July 2004: Managing Menopausal Symptoms

How long do hot flashes last?

Question from Beth: I was thrown into menopause, due to an A/C regimen of chemo. I'm now on Arimidex and having hot flashes. Since my situation is not a 'natural' menopause, how long can I expect hot flashes to last? Duration of taking Arimidex for five years?

Answers —Mindy Goldman, M.D.: It's very common to be thrown into temporary or permanent menopause from the chemotherapy drugs used to treat breast cancer. Some of the hormonal drugs that we use to treat breast cancer can also cause menopausal side effects such as hot flashes, so that it's sometimes difficult to know if it's chemotherapy-induced menopause or side effects induced from hormonal drugs used.

Regardless, the symptoms tend to be the same. The primary complaint is hot flashes and night sweats. Often times, they're more severe than for women who go through natural menopause, because someone had previous normal ovarian function and then, "Boom!" They get put right into menopause. The length of time that women have hot flashes and night sweats varies incredibly. Some women don't experience it at all or have very few or mild symptoms, and for other women they're really disabling.

If you look at women who naturally go through menopause, more than 80 percent will have hot flashes in the first year. And by year three, they're decreasing in both frequency and intensity. And only about 15 percent of women will have hot flashes throughout their menopausal years. With chemotherapy-induced menopause, we don't have a good handle on the natural course, because many times we don't know if it's permanent or temporary menopause.

What I mean by that is when someone gets chemotherapy, it depends on the age of the patient, the type of chemotherapy, and the dose that's given that determines whether their menopause is temporary or permanent. Also, some of the hormonal drugs can affect whether someone gets a period. So it's possible that someone can actually be coming out of the chemotherapy-induced menopause but persists in having hot flashes as a side effect of drugs like tamoxifen or Arimidex (chemical name: anastrozole).

Marisa Weiss, M.D., president and founder: Also interesting, sometimes a woman who was thrown into menopause early just from chemotherapy and who notices eventual improvement in hot flashes may be having return of a period. That is, sometimes when your hot flashes ease up, it may be a sign that you will have return of your period. During the time of uncertainty relative to being in a temporary or permanent menopause, be sure to use birth control if you are sexually active.

Mindy Goldman, M.D.: If you look at drugs like tamoxifen, 25-50 percent of women will complain of hot flashes, but they tend to get better with the longer length of time being on tamoxifen. There are also some reports from women who were post-menopausal before they got their breast cancer and their breast cancer drugs, that if they had an easy time with menopause, they tend to have an easy time with side effects from drugs like tamoxifen and Arimidex.

Because the aromatase inhibitors, including Arimidex, haven't been used as long as tamoxifen, we don't have a good handle on how long the hot flashes should last. We do have reports that there tend to be fewer complaints of hot flashes on the aromatase inhibitors compared to tamoxifen. But, again, we can't give someone a prediction as to how long they will continue.

Marisa Weiss, M.D., president and founder: It's important to recognize that the aromatase inhibitors are only used and effective in post-menopausal women.

How long does natural menopause last?

Question from Cheryl: So how long does natural menopause last? I started 15 years ago and went on HRT. Now that I have breast cancer, I have stopped taking the HRT, and I'm back to having night sweats. Does it ever end?

Answers —Mindy Goldman, M.D.: The good answer for most women is yes, but about 15 percent of women may persist in having hot flashes throughout their menopausal years. For most women, however, the intensity and the frequency of the hot flashes get less with time. There is data that says hot flashes are brought on by things like stress, alcohol, spicy foods, and changes in temperature — particularly going to a warm environment. Sometimes women can make lifestyle adjustments to help decrease the intensity of the hot flashes.

Marisa Weiss, M.D., president and founder: That's another reason for "anger management" or anything else in your life that makes you "hot and bothered." One of the difficult challenges of breast cancer is having to confront so many different issues at one time. For sure, your emotional life has a significant impact on how you experience this whole process and these kinds of symptoms.

Estroven okay for ER+?

Question from Nancy: I am having hot flashes (sweat like crazy). My cancer is estrogen-positive. Can I take over-the-counter Estroven to help?

