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Dr. Bernard Presser D.C.
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Hormone replacement therapy (HRT) derived from horse urine and/or manufactured chemicals were, for many years, considered "the treatment" for menopause. Annual prescriptions amounted to about $90 million a year. Many women were leery about taking such drugs and/or didn't like the side effects. Many others were afraid not to take HRT, believing they would dry up like an old prune, get heart disease, cancer, or osteoporosis, and cease enjoying sex if they didn't take hormones. Many clamored for HRT due to hot flashes they experienced.
Then came the crash. Studies began to show that HRT causes the very things it was supposed to prevent! HRT increases the risk of breast and uterine cancers, blood clots, heart disease, abnormal vaginal bleeding, stroke, and more. Women who discontinued using HRT are more likely to experience night sweats, hot flashes, pain, and stiffness-especially if they experienced them before starting to take hormones. HRT did not "cure" the complaints of menopause-it only delayed some of them, plus added risks of more serious conditions like breast cancer. Although hormone therapy may reduce fracture risk a little, the detrimental consequences of HRT far outweigh this possible benefit. Overall, HRT "was not beneficial to overall health;" it was "a national and international tragedy" caused by the greed of the drug industry seeking constantly increasing profits. After being scared off HRT, women are now seeking alternatives.
The search is often for another drug or drug-like magic bullet. There is a tendency to "medicalize" menopause. A panel convened by the National Institutes of Health pointed out that, "There is a great need to develop and disseminate information that emphasizes menopause as a normal, healthy phase of women's lives and promotes its demedicalization." Now they tell us after decades of hormone prescriptions! Menopause is not a disease. It is a transition just like puberty is a transition. Menopause is simply a natural part of the female aging process. This doesn't necessarily mean decrepitude and dilapidation! Many "symptoms" attributed to menopause may be the result of aging, but they may also be due to other disturbances or disorders that can be tackled, at least to some extent, by lifestyle changes and other health-promoting strategies. i
There's a lot of confusion about menopause. Much is known, but much is assumption or conjecture. The range of advice is chock-full of contradictions. The term "menopause" comes from Greek words "meno" (month) and "pause" (to end). It's the end of the cycle of monthly menstrual bleeding. Technically, a woman is menopausal when she has gone a full year without menstruating. There are basically two views of menopause. The first is that hormone levels prior to menopause are normal and women who have gone through menopause are hormone deficient. This has been the medical theory for over 50 years-‘let's keep these unfortunate women young and sexy by giving them hormones.' The other view is that menopausal women are normal and Nature did not make a mistake by sending them through menopause. This is the perspective taken here.
There are several ways a woman may go through menopause, and hormone levels can be quite different along each route. First is natural menopause wherein a woman simply stops releasing eggs every month and the levels of hormones slowly descend over several years. There is absolutely nothing wrong with the ovaries. As Susan Love, MD, says, "the ovaries don't quit, they just change careers." Natural menopause has no major impact on health or health behavior. It's normal. It's time to stop having babies and move into another life stage. The timing is influenced by genes-the age your mother experienced menopause may give you an idea of when you might do so. The second way to menopause is by having a hysterectomy (removal of the uterus) and/or oophorectomy (removal of the ovaries)-either way, there is a significant, sudden change in hormone levels. About one-third of American women have had hysterectomies at an average age of 44. Most are unnecessary, but that's another subject. The third form of menopause is one in which a woman's ovaries haven't run out of eggs; they have "run out of gas" so to speak. The ovaries aren't functioning up to par along with, perhaps, other glands, organs, or tissues that affect the ovaries. This form of menopause is premature. A 2005 study showed that 40% of women with premature menopause had inflamed ovaries, indicating an unhealthy condition.
Natural menopause is not an illness or medical condition requiring hormone replacement. Menopausal women don't make as much hormones as women before menopause because they no longer need to. Menopause does not cause arthritis, heart disease, osteoporosis, cancer, or other chronic ailments. Rather, it is a natural progression, a woman's rise to a higher level of maturity, the beginning of a rewarding time of life. If there are bumps along the way, they can often "be facilitated with self-care measures". Symptoms of imbalances or disturbances, including worsening of already-existing ailments, can often be assuaged. However, natural remedies mean the woman, herself, must take responsibility-whether cleaning up her diet, addressing psychological issues, starting an exercise program, taking herbs and/or supplements, getting enough sleep, or whatever.
