(Dr. Altman's first visit to Power Surge)

Dearest:  Midlife and menopause are times of change -- changes which include more 
than hot flashes and insomnia, but issues of sexual intimacy. This passage 
should be a gateway to "change" our lifestyles and manner of thinking and explore 
our newfound strength. With women living longer, they can have longer and fuller 
sex lives. If we think we'll never be sexual again after menopause, we just 
may not :(

In My Menopause, My Sexual Self, Power Surge explores intimacy -- sexual 
and self. It addresses the way we communicate to ourselves and our partners.

Tonight, to help us explore our menopause and our sexual selves is a doctor who 
has been quoted in "Time Magazine", "The Boston Globe", "Glamour", "Self Magazine"
and many others. He is a Harvard Medical School Assistant Professor, a Gynegologist 
in private practice, specializing in menopause and midlife sexuality. He is the 
President and co-founder of Women’s Healthcare Video Library and wrote and 
co-produced, "Transitions: Preparing for Menopause," among other highly 
acclaimed video productions.

My guest tonight is co-author with Laurie Ashner, of the upcoming book,  "Making 
Love the Way We Used To: The Secrets of Midlife Sexuality,"  due out early 
in Jan. 2001 (Contemporary Books) . . .   D  R.     A  L  A  N      A  L  T  M  A   N


Welcome to Power Surge, Dr. Altman :) What do you see as the greatest 
concern your menopausal patients have about their sexuality?


Dr. Alan Altman:    Hi everyone. Libido is the main concern. Loss of libido is 
paramount to many of my patients.


Dearest:     When a woman comes in complaining of loss of libido, what
are your recommendations? 


 Dr. Alan Altman:   To begin, other causes than hormonal should be ruled out.  But if 
all seems to point to hormonal, then we need to look at her whole picture.
We talk about her symptoms and ways to correct possible deficiencies - i.e. 
testosterone, estrogen etc. 


Dearest:     When you say, "if all seems to point to hormonal..." -- can you share 
with us what other circumstances could effect a diminished libido? 


Dr. Alan Altman:    Medications such as birth control pills, antidepressants, 
antihistamines, boredom all can have an effect. 


Dearest:     Thank you. Have you heard of women whose libido is decreased by menopause, 
but who mistake it for boredom in the marriage and seek affairs outside as a 
solution? 


Dr. Alan Altman:    Certainly many women feel that way due to menopause, but also 
all the things surrounding that transition as well. The great taffy-pull of life.


Dearest:    Ahh...  I do hope it's chocolate taffy  :) 


Dr. Alan Altman:    No -- midlife taffy  :)


RLR818:   How do I get my doctor to test for menapause?


Dr. Alan Altman:    Use the bioassay of your body.  Do you mean how to test when 
you're perimenopausal or post? 


Geebee2000:   How long after starting hrt could a woman expect to  notice some 
kind of improvement? 


Dr. Alan Altman:    Within weeks for most. 


Dearest:     Whiteorkid, go ahead, please.


Whiteorkid:   What do you think about Provera, or would you suggest something 
else? 


Dr. Alan Altman:    Definately Prometrium (natural progesterone) is better for your 
heart than Provera. 


Dearest:     Thanks, Dr.Altman. Wingy, go ahead, please.


Wingy54:   In your opinion, how safe is Testosterone replacement, and what dose 
would you prescribe?


Dr. Alan Altman:    Testosterone is quite safe at the right dosage. Orally start with 
EstratestHS or try testosterone 0.4% cream paraclitorally. 


DJJax11:   I am experiencing poor memory, loss of concentration, inability 
to focus, dizzy, headaches, what do you suggest?


Dr. Alan Altman:    DJ are you peri or postmenopausal and are you on any hormones?


DJJax11:   Perimenopausal and not on hormones.


Dr. Alan Altman:    Your best bets are Low-dose oral contracteptives, or a low-dose 
estrogen patch,  Loestrin 1/20 is good or FemPatch.



Dearest:     Dr.Altman, many women don't have the patience to read the scores of 
menopause books out there. How would your tape, Transitions: Preparing for 
Menopause, be helpful to us?


Dr. Alan Altman:    They're easy to view, in stages, and your family can learn from 
them as well.  They're produced in people-speak ... easy to understand.


Dearest:     Thanks I'll give more info about them at the end of the chat.
Marylinden, please go ahead.


MARYLINDEN:     What do you think of saliva tests for testiing for testosterone? 
Are there others? And what is a normal level for a post-meno woman? Also, 
what do you think of Halotestin?


Dr. Alan Altman:  Aeron saliva tests are not the best assay...blood levels still are 
the standard, but why do them when your body can guide you and your doctor?


Dearest:     MarRil, go ahead, please.


MarRil:   What if any effect  does taking all three hormones have on your 
metabloism, thyroid functioning and if so could you discuss any symptoms. 


Dr. Alan Altman:    By all three,  I assume you mean Estrogen, Testosterone and 
Progesterone.


MarRil:   Yes, that's right. 


