NOT be taken
by people with hypertension.
Nettle (Urtica dioica): Thought to fight urinary tract infections, kidney and bladder stones, and rheumatism. It is
used externally to control dandruff. Caution: Nettle should not be taken by people with fluid retention caused by
reduced heart or kidney function.
Kegel Exercises: Kegel exercises help prevent incontinence and uterine prolapse. It also serves to strengthen
pelvic muscle tone, to firm up the vaginal canal to control urine flow. You can tighten and relax the muscles you use to
stop urination and enhance orgasm. The muscles are attached to the pelvic bone and act like a hammock holding in
your pelvic organs. To try and isolate these muscles trying stopping and starting the flow of urine.
How do I do the exercise?
Once you have located the muscles simply tighten and relax the mucsle over and over, about 200 times a day. These
are basic kegels. There are many variations on kegels: elevator kegels (Where you tighten slowly, in increments
going in and out, like an elevator stopping on several floors.), you can hold the muscle tightened for five seconds, you
can bulge the muscles out at the end, and many other variations.
Do at least five Kegels in a row several times a day:
• Tighten a little -- count five
• Tighten a little more -- count five
• As hard as possible -- count five
• Relax in reverse steps, counting five at each step
Additional reading about kegel exercises, sexual libido and vaginal dryness.
Communicate with other women about sexuality issues and vaginal dryness during menopause.
Meditation: Whatever you do, learn meditation. Learn relaxation breathing exercises. Learn self-hypnosis. Don't be
afraid to find your inner self. The inner child. That peaceful place within yourself that too often we sequester away and
forget how to call on during times of stress, not only menopause, but due to the vulnerable circumstances in our
country at this time. Moments of fear and confusion, frustration, anxiety, depression and pain. In my moments of
anxiety and stress, on so many of those occasions, I have found that peaceful place inside of me with the help of
Power Surge friend, Harpist, Christine Magnussen, to soothe the soul with her, "On Wings Of A Dove." Interestingly
enough, Chris sent me a copy of her beautiful CD just before the Sept. 11th attack on the World Trade Center. Being
a New Yorker, the attack hit very close to home. I can't tell you how her music comforted me during those stressful
days and many others. You can listen to samples at the above link.
Strongly recommended: Power Surge's Menopause Survival Tips.
Disclaimer: These statements have not been evaluated by the Food and Drug Administration. The products and
information contained herein are not intended to diagnose, treat, cure, or prevent any diseases, or medical problems.
They are not intended as a substitute for a visit to your health care practitioner, nor to replace your doctor's
recommendations. This information is provided for educational purposes. Nutritional benefits can vary from one
person to another.
The Signs of Menopause -- Tests

By Dr. Joan Irvine and Alice Stamm (Dearest)