Answers —Mindy Goldman, M.D.: The problem with herbal products such as Estroven is that we don't have good quality studies to be able to tell women for sure that these are safe to use. That being said, many women choose alternative therapies to try and decrease their menopausal symptoms. I have had success with women using herbal products like Estroven. Herbal products like Estroven contain the so-called herbs that are thought to be beneficial in treating menopausal symptoms. These include black cohosh, Chasteberry tree/Vitex, and some contain evening primrose, all in different combinations and amounts.

Some of the difficulties with the herbal products are the lack of standards in their preparation and, as I mentioned, the general lack of data assessing their efficacy and safety. That being said, I do recommend herbal products to a number of my breast cancer patients as long as they understand the lack of information that we have about them. I think that they may provide benefit for many women.

Marisa Weiss, M.D., president and founder: What about green tea?

Mindy Goldman, M.D.: Typically, I've not recommended green tea. Part of that is because most people use the green tea heated, and the heat can make the hot flashes worse sometimes. If people find it's beneficial, as long as they tell us what they're using, I'm fine with that.

Talk to your doctor to make sure there are no drug/herb interactions, but for the most part, the herbal products that are used with menopausal symptoms seem to be safe.

ER+ patients should avoid phytoestrogens?

Question from Ann: Phytoestrogens (plant estrogens like soy) are not the same as human estrogen. Why should ER-positive breast cancer patients avoid phytoestrogens?

Answer —Mindy Goldman, M.D.: Phytoestrogens and soy are natural forms of estrogen. In some countries where the average daily intake of soy is much higher than those in the U.S., such as the Asian countries, the incidence of estrogen-receptor-positive cancers like breast cancer is actually lower. So some people think that soy and phytoestrogens may be beneficial and help protect against cancer.

Other people are concerned that, because soy is a form of estrogen, it may be dangerous for someone who already has an estrogen-receptor-positive breast cancer. The bottom line with soy is that, similar to the herbal products, we need more quality studies and randomized controlled trials looking at its safety and efficacy.

What the oncologists in our breast cancer center and I have adopted is that if someone with an estrogen-receptor-positive tumor wants to use dietary forms of soy, such as soy milk, tofu, tempeh, we're comfortable with that. But we discourage people from going to the health food store and picking up soy phytoestrogen tablets or other phytoestrogens.

I have found that soy is frequently beneficial, particularly for women who notice hot flashes at night or night sweats. I often have them drink eight to ten ounces of soy milk before bed.

Success seen with omega-3 fatty acids?

Question from Teri Melton: Do any of your patients have success with omega-3 fatty acids such as fish oil or flaxseed oil? 

Answer —Mindy Goldman, M.D.: I have found that some patients find this beneficial, particularly the flax, and I think this is probably a function of the phytoestrogen content. I have not seen as much success with the omega-3 fatty acids.

Does menopause affect quality of sleep?

Question from Rosie: I have a terrible time sleeping. Throughout treatment — chemo, radiation, surgery — I took Ambien nightly. It's been 7 months since the end of treatment, and I am trying to stop taking it but have a horrible time sleeping. Is this menopause? And is it safe to continue taking Ambien for this long?

Answers —Mindy Goldman, M.D.: It's hard to say if it is menopause, but we do know that one of the menopausal complaints is often sleep disturbances. One of the things that help me determine if it may be menopause is the type of sleep disturbance someone has. For example, if you fall asleep but are awakened by hot flashes or night sweats, and then have trouble falling back to sleep, that's more likely to be menopause. If you have trouble falling asleep, that may be less likely to be menopause, and it may be a primary sleep disorder problem.

There are also some women who may fall asleep, awake early, and not be able to get back to sleep. This can sometimes be a sign of depression, particularly if they have other symptoms like depressed moods, changes in appetite, and changes in energy level. It's important to talk to your clinician if you are feeling depressed, because that can be treated separately. It's sometimes confusing, because mood changes may also accompany menopause.

I think that each person's menopausal symptoms may be different, so I really try to tease out what sort of sleep problems it is. Is it trouble falling asleep or being awakened by hot flashes, or a mood disorder, or depression? Sometimes it may also be due to an irritable bladder, which is more common in the menopausal years. Once we figure out what it may be due to, it allows us to guide our treatment better.

Marisa Weiss, M.D., president and founder: As you can hear, no two women are the same. I can't emphasize enough how important it is to spend the time and do the work with your doctor to figure out what all the issues are that you're up against in order to develop the best solutions possible.