Menopause cannot be defined by averages. Although eventually every woman's production of estrogen and progesterone will take a dive, what this means individually will vary. Some women breeze through menopause without difficulty. One woman may have only a general sense of emotional fragility, while another woman may experience incontinence, itchy skin, and painful intercourse. One gal may feel fatigued and have difficulty sleeping due to hot flashes. For another, menopause may be a continuous nightmare of symptoms. If there are symptoms (yes, some women don't have any), "they are as individual and unpredictable as one's fingerprints." Each woman enters menopause with a unique hormone balance-or imbalance-and tissue sensitivity which can determine her reaction to the change. Menopausal symptoms even differ markedly between racial and ethnic groups. And, what a woman does in the years prior to menopause can have a huge impact.
Perimenopause is the term used for what many women would call "being in" or "going through" menopause; this period may begin as early as age 35 to 40 and continue through actual menopause, usually around age 50 or 51. Premenopause is the time before menopause, a part of perimenopause. Postmenopause means you have passed through menopause. The whole thing could just as well be called "before, during, and after the change!"
Symptoms usually occur during perimenopause and can include (but are not limited to) hot flashes, menstrual irregularities, night sweats, vaginal dryness and thinning, skin changes, fatigue, decreased sexual desire, breast soreness, mood swings, weight gain, nausea, depression, anxiety, changes in memory and cognition, sleep disturbances, hair loss from the head, acne, heart palpitations, headaches, dizziness, facial hair growth, urinary tract "infections", the onset of bone loss, cholesterol changes, and so on. They can be mild, moderate, or severe. Some women may experience only slight changes, while others may have escalating health problems over time. Symptoms often stop with menopause, but not always. Only about 15% to 20% of women report symptoms that seriously hamper their lives. But 85% get hot flashes and 90% notice changes in their menstrual periods. Cycles get shorter or longer; flow becomes heavier or lighter; more cramping; more or less PMS; or all of the above at different times. No symptom or laboratory test is accurate enough by itself to determine whether a woman is in perimenopause. Hormone tests don't always provide answers because, during perimenopause, most women have subtle changes in hormone levels that fluctuate during the month, and these are difficult to interpret. Your own personal history and circumstance must be the determinant factor.ii
Starting at puberty, the ovaries produce estrogen, which prompts the multiplication of cells and the buildup of the lining in the uterus during the first half of the menstrual cycle. Estrogen in the bloodstream bathes the brain's hypothalamus, which signals the pituitary gland to release two hormones-follicle-stimulating hormone (FSH), which helps the egg follicle to ripen, and luteinizing hormone (LH), which causes the egg to mature and be released from the follicle. FSH travels through the bloodstream to the ovaries and "tells" the immature eggs to mature and make estrogen. Some eggs start to mature until one of them gets a lead and becomes the next egg that will "hatch," so to speak. The estrogen released "tells" the uterus to thicken its lining. The elevated levels of estrogen signal the hypothalamus and pituitary so that FSH production is stopped-the ovaries have already gotten the message. About 14 days after this begins, the hypothalamus tells the pituitary to spit out LH, which "tells" the mature egg to burst out of the ovary and to move down the fallopian tube. Once the egg is released, the empty follicle in the ovary produces both estrogen and progesterone. Progesterone signals the brain, via the hypothalamus and pituitary, to stop the ovaries from producing estrogen, which slows the multiplication of cells in the uterine lining. Progesterone also nudges blood vessels to grow in the uterine lining to prepare for pregnancy. If the egg isn't fertilized, estrogen and progesterone levels drop, the uterine the lining is shed, and you get your menstrual period. Then the whole process begins again.
That's how it goes-all other things being balanced and healthy-until perimenopause starts. At that point, the ovaries don't respond as much to FSH. If they don't make as much estrogen, the signal to the brain to stop making and releasing FSH is diminished, and so levels of FSH shoot up. When and if the ovary does respond, all that extra FSH can prompt a high surge of estrogen. During perimenopause, fewer follicles exist and the process of egg maturation becomes a bit erratic. You'll have cycles in which a mature egg is not produced-ovulation doesn't occur-and the length of the cycle is unpredictable, as are the amount of bleeding and the range of symptoms. As you have more "anovulatory" (without ovulation) cycles, your levels of estrogen and progesterone (and even testosterone) slowly drop. This continues gradually until menopause, when there are no longer any viable eggs and hormone production diminishes. Hormone levels fluctuate for a while-it's hormone havoc-and it's these hormonal changes that can trigger some of the afflictions associated with menopause.
