Dearest: 	Tonight's guests came to my attention when co-author, Laurie Ashner, 
a Medical Journalist, Researcher and Author was seeking resources on menopause 
on the Internet. Her search brought Laurie to Power Surge and I'm so proud to be
included in (5 pages) of their new book, "Could It Be....Perimenopause?" 
(Little Brown) as "the premier site for women in menopause on the Internet." 
(blushing with pride).

Laurie Ashner and the physician behind the book, Dr. Stephen R. Goldstein, have 
written one of the clearest and most readable books on menopause I've yet seen (and 
that's a lot). Dr. Goldstein is a Professor at New York University School of Medicine;
Director of Gynecologic Ultrasound, Co-Director of Bone Densitometry at NYU and 
the immediate past Chairman of the American College of Obstetrics and Gynecology 
for New York.  (Where on earth does he find time to write books) :)

Every paragraph of "Could It Be....Perimenopause?" is chock-a-block full of the 
"Questions Women Ask"- the questions WE ask, not simply medical lingo many of 
us simply don't understand.  Questions like:
 
"I'm 51 and I'm spotting every day. Is this normal like a long last period?" ...
"Is compulsive eating a symptom of perimenopause?" ...
"I'm becoming forgetful and accident-prone. Is this due to perimenopause?"

Dr. Goldstein and Ms. Ashner discuss HRT, SERMS (Raloxifene), HMO's, birth control 
pills and natural treatments for perimenopausal symptoms, too!

It's my pleasure to welcome you both to Power Surge :)  Could you begin by 
explaining the differences between "perimenopause" and "postmenopause?"


Dr. Goldstein and Ms. Ashner:	I think there's tremendous confusion between peri, post and 
menopause. Menopause is when there is absent estrogen due to a lack of ovarian 
function.  Perimenopause is characterized by fluctuating levels of unopposed 
estrogen secondary to anovulation, or lack of ovulation.  It is the change in 
estrogen levels that results in many of the symptoms of perimenopause, rather 
than the absent estrogen of menopause. 


Dearest: 	   So, would it go without saying that once those estrogen levels have 
"leveled out" -- the uncomfortable symptoms associated with perimenopause
will disappear? 


Dr. Goldstein and Ms. Ashner:	You have to realize that there is a difference between absent 
estrogen and dry vagina, skin changes, decreased libido and the transitional 
symptoms of the perimenopause.  Initially the hot flashes are related to 
very low and absent levels of estrogen.


Dearest: 	    You mean the severe hot flashes we experience during Perimenopause 
while we're still menstruating are due to low and absent levels of estrogen? 


Dr. Goldstein and Ms. Ashner:	The subtle changes that we speak about in the book occur sometimes 
up to ten years before the first hot flash or vaginal dryness.  Yes, those hot flashes 
are due to that although rising FSH (follicle stimulating hormone) may also play a role.  


Dearest: 	  Don't the FSH levels rise as the estrogen drops? 


Dr. Goldstein and Ms. Ashner:	Realize that paradoxically late in the perimenopausal transition, 
there will be estrodial levels in a premenopausal range while there are FSH levels 
in a postmenopausal range.  In many women FSH rises while estrogen does not 
fall to menopausal levels as quickly.


RKP50:	Could you explain the benefits of taking Evista over the other designer 
estrogens. I have felt so sick on HRT.  I am about to start on it and I am worried 
that I will be sick again. 


Dr. Goldstein and Ms. Ashner:	Designer estrogen is a poor term.  Evista is a SERM--  Selective 
Estrogen Receptor Mdulator.  That means it acts like estrogen in some tissues -- bone, 
lipid, etc. while being an estrogen blocker in reproductive tissues.  (Breast, uterus).  
It is not estrogen.  It should not be confused with estrogen.  It has great potential 
for extending postmenopausal women's health, but it is NOT a treatment for 
menopausal symptoms (hot flashes, etc.)


Dearest: 	Others have reported that Raloxifene can even cause hot flashes.   


Dr. Goldstein and Ms. Ashner:	No.  In 24 percent of the women in clinical trials reported hot flashes 
at some time in the clinical trials over two years, but only 1.9 percent discontinued 
the study because of hot flashes.  The implication is and it has been my clinical 
experience as well, that they are mild and short lived.


