ask the expert

Expert: Dr. Carlin Vickery

Partner, 5th Avenue Millennium Aesthetic Surgery
Associate Clinical Professor in Department of Surgery at Mount Sinai Medical Center

Ranked as one of NYC’s top board certified plastic surgeons, Dr. Vickery was one of the first women to train in plastic surgery and reconstructive microsurgery.  Dedicated to innovation throughout her 30 year career, she continues to use cutting edge techniques to achieving long lasting, optimal, aesthetic improvement of the breast, body and face.

Dear Dr. Vickery,

I am 49 and have terrible frown lines between my eyes.  Suffering from bad allergies (Penicillin, aspirin, Cipro and many others), and environmental substances (dander, dust, pollen), is Botox a safe option?

In all likelihood, Botox will be an excellent and safe option for your frown lines.  Reported allergic reactions are limited to patients with a sensitity to Albumin and to those who have already been exposed to Botox and have showed sensitivity.  Many patients with the allergies you describe have successfully had Botox treatment.  Discuss your concerns with a qualified physician, and if you want to be cautious, you could always have a small test dose before you have a full treatment.  Good Luck!

Dear Staness,

Confused in Connecticut

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Dear Confused,

This is a GREAT question! I was shocked at the amount of misinformation online too. The Menopause Makeover co-author Dr. Wendy Klein led me to reliable information sources.

Since menopause is a natural transition, most of us are searching for “natural” management options.

If a website is selling a product, you can bet there will be editorial material supporting their product. How do you know if you can trust what you are reading?

Enter center stage – our leading lady to save the day: science.

The word science comes from the Latin “scientia,” meaning knowledge. Science refers to a system of acquiring knowledge.

Many people associate science with the medical community, and make the assumption that alternative methods are not supported. This is not true.

There are excellent, non-commercial resources supported by science that provide sound information on alternative, complementary and medical menopause treatment options. They are not selling anything. These resources are available to provide you with information supported by scientific research… knowledge based on concerted human effort to understand, or to understand better, the natural world and how the natural world works, with observable evidence as the basis of that understanding.

The North American Menopause Society is a professional, non-profit organization. To find your answer about hormone saliva testing, go to The North American Menopause Society and enter “hormone testing.”

“Saliva testing to determine if a woman has the “right amount” of hormones has not been proven accurate or reliable. Even blood testing of hormone levels has the drawback that levels vary throughout the day as well as from day to day. More important, the desired levels in postmenopausal women have not been established. In addition, an individual woman’s physical comfort may not even be related to her absolute hormone levels.”

On any website, it is wise to read the “About Us” link so you know WHO is providing the information. Generally, non-commercial websites make that information readily available so you can see the credentials and expertise of the people who are providing your advice.

We are all different. Work closely with your healthcare provider to discuss menopause treatment options specific to you.

Dr. Klein says, “Know where your medical health information is coming from, and don’t trust the biased medical information on websites that are selling products.”

I applaud your efforts to get educated on menopause matters. Gather information from reliable sources. My favorites are listed below.

Staness

Reliable resources that are unbiased and supported by science

North American Menopause Society

National Institutes of Health

The National Library of Medicine
MedlinePlus

American College of Obstetricians and Gynecologists

Centers for Disease Control and Prevention?

Are you suffering from hopelessness, apprehension, and deep sadness for prolonged periods? If so, you may be suffering from depression. During my menopause transition I felt blue for no reason at all. I could not snap out of it, and my friends and family were mystified.

Most perimenopausal women do not experience major depression, but many have symptoms of feeling depressed, stressed, and anxious.

If you are experiencing menopausal symptoms such as severe hot flashes and lack of sleep from night sweats, it may be causing you to feel depressed. Are you in a depressed mood and feeling sad, or are you suffering from clinical depression resulting from a chemical imbalance in the brain?

I recently teamed up with leading menopause expert and co-author of The Menopause Makeover, Dr. Wendy Klein, to get the latest scientific information on perimenopausal depression.

Perimenopause Depression Interview

Staness: What are the most common signs of depression?

Dr. Klein: The most common signs of depression are feeling sad, feeling worthless and losing interest in the things that normally engage you. Having no “get up and go,” you would rather sit on the couch doing nothing than get up and do something that would normally engage you. Other symptoms include the loss of libido, changes in appetite – too much or too little – feeling very sleepy and tired and fatigued, or having insomnia, not being able to sleep. A common sign of depression is a change in your normal habits.