Once a woman is menopausal, estrogen levels stay down and FSH stays high. But throughout perimenopause, hormone levels can be all over the map and jump up or down even within minutes. The decline in hormone levels is thought, medically, to contribute to most afflictions associated with menopause-from hot flashes to heart disease.
Hormones are complex and powerful substances. Minute amounts can induce profound changes. Estrogen and progesterone can elicit responses from hundreds of tissues in a woman's body, either directly or indirectly. Most parts of your body have "estrogen receptors" including the breasts, heart, lungs, brain, and immune system. No wonder fluctuations can produce changes and symptoms! However, large fluctuations may reflect underlying disruptions that relate to the ovaries, other glands, and/or other conditions. These underlying disruptions may be due to poor nutrition, toxins, stress, lack of fitness, and other health issues. Good nutrition including herbs and supplements can help ease complaints like cramping, breast tenderness, bloating, food cravings, irritability, and others. Fitness can significantly decrease problems such as breast cancer, heart disease, and osteoporosis. Mind/body techniques can reduce symptoms such as mood swings, night sweats and hot flashes. So the drop in estrogen and progesterone may not be the only cause for afflictions linked to menopause. Even if a deficit in hormones is involved, there are other ways to help the situation besides drugs. It has even been shown that women who struggle with the current deprecating view of menopause, women who experience panic, sorrow, or denial due to the implications of menopause-in short, women who have a hard time accepting the transition-have more physical and emotional symptoms than women who are able to process what they are going through.
Dr. John Lee contended that the lack of progesterone during perimenopause is the crucial factor. Each time you go through a cycle without ovulating, he said, you miss making progesterone that month. He felt there is too much estrogen and not enough progesterone to balance it-that's what produces symptoms. His solution was a synthetic progesterone cream (called "natural" progesterone because it's chemical composition is like the body's hormone) to be rubbed onto the skin. But there are questions and doubts about this approach (see Part II). Other researchers think the basic problem has to do with the fluctuation in estrogen levels, not progesterone. The fact that estrogen drugs alleviate symptoms like hot flashes gives them impetus. But this doesn't provide all the answers either. The medical trend is to seek one cause (drugs) that has one effect and only on symptoms. Real people aren't that simple.
Recent research is providing a more complex and complete picture. Whereas the onset of menopause was thought to be caused solely by depletion of eggs and ovary "shut-down", it is now known that the central nervous system is also involved. The hypothalamus and pituitary glands become insensitive to estrogen. The scenario developing is that many areas of a woman's body, from the brain on down, determine that it is time to stop having babies, to enter into another phase of life. It's not just the ovaries and the estrogen/progesterone!
Sometimes menopause is described as "ovarian failure." This isn't really accurate. Women stop manufacturing eggs to be fertilized, but this isn't the only function of the ovaries. Actually, the ovaries continue to function throughout a woman's life (unless something interferes). For example, the inner part of the ovary, the stroma, responds to LH at menopause, and produces androgen hormones that can be converted into estrogen-like hormones. The adrenal glands also produce small amounts of androgens that can be converted by an enzyme-found in muscle and fatty tissues-into estrogen. Thus, a woman's body continues to make estrogen, albeit at lower levels. There is a 40% to 60% reduction of estrogen production by the ovaries after menopause, but what they do produce, in addition to what the adrenals, fat and muscle tissues produce, can be quite sufficient to support the skin, libido, bones, heart, blood vessels, and any other area normally affected by estrogen. An elderly woman who keeps a youthful appearance and vitality is producing the amount of estrogen she needs.
Reasons for symptoms during and after perimenopause include abnormally low levels of estrogen and/or progesterone, hormone imbalance, and lack of hormonal synchronicity. The hormone "dance" is intricately programmed. Anything that disrupts it can result in things going "wrong." In the hormonal "dance" every hormone and many other substances affect all the other hormones and associated substances or tissues. When the ovaries, adrenals, and other hormone-producing glands and tissues are functioning normally, they all work together to balance all the other hormones, which, in turn, affect just about every tissue in the body, even though there are adjustments to be made. If the hormonal "dance" is disturbed, then this transition can mean chaos and disorder rather than a smooth, cohesive, synchronized change. Hormones inform every cell what is happening inside and outside the body. So, if all the hormones are balanced, then there is flexibility in the system. The hormones can "dance" with each other, compensate for changes in other hormones, and interact with other tissues and glands to maintain equilibrium. Estrogens, for example, interact with other hormones so that levels change from day to day and even from minute to minute, depending on needs and circumstances.