Additional Reading: The 34 Signs of Menopause


Menopause is a transition -- the signs are temporary -- but what you do during this transition can affect
your health for the rest of your life. It may affect the hidden risks of diseases, such as breast cancer,
endometrial cancer, ovarian cancer, osteoporosis (the thinning of the bones) and cardiovascular
disease (heart and blood pressure). Whether or not you have a family history of these diseases, please
have your health care practitioner test you for them.
Certain tests are important in understanding and working with the signs of menopause.
The main tests are:
• Follicle-Stimulating Hormone (FSH) test -- a blood test that checks the level of the FSH.
When it is above ovulation range, menopause is complete. This test usually just verifies what
you already know -- that you have gone through a hormonal change. It isn't helpful in the peri-
menopausal stage. It doesn't give you the information you need to manage this change. Insist
that you have a blood test that also checks levels of estrogen, progesterone, testosterone and
other hormones at mid-cycle. Contrary to popular belief, estrogen is not the only hormone that
changes during this transition.
• Pelvic exam -- to check for ovarian and uterine tumors, cysts and cancer. Two new tests that
detect or at least verify ovarian cancer are CA 125 (a blood test), and pelvic ultrasound, which
helps distinguish between cysts and tumors.
• PAP smears -- to check for cervical, uterine or endometrial cancer.
• Bone density test -- to check for osteoporosis. According to Dr. John Lee, an option is to keep
track of your height. If you notice a decrease, quickly consult with your health care practitioner.
• Blood pressure and cholesterol levels -- to check for risk of cardiovascular disease.
• Mammogram -- to check for breast cancer. Read Dr. Susan Love's Breast Book for good
detailed information. You can also read the transcripts of Dr. Susan Love's visits to Power
Surge.
• Breast Self-Exam -- at the same time each month, examine your breasts to learn what is
normal for you. This helps you to notice any changes. Early detection of breast cancer is
important for one's survival. See your health care practitioner immediately if you notice
changes.
It is important to establish a baseline (a first test with which to compare future tests, to decide if there
is a change) at age 35. In the past, when women experienced signs of menopause, they were often
prescribed valium for hot flashes, or a tranquilizer for depression.
According to some current research, ERT (Estrogen Replacement Therapy) can reduce hot flashes and
mood swings. And more importantly, it may protect us against osteoporosis and heart disease.
Physicians prescribe HRT (Hormone Replacement Therapy) if a woman still has a uterus to protect her
against endometrial cancer. The objective is to replicate our natural cycle.
The following are questions you should discuss with your health care practitioner:
• Should I take a synthetic or a natural form of HRT?
• What are the possible side effects of ERT and HRT?
• Should I take estrogen, progesterone or testosterone? Several days or every day?
• Should I use tablets, creams, transdermal (skin) patches or suppositories?
• When should I start?
• Am I experiencing menopause or are my signs an indication of something else?
Some women swear by ERT or HRT. One woman was amazed how quickly her hot sweats, swollen
breasts and mood swings went away as soon as she started on HRT. Another woman, who had been
depressed for five years, immediately felt better when she started on HRT. Some women react
negatively to synthetic ERT and HRT, but find that natural alternatives work for them. Many women use
a combination. Whatever you do, do something! This transition can be pleasant and empowering by
"taking charge of your changes."
There are more than a dozen members of the estrogen family. Two of the major types of estrogen
are estradiol and estriol. Each type of estrogen has different effects. This is important to
know if you choose ERT or HRT. For example, estradiol directly effects the breasts and there may be a
link between an abundance of estradiol and breast cancer prior to menopause. Estriol is most active on
the vagina, cervix and vulva. So if you have vaginal dryness during this time, this may be the type of
estrogen you need. It is important to keep track of your change, so you can get the correct treatment
for your particular signs.
Alternatives -- Additional information in the recommendations area
You may want to investigate alternatives or more natural approaches such as:
• Homeopathy (mini-doses of herbs and plants to relieve various signs)
• Herbs and vitamins
• Chinese herbs/medicine
• Acupuncture (a trained acupuncturist places small needles into the specific areas of your body
that help regulate the energy flow).
A few examples of the use of vitamins and herbs are:
• Vitamin E -- regulates hot flashes and helps with sexual desire.
• Dong Quai -- a Chinese herbal remedy, contains a natural form of estrogen.
• Mexican wild yam root -- contains a natural form of DHEA (dehydroepiandrosterone), called the
"Mother hormone" by some people because it converts to the hormones your body needs, be it
estrogen, progesterone or testosterone.
• Ginseng root -- balances internal temperature, builds energy levels and regulates blood
pressure.
• Cinnamon -- helps with spotting and relieves cramps.
• Dandelion greens -- a great source of iron and helps eliminate gas.
There is more to consider than just ERT, HRT, herbs or vitamins. Often the negative signs of
menopause can be alleviated just by a change in diet, or by taking nutritional supplements. Some
signs of menopause may be the result of the lack of sleep or sleep interruption. Stress aggravates the
signs of menopause. How you feel about yourself can affect your health.

To find out what to know about and what questions to ask of your healthcare provider, be
sure to read Selecting A Healthcare Practitioner.

Join in the message board's discussion about My Doctor's Attitude.


Power Surge provides not only hundreds of transcripts by prestigious women's health
experts, but an an Ask The Experts area where you can ask questions of many of these experts,
plus a wonderfully supportive women's forum where you can share your experiences with other
women going through menopause.
Fri, 9 December 2005 http://oguchi.libsyn.com/index.php?post_id=39637
Doctor's Log--Menopause

Menopause

I am amazed at how underestimated the condition called "Menopause" is. To most, it is simply a physiological condition of aging
resulting from a change in hormonal productions, fluxes and balance in the female gender. That clinical mouthful is reduced in
lay terms to: unpredictable hot flushes in afflicted women, irritability and loss of interest in romance and related activities.