Dr. Alan Altman:    In appropriate doses there may be the same effect one would see 
with a birth control pill -- no more than that.  


MarRil:   I have never taken birth control pills so dont know what that effect is. 


Dr. Alan Altman:    Minimal effect, if any, MarRil.


Dearest:     Isn't it true that getting on a regular exercise program can not only 
help improve one's sexual experience, but restore a waning libido?


MarRil:   I  walk 3 miles a day  and do low impact aerobics.


Dr. Alan Altman:    Yes, especially strength training can help. It can increase metabolism 
and help with PMS, libido and mood swings. I mean like lifting weights and other 
resistance training. 


Dearest:     Would you say the endorphins alone would produce a better
frame of mind which might, in turn, effect libido?


Dr. Alan Altman:    Thats a possible additional effect, but just metabolism increase can 
help greatly. Also, some brisk exercise before sex can help increase orgasm.


Dearest:     Can you please describe, blow by blow, Kegel exercises for those 
who don't know.


Dr. Alan Altman:    Kegel exercises are performed to strengthen the pelvic floor muscles 
which can help improve problems like urinary stress incontinence or, in some 
cases, tighten the vaginal muscles to improve intercourse. To learn what muscles 
to exercise, try to stop urinating mid-stream...that's a Kegel!  But only learn Kegels 
by stopping mid-stream; do Kegels regularly when not urinating, ie sitting at at 
your desk at work, standing on a bus, etc. Even better, use vaginal weights, 
which can exert more resistance against the Kegel and give much better and 
quicker results. 


Dearest:     Thank you, Dr. Altman. MBarr, please go ahead.


MBarr227:   Would you suggest Evista?  What are the pros and cons? 


Dr. Alan Altman:    Evista is a good niche drug.  It's good for women with a history of 
breast problems. By a niche drug I mean it's got a specific use -- it's not good for 
all postmenopausal women. It can cause hot flashes. It is not as protective 
against heart attack and stroke and I'm as concerned about effects on the brain.


Dearest:     RCHCTH,  go ahead.


RCHCTH:   What start dosage of Prometrium in perimenopause for heavy 
bleeding is appropriate?


Dr. Alan Altman:    A good starting dose for Prometrium is 300 mg, days 16-25 of every 
cycle for perimenopause. The doses for postmenopausal HRT are lower.


Dearest:     Toga, go ahead.


TogaGirl4U:   I am trying to cut down on estrogen patches and just use Revival.  
It is so hard.  Any suggestions on how to ease the transition.  I have cut 
it down 75 percent.  Also what do you think of sublingual progesterone? 


Dr. Alan Altman:    I suggest switching to oral, low dose estrogen, such as .3 mg. of Estratab 
and then go to every other day and then every third day to slowly wean over time. Sublingual 
progesterone can be quite useful if oral Prometrium is not working as well as you need it 
to. The taste is not the best, but the absorption is excellent.


CattAround:   About how long after a hysterectomy do you experience 
menopause symptoms?               


Dr. Alan Altman:    Were your ovaries removed, Catt?


CattAround:   Yes


Dr. Alan Altman:    It can be immediate and I alway start patients on both estrogen 
and testosterone when ovaries are removed using Estratest HS.


DJJax11:   What do you think of Prempro vs. Loestrin 1/20 or Fempatch? 


Dr. Alan Altman:    I think Loestrin or FemPatch is very useful for perimenopause. 
Prempro, on the other hand, is better postmenopausally, although I don't 
personally like it. U'd rather use natural progesterone (Prometrium) 
instead of the Provera in Prempro.


Sally1019:   After 4 yrs of suffering perimeno symptoms I have found relief 
with soy protein shakes - namely Revival, what is your opinion of soy as a 
natural HRT? 


Dr. Alan Altman:    Soy is probably going to be the best future selective estrogen. By 
that I mean that soy is a natural selective estrogen that acts as an anti estrogen 
in the uterus and in the breast.  The future of soy will probably be in conjunction 
with, or in addition to,        estrogen instead of progesterone. In other words, in 
the future, women can take their estrogen along with SOY and not need to take 
progesterone at all.   For a Soy product to be adequate, you should be able to 
take in 60mg of phytoestrogens (isoflavones) + 25gms of Soy protein. You need 
both together.


Dearest:     Dr. Altman,  doesn't Estratest have too much testosterone?  


Dr. Alan Altman:    For most people, Estratest HS is an excellent combination. For those 
who find it too stimulating, lower doses can be compounded in appropropriate 
pharmacies.  That is, women's compounding pharmacies that deal with hormones. 
In my practice,  I have had a good deal of success with Estratest HS even if I have 
to alternate it with Estratab every other day. That would lower the testosterone 
dose that gets to the patient.


Dearest:     Thank you, Dr. A. SaltAir W, go ahead.