Women are often told that, once they are menopausal, the uterus is no longer needed-that it's just a "baby carriage" that can now be disposed of. Not true. The uterus produces a hormone called prostacyclin which has many protective functions and no synthetic replacement. The uterus also prevents prolapses of internal organs.
Surgical removal cuts off hormonal communication with the ovaries, so that, within a few years, the ovaries atrophy and stop producing hormones. Some experts believe that, in general, a hysterectomy is never necessary unless a woman has cancer. iii
Hormonal balance is affected by a number of other factors besides age. Liver health, adrenal gland health, thyroid function, stress, diet, exercise, toxic exposures, and other aspects can and do affect estrogen and progesterone levels and functions. A woman may be able to go for years without exhibiting any major effects from an unhealthy lifestyle, but the payoff is often symptoms in the perimenopausal years. Many symptoms associated with menopause can come from other causes, including poor nutrition, worry about not being young or desirable any longer, stress from taking care of aging parents, and any number of other factors.
The liver has many jobs, one of which is to convert hormones into forms the body can use and/or break them down so they can be properly excreted. Many afflictions blamed on low estrogen may actually be a problem with the liver rather than with the hormones Nature provided for feminine features and functions. If the liver cannot convert the hormones or break them down properly, then problems can develop.
Adrenal gland fatigue is common in women going through perimenopause due to the extra duty demanded from them during this time. Rapidly changing hormone levels and imbalances that may occur make it more difficult for women who have inadequate adrenal "bank accounts". Adrenal hormones like epinephrine and cortisol-stress-reaction hormones-play important roles in the menopausal process. The adrenals are also called upon to make estrogens. So it would be prudent to assure there is sufficient adrenal function and that its assets are not being foolishly spent. When the adrenal bank account is depleted, the body can't respond properly to outside stressors, including the stress of fluctuating hormones. And the adrenals are then not able to help produce the required amount of estrogen that would otherwise be synthesized during this transition and thereafter. DHEA, an adrenal hormone that affects several hormone parameters and is associated with "anti-aging" effects, was shown to have similar effects as HRT on growth hormone-releasing hormone. Nutritional support to adrenal health-in addition to relaxation techniques-can reduce stress, help replenish adrenal performance, and counter many detrimental effects associated with menopause. Chronic daily stress can actually impair the production of estrogen by the ovaries as well as by the adrenals and fat tissues. Tension, nervousness, irritability, anxiety, and sleeplessness have been linked to lower estrogen and progesterone levels.
Extreme weight loss can lower levels of estrogen because estrogen is produced in fatty tissues as well as the ovaries. A sudden or severe weight loss can speed up the transition into menopause or increase symptoms during perimenopause. About 66% of postmenopausal women have enough fat for making sufficient estrogen during their postmenopausal years up to at least age 80. Thin women make less estrogen due to less body fat. Following a low fat diet-ingesting insufficient fat-can result in decreased estrogen and/or progesterone. The body is deprived of good fats it needs to stay healthy and manufacture required hormones. A high intake of fat is associated with higher serum levels of estrogen and other steroid hormones, even in postmenopausal women.
These days we are surrounded by hormone-disrupting chemicals-from plastics, pesticides, detergents, furniture, carpets, electronics, and cosmetics. From dioxins in chlorine-bleached paper to solvents in Styrofoam, exposure to hormone disruptors is so common that researchers have found them in household dust. Even chemicals (called perfluorinated compounds) that keep water from soaking into raincoats, grease from sopping through microwave-popcorn bags, and foods from sticking to cookware can act like fake estrogen. Most of these chemicals can be avoided once we learn where they are found.
Foods can also contain chemicals that disrupt hormones. High up the food chain, animal-source foods have more problem contaminants than do plant foods. Residues of growth hormones are found in meats and milk products. Animal feeds are laced with pesticides, many of which are hormone disruptors, and often contain rendered fat (often adulterated with melted plastics and other substances). Large fish with a high fat content or fish living near large ports as well as most farmed fish accumulate more hormone disruptors and pollutants. Using organically-raised meats, poultry, eggs, and milk products; obtaining smaller deep-ocean fish; and getting organic produce, grains, and beans are all methods to avoid hormone disruptors and other toxins. Remember, foods, drinks, supplements, drugs, or anything else you put into your body affects your hormones. Smoking tobacco can alter the breakdown of estrogen in the liver and subsequently lower one estrogen form in the blood. Chemotherapy or radiation can bring on early menopause.