Menopause is most likely a leading cause, if not the leading cause, of relationship problems and failures in the age groups
affected. Divorce and marital separations are the result. When the term "Midlife Crisis" is used to summarize these problems, the
fact that it is Menopause that may be causing the problems is somehow overlooked.

I was moved when once a patient who had earlier started taking Estrogen to improve the symptoms of Menopause was recalled to
re-assess the treatment after a new scientific study implicated such Estrogen treatment as presenting a risk for certain types of
Breast Cancer. The patient flatly refused to stop taking Estrogen. Why? Because without Estrogen, her marital relationship would
be over for sure. That was not an option for her. What a choice to make--between Breast Cancer risk and Divorce certainty.

The relationship-burden of Menopause is huge. If better understood and properly taken care of, such a burden may not, and
should not result in the wrecking of the relationships and lives of those affected. These relationships are not just important: they
also define the essence of life and well-being for the affected; and perhaps, the way most people see themselves--their roles and
place--in the larger society; that is, their whole identity. Since every woman, if she lives long enough, will undergo Menopause,
and her relationships will thus be "touched," some focus should be directed towards managing and maintaining relationships.

The typical man's reaction to Menopause is to feel rejected just because his partner does not respond to sexual cues any longer,
nor does she appear to have any interest in romance. It appears that no amount of education, professional or otherwise, can
convince the man that this is not really about him per se, therefore, the issue is NOT REJECTION. I believe that most men are
reasonable, especially those men who are interested in protecting and preserving a hard-won, valuable and indispensable
relationship, which most such relationships are. When a man can be led to understand that he is not being rejected, that this is a
condition beyond the control of the woman, an "issue" wherein his partner finds herself a victim, too, then, the man will naturally
swing into the role of an understanding partner-helper, just as he would were his partner to be diagnosed with a serious long-term
ailment.

A woman going through Menopause, besides putting up with all the usual problems, often feels guilty for "being accused of
rejecting" her partner; then, she is saddled with being rejected herself by a partner reacting to perceived initial rejection. The
vicious cycle does not end; and this is at a time when what the woman needs most is understanding--by her partner, and also by
her own self. For, many women going through menopause actually believe that the loss of interest in sex and romance is their
own fault--maybe they are not trying hard enough, maybe they actually made the choice... Is there an element of "shame" there,
perhaps?

I think that even Nature itself groans under such a burden, because, some women are spared in the sense that not every woman
will experience all the symptoms of Menopause; the seriousness and how many years the symptoms persist vary, too. Not every
relationship will be stretched and stressed and torn apart.

When the effects of menopause are interpreted as REJECTION by the man, the results can be disastrous to a relationship. This
interpretation needn't be so. When Menopause is seen as an undesirable but nevertheless a natural "change-event" which has the
same effects as an ailment afflicting a loved and dear partner, the Compassionate power and role of the man can be brought out to
maintain and nourish the relationship. Guilt, shame and any sense of rejection on the part of the woman going through
Menopause can only add to the destruction of relationships.

While medical and folk-remedy treatments continue for Menopause, I wonder if it can be seen as a form of "aging," or at least,
"unavoidable change," hence, placing it among the long list of other life-management issues, that way, its brutal bite on
relationships can be stopped?

In summary: Menopause wrecks relationships, among other problems; it does not have to when it is remembered, especially by
the man, that it is not about REJECTION; and by the woman, that it is not about shame and or guilt. This aspect of help does not
require medication. If the new medications coming down the line can actually restore normal feelings and attitude toward
romance even during Menopause, and not carry the risks of Estrogen, that will be great all around. Until then, remember...and
protect your relationships.
http://www.regardinghealth.com/nam/RHO/2007/07/Article.aspx?bmkEMC=30891

