Frequently asked questions

Can you give some general information about menopause?

Menopause is defined as the absence of a period for 1 year The average age in the US for the onset of Menopause is 51 years old. The range for the vast majority of women is 47 – 55 years old, while, for approximately 6% of women, onset of Menopause occurs in the early 40′s, in the apparent absence of any disease. Menopause usually begins with the shortening of interval between periods. But really, in the peri-menopausal period, anything can happen: long or short periods, from heavy bleeding to spotting. The earliest laboratory test to become abnormal is an elevation of the FSH. Surgical Menopause is having functioning ovaries removed. Menopause starts the day after surgery with a vengeance. Menopause can also be caused by radiation to the ovaries and certain kinds of chemotherapy. Some women have no symptoms; some women develop symptoms for less than year, others for 5 or more years. The symptoms vary from life-altering to minor discomfort.

What are the symptoms of menopause?

Symptoms of Menopause can include the following: HOT FLASHES NIGHT SWEATS* DISTURBED OR LACK OF REM SLEEP* INSOMNIA* DEPRESSION IRRITABILITY MOOD SWINGS NERVOUSNESS PAINFUL SEX** DRY VAGINAL MUCOSA** DECREASED LIBIDO OR SEX DRIVE*** *Note that non-restful sleep can lead to fatigue the next day and the worsening of irritability, depression and chronic pain. **Loss of the natural lubrication can lead to painful sex. Water soluble lubricants like K-Y are helpful, but the feeling is not the same as before the Menopause. Naturally, painful sex eventually leads to a decreased interest in sex. ***Decreased libido can be the result of depression, chronic sleep deprivation, chronic pain or constant irritatibility. The decreased sex drive can also stem from painful sex as noted above. Frequently though, the problem remains once adequate lubrication is achieved. The problem is due to Estrogen’s direct effects on the brain. Decreased sex drive may worsen depression in women for whom sex was an important part of their lives and may lead to the deterioration of a long term relationship.

Can you give an overview the diagnosis and laboratory follow up processes?

Tests are available for all the hormones involved in Menopause. Menopause can be confirmed by laboratory testing when the Estradiol and Progesterone levels are low, while the FSH (Follicle Stimulating Hormone) and LH (Luteinizing Hormone) are elevated. Hormonal Treatment of Menopause can be monitored by periodically measuring the Estradiol and/or Progesterone and/or Testosterone levels. The goal of treatment is symptom relief and bringing these levels up out of the Post-Menopausal range into the Pre-Menopausal range at the lowest dose of medicine possible.

What hormonal treatments are available?

Estrogens: Estradiol is the dominant, active hormone from Puberty until the Menopause. Women are women because of Estradiol. Estradiol affects the brain, bones, heart, breast and skin. Estriol and Estrone are weaker, less important Estrogens. Progesterone: Progesterone is a counterbalance to Estrogen. If a woman still has her Uterus intact, then it is necessary to take Progesterone with Estradiol. Testosterone: Estradiol is required to restore Libido but may not be sufficient; occasionally low dose Testosterone is required

What do you think of Suzanne Summers?

Suzanne Sommers has single-handedly transformed Menopause awareness and treatment, for the betterment of millions of women. As an Endocrinologist, this is extremely embarrassing. But, in reality, we should have offered more than Premarin (aka horse piss) or oral contraceptives. We should not have told so many women to “just live with it.” Having said that, I disagree with her on several issues. Having periods forever is not necessary for good health. Suzanne Sommers advocates having periods. However, 98% of the women that I have interviewed do not want to have their periods again. Having periods after the menopause through hormone manipulation is not necessary in order to feel better. Bleeding every month is easy to arrange: just take the estrogen component of the hormone replacement therapy for the first 25 days of the month. Then take the progesterone component for the last 5 days of the month. However, the menstrual cycle is much more complicated than that and involves other hormones like FSH, LH and Inhibin acting in concert with Estrogen and Progesterone. Periodic bleeding is not the same as menstruation. Using Estrogen if you have breast cancer is probably not a good idea As you probably know, Suzanne Sommers had breast cancer. Many breast cancers (but not all) have a receptor on the surface of the cancer cells for Estrogen. This receptor is an “on” switch for the cancer to grow.

