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Conversations about Menopause

by Stephanie Sides

I first started thinking about menopause when my oldest sister, four years my senior, began complaining of severe headaches. I, being unschooled in the matter (which meant I had yet to read any books on it) and still too young, didn’t make the connection with menopause. My sister finally figured it out but only after a long period of debilitating pain, confusion, and annoyance.

My days were numbered. But I still didn’t worry about it. It wasn’t yet real for me.

My middle sister, two years older and right on schedule, handled it in a businesslike manner: You go to the doctor, learn about the options, make a decision, and get on with it. At least that’s the way I heard it. And that’s the way she always dealt with any issues. But, in her case, there was probably more to-ing and fro-ing behind the stoic public face she presented than she let on. It was just not her style to get all hysterical about it.

When “my time” came, the symptoms were obvious but not hugely debilitating: regular night sweats but only an occasional bona fide hot flash. The first one I noticed was when I was cleaning the cat box, hardly an aerobic activity. But the symptoms became annoying enough to investigate remediation.

I was on birth control pills at the time, making, I was told, the pharmaceutical decision a bit trickier. My doctor prescribed standard hormone replacement therapy “to make the experience less problematic.”

Less problematic than what?, I wondered. Than the symptoms I was having? Than the symptoms I would have on other medications? “Less problematic,” I decided, was the catch phrase to make me feel lucky my symptoms weren’t worse.

I should have pursued it, but Healthnet had us on a schedule and my 10 minutes were up.

The drug she put me on consisted of two formulations, one for the first two weeks and one for the last two weeks of the month.

For the first two, I felt great, even better than usual. I felt like the President of the United States. I felt as if I could do ANYTHING.

Was there some anti-depressant lurking within?

For the latter two weeks, I felt bushwhacked. While this lessened a bit with each passing month, I still believed it was possible to feel nearly perfect most of the time. At least that’s the message you get from TV.

So my idea of a solution was to get on something with a consistent chemical formulation for the entire month.

My middle sister suggested “bioidenticals,” a cream mixed “especially for me” in relatively few places with the exotic name of “compounding pharmacies.” You rub it on your skin. This was supposed to be better because the cream wasn’t absorbed by your organs, unlike with hormone replacement therapy. This sister was known for doing her homework.

At a writing workshop I attended at the Esalen Institute during this timeframe, I met a nurse who, in the course of our conversation, recommended the same thing. I was reminded that when women “of a certain age” meet for the first time, this is almost invariably a topic for discussion. Maybe because, like the weather, it’s safe and something we’re clearly all interested in. Score 2 for the bioidenticals. Was it really nothing more than a competition with the highest scorer winning?

So back I went to the doctor, armed with a printout of an e-mail about bioidenticals from my sister. We talked about plant- vs. animal-based (e.g., mare urine) hormones and bioidenticals. Was I willing to take more than one pill a day? Sure, no problem, if that would solve the problem.

When I’m presented with an array of options, all of which seem of equal weight as in this case, my bottom-line question to the doctor or vet is this: What would you do if it were your [body, horse, dog, cat,…]? My doctor, a young, petite women barely out of medical school by the look of her, was struck dumb with bewilderment. As if no one had ever posed that type of question to her before. How was that possible? It was the only question to ask.

But she was a long way off from the ordeal. She had just given birth to her first baby so had more compelling things to be dealing with than something as textbook-theoretical as menopause. Plus, as she raced from one appointment to the next, no doubt she felt compelled to give sound bites reminiscent of Marcus Welby, MD. (But, then, I reminded myself, he would never have dealt with such a potentially offensive topic on TV.) I found myself wondering if communication skills were part of her curriculum in medical school.

She came down on the side of FDA-approved medications, which seems predictable in retrospect. That excluded the bioidenticals. Those had to be formulated by an individual for an individual each time, she said, so the formulation could, and likely would, vary. Oh, and the issue about them not being absorbed by the body’s organs? That wasn’t necessarily true.

Excuse me: What does “not necessarily true” mean? That sounded like a medical copout. Either the studies showed it to be true, or not, or had not been able to confirm it one way or the other.

Just give it to me straight.

I realized she wasn’t current on the literature. The baby, understandably, was taking too much of her time. It was hard to fault her on that.

Still, I became more skeptical as I looked around the examining room. I saw a pharma-sponsored calendar, clock, and literature for the taking, all from different companies -- to render them harmless in aggregate, I supposed, and designed not as advertising. How often has my doctor given me free samples of medications to see how well they worked? Or pulled out her prescription pad the minute I mentioned some medication by name as seen on TV? At the time, I remember wondering whether pharma companies sponsor scholarships to medical school… and what allegiance that might entail after graduation…

How could she not come down this way? I was beginning to think that she was more compromised than I with my menopausal symptoms.

As I pondered all this, I was sitting on the “bed” – I don’t know what else to call it as I’ve never heard any medical person refer to it any way other than “here,” as in, “sit up here while you wait for the doctor.” I was above the doctor. She was sitting on a stool on wheels. It seemed like an odd spatial relationship power-wise, as if the height I had over her gave me more authority. I’ve heard the theory about how to establish authority by standing up over someone sitting down. But she had the option of motion. Was that somehow symbolic? Or a new twist on the old theory?

I decided to go with the plant-based, two-pill-daily solution – one estrogen, the other progestin. Even before I started taking these, I was met with an additional problem, namely a double co-pay. And not just two times the $20/prescription I’m used to. How do two co-pays end up totaling $55? This was “new math” insurance-style.

The second day on the new regime I felt as if I were hit by a ton of bricks. So I opted out of my normal daily schedule with a three-hour nap. Was this a result of a lingering sore throat or just part of the invariable process of “getting used to” the new meds? I don’t remember having this problem of accommodation when I was young. Was this was an “age thing”?

A bit more of this, I thought, will make the unmedicated symptoms of menopause not so daunting after all.

Then: Maybe this was one of those times that it pays just to tough it out. Interestingly, that seems to be an option that’s not encouraged: It doesn’t sell pills or creams. I’m reminded of a song in one of my favorite musicals: Cabaret – “Money makes the world go around, the world go around, the world…”

So I think more about that. We’re sold a bill of goods that there’s a pill, better yet many pills, for every problem, and then we’ll be just fine. It’s an ongoing regime.

It’s hard to find a doctor who doesn’t work this way. So it’s equally hard to get an opinion you can trust, at least from western medical practitioners, representing the other side.

Maybe there are many sides to medical care and patient decisions beyond just the traditional “second opinion” that’s intended to confirm the original diagnosis.

While my doctor is the nearest at hand to blame, I’m not sure it’s entirely her fault. She, along with fellow med school grads, seem worked to death by the HMOs. Sadly, they’re trained for that. After all, aren’t medical schools famous for their regimes of working nearly graduated students for 36-hour periods at a stretch? Doctors are trained to react, not to think, certainly not to question.

So they’re psychologically equipped to deal with the early years of HMO-supported bondage. It’s probably the easiest way to become employed, get experience, and, most importantly, begin paying off the huge loans incurred by medical school.

But it’s no wonder they don’t last long on these kinds of jobs. Over the 20 years I’ve been going to the same medical clinic, I had first one doctor, then another for the huge bulk of that period, then a succession of three more, younger and younger, over the last five years. The turnover is quicker and quicker, like life itself.

So what’s the alternative?