SALTAIR W:   What do u suggest for lack of drive at work?  Test no help 
postmenopausal and if you use soy with Estrogen is that enough to oppose the 
cancer effect of E all


Dr. Alan Altman:    First of all, please don't use SOY instead of progesterone yet.  
That's in the future after we've gotten more data. As far as lack of drive at work, 
I'm surprised testosterone hasn't helped. If strength training exercise won't help, 
then maybe there are other reasons for the lack of drive -- i.e., unhappy at 
work or bored. Are you on estrogen, Saltair?


SALTAIR W:   Do you feel P creme overdose causes depression?  Estradiol 
Test Proges creme and Test creme...


Dearest:     Saltair, the question Dr. Altman was asking you was... are you on 
estrogen currently?


SALTAIR W:   Estradiol orally


Dr. Alan Altman:    Go with the exercise or look for another reason why the lack of 
drive is there at work.


RCHCTH:   What can be done for extreme cramps (cannot take aspirin or 
NSAIDS)?


Dr. Alan Altman:    RCH, are you still menstruating?


RCHCTH:   Yes


Dr. Alan Altman:    If NSAID's (Non-steroidal Anti-inflammatory Drugs) are not successful, 
the best alternative is a low dose birth control pill OR see your gynecologist 
about the possibility of dilating your cervix to see if that helps or if there 
is any other cause of the cramping.


LinWeeksRE:   I am currently on Estrace 5 mg. and provera 2.5, but after 
1 1/2 mo. have headaches, night sweats, and back where i started - help!


Dearest:     Lin, do you mean Estrace .5 mg?


LinWeeksRE:   Yes


Dr. Alan Altman:    I would move up to 1 mg. of Estrace and see how you do with that.
.5 sounds like it may be too low. The Provera is okay but again, I prefer 
Prometrium.  That would be 100 mg. of Prometrium at night before bedtime.  


LinWeeksRE:   Sorry, I meant 1 mg. of Estrace


Dr. Alan Altman:    Lin, what you may want to try is 2 mg. of Estrace or change completely 
to Estratest HS which would allow more estrogen to be free in the bloodstream.



LinWeeksRE:   What is difference in Prometrium vs. Provera and Estratest 
HS vs Estrace?


Dr. Alan Altman:    Prometrium is natural progesterone and Provera is a synthetic progestin.
Estrace is pure estradiol. Estratest HS is plant based estrogen with the addition 
of a small amount of testosterone.


Dearest:    Jilly, go ahead.


JILLY:  Can one be on continual dose of prometrium or do you always have to 
go off of it? 


Dr. Alan Altman:   It depends on the regimen. If you are on cyclic HRT you need Prometrium 
200mg the first 12 days of each month.  If on continuous combined HRT you need 100mg 
every day. Remember to take it at bedtime.


Wingy54:   How much Testosterone is in Estratest? 


Dr. Alan Altman:    Estratest HS has 1.25 mg. of methyltestosterone, while Estratest has
2.5 mg. HS means half-strength.


Allbritain:  What do you think of herbs for lack of desire and vaginal atrophy 
such as black cohosh? 


Dr. Alan Altman:    Remfemin, or black cohosh, can be useful if it works! Tada!
It's a very low level of phytoestrogen but can be helpful for some women.       
My concern is the safety of unregulated herbal therapy sold as food additives 
in health food stores; not all are the same and not all are safe. The bad ones 
can give the good ones a bad name. That's it.


Geebee2000:   Prometrium at night?  I've been cutting my Estratest in half and 
taking a.m &p.m.    


Dr. Alan Altman:    Prometrium has to be taken at night because some of the metabolites 
are sedating. So it's very important to take it before sleep.  It'll also HELP 
with sleep.  Instead of cutting Estratest in half, take Estratest HS each time 
(which is half the dose).


SALTAIR W:   Does Progesterone Creme-oral ineffective- build up in the tissues 
and lead to depression?


Dr. Alan Altman:    Saltair, the question is whether or not you're absorbing adequate 
levels of the progesterone by using the cream. If, indeed, you are, it is possible 
that it is leading to deprssion.... but menopause, itself, can be affecting this 
more than the progesterone.


SALTAIR W:  No - is the creme poisoning me after 9 months of using it!


Dr. Alan Altman:   Saltair, I doubt you're being poisoned because you're not getting 
enough transdermally to poison you.


Dearest:     Dr.Altman, thank you for joining us in Power Surge to field our 
about questions about menopause and midlife sexuality.

Anyone interested in more information about Dr. Altman's Women's Healthcare
Video Library can call: 1-800-300-TAPE.


Anyone interested in asking questions of Dr. Alan Altman, can do so on the 
Power Surge Web site's "The Doctor Is In."

Don't forget to look for Dr. Alan Altman and co-author, Laurie Ashner's 
upcoming book, "Listen, Do You Want To Know A Secret? Reviving Midlife 
Sexuality" (Contemporary Books).


Dearest:   Thank you for a wonderfully informative evening, Dr. Altman :)


Dr. Alan Altman:   It was my pleasure and I hope to do it again some time soon.


Dearest:    We'd love to have you back again soon. Goodnight and goodnight, everyone.



Read Dr. Altman's second transcript



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