BARANDSTEP:	I have had daily breast discomfort and tenderness. Is this a symptom 
and what can one do about it?


Dr. Goldstein and Ms. Ashner:	Symptom of what?


BARANDSTEP:	Either peri or menopause? Due to unopposed estrogen.


Dr. Goldstein and Ms. Ashner:	Perimenopause, certainly--this is usually an estrogen effect.  
You would not expect breast tenderness in menopause.  


RCHCTH:  If you're having very heavy periods, wouldn't adding ERT make it worse?


Dr. Goldstein and Ms. Ashner:	Absolutely it would.  There's a difference between replacing estrogen 
in menopause and using ultra low dose birth control pills in perimenopause.  ERT does 
not turn off the erratic ovarian function of perimenopause.  Low dose birth control 
pills shut down your own ovarian function and substitute a small amount of estrogen 
and progesterone all month long.  


Dearest: 	  Dr. Goldstein, you write about the new low-dose estrogen/progesterone 
therapy, a la HRT or BC pills.  I even read where you talk about the almost non-existent 
risk of stroke. Do you believe these low-dose pills are so much safer than we are told? 


Dr. Goldstein and Ms. Ashner:	In non-smokers, Dearest, yes.  The total estrogen in pre menopausal 
woman on these pills may in fact be LESS than what your own body makes monthly.  
People are confused because clearly in post menopause, if you take HRT, your body 
and your breasts will have more circulating estrogen than if you don't take HRT.
But with birth control pills, remember they SHUT DOWN estrogen your ovary is making 
and substitute an even smaller amount.  


Dearest: 	    I had a doctor in Power Surge who told us any woman who smokes 
is "safe" taking HRT. What are your feelings about this? It goes against everything 
I've ever read about HRT and smoking.


Dr. Goldstein and Ms. Ashner:	Smoking and HRT -- Standard HRT is about one half the dose of 20 
micrograms birth control pills.  I think any woman who smokes and uses estrogen 
at any dose is playing with fire, no pun intended.  


GMAMATT:	Do the hot flashes ever subside and does sleep return to normal 
if one isn't on hormones?  Do you recommend Evista? 


Dr. Goldstein and Ms. Ashner:	In the overwhelming majority of women, the hot flashes and sleep 
disturbances are marketedly diminished over 12, 18,24 months.  A very small percent 
of women, may be affected over a longer period of time.


Dearest: 	 Dr. Goldstein, what women are NOT candidates for hormone therapy?  


Dr. Goldstein and Ms. Ashner:	Are we talking replacement or birth control pills in terms of who 
is not a candidate? 


Dearest: 	   Wouldn't it be pretty much the same for both? 


Dr. Goldstein and Ms. Ashner:	Yes, with the caveat of the smokers.  Birth control pills are contraindicated 
in smokers over 35, but HRT is not such an absolute.


MMSCHEER16:	I'm having hot flashes and feeling sick to my stomach and tenderness 
in my breast is there any thing I can do?  Any medications?


Dr. Goldstein and Ms. Ashner:	Are you still getting periods? 


MMSCHEER16:	Yes 


Dr. Goldstein and Ms. Ashner:	Two month trial of 20 microgram birth control pills.  In addition, exercise, 
anti oxidant vitamins, moderate alcohol, low fat diet will all help.  
They apply to everybody, perimenopausal, or not.


MMSCHEER16:	How would I get that ?


Dearest: 	   MMSCHEER, best thing is to get it from your doctor. 


Kaaitjie:	  I am post-menopausal (no period for 18 months)& using compounded 
"natural" HRT. What regimen would you recommend for post menopausal me/women?


Dr. Goldstein and Ms. Ashner:	What do you perceive to be the benefits of "natural" HRT? 


Kaaitjie:	   Right now I'm not sure - I'm not having flashes, bone density OK,  
high blood pressure though.  I could not use regular HRT - migraines   


Dr. Goldstein and Ms. Ashner:	Many many people equate natural with risk free.  Just because 
it comes from a health food store doesn't mean it's safe.  There are many phyto 
estrogens that are powerful.  If they relieve hot flashes, you should realize 
that your breasts are seeing it as estrogen too, except it has no quality control, 
or standardization like pharmaceuticals do.