What does "compounded" mean?

Compounded simply means a Pharmacist with Compounding experience has mixed up the medicine by hand. Many Pharmacists have the training but not the experience. Years of experience are required in order to get it right every single time. Usually, but not necessarily, Compounding refers to Hormones. Compounding refers to mixing several hormones together like estradiol, progesterone and/or testosterone. Compounding refers to creams. Compounding refers to prescription medicine preparations, not made by a pharmaceutical company. With Compounding, there is, in theory, the possibility that one batch will not be the same as the next batch made up by the pharmacist. Compounding pharmacists with a lot of experience dispute this vehemently.

What's the difference between natural vs. synthetic hormones?

The term “Natural” has been used and misused almost to the point of meaninglessness. Almost everyone selling medicinals nowadays claims that their product is natural. The Pharmaceutical company Wyeth claims that Premarin is natural, since it is derived from the urine of pregnant mares. Natural, in this instance, while true enough, is not necessarily desirable. Synthetic is a little easier to define. For example, birth control pills contain synthetic estrogens, like ethinyl-estradiol and medroxyprogesterone. These synthetic compounds do not occur in nature and were designed to impart to the base molecule (estradiol and progesterone) certain pharmacalogical properties thought by the pharmaceutical company to be desirable. The bottom line is that pure Estradiol is a naturally occurring Estrogen. Pure Estradiol is the active and dominant hormone made by women’s ovaries prior to the Menopause. For various reasons, we do not collect the urine of pregnant women; therefore, in order to treat the Menopause effectively, we use preparations of pure Estradiol (whether made by large pharmaceutical companies or small Compounding Pharmacies) which are manufactured from naturally occuring compounds in Soy or Yams. I consider the best use of the term “natural” to mean “naturally occurring in Pre-Menopausal women”.

What's the difference between oral and topical treatments?

THE LIVER FIRST-PASS EFFECT When medicines, like testosterone, estradiol or progesterone are ingested orally, they are absorbed in the gastrointestinal tract and then transported to the liver. One of the liver’s most important functions is detoxification. Most of the medicine is metabolized and rendered useless by the liver. Up to 50-90 % of the oral dose is “lost” in this way. As a result, higher doses of these medicines are required to get an effect. The high dose hormones have a negative effect on the liver. High dose oral Estrogen, for example, leads to the production of liver proteins that making blood clots more likely. This negative side effect of oral Estrogen can be mitigated or avoided completely by Estrogen creams or gels.

Can you tell me more about Premarin and Prempro?

Premarin is used alone for post-menopausal women without a uterus. PremPro is used for post-menopausal women with a uterus. Premarin is short for “Pregnant Mares’ Urine”*. Premarin is a Conjugated Estrogen, a mixture of estradiol and several minor estrogens. Estradiol is the active hormone; the others are significantly less potent and unnecessary. Furthermore, many of these estrogens in Premarin are unique to horses. Horse Estrogens no longer have a role in treating humans when there are available purer compounds identical to the hormones made by pre-menopausal women. *(Premarin is farmed from pregnant mares housed in massive, crampt wharehouses (mainly in Alberta, Canada). Horses are bred, not for their speed or beauty, but for their ability to produce estrogen-rich urine. Thousands of foals and older mares no longer able to conceive are starved to death or destroyed and sold for horsemeat in Europe.) PremPro is a combination pill: Premarin + medroxyprogesterone (Provera). Medroxyprogesterone is a synthetic progesterone with side effects that naturally occurring progesterone does not have.

Don't hormones cause cancer?