Women who are "sun-deprived" appear to become menopausal 7 to 9 years earlier than women who get regular sun exposure. We spend most of our time indoors and have been warned about so-called dangers of natural sunlight, another medical hoax. Now more studies are showing that, not only does the sun protect us from many cancers and is the best source of vitamin D needed for everything from bone and cardiovascular health to immune response, but the sun has the potential to modulate many other diverse biological phenomena, including "neuroendocrine mechanisms"-nerve, gland, and hormone workings-including those of the ovaries. Excessive or very heavy physical activity can lead to an early (premature) menopause due to some disarray in female hormone balance. A classic example is the female athlete who stops menstruating. Older women who exercise too hard or too much may become menopausal too early or suffer symptoms of estrogen disruption.
Menstrual bleeding irregularities can develop in some perimenopausal women due to widely fluctuating and decreasing levels of hormones. If this becomes serious, professional help should be sought. Very often an improved diet and some supplements will help. For example, blood-cell development requires vitamins B6, B12, folic acid, and E complex; iron may need replacing too. Vitamins A and E complexes promote the health of reproductive tissues. Magnesium, vitamins C, E, and B complexes help keep blood vessels flexible and supple. Many of these and other nutrients aid in hormone synthesis and balance. Essential fatty acids are essential for hormone production, muscle contraction, blood vessel dilation, and the shedding of the uterine lining. Chlorophyll contains fat-soluble vitamins, magnesium, and other healing substances that can slow excessive bleeding and support repair of tissues involved. Herbs such as shepherd's purse, chasteberry, and dong quai may affect glandular functions, stabilize blood vessels, regulate menstrual functions, and ease heavy bleeding.
It used to be thought that menopause caused rapid bone loss for several years and that taking estrogen during this time would prevent it from occurring. But it's now known that, for most women, it's increasing age, not menopause, that increases bone loss. About 50% of bone loss occurs in premenopausal women. During several years of perimenopause, 3% to 4% of bone may (or may not) be lost, but after that it slows down to 1% a year. Yet many steps can be taken to prevent or at least slow the loss of bone. Bone mass can be rebuilt at any age! Many women live to be quite old without ever developing osteoporosis. A number of nutrients and physical activity can assist, but this is a separate subject. Just one tidbit: The trace mineral boron, given to post-menopausal women (3 milligrams a day), resulted in a rise in estrogen equivalent to "levels found in women on estrogen replacement therapy." Less calcium was lost through their urine by 40%. Boron is essential to healthy, strong bones. Dark green leafy vegetables, fruits (not citrus), nuts, and legumes all contain boron.
Another ailment associated with menopause is heart disease. Yet the evidence shows that heart disease is largely determined by diet and lifestyle, not necessarily by menopause. Good nutrition and exercise are big preventives and benefactors. Omega-3 fats, garlic, vitamins E, C, and B complexes, calcium, potassium, magnesium, phytonutrients, and many other foods and nutrients are beneficial. A diet of whole, natural foods that minimizes processed, refined, adulterated, chemicalized, altered nonfoods will go a long way to prevent cardiovascular disease. Women who smoke should be encouraged to stop.
Although depression is associated with the transition to menopause and its changing hormonal milieu, the evidence has been inconsistent and difficult to interpret. The emerging picture, however, is that some women are more vulnerable to depression-the vast majority experience no mood changes. Depression may develop even with no previous history of depression due to greater fluctuations in hormone levels (with extra stress on the adrenals and nervous system). Several studies have shown that what is occurring in a woman's life is more likely to account for her emotional state than her menopausal status. So, for most healthy, middle-aged women, menopause does not lead to emotional instability or psychological problems. Neither is menopause automatically accompanied by a decline in memory and cognitive abilities. Again, with big bounces in hormone levels, memory and complex problem-solving difficulties can develop. But this doesn't mean Alzheimer's or another form of dementia is creeping in-that's very rare. Headaches and fuzzy thinking may relate to estrogen, but studies have been inconclusive. Estrogen does increase production of acetylcholine, a chemical used in brain-cell communication. HRT failed to protect against age-related dementias; actually, it made matters worse! Sleep deprivation from hot flashes can reduce mental sharpness and productivity. Nutritional support to ovary and adrenal health as well as to mental and emotional function may smooth the perimenopausal brain journey.