Sealoom:	Dr. I am 43 full blown menopause for at least a year. HRT made me 
sick so I am taking Pro-Gest cream and soy protein.  My blood test came back low 
on estrogen. the doctor wants to put me on estrogen and I don't want to because it 
makes me sick.  Any advise?  The doctor said that in 6 months if the estrogen 
is not higher he wants me on it. 


Dr. Goldstein and Ms. Ashner:	For patients like you with premature ovarian failure, I often still 
use 20 microgram birth control pills because a younger woman like you has even 
higher estrogen requirements than someone older first going through menopause.  
You will do better (all of the people in this room) if you markedly restrict your 
salt intake while on birth control pills or estrogen and add 200 mg vitamin B-6 
time-released a day. 


Dearest:   Dr. G and Laurie, what would be your suggestions for women who are 
postmenopausal and who can't take HRT?  


Dr. Goldstein and Ms. Ashner:	I depends on why you can't take HRT, and is the goal treatment of 
symptoms or extending health. 


Dearest: 	  Extending health.  Can't take HRT - history of phlebitis and don't prefer 
HRT and its risks, to say nothing of its side effects. 


Dr. Goldstein and Ms. Ashner:	Extending health?  Then it depends on what the reason is to not 
take HRT.  Are you a candidate for Evista? 


Dearest:   I, personally, am not a candidate for most drugs. I don't react well.


Dr. Goldstein and Ms. Ashner:	Watch your diet, stay on anti oxidant vitamins and B-6.  Don't 
discount Evista, it may be what you need, since it lowers breast cancer, lowers 
uterine cancer, preserves bone, prevents fractures and lowers cholesterol.  It's 
the most exciting drug to come along since penicillin.  


Dearest: 	   I treat all those with vitamins, minerals, herbs and phytoestrogens. 
I got thru the worst part of menopause without hormones. Think I"ll make it through 
the rest :) Mom just turned 87 :)


RCHCTH:	History of breast cysts, will ERT make cysts worse and breasts more tender? 
(in peri) 


Dr. Goldstein and Ms. Ashner:	Absolutely.  You should consider 20 micro birth control pills, 
decrease salt, decrease caffeine.  The problem is your own FLUCTUATING estrogen.  
Birth control pills will turn that off.  You'll feel better, your breasts won't hurt.
But you must decrease salt and caffeine.


Dearest: 	  Can you make the distinction between 20 mcg of BC pills and traditional 
ERT menopausal women take? Thanks 


Dr. Goldstein and Ms. Ashner:	The total effective estrogen of 20 mcg pills is about double .625 
milligrams of conjuted estrogen.  But remember that the BCPs TURN OFF your own 
ovarian production and substitute this low dose instead.  


Dearest: 	  Then wouldn't 20 mcg BC pills put us more at risk for cancer? 


Dr. Goldstein and Ms. Ashner:	Than what?  It doesn't put you at more risk because it turns off 
the estrogen you're already making.  


Dearest: 	  But it's adding synthetic estrogen to your body, right?  I'm 
confused here. 


Dr. Goldstein and Ms. Ashner:	A point I'm trying to make is if you're post menopausal all you need 
all you need is .625 mg of conjuted estrogen is sufficient unless you are under 
age 45.  This dose in perimenopausal women, however, will not be able to 
SUPRESS your own ovarian production.  20 mcg bcp pills are the lowest dose 
effective to do this.  


Dearest: 	 Interesting. Another point, we're told to take conjuted estrogens 
for heart health....yet I've read that they can elevate triglycerides which contribute 
greatly to heart problems.  What are your thoughts? 


Dr. Goldstein and Ms. Ashner:	The relationship between estrogen and heart disease as mediated 
through the SECONDARY markers, known as lipids is still unclear.  Yes estrogen 
raised triglycerides (not a great thing) but estrogen increases HDL (a very great 
thing).  Hopefully the Women's Health Initiative will yield some answers.


Dearest: 	Yes, we're all looking forward to those results in 2005. 


Annetteb2:	I'm 49-- many symptoms, yet have regular periods.  I am presently 
taking natural progesterone (capsules). When the time comes is there a natural 
estrogen and when should I consider it is time?


Dr. Goldstein and Ms. Ashner:	When you stop having any vaginal bleeding.  Vaginal bleeding is a 
sign of enough estrogen priming of the uterus.  The use of progesterone, natural 
or otherwise, can help to regulate your bleeding pattern, but will do little for 
the symptoms of fluctuating estrogen. 