Mindy Goldman, M.D.: In general, I think Ambien (chemical name: Zolpidem tartrate) is a very effective sleeping medicine, but it can be addicting. Over time, I recommend to patients to try and slowly wean themselves off the Ambien and really try to target other treatments towards whatever other symptoms may be going on. There are also other sleeping medicines such as temazepam (brand name: Restoril), as well as some natural products such as melatonin or valerian, which may be beneficial.

Sometimes people can change from one medication to another medication, and this would be important to discuss with your doctor. If you're going to use herbal products like valerian or melatonin, it's important to discuss that with your doctor to ensure there's no drug/herb interaction.

Marisa Weiss, M.D., president and founder: What if you tell your doctor and the doctor has a blank look on his/her face? They say it's probably okay, but they don't know as much about it.

Mindy Goldman, M.D.: If your doctor is not familiar with herbal products you are taking, you may be able to find resources online through places such as NCCAM, which stands for the National Center for Complementary and Alternative Medicine.

Antidepressants no longer effective?

Question from Ann: I am dealing with stage IV breast cancer and surgical menopause. My menopausal symptoms are brutal. I have been on antidepressants, but they are no longer effective. Any suggestions?

Answer —Mindy Goldman, M.D.: There are a number of prescription alternatives to hormones to treat menopausal symptoms. Typically, most people use some of the SSRI antidepressants as first line treatment. With these, it's important to note that the doses used to treat hot flashes are very different from the doses used to treat depression. They are much lower doses.

The antidepressant that has been studied the most is Effexor (chemical name: venlafaxine), but Paxil (chemical name: paroxetine), Prozac (chemical name: fluoxetine), and Zoloft (chemical name: sertraline) may also be beneficial. If you are using low doses of an antidepressant specifically for hot flashes and one isn't working, it's possible to switch to a different one. There are also other prescription drugs which may help.

If your blood pressure is on the high side, there is an antihypertensive medicine called clonidine (brand name: Catapres), which may be helpful. It's important not to use this medicine if you have normal or low blood pressure as it can make you light-headed or dizzy. There have also been two studies recently published looking at the neuropathic pain reliever Neurontin (chemical name: gabapentin) for treatment of hot flashes, so this may also be an option. Another option that some find very useful is Vitamin E at a dose of 400 IU two times per day.

Editor's Note: If you are taking tamoxifen, talk to your doctor about which antidepressants are safe for you to take. Some antidepressants -- including Paxil, Wellbutrin (chemical name: bupropion), Prozac, Cymbalta (chemical name: duloxetine), and Zoloft -- interfere with the body's ability to convert tamoxifen into its active form, preventing you from getting the full benefit of tamoxifen. For more information, please visit the Tamoxifen page.

Menopause permanent after chemo?

Question from Website Question: For adjuvant chemotherapy in premenopausal breast cancer women, is the induced menopause reversible? How do we know whether the menopause is going to be permanent? Does this influence the choice of hormonal therapy (i.e., tamoxifen or aromatase inhibitor)?

Answer —Mindy Goldman, M.D.: It's a difficult question to know whether someone's menopause is temporary or permanent. For most women who get chemotherapy when they are less than 40 years old, they tend to get their periods back. There is data, however, that suggests women who get chemotherapy tend to go into an earlier menopause than they normally would. One of the ways that we can tell if someone is getting return of ovarian function is to do a blood test where we check someone's estradiol level.

This is important because if someone is on a drug like tamoxifen, they may not get periods because of tamoxifen itself, yet they still may have had return of ovarian function. It's important to note that 50 percent of women who are on tamoxifen will generally have changes in their menstrual cycles, and the most common is either less frequent cycles (called oligomenorrhea), or no periods (called amenorrhea).

Other hormonal drugs are the aromatase inhibitors, and those are only effective in postmenopausal women. In order for them to be used in premenopausal women, you need to have ovarian suppression, which is usually done by other hormonal drugs, such as Lupron (chemical name: leuprolide). Those drugs can make a woman pseudo-menopausal and then allow the aromatase inhibitors to be used. Depending on your particular cancer, it would be up to your oncologist to decide whether tamoxifen or an aromatase inhibitor would be used.

Vagifem safe while on Arimidex?