In 2004, Women’s Health Initiative (WHI) created a lot of negative media attention about Hormones. A study out of the NIH in 2007 re-worked the data from the WHI and showed that, for women without a uterus, there was no increased rate of breast cancer! Despite the negative attention Hormones have received in the media, the risk is actually quite low even for women with a uterus. Furthermore, most experts agree that, for almost all women, the minimum amount of hormones required to relieve symptoms can be used for a limited period of time without harm. If your or someone in your family has breast, ovarian or uterine cancer, you should think twice about starting hormone therapy for the Menopause. If all women were given hormones tomorrow willy-nilly without much thought (which has happened in the past), then naturally the number of women diagnosed with breast cancer would increase. The idea is, of course, to target those women whose symptoms are severe enough and their risk low enough to warrant treatment. Life and medicine are a balance between risk and benefit. The uncertainty of a low risk of cancer in the future must be weighed against the potentially dramatic improvement in the daily quality of life.

What can you tell me about Tri-est or Bi-est?

Tri-Est and Bi-Est are natural, compounded and Bio-Identical but… Bi-est is a combination of Estradiol and Estriol Tri-est is a combination of Estradiol, Estrone, Estriol. While Estriol and Estrone do occur natually in pre-menopausal women, they are neither the active nor the dominant hormone in pre-menopausal women. This is only Estradiol Estriol is the dominant estrogen of pregnancy. Estrone is the dominant estrogen of untreated post-menopausal woman. The levels of Estrone are the same before and after the menopause. Estrone cannot therefore be responsible for the symptoms of the menopause. More estrone will not help the symptoms of the menopause. Both Estrone and Estriol are very weak compared with Estradiol. Tri-Est and Bi-Est both usually have a low concentrations of Estradiol (as low as just 10%) They are less effective than pure Estradiol That does not mean they have low or no risk for breast cancer, though they have been marketed in this way.

What non-hormonal treatments are available?

This list is by no means exhaustive. Prescription: Anti-Depressants, Clonidine, Neurontin These non-hormonal Prescription Drugs may or may not be effective but are not harmless: they usually have undesirable side effects Over-the-Counter: DHEA, Black Cohosh, Tibolone, Red Clover, Phyto-estrogens The Over-the-Counter remedies are usually harmless but also less effective. Non-Medicinal: Accupuncture No one can argue against a trial of Accupuncture which is completely safe and may be quite effective

Our Approach  to the Menopause

I have listened to the stories of thousands of women. I hope to reach women who suffer from symptoms of  Menopause but have been scared or misinformed by the media or other practitioners about hormones, women who do not normally have access to an Endocrinologist and women who want to hear every side of the story so that they can make an informed decision.

I advocate a sensible approach to Menopause, devoid of media hysterics. I have nothing to sell. I have no agenda. Most Internet sites hope to sell you a product and, in order to be heard above the din of the marketplace, represent themselves as the only purveyors of the truth about Menopause. As a result, extremism has become more common than common sense. Extreme point of views in Medicine are almost always wrong. There are no absolutes in Medicine, just an ever changing conception of the way things are.


Menopause is not a disease: it is a natural event in every woman’s life.

If you have bothersome symptoms of Menopause, you should be treated for them: you should not be told to “live with it”.

Hormone preparations from horse urine (Premarin) are no longer appropriate.

Synthetic hormones such as those used in birth control pills are sub-optimal.

If a close relative (mother, daughter, sister) has breast, ovarian or uterine cancer, you may want to re-consider the use of hormones.

Estradiol is the major hormone lacking in Menopause. It is the hormone that makes women, women.

It is not a cure-all but clearly helps the Brain, Sleep, Weight, Skin and Bones.

You should always be on the lowest effective dose.

You should not be on hormones forever. Treatment from 1 to 5 years with hormones is most likely quite safe.

You (and only you) must balance your fear of cancer in the long term against potentially improved quality of life now.

Estrogen is most beneficial if taken early on in Menopause, not years later.

Oral Estrogen preparations have untoward liver side effects; Creams and Gels are preferred.

If you still have your uterus, you should be treated with Progesterone in addition to Estradiol.

It is not important to have your periods back.

If your sex drive does not return with Estrogen alone, then Testosterone may be required.