Menopause: Baby Boomers’ Next Step : Health: Thirty million women are on the verge of the change of life. Although some will suffer little, others are facing challenges their mothers never dreamed of.

When Susan Leary turned 40, she found herself wondering out loud with a friend about what her biological clock would bring in the next decade.

“I said, ‘Gosh, when do women go through menopause? And she goes, ‘Well, I don’t know.’ And then I asked a couple of other friends. No one seemed to know--and these were all women in their 40s,” the San Francisco health care executive said.

“I don’t really know what to expect,” Leary said. “Is it like chronic PMS (premenstrual syndrome)? Or are you going to be depressed for 15 years, or what?”

If U.S. demographics have anything to do with it, Leary can expect to hear a lot more about what is in store for her over the next few years--for she is at the leading edge of a U.S. “meno boom.”

More than 30 million women in the baby boom generation, born between 1946 and 1965, will pass age 40 over the next two decades.

This middle-age milestone marks the beginning of a decade in which the estrogen trigger of a woman’s reproductive system gradually weakens. Menopause, when the signal gets so weak that menstruation stops, occurs on average at age 51.

The baby boomers’ aging will increase by more than a third the number of women most immediately affected by menopause, the group 45 to 64 years of age, the U.S. Census Bureau predicts. And with more and more women postponing childbirth, many of these women may be dealing with the stresses of rearing children and teen-agers at the same time their bodies are, in one sense, winding down.

The good news for this wave of women approaching menopause: A healthful life style and thoughtful medical care during the “peri-menopausal” time in a woman’s 40s can make the change of life easier and assure better health in old age.

The bad news: There still aren’t very many health practitioners geared to give women a comprehensive approach to mid-life health care.

Indeed, in the Los Angeles phone book only two gynecologists even mention menopause in their advertising listings.

Yet the decline of estrogen in a woman’s body has profound physical effects--notably increased likelihood of heart disease and osteoporosis--that some believe could be eased or even avoided with better diet, regular exercise and preventive health care in the years immediately preceding menopause.

“Most of the problems we encounter in menopausal women are actually due to poor life style and possibly neglect in the earlier pre-menopausal years,” said Dr. Morris Notelovitz, who runs one of the few pre-menopause clinics in the nation in Gainesville, Fla.

“Age 35 is sort of a turning point because from that point onward most body functions (such as bone formation) start decreasing at roughly 1% per year,” he said. “So if we measured a woman’s bone density now and found it was deficient, we could start doing something so she wouldn’t have that drop-off in bone mass between age 35 and age 50.”

Notelovitz is among those who want the climacteric--the two to three decades around menopause, or roughly ages 40 to 65--to gain recognition as a specialty in gynecologic or internal medicine.

Ideally, in this framework, a woman’s medical care would involve a well-defined series of medical specialties throughout her life: first pediatrics, then obstetrics, climacteric medicine, and finally geriatrics.

Even if the climacteric does not become a formal medical specialty, its validity as a field for medical concern was cemented in September when 400 health professionals and activists met in New York to form the North American Menopause Society.

“This isn’t a trend,” Notelovitz said. “This is a discipline. It’s a science of middle age and aging.”

Estrogen is the dominant sex hormone that a female begins producing at puberty. Each month, estrogen levels rise as the uterus is prepared for ovulation and potential pregnancy, then falls when the egg is not fertilized and the menstrual period begins.

By around age 40, though, the number of immature eggs in the ovaries has degenerated extensively, cutting down on estrogen production by the cells surrounding them. Estrogen levels begin a peri-menopausal decline. This fall is less precipitous in obese women--who also suffer fewer menopausal troubles overall--because estrogen is also synthesized in fat.

When the estrogen level falls low enough, menstrual periods stop, although ovulation can still occur sporadically even after menopause.

The general rule of thumb is that the more problems with pre-menopausal symptoms a woman’s mother or grandmother had, the more she will have. Symptoms can include irregular periods, more rapid bone degeneration that could lead later to osteoporosis, vaginal infections or atrophy, dry skin and irritability.

Most discouraging: Doctors still aren’t sure whether some of the more notorious symptoms--irritability, mood swings and depression--are actually linked to the climacteric or are purely individual reactions to other life stresses.

The manifestation that sends peri-menopausal women to the doctor most often is the hot flash, a wavelike sensation of heat in the upper body accompanied by profuse perspiration.

They can occur as often as every 45 minutes and last about three minutes. In 80% of women, hot flashes occur for more than a year; at least a quarter of women have them for more than five years.