Surviving the Menopause Blues


Here’s another Change One Thing Challenge -- where we provide simple suggestions for positive changes and you choose one
change and make it. Our suggestions and survival techniques for menopause and mental health are a great place to start.
Survival Technique 1: Blame your hormones anyway.
Few scientific studies demonstrate that menopause contributes to true clinical depression, severe anxiety, or erratic behavior.
However, some perimenopausal women report symptoms of tearfulness, mood swings, and feeling blue or discouraged. It is
unclear whether these mood symptoms are related to a decline in ovarian hormone levels, but sleep deprivation due to
menopause-related night sweats often results in fatigue, irritability, and moodiness. Abrupt hormonal fluctuations during
perimenopause may have an impact on these symptoms as well.
Depressed mood during perimenopause is associated with a history of depressed mood earlier in life (including PMS), a longer
menopause transition, or severe menopausal symptoms such as hot flashes. Other causes of mood disturbance during
perimenopause include:
• Thyroid disorders -- fatigue, depression, mood swings, and sleep disturbances are frequently associated with
menopause, but they may also be signs of hypothyroidism. The thyroid helps regulate metabolism and influences the
heart, brain, kidneys, and reproductive system.
• Medication side effects -- some menopause-like symptoms may be side effects of medication a woman is taking for a
different problem.

• Midlife stresses -- floundering relationships, undesired childlessness, divorce or widowhood, struggles with
adolescents, return of grown children to the home, empty nest, concerns about aging parents, elder caregiving
responsibilities, and career and financial issues.
• Difficulty aging -- changes in self-concept, self-esteem, and body image. Women may begin to contemplate their own
mortality and become introspective about the meaning or purpose of their lives.
Survival Technique 2: Repeat after us: Change is good, change is good, change is …
During the menopause transition, women may feel overwhelmed, out of control, angry, or numb. They may seek refuge in
alcohol or drugs and thus compound their problems. In fact, women are more likely than men to drink alcohol as a way of dealing
with blue moods, loss, divorce, or children leaving home. Although psychological problems are not caused by menopause, they
can begin or become worse at this time. Support and encouragement can help women thrive once again during what can be the
best years of their lives.
Emotional health during perimenopause requires a balance between self-nurturing and the obligations of work and caring for
others. Many women are able to identify and describe sources of tension and symptoms of stress but find it difficult to take time
for themselves. Recognizing a problem is the first step to coping. Although many stressors cannot be altered, coping skills enable
women to meet life’s challenges and create a renewed sense of self-confidence and balance.
Survival Technique 3: Don’t worry, get happy.
Sometimes, coping skills and lifestyle changes are not sufficient to relieve symptoms of stress. These symptoms may be a side
effect of medication, a symptom of a medical condition, or the result of clinical depression or anxiety. A healthcare provider can
help determine the cause of mental health stressors, assess options, and prescribe appropriate treatment.
For example, mood disturbances brought on by sleep deprivation resulting from nighttime hot flashes (night sweats) usually
improve when hot flashes are treated.
During perimenopause, hormone drugs such as low-dose oral contraceptives may help stabilize mood by controlling hormone
fluctuations. This may be particularly true for women who suffered from postpartum depression or PMS. However, no hormone
drug is government approved for the relief of psychological symptoms.
Some women use nonprescription remedies to improve mood and mild depression. Supplements containing the herb St. John’s