Question from Website Question: My OB/GYN (with my oncologist's knowledge) prescribed Vagifem for severe problems with vaginal dryness and atrophy. My oncologist is not happy about this and has asked me to consider switching from Arimidex to tamoxifen, as he feels estradiol is getting into my bloodstream from the Vagifem. I don't want to stop using the Vagifem, but don't want to switch to tamoxifen, either.

Answer —Mindy Goldman, M.D.: Typically we treat vaginal dryness with local forms of hormonal therapy. These include estrogens or the male hormone, testosterone. Typically these are in the form of creams, ointments, gels, or suppositories. Some of the problems with these treatments are that women may have estrogen absorbed into their bloodstream, and that may be dangerous if they have an estrogen-receptor-positive tumor. The truth is that there have not been good studies that have shown the danger or safety of using local forms of estrogen.

Nowadays, what many oncologists are choosing to use is something called the Estring. What I like about this option is that it's not messy, it doesn't require a cream or an applicator, it stays in place for three months, and women can have intercourse with it in place. And the main reason I like it is because of any form of local hormonal therapy, it has the least amount of estrogen that gets absorbed into your bloodstream. In our breast center, our oncologists feel very comfortable using the Estring to treat dryness.

If your oncologist doesn't feel comfortable with any form of estrogen, it is possible to consider testosterone. But again, we have limited research done in breast cancer patients showing the safety and efficacy of testosterone. One of the things that can be tried is over-the-counter lubricants, and I think some are better than others. I have found water-based lubricants such as Astroglide and Probe or Silk very helpful. I generally recommend these first, because they are not hormonal-based at all.

Women may also use the moisturizer Replens, although this tends to be less successful as a sexual lubricant. If you don't have enough relief with the lubricants alone, I would recommend the Estring as a first-line therapy.

Natural alternatives for loss of libido?

Question from Website Question: What are my options regarding loss of libido? Are there any natural alternatives?

Answer —Mindy Goldman, M.D.: One of the problems with treating loss of libido is our general understanding of what someone's libido should be. We don't have good normative data on the natural history of someone's libido. Most women will notice a decrease in their libido around the time of menopause. Many times that is temporary. For some women, they do notice that their libido is permanently decreased.

A lot of the research that has looked at libido has been done in men, and there haven't been very good studies done in women. There are a few potential herbal options, although there is limited data on their safety and efficacy. These include DHEA, which is a precursor to the male hormone testosterone. There is also an herbal product called Arginmax, which contains the amino acid L-Arginine and ginkgo biloba, and, in combination, these are thought to produce smooth muscle relaxation of the muscles around the vagina and potentially increased blood flow to the genital area. I personally have not found this to be that successful, but I do think it is a safe herbal product to use.

There are a number of other herbal products starting to come on the market, but little is really known as to how safe or effective they are. In terms of prescription alternative, one option is the antidepressant Wellbutrin (chemical name: bupropion). One of the problems with treating depression with the SSRI antidepressants (including Prozac, Paxil, and Zoloft) that are commonly used is sexual dysfunction. Most commonly they cause delayed orgasm or inability to have an orgasm, but frequently decrease libido as well.

For years, psychiatrists have counter-balanced this sexual dysfunction from SSRI antidepressants by using Wellbutrin together with their other antidepressants, and we have tried primary Wellbutrin alone in some of our breast cancer patients to see if we can boost libido. It's hard to know whether you are improving someone's mood and whether that may be improving libido as well, but I have found this to be safe and effective for many women.

Another option is the male hormone, testosterone. We know that testosterones are involved in women's sexual functioning. For women who have decreases in libido and don't have breast cancer, gynecologists frequently will give very low doses of either oral or vaginal testosterone. With breast cancer patients, particularly if their tumor is hormone-receptor-positive, we don't know about the safety of testosterone. So it's important, if you are considering this as an option, to discuss this fully with your oncologist as well as your gynecologist.

Editor's Note: Wellbutrin, Prozac (chemical name: fluoxetine), Paxil (chemical name: paroxetine), and Zoloft (chemical name: sertraline) are known to reduce the effectiveness of tamoxifen. If you are taking tamoxifen, talk to your doctor about alternative antidepressants. For more information, please visit the Breastcancer.org Tamoxifen page.

Ovary removal for bad menopause symptoms?