But this natural, if sometimes difficult, process of ending a woman’s reproductive years is fraught with ignorance, confusion and folklore.

“I kept thinking, ‘I don’t want to go through menopause.’ To me, that signaled becoming an old lady,” said Scottie Hotchkiss of her own attitude after she began having regular hot flashes late last year, when she was 51.

It took a few months before she could admit to herself that she needed medical help in alleviating the hot flashes so she could sleep at night, the Yuma, Ariz., psychotherapist said.

Dr. Cynthia A. Stuenkel, who directs the UC San Diego menopause program where Hotchkiss went, traces menopause’s negative image back to the turn of the century. It wasn’t until then that most women lived long enough to experience menopause, she notes.

“So you can imagine that if you knew that when Grandma started having hot flashes she died soon, you would start to think some pretty awful things were happening,” Stuenkel said.

The reality is that the American woman of today will live on average another 30 years beyond menopause, Stuenkel said.

Estrogen supplements--which remain controversial--and social support can alleviate the most troublesome symptoms of menopause, Stuenkel and others say.

Furthermore, these women’s health advocates suggest that better medical screening, such as exercise stress testing for heart disease, and attention to diet and exercise in a woman’s 40s would limit her need to take estrogen after menopause.

The American College of Obstetricians and Gynecologists recommends that every woman be considered for estrogen replacement therapy (ERT) to protect against osteoporosis and heart disease and to relieve hot flashes and vaginal atrophy. Estrogen should not be given, however, if a woman has breast or uterine cancer, blood clots, high blood cholesterol, hypertension or liver disease, the college says. Most estrogen replacement therapy in the United States includes the hormone progestin, to prevent endometrial cancer.

Only 10% to 15% of menopausal women are taking estrogen replacement therapy, said gynecologist Dr. Sadja Greenwood of San Francisco. However, among upper middle-class women the percentage appears much higher, she said. Author of the book “Menopause Naturally,” Greenwood consults and lectures on the climacteric.

“I go and talk a lot about menopause in wealthy Marin County. If I have an audience of 200 people, at least 3/4 of the audience is on estrogen,” she noted.

But these same women also express concerns about recent research indicating that estrogen replacement raises the risk of breast cancer, Greenwood said.

Swedish researchers reported in August that taking estrogen and progestin for six years or longer raised breast cancer rates to four times what they were in women who did not take the supplements.

Estrogen also is known to increase the risk of gallbladder disease.

More immediately troublesome to a woman approaching or passing menopause, however, is concern about emotional symptoms that are the source of much discussion among researchers.

If a woman is depressed during the peri-menopause, researchers ask, is it because of her hormonal changes or because of life stresses?

A Massachusetts study by epidemiologists Sonja and John McKinlay concluded after interviewing 2,500 women that middle-aged women were no more likely to be depressed than other women. It discounted the notion that women routinely experience menopause as a negative event.

However, even those who promote menopause as a liberating time in a woman’s life say women commonly report emotional problems as they near it.

“It’s like trying to assess pain. Not everyone experiences the same stimulus in the same way,” said San Francisco psychotherapist Sallie Olsen, who emphasizes women’s issues in her practice.

Furthermore, a woman’s attitude toward menopause and how much information she has about it make a difference in how she experiences the process, Olsen said.

The debate over what is responsible for these symptoms is occurring with very little solid information, contends Dr. Peter Schmidt, chief of the reproductive endocrine studies unit at the National Institute of Mental Health.

“People have spent a lot of time investigating what the menopause isn’t. And I think it’s time that we open our eyes more and look at what’s actually there,” Schmidt said. The unit has established a menopause clinic and is tracking hormone levels and behavior and mood swings in peri-menopausal and menopausal women, he noted.

The emotional tangle could get even more complicated for peri-menopausal baby boomers whose children are still quite young or--perhaps worse--are entering their teens.

“One thing we are seeing is that, particularly as women are postponing childbearing, you have a 50-year-old mom and a 12-year-old daughter,” Stuenkel said. “So the little girl is going through puberty, Mom is going through menopause. There are all these raging hormones within the household.”

“Bringing up teen-agers is one of the more difficult things in our society to do,” Greenwood said. “And when you’re younger and have plenty of energy, that’s one thing, but when you’re going through menopause, it becomes more and more difficult. And I’ve seen that with lots of patients.”

Clearly, though, sorting out the physical from the emotional and dealing with each adequately is a complex task requiring much time and cooperation between physician and patient.

This is where the few menopause clinics in the U.S.--there are perhaps half a dozen full-fledged clinics--feel they are providing a service that is rarely available elsewhere.