wort may be helpful. Side effects include gastrointestinal upset, fatigue, and increased sensitivity to sunlight (so it is advisable to
wear sunscreen, a hat, and wraparound sunglasses when outdoors; and sunbathing must be avoided). Women should not use this
herb with drugs that alter blood clotting, such as aspirin or warfarin (Coumadin). Consultation and follow-up with a healthcare
provider is important to evaluate symptoms and the effectiveness of the supplements, and to determine the length of treatment.
Many practitioners advise using this herb for no more than 2 years.
Another nutrient, omega-3 fatty acid, may also improve mood. Food sources include fatty fish (such as salmon, tuna, herring, and
sardines); supplements are also available. More research is needed to determine their effects on mood.
Survival Technique 4: If you notice your menopause “blues” getting darker, seek expert advice.
More severe depression and anxiety require special attention. Clinical depression is one example. Often a perimenopausal woman
will say she feels “depressed.” It’s important that a healthcare provider distinguish whether she is feeling blue or if she is actually
“clinically depressed,” a condition associated with a chemical imbalance in the brain. The following symptoms, lasting for more
than 2 weeks, can indicate this condition:
• Prolonged tiredness/lack of energy
• Loss of interest in normal activities
• Sadness/depressed mood
• Irritability/tension/nervousness
• Physical symptoms of anxiety (diarrhea, indigestion, heart palpitations, headaches, hyperventilation, sweating)
• Decreased sex drive
• Feelings of guilt
Clinical depression is not caused by menopause, but women who have had depression in the past are vulnerable to recurrent
depression during perimenopause. For severe depression, prescription antidepressant medications can be given to help correct the
chemical imbalance. Although several weeks are usually needed to experience a drug’s full effect, most women show a marked
improvement with these medications with relatively few side effects. Antidepressant medication is most effective when used in
combination with counseling or psychotherapy. Although proven effective for mild depression, St. John’s wort is not effective for
clinical depression.
Anxiety is another condition that goes beyond the blues. Anxiety is an agitated sense of anticipation, dread, or fear experienced
by everyone at one time or another. Menopause does not cause anxiety, but women may experience more anxiety because of how
they react to physical and psychological changes during perimenopause, coupled with other midlife stressors. Although anxiety
usually resolves without treatment, it may accompany or be a warning sign of a panic disorder. Symptoms of a “panic attack”
include shortness of breath, chest pain, dizziness, heart palpitations, and/or feelings of being out of control or “going crazy.”
Sometimes the unsettling feelings that precede a hot flash can trigger such an attack. Anxiety can be related to depression. Severe
symptoms of anxiety can usually be relieved through one of several therapeutic approaches including:
• Relaxation techniques
• Stress reduction techniques
• Counseling
• Psychotherapy
• Prescription drug treatment
Survival Technique 5: Lie down on their couch.
Although some individuals feel embarrassed or ashamed about discussing their mental health concerns, no one should suffer in
silence. Healthcare providers are better able to help when given as much information as possible about personal and family
history. Most primary care providers are not extensively trained in the management of mental health disorders, but they are often
knowledgeable and helpful. The next step might be consultation with a mental health professional -- an expert opinion can be
reassuring. Treatment for a specific problem, such as marital difficulties or an eating disorder, is best provided by a counselor
with expertise in those areas.
Last reviewed: July 2007
http://aneas.net/womenhealth/menopause.asp