Question from Norma: I am 37, diagnosed last year, and taking tamoxifen. I am premenopausal. One month I have a period, the other I don't. I have very bad hot flashes, some night sweats and bad swings emotionally. My doctor wants me to take my ovaries out. What do you think?

Answers —Mindy Goldman, M.D.: The problem with taking the ovaries out is that it will make you permanently menopausal. There are certain times where an oncologist may feel that removing the ovaries is important for someone's breast cancer treatment, but this is pretty unusual. It's more likely that your side effects are due to tamoxifen. Most women notice changes in their menstrual period, and 25-50 percent of women will often complain of hot flashes. If your mood is also disturbed, I would recommend a low dose of an antidepressant such as Effexor, which may treat your mood, as well as your hot flashes.

If your doctor thinks that it would beneficial for you to be menopausal relative to your breast cancer, it is easier to use a reversible form such as drugs like Zoladex (chemical name: goserelin) or Lupron. There are some breast cancer patients, however, that may also be at a higher risk for ovarian cancer. If someone has a mutation in the breast and ovarian cancer genes, BRCA1/BRCA2, she is at risk not only for breast cancer, but also for ovarian cancer.

It is more common to have a mutation in one of these genes if you are diagnosed with breast cancer at a very young age, particularly in your 20s or early 30s. I recommend ovarian surveillance for anyone diagnosed with breast cancer younger than 40. This consists of pelvic ultrasounds and the tumor marker CA125. In general, this tumor marker, CA125, is not a good screening test for ovarian cancer because it has a lot of false positives, but in high-risk women we recommend performing the test anyway.

If you are known to have a mutation in one of these genes or are at high risk, some oncologists may recommend having your ovaries out once you have completed child bearing.

Marisa Weiss, M.D., president and founder: This is called prophylactic ovary removal. It's done to lower the risk of getting ovarian and/or breast cancer in the future.

Tips to revitalize skin after diagnosis?

Question from Website Question: My skin has aged 10 years since my diagnosis two years ago. Is there anything I can use to revitalize it?

Answers —Mindy Goldman, M.D.: I wish I knew of a good option. I do think that it is important to hydrate the skin well with moisturizers such as Eucerin. It's also important if someone has noticed skin changes to make sure it's not due to something like thyroid disease, because this can cause skin changes as well. So if your thyroid function has not been checked, I would ask your physician to do that.

Marisa Weiss, M.D., president and founder: If you have lingering skin changes after radiation therapy, the skin can be 'thirsty' for a long time after treatment is finished. Moisturizers like Eucerin, as Dr. Goldman mentioned, as well as Vaseline Intensive Care, Moisturel, or a new line of products called LindiSkin (available only on the Internet) can help your skin recover more fully.

The pinkness after radiation tends to go away relatively quickly, but if it lingers or worsens, you should bring it to your doctor's attention. The tan-ness takes longer to go away but will respond to the moisturizers mentioned above. Of course, if you notice new pinkness as well as swelling of your arm on the same side as your lymph node removal from the armpit, bring this to your doctor's attention in case it could be signs of infection.

Help for weight gain after ovary removal?

Question from Ann: I have gained weight since having my ovaries removed. I am stage IV and very concerned about the estrogen coming from fat cells. What strategies do you have for weight management?

Answer —Mindy Goldman, M.D.: I think it's important to work with your doctor on safe dietary measures. Certainly decreased caloric intake and exercise are the safest. There are some programs that may have specific diets, but those should be done under a physician's supervision. Some patients who have estrogen-receptor-positive tumors may also be treated with aromatase inhibitors. These drugs work by shutting down all peripheral estrogen. In someone who is heavier, one of the primary sources of this estrogen is in fat cells. So if you are on an aromatase inhibitor, this may help to decrease your concerns.

Exercise good deterrent for menopause?

Question from Website Question: Is exercising a good deterrent for menopause?

Answers —Mindy Goldman, M.D.: We do have some studies that suggest that women who exercise on a regular basis tend to have fewer menopausal complaints. It certainly is healthy and decreases risk of cardiovascular disease, which is one of the major killers of women in the postmenopausal years. So in general, I would recommend regular weight-bearing exercise for at least 30 minutes a day, three times per week. And this helps protect against osteoporosis, as well.