Howard1978:	I'm DES exposed and have trouble with synthetics because of bad 
receptors. Is there a *safe natural estrogen?  I'm 41, started periods again after 
using progest cream. 


Dr. Goldstein and Ms. Ashner:	This is a case when you should see your doctor.  DES exposure 
usually causes anatomic changes in the genital tract, but I am unaware of any 
changes to overall estrogen receptor function.  Obviously, yours is a unique case, 
and you should discuss this with your doctor.


Lrj48:	I am 50; went into meno early--at 43 & took HRT for 7 yr.--just had 
hysterectomy w/ovaries removed, and I'm wondering if I should take testosterone 
in addition to estrogen now. 


Dr. Goldstein and Ms. Ashner:	Testosterone with estrogen helps with libido in about 50 percent 
of patients who have that problem.  In that case I'd say, other functions of testosterone 
are not well studied or understood.  The jury is still out.  


Lrj48:	Is there any point other than libido?  Are you saying there's no evidence?


Dr. Goldstein and Ms. Ashner:	Other than libido, in my clinical practice, that's been the only 
significant addition of testosterone.  


GMAMATT:	Wanted to know more about Evista.  Went off HRT after ten years, 
concerned about long term use causing breast cancer.  Dr. wants me to take Evista 
for bone health


Dr. Goldstein and Ms. Ashner:	Excellent choice.  Evista preserves bone, prevents fractures, 
lowers breast cancer, lowers uterine cancer, lowers cholesterol.  It's worth a try. 
Little to lose.  


JanNJess:	at 45 had precancer in breast, on tamoxifen until 50, had total 
hysterectomy at 46, off tamoxifen now. mood swings, weight etc.  Any suggestions?


Dr. Goldstein and Ms. Ashner:	Were your ovaries removed?  If yes, it's a tough one.  I'd definitely 
consider Evista.  I cover this in my book "The Estrogen Alternative" (Putnam). 


Sue:	If taking the low dose BC pills turns off your ovarian function, 
what happens when you stop the BC pills?  How long do you normally keep someone 
on such a treatment program?   


Dr. Goldstein and Ms. Ashner:	Until around age 50.  Soon, after coming off the pill, ovarian 
function resumes.  Around age 50 in women on dose pills you can check FSH on 
day 6 on the pill free week and if it is elevated, you can switch the patient 
to more traditional forms of HRT.  


Sealoom:	Dr. since I haven't had a period in over a yr.(43 yr. old). HRT made 
me sick. Would you prescribe birth control or Evista and why can't I get the same 
amount of estrogen from soy protein the natural way? 


Dr. Goldstein and Ms. Ashner:	I would give someone your age 20 mcg birth control pills and then 
the amount of soy you would have to ingest would be 40 to 50 grams a day.  It's 
not enough to sprinkle a little soy in your spaghetti sauce.  It think soy may 
turn out to be a phyto SERM and I am very interested and following the research 
carefully.  


Sealoom:	What about eating enough of a half a block of tofu? 


Dearest: 	You can get 184 mg. soy isoflavones in one Revival Soy Protein 
shake.   


Dr. Goldstein and Ms. Ashner:	You'd need forty of those shakes a day to get to the 
dose I'm talking about!  


Dearest: 	Dr. Goldstein, why would you have to drink 40 soy shakes of 184 mg. 
soy isoflavones to get the same effect? Japanese women consume approximately
200 mg. of soy isoflavones in their diets daily.  If I drank that many shakes, the 
flatulence alone would cause WW III  :)


Dr. Goldstein and Ms. Ashner:	The amount of breast cancer as well as menopausal symptoms in the 
Japanese culture is markedly less than here. However, the amount of soy in their 
diets is SIGNIFICANTLY greater than the soy protein shakes.  


Dearest: 	 Don't you attribute that, in good part, to their diet rich in soy isoflavones?  
A typical Japanese woman consumes approximately 200 mg. of soy isoflavones
per day.  Revival Soy Protein Shakes currently being used in research at Johns Hopkins, 
contain 184 mg. per shake. 200 mg. is sufficiently higher than 184 mg.? 


Dr. Goldstein and Ms. Ashner:	Probably