A more serious symptom of depression is sustained loss of interest in things that you just can’t seem to break out of, which is called dysthymia. Things seem really bleak and you just can’t quite punch your way out of this paper bag of darkness and it lingers. If it lingers or if you have thoughts that are scary, such as wanting to give up or wanting to hurt yourself or even suicidal thoughts, you must talk to your clinician because there are things that can be done to help you.

Staness: What can cause these feelings of depression during menopause?

Dr. Klein: Depression is multi-factorial. There are many factors that can cause an increased risk for depression. If you have depression in your family, a prior history of depression, and even some medications can cause an increased risk of depression. Certain endocrine disorders, such as hypothyroidism, or other illnesses, such as chronic fatigue syndrome, are also associated with depression.

Depression is an illness that can be triggered by the chemicals in your brain. Serotonin regulates your moods. It is the “feel good” hormone. When serotonin levels drop you can experience extreme episodes of depression.

You also want to look at lifestyle stressors – a change in relationship, finances, loss of a loved one, caring for parents – and consider the many modalities of treatment that are available to help you.

You approach depression in menopause the same way that you would approach depression at any other time: you first want to rule out other medical causes, or other medications that might be contributing.

Staness: Many women live with daily stress and then throw in menopause and a few medications, and it is no surprise menopausal women may suffer from depression. What depression treatment options are available?

Dr. Klein: A number of options are available, including psychotherapy, and antidepressants and can assist you if you are suffering from depression.

There are degrees of depression. Mild depression, feeling blue or sad, can be dealt with cognitive therapy, psychotherapy, meditation, yoga, eating healthfully, and exercise. We know that exercise does boost your endorphins and can lift your mood. Also, engaging in new activities may help, such as making yourself take classes, making yourself get out and do things, and enlisting the support of your family and friends.

If you have lingering or worsening symptoms, you may need medication, because we know that depression can be a malfunction of your neurotransmitters, particularly serotonin, which is the feel good neurotransmitter. Medicines can be enormously helpful, although you will want to incorporate lifestyle changes as well.

In short, if someone is experiencing the signs or symptoms of depression, there are number of things you can do. Eating healthfully, exercising regularly, and seeking support from family and friends may help. Also, you can engage in any activity that gives you a sense of achievement. It may be taking a class, taking up something new such as yoga, or trying the drawing class that you always wanted to take, or volunteering and getting outside yourself. All of these things are very useful.

If you are still feeling very stuck and sad, talk to your clinician so you can get a referral to a good psychotherapist. If you need medication, in the broader context of menopausal symptoms, there is some evidence that hormone therapy can augment treatment and help people who are on anti-depressants feel even better. That is a decision for you and your clinician.

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If you suffer from depression or someone you love is depressed, get support, visit your health care provider and discuss your options for treating depression.

Hot Flash 101

The most common and often the most irritating symptom associated with menopause is the hot flash. As many as 75 percent of women going through menopause in the United States experience hot flashes with 10% to 15% of women having severe or frequent hot flashes. I had miserable hot flashes that heated up at the most inconvenient times and sometimes flaring up every few hours. I tried every trick in the book to eliminate this miserable symptom – from herbs, to teas, to exercise, to diet, to praying hourly that they would disappear – but they persisted.

With confusing and conflicting information online and in best-selling books, I teamed up with leading menopause expert and co-author of The Menopause Makeover, Dr. Wendy Klein, to get the latest scientific information on alternative, complementary and medical options to relieve hot flashes.

Understanding available hot flash options will give you the opportunity to discuss menopause management with your clinician. This interview with Dr. Klein is the first in a series that addresses the various menopause symptoms.

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Hot Flash Interview

Staness: Dr. Klein, what exactly is a hot flash?

Dr. Klein: A hot flash is a sensation of extreme heat in the head and upper body generally associated with sweating.

We know from studying women that the internal core temperature does increase. You can a put a sensor on the skin and before a woman experiences a hot flash she will be able to tell you, “I am going to have a hot flash.” And sure enough, there will be an increase in internal core temperature followed by profuse sweating which is very uncomfortable. As you know, the purpose of sweating is to cool the body so there is often a reflex of sort of chill that follows the hot flash. It is a very uncomfortable and distracting sensation. It can occur at any time of the day. It can occur with tremendous variability, it can happen many times an hour or only just once or twice a day. Some women have one or two hot flashes a day, and get through menopause with no problems while other women have fifteen or twenty a day. We are all different.

Staness: What causes a hot flash?