Marisa Weiss, M.D., president and founder: If you are concerned about the safest way to get back to an active lifestyle and an exercise routine that's comfortable for you, ask your doctor to refer you to a physical therapist to help you make this transition into a more active lifestyle so you don't put unnecessary strain on your body.

Increased bone loss risk for medical menopause?

Question from Website Question: Is there more risk for bone loss with an early medically imposed menopause than if menopause had occurred naturally?

Answer —Mindy Goldman, M.D.: We know that women reach their peak bone density at age 30-35, and then there's a gradual decline until menopause, when women tend to lose as much as two to three percent of bone per year. If someone goes into an earlier menopause, they may not have reached their maximum bone density or have more years of bone loss. So it is important if you are in menopause that your bone density be followed.

If you're on tamoxifen, it actually increases bone density, so that it's less of a concern. If you're on an aromatase inhibitor, however, these drugs can cause decreases in bone density, so it's important to make sure your doctor is following your bone density tests on a regular basis. In general, bone density tests should be done at an interval of 1.5-2 years apart.

For many women who are on aromatase inhibitors, if their bone density tests have shown evidence of mild loss or osteopenia or certainly osteoporosis, their doctors will frequently have them on one of the drugs called bisphosphonates, such as Fosamax or Actonel.

One of the ways to help prevent bone loss is adequate calcium and weight-bearing exercise. If you are menopausal, the daily requirements for calcium are 1500mg per day. It's hard to absorb this all in one sitting, so I recommend divided doses two to three times per day. In addition to calcium, the recommendation to prevent bone loss is weight-bearing exercise such as walking on a regular basis 30 minutes per day, three times per week.

Herbalife okay while on tamoxifen?

Question from Dee: I am 46 years old. I have been taking tamoxifen for three months now. I gained 10 pounds already. Can I take Herbalife diet products to help me lose the weight?

Answers —Mindy Goldman, M.D.: First of all, it's important to note that weight gain is common for women taking tamoxifen. Most reports suggest 7-10 pounds. My experience has been that most women gain the weight early on and then it stabilizes, but they frequently have trouble losing weight while taking their tamoxifen. If you're going to use any product to stimulate weight loss, I would recommend talking to your physician first.

Marisa Weiss, M.D., president and founder: As far as you know, is there anything in Herbalife that has phytoestrogen?

Mindy Goldman, M.D.: Not that I know of. It would be important to read the contents in Herbalife to make sure there are no estrogen-containing products.

When check bone density after starting AIs?

Question from NY Nancy: How soon after starting an aromatase inhibitor should a woman have her bone density checked?

Answer —Mindy Goldman, M.D.: We frequently will recommend a baseline bone density right when someone is beginning an aromatase inhibitor. This allows us to have a guide as to what someone's bone density was before initiation of the drug. There is data that the aromatase inhibitors decrease bone density. But the most recent published data looking at fractures suggest that by two years of being on an aromatase inhibitor, there are no increased risks of fractures.

Will menopausal incontinence ever diminish?

Question from Carol: Will the incontinence associated with menopause and after breast cancer ever diminish?

Answers —Mindy Goldman, M.D.: Although incontinence is more common during the menopausal years, incontinence is not a normal part of menopause. There are many causes of incontinence, and it's important to have this evaluated by a physician who specializes in incontinence. For some women, their incontinence may be related to loss of estrogen around the urethra and portions of the vagina, and some women may find local forms of estrogen such as the Estring helpful. We don't have studies that actually show this, but I have found that for many women the Estring really helps.

Marisa Weiss, M.D., president and founder: Sometimes you can get incontinent because of a urinary tract infection or also because of irritation through sex because of the friction. It can be very helpful if you can urinate before and after you have intercourse or before or after you engage in other forms of sexual stimulation, as it can reduce your risk of developing a urinary tract infection.

Mindy Goldman, M.D.: In addition, after you have sex and have emptied your bladder, I recommend wiping the vagina well with a towel to keep the area as dry as possible. This also helps to minimize risks of infection.

Marisa Weiss, M.D., president and founder: Many women will use a panty liner in case of a little leak. There are some liners that are more comfortable and others that are more irritating. Do you recommend a particular brand?