What about sexual desire? Does it plummet to nothingness during or after perimenopause? Not necessarily. Studies have found that no single level of steroid hormones-not even DHEA, testosterone, or precursors to testosterone-predicts low female sexual desire. There may be some changes in the comfort level of sexual intercourse during the years immediately before and after menopause due to thinning and dryness of vaginal tissue, caused in part by lowered stimulation by estrogen. As estrogen levels decrease, the vagina shortens and narrows and the walls become thinner, less elastic, paler in color, and more easily irritated. The glands that lubricate the vagina become less active. The result is vaginal dryness and sensitivity. Decreasing levels of progesterone and estrogen cause the vulva to lose roundness and prominence. The area may itch and feel irritated. Sexual activity may become uncomfortable. Whereas young women may become sufficiently aroused, with plenty of vaginal lubrication for penetrative sex, in just a few seconds, menopausal women may take as much as 5 minutes or more. They need longer love-making! Vaginal dryness affects about 1 in 4 women after menopause. Sometimes less moisture means fewer friendly bacteria that help keep the vagina acidic. Less acidity may allow an overgrowth of candida or other yeasts to develop, causing further irritation and discomfort. Vaginal lubricants (water based) are helpful. Something as simple as unrefined coconut oil can be used.
Avoid douches, intimate deodorants, bubble bath preparations, perfumed bath products, and detergents that cause dryness. Include unrefined oils, real butter, and other natural fats in your diet. Have regular intercourse-this increases vaginal blood flow, promotes repair of cells, and stimulates secretion of mucus from the vaginal walls. Exercises that enhance blood flow to the pelvis may also indirectly aid the lubrication of these tissues.
Blood flow and nerve response can indirectly be influenced by ovarian hormones. This is why estrogen drugs can dramatically increase blood flow to the vagina and vulva. During sexual response, sensory stimulation (touch, sound, smell) is carried to the brain which, in turn, induces the cardiovascular system to increase blood flow, blood pressure, and heart rate. When estrogen levels drop, it may take longer for your body to respond to sexual stimulation. But it can and will respond! Actually, the majority of sexual problems involve both partners, not just the woman. In one study, 14% of postmenopausal women did not report any sexual problems at menopause. One-third of them had solved any sexual difficulties that did exist by finding new sex partners, on average 10 years younger than they were! Much of the desire for and enjoyment of sex comes from the mind. Fading sexual desire may be the result of a negative body image, not hormonal changes. More than 20% of women, ages 35 to 55, were so dissatisfied with their bodies that they couldn't name even one attractive feature about themselves. Two-thirds of them had or desired sex less often than 10 years ago. Menopausal status did not have a significant impact. When they did have sex, 72% said it was physically and emotionally satisfying. iv
Perimenopause is a time of change. Postmenopause may present challenges. Now that the dangers of HRT are well known, many alternative approaches have been proffered to improve or maintain health, wellness, and youthfulness. Some may be better than others. We will peer into some of these in Part 2 of Menopause.
This website has excellent nutritional protocols for menstrual and menopausal problems which are available in conjunction with the Symptom Survey. Take the Symptom Survey to discover specifically what nutrition you need for your individual health problems.
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ii Rececca Voelker, JAMA, 18 May 2005, 293(19):2329-31; Emily A Kane, ND, LAc Managing Menopause Naturally Before, During, and Forever, N Bergen, NJ: Basic Health Publications, Inc., 2004; Judyth Reichenberg-Ullman, Nat Health, Mar/Apr 1992:75-81; Bethany Hays, Integrative Med, Oct/Nov 2006, 5(5):32-5; Tori Hudson, Healthy Lifestyles, Summer 2001, Is.287:2, 10; Rosie Mestel, Health, Sept 1999, 13(7):113-8; Janet Torpy, Cassio Lynm, et al, JAMA, 19 Feb 2003, 289(7):940; Lori A Bastian, Crystal M Smith, et al, JAMA, 19 Feb 2003, 289(7):895-902; Judith Wylie-Rosett, Amer J Clin Nutr, May 2005, 81(5):1223S-31S; Kelly Morris, Lancet, 9 Sept 2000, 356(9233):916.
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Originally published as an issue of Nutrition News and Views, reproduced with permission by the author, Judith A. DeCava, CNC, LNC.