Dealing Actively With Your Midlife Changes


There are many choices in dealing with symptoms associated with approaching menopause. These
include healthy lifestyle changes, hormone replacement therapy, other medications, social support and
therapy.
Healthy Lifestyle Changes: Regular exercise may decrease depression and irritability. Good muscle tone can also improve energy
level and decrease aches and pains. Some forms of exercise may help decrease bone loss. Yoga or Tai Chi decrease stress and
may reverse the decreased flexibility often associated with aging. Regular Tai Chi has been shown to decrease the incidence of
hip fractures in older individuals. A diet high in complex carbohydrates, including multiple small meals may reduce irritability
and improve one’s feeling of well-being.
Social support: Many women experience menopause as a time of increased freedom and new possibilities. As their own children
grow up, they may have more time and flexibility. However, some women experience the empty nest as the loss of their central
role in life. Loss of a spouse through death or divorce can increase isolation. The physical changes associated with hormonal
fluctuations can be confusing. Menopause may cause some women to start to think about the finite nature of life. Supportive
friends and family can help a woman understand and cope with life changes. Reading about menopause or talking to one’s doctor
can help make the changes less mystifying. A return to spirituality can spur growth at this phase of life.
Hormone Replacement Therapy (HRT) Taking estrogen and progesterone can help some of the symptoms associated with
approaching menopause. The decision to take hormones is an individual one. A woman considering HRT needs to consider the
severity of her symptoms, her health history and her family history. She may also have personal preferences about taking
medications. Estrogen is the hormone that seems to relieve many of the symptoms of approaching menopause. If a woman has
already had her uterus removed, she may take estrogen by itself. However, if a woman with an intact uterus takes estrogen
without progesterone, the lining of the uterus may build up, and the woman may be at increased risk of uterine cancer. Thus HRT
often requires a combination of estrogen and progesterone. The doses of estrogen and progesterone used for HRT are generally
lower than the doses used for birth control pills. Often, women only need HRT for a limited number of years after menopause.
There can be benefits and drawbacks to the use of HRT. Estrogen can relieve hot flashes, vaginal dryness, urinary problems, and
sometimes insomnia. It can also promote a feeling of well-being. Some women feel that it improves memory and concentration.
HRT can reduce the chance of osteoporosis. Estrogen may help prevent heart disease, but recent data has suggested that this
effect may not be as dramatic as previously thought. For some women there may be drawbacks to HRT. Some studies have
suggested a link between HRT and an increased incidence of breast cancer. Estrogen may elevate blood sugar, cause headaches,
weight gain, or other side effects.
Psychological support: For some women, social support, healthy lifestyle changes and hormone replacement therapy are not
enough. The death of loss of a spouse, heath changes and other stresses may cause stress. Depression and mood swings are more
common during perimenopause than after menopause is well established. However, a woman with a history of anxiety or major
depression may have a reoccurrence during either of these periods. Counseling may help some women deal with losses.
Counseling may also help a woman review her life and make decisions about new directions and interests. If a woman has a
persistent depression or experiences sleep, appetite and energy changes, or has suicidal thoughts, she may want to consider a
psychiatric consultation and antidepressant medication.
Passage through this life transition may leave one with a larger view of the rhythm and flow of life.
Menopause and Disorders of Desire
Sexuality and sexual function involve more than just physical ability; psychological factors are just as
important. The aging process involves many normal physical changes, some of which naturally affect
sexuality. There is a gradual slowing of response, but women do not ordinarily lose their capacity for
orgasm.5,6 During menopause, women may experience a variety of conditions that cause changes in
sexual function. These changes include diminished sexual responsiveness, dyspareunia (painful
intercourse related to estrogen deficiency), decreased sexual activity, decreased desire, a
dysfunctional male partner, or lack of a partner.7 When assessing disorders of desire, answers to the
following questions will provide important clues:
What is the nature of the patient's current sexual activity? Is there an identifiable event associated with loss of desire? How much
disparity is there between the patient's desire and her partner's? It is the issues surrounding a woman's autoerotic behavior, her
own sexual thoughts, dreams and fantasies, and masturbation, which define a woman's libido that need to be examined. Is the
problem really lack of interest or is it anger, fear of rejection, or negative messages partners give to one another? Is the lack of
desire selective? Is the underlying effort to remain sexually aloof a way to punish or control the partner? Have there been
attempts to solve the problem?
It is important to determine if there is a surgical event connected to loss of desire. Women who can clearly define their sexual
\drive through issues of fantasy and desire, and who can say there was a specific drop associated with a specific medical event,
are very likely to respond to androgen therapy.8
There are a number of medical causes of decreased libido. These include acute and chronic illness, fatigue, malnutrition, alcohol,
drugs, stroke, pituitary disease, renal disease, depression, and testosterone and estrogen deficiency. Traumatic deliveries can also
result in chronic dyspareunia and incontinence, both affecting sexual relations and satisfaction.
Possible Medical Causes of Decreased Libido
• Illnesses Virtually any illness (genital or general; physical, emotional, or both): liver, renal,
cardiac or hormonal disease, cystitis,
• anemia, hypertension, stroke, cancer, neurologic disease, colostomy, neostomy, bladder
surgery, incontinence, herpes virus or
• HIV infection, gonorrhea, venereal warts.
• Medications Antihypertensives, antineoplastic drugs, some antidepressants, (including
selective serotonin reuptake inhibitors),
• major or minor tranquilizers (depending on dose), diuretics, antihistamines.
• Treatments Major surgery (hysterectomy, mastectomy, cardiac bypass, organ transplant),
dialysis, radiotherapy, chemotherapy.
There are also interpersonal causes of disorders of desire. These include reduced sexual attractiveness
of patient or partner, boring sexual routines, situational disturbances, and marital adjustment
problems. Contrary to popular belief, marriages do not increase in emotional intimacy with time.9 It is
not uncommon for a couple who were very sexually active in their twenties to lack emotional intimacy
in their forties. The kind of emotional intimacy that leads to desire is often lacking in long-term married
relationships.
In disorders of desire, 90 percent of it has to do with the relationship. However, 10 percent of it may be related to decreasing
levels of testosterone. The biggest question to ask in evaluating disorder is whether the patient has had desire in the past,
including autoerotic behavior and fantasies.