Mindy Goldman, M.D.: I don't necessarily recommend a particular brand, but usually ones that are not scented. For many women, the scents may be irritating and can actually worsen their symptoms. If someone is soaking through more than one pad per day, particularly a full thickness pad, it's important to see your gynecologist or a uro-gynecologist who specializes in treating incontinence. There may be simple solutions such as pelvic muscle training exercises or medications that may help to treat incontinence. In some cases, surgery may be indicated as well. So it's important to have this evaluated.

Marisa Weiss, M.D., president and founder: For some women who may have lost some of their libido and their ability to have an orgasm, they may require a lot more stimulation of the clitoris in order to reach sexual arousal and possibly orgasm. Sometimes with all this extra stimulation, the urethra which is located close to the clitoris can also be over-stimulated. If this is your situation, good communication with your partner and a "roadmap" of the different small but very important structures down there can be useful. Stimulation can be directed to the areas most pleasurable to you, and the urethra can be avoided as much as possible, and then you'll have less irritation and subsequently less urinary infection.

When to wean self off Celexa?

Question from Rosie: Celexa is really controlling my hot flashes. How long should I wait before I try to wean myself off of it?

Answer —Mindy Goldman, M.D.: In general, I recommend women having control of their symptoms for at least six months before they begin trying to wean themselves off the medication. If you do wean off the Celexa (chemical name: citalopram) and your hot flashes return, it's certainly safe to start back up on the medication. There's nothing wrong with staying on medications such as Celexa if it's helping you.

Increased health problems with menopause?

Question from Website Question: Is there an increased risk for health-related problems with menopause such as high cholesterol, heart attack, high blood pressure, and stroke?

Answer —Mindy Goldman, M.D.: We do know that after menopause the risk of heart disease goes up. In fact, heart disease is the number one killer of women in the menopausal years. We also know that after menopause the risk of osteoporosis is increased, because estrogen helps to protect against bone loss. In order to help prevent against both of these conditions, it's important to have a healthy lifestyle and habits including regular exercise, maintaining a normal weight, not smoking, and minimizing the intake of alcohol. It's also important to take adequate amounts of calcium after menopause to help protect your bones. And if someone is not on hormonal therapy, the recommended amount is 1500mg per day.

Safe way to get ovaries functioning again?

Question from Website Question: I feel way too young to be in menopause. Is there any safe way of starting up my ovaries again now that I'm done with treatment?

Answers —Mindy Goldman, M.D.: There is nothing that we know of that can kick start the ovaries back into functioning. But if you were less than 40 when you received chemotherapy, chances are you will get return of ovarian function. Although being in menopause may cause some uncomfortable side effects, if you have an estrogen-receptor-positive breast cancer, there may actually be benefits to your breasts by not having your ovaries produce estrogen. So I would recommend just letting things occur naturally.

Marisa Weiss, M.D., president and founder: How reliable are the blood tests of FSH or LH in helping your doctor and you know if you are in a temporary or permanent menopause?

Mindy Goldman, M.D.: These tests may not be as reliable in women who are on hormonal drugs like tamoxifen. The estradiol level is much more reliable. In general, I recommend checking both the FSH and the estradiol, but I let the estradiol guide my management.

Reason/solution for vaginal pain during sex?

Question from Website Question: Is there an explanation and solution to vaginal pain during intercourse? The pain is greater the dryer I am, but still uncomfortable when I am lubricated.

Answers —Mindy Goldman, M.D.: When someone becomes menopausal and the ovaries stop producing estrogen, most women will notice some vaginal dryness. This is because the vaginal tissues are estrogen sensitive. With loss of estrogen, the vaginal walls tend to get thinner, and blood vessels can be closer to the surface. Many women will find intercourse uncomfortable. Typically, we will try treating this first with lubricants like Astroglide, because these are not hormonally based. If this doesn't work, even if you have enough vaginal lubrication, the vaginal Estring might be beneficial for you. The other thing that is important is trying different positions when you are having sex to try and alleviate discomfort.

Marisa Weiss, M.D., president and founder: One of the most effective lubricants in the vagina is the one you can make yourself when your vagina is stimulated and excited. You may be more receptive and able to enjoy intercourse if you have good foreplay. The vagina is an amazing structure that can do all kinds of cool tricks for you. It can get wet, longer and wider, and more elastic with sexual stimulation. This may be a good time to explore your fantasies, sexual toys, oral sex, or other things that can help get you ready for action.