Dr. Klein: We are still trying to understand exactly what causes hot flashes. We know that they are related to the hypothalamus, which is in the center of the brain and acts like the thermostat for the body. What we don’t understand is why some women are so troubled by them and others are not.

Certain women seem to have triggers. An alcoholic beverage may bring on a hot flash, or a change in external temperature can cause a hot flash for some women. In general, the hormonal flux or variation in hormone levels seems to be related to this sensation in some women.

Staness: Are there other causes?

Dr. Klein: We know that smoking is associated with hot flashes. Women who smoke have a higher risk of troublesome hot flashes, so obviously you should not smoke.

Also certain medicines can cause hot flashes such as certain antidepressants SSRI, Selective Serotonin Reuptake Inhibitors, are common antidepressants that can actually cause an increase in hot flashes. Yet, for some women, a very low dose can actually alleviate hot flashes, making antidepressants an alternative to hormone therapy.

Illnesses and fever can cause hot flashes, as can malignancies, and tuberculosis – many illnesses can cause hot flashes.

Increased BMI, Body Mass Index, has been associated with hot flashes. We used to think that women who were heavy had excess estrogen, and therefore fewer hot flashes. Now from the major study that was done in the SWAN, Study of Women Across the Nation, we know that women who are heavy, who have abnormally high body mass index, are at increased risk for hot flashes.

Staness: What’s a menopausal gal to do if she suffers from hot flashes?

Dr. Klein: The real issue is how troubled are you. Some women find that they can manage their hot flashes with simple lifestyle changes, such as wearing layered clothing, lowering the thermostat, carrying a fan, drinking cool beverages, avoiding triggers like caffeine and alcohol. Some women can have a few hot flashes a day and over time, seventy-five to eighty percent of cases the hot flashes will diminish and disappear. Then there is a subset of women for whom hot flashes are really troubling and don’t go away. Lots of women have recurring hot flashes waking them up over and over again and they can’t go back to sleep. They are not getting enough rest; they wake up grouchy, tired, and sweaty. If it is really a problem, there are hormonal therapies that will alleviate these symptoms. As you know hormone therapy can have side effects, so you must always weigh the benefit versus the risk. There are very low dose hormone therapies that are now available that can be extremely useful for alleviating hot flashes.

There are some other options to consider such as soy and black cohosh. The studies regarding soy are mixed, with some showing that soy can be helpful; while there are other studies that show soy may help with mild symptoms. Soy is benign and easily available and may be worth trying. Black cohosh is another herb and has been used in Europe widely, but you have to be careful because there have been reports of toxicity with high doses. Used in limited amounts in standardized doses black cohosh supplements may help some women with hot flashes. Again, there have been mixed studies, so whatever you do, and with anything you take, you should always discuss with your clinician.

You can also try lifestyle changes – wearing layered clothing, practice deep breathing, meditation and yoga, exercising – all of these things that can be really helpful in learning to live with the symptoms if they are moderate.

Another option to treat hot flashes is gabapentin. This is a drug that was originally developed as an antiseizure medicine. Gabapentin is widely used for pain relief, because it was discovered that with patients in whom it was used for seizures, it helped with pain. It was then found that it helped with hot flashes. Gabapentin is a reasonable alternative to discuss with your clinician if you do not want to or if you cannot take hormone therapy.

Staness: I was on birth control pills for years and had no idea I was perimenopausal until I stopped them, then the hot flashes started erupting. Are birth control pills a good option for hot flashes?

Dr. Klein: Birth control pills are a form of hormone therapy. They are a higher dose than standard menopausal therapy, but there is estrogen in most birth control pills and that keeps hot flashes away. If you are in the perimenopausal phase, birth control pills can also be useful for regulating your periods, plus they keep hot flashes away.

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Understanding the causes and solutions for hot flashes is the first step to managing your menopause. If you suffer from hot flashes, discuss your treatment options (alternative, complementary and medical) with your healthcare provider.

If you need a certified menopause expert in your area, click here and enter your zip code.

Expert: Wendy Klein, MD co-author of The Menopause Makeover

Dear Dr. Klein,

I’m really baffled as to why I’m having urinary problems now, when nothing has changed in my lifestyle except the onset of perimenopause.