In San Diego, women go through a half-day session getting basic information about the climacteric that they can use in making decisions about their own therapy. Sonia Hamburger, who directs the educational/social support services offered at UCSD’s menopause clinic, operates a “hot flash line” that women can call when they need emotional support.

Stuenkel then spends a full hour with each patient, taking detailed medical history and evaluating the need for tests such as bone density measurements for osteoporosis. For now, this unfortunately represents a “luxury service” in medical care, she said.

At Notelovitz’ clinic in Florida, doctors give each woman a full physical, mammogram and cholesterol profile, and encourage a bone density measurement and exercise stress test. Specialists available at the clinic include physicians, a psychologist, a nutritionist, physical therapist and an exercise physiologist.

One important evaluation is of muscle strength, Notelovitz said. A sedentary woman might be prescribed three months of exercise on resistance training machines before beginning regular aerobic exercises, so her joints and bones aren’t hurt.

“I tell them not to worry so much about their total weight but about how much lean body (muscle) mass they have,” he said.

Notelovitz believes these evaluations should be done between age 35 and 40, and favors the one-stop shopping approach as easiest for women.

“I don’t care who does it, whether it’s the internist or the gynecologist, but somebody has got to look at the patient as a whole,” he said.

A difficulty with the kind of comprehensive health evaluation that climacteric specialists are urging is its cost. In a peri-menopausal women who has no evidence of disease, it is difficult to get insurance companies to pay for exercise stress tests or bone density measurements, Notelovitz noted.

So that often means a woman who comes to his clinic has to pay for a bone density test or an exercise stress test herself. “I tell them it is an investment in themselves to spend this money,” he said.

Having educated herself and located comprehensive, thoughtful health care, a mid-life woman can be free to anticipate what anthropologist Margaret Mead referred to as her “post-menopausal zest.”

“Women can look forward to 30 possible years of doing whatever they feel like doing,” said Hamburger. “Of really being in charge of their lives for the first time, of not having to deal with family problems or family situations, of just enjoying almost a third of their lives.”

SIGNS OF APPROACHING MENOPAUSE

The average woman reaches menopause, or cessation of menstration, at approximately age 50. However, some of the symptoms of menopause can occur several years earlier and continue for a few years after the onset of menopause.

Hot flashes or hot flashes: these may begin a few years before menopause, and are felt from 75 to 80% of women. Flashing starts in the face, neck or chest and spreads to the rest of the body. It is characterized by a sensation of heat, increased heart rate and sweating, and may be followed by chills.

Irritability and depression, but there is controversy over their origin. Many researchers say they result from major life changes women experience in their 40s or sleep deprivation caused by hot flashes, rather than from hormonal changes.

Estrogen released by ovaries decreases. Ovulation stops or becomes infrequent. Periods may be scantier or heavier, and the length of the cycle often varies.

Pain in joints.

Tingling, prickling or creeping of the skin.

PREDICTING MENOPAUSE

Women could be better prepared for menopause if they only knew when it was coming. Unfortunately, that knowledge is not available.

Researchers have considered many possible predictors: age of menarche, use of birth control pills, age at first pregnancy, age that a woman’s mother began menopause--all to no avail. The average age of menopause probably has not changed since antiquity. The average age remains 51.

Consider menopause as a natural part of life. Anxiety accompanies change. Also, keep in mind that every ache and pain is not associated with the “change of life.”

The best way to cope is to stay active and healthy. If you think menopause is approaching, note your symptoms on a calendar. Do they occur in a pattern? Have your periods been irregular over several months? This approach can help you identify the onset of menopause.

Source: Mayo Clinic Health Letter, Rochester, Minn. 55905

OVARY REMOVAL’S IMPACT ON MENOPAUSE

Natural menopause occurs gradually. Some women observe no symptoms beyond the loss of their monthly menstrual periods.

But women who have had both ovaries removed by surgery or destroyed by radiation or chemotherapy experience menopause suddenly, and with drastic symptoms.

These women have twice the rate of depression of those who undergo natural menopause. They are at significantly greater risk for heart disease. Their hot flashes and vaginal dryness may be more intense. Removal of both ovaries, called an oophorectomy, often accompanies a hysterectomy.

Fortunately, estrogen replacement therapy can relieve many problems associated with these forms of early menopause if no coexisting disease (such as breast cancer) precludes its use. Removal of the uterus eliminates the need for the progesterone component, since endometrial cancer is no longer a risk.

Source: Mayo Clinic Health Letter, Rochester, Minn. 55905