Answer: Many women have recurrent bladder infections, and, as you have already learned, untreated bladder infections can track up the urinary tract and lead to kidney infections. Not good. What you can do to prevent these -

1) Stay hydrated. Keep water with you at work & drink through the day.
2) Do not delay when you feel the need to urinate! Empty your bladder regularly and do not hold your urine.
3) If possible, empty your bladder after sex. Although difficult to prove, there is anecdotal evidence that urinating after sex may help to “wash away” bacteria.
4) Have a healthcare provider dipstick your urine at the first sign of problems to rule out an infection. If your bladder is infected, white blood cells will show up on your dipstick test, indicating a need for antibiotics. If there are no white blood cells, and you are having pain with urination, this may be a sign of low estrogen, which is easily treated with vaginal estrogen tablets or cream.

Also, if there is a history of diabetes in your family, have your blood sugar checked. New onset of recurring bladder or kidney infections can be a sign of diabetes.

One of the first symptoms you may notice during perimenopause is irregular periods.

Interview with Dr. Wendy Klein, leading menopause expert and co-author of The Menopause Makeover

Staness: What is one of the first symptoms of perimenopause?

Dr. Klein: The hallmark of perimenopause, which is the phase prior to menopause, is irregularity. We all grow up thinking that when you enter the change of life and become menopausal, your periods just stop. That is not the case.

What happens is your periods start to become irregular. You can have too many periods, you can have too few, you may skip a period and then get regular again, and you may skip a few periods. You may think, “oh my, I am in menopause,” and suddenly your period comes back again.

Staness: Why does this happen?

Dr. Klein: Prior to menopause your periods are usually very regular. The amount of hormone that you are producing is very regular and predictable. However, as you approach menopause, entering the perimenopausal phase, the ovaries are unpredictable. You will have months when you don’t ovulate, and that causes irregular bleeding.

Staness: How long does period irregularity last?

Dr. Klein: How long that lasts is highly individual. Could be a year, could be two years, could be three years and that is all normal variation. I like to say that the ovaries are stuttering. You don’t always ovulate and your previous hormonal milieu begins to change.

Eventually you will experience fewer periods and finally your periods will stop. You are not officially in menopause until you have skipped 12 consecutive periods.

Staness: How does a woman know her periods are irregular?

Dr. Klein: You may get too many periods. You may get too few. You may skip them. The bleeding may become heavier, or it can become lighter.

Staness: What should a perimenopausal woman with irregular periods do?

Dr. Klein: Well the easiest thing to do is keep track of your periods. Write them down in the your calendar and track them. Keep a record of when you are having your periods and what your symptoms are, so when you visit your clinician you can discuss the changes using actual dates.

If you are troubled by irregular periods, you can discuss the option of low dose birth control pills. This can help with regulation, with excessive flow, and also with contraception.

One of the issues of which you should be aware is that even in perimenopause you can still become pregnant and since your periods are not regular you have an increased risk of unintended pregnancy. Birth control is still necessary as long as you continue to ovulate, even if you are irregular.

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Menopause is a normal and natural part of a woman’s life. Arm yourself with knowledge, build a strong relationship with your clinician and manage your menopause empowered.

Expert: Ernst Schwarz, M.D., Ph.D.
Director of Multi-disciplinary Heart Failure Research, Cedars-Sinai Heart Institute

Dear Dr. Schwarz,

Now my menopause symptoms are finally under control, something seems to be going on with my husband of 27 years. We used to have a great sex life but now his performance isn’t what it used to be. I have read that he should see a doctor to rule out any physical health issues. But what kind of doctor? And what kind of health problem could be causing this?

Although I can’t diagnose your husband based on an email, I can tell you that it might be a good idea to make an appointment with a cardiologist for a thorough check-up.

You say you have been married 27 years, so your husband probably is getting to the age when a heart check-up is appropriate. Also, reduced sexual performance capabilities can be a warning sign that a man is suffering from a heart or circulation (vascular) problem.

The main underlying cause is unhealthy changes in the functioning of the blood vessels carrying blood to the penis. That condition, called endothelial dysfunction, can be an early sign for underlying vascular diseases and conditions that can affect the heart and the brain among other organs.

Risk factors include diabetes, uncontrolled high blood pressure, elevated cholesterol and triglycerides, smoking and chronic alcohol or drug abuse. Endothelial dysfunction also can be a side effect of many medications, in particular medications to control blood pressure or treat depression.

Erectile dysfunction affects an estimated 30 million to 50 million U.S. men and can be successfully treated in most cases. But treatment requires letting your doctor know and men often shy away from admitting sexual problems to their doctors. That’s why many of my male patients hesitate to make the appointment. They finally come to see me when their wives become aware of the link between health issues and impotence and call my office to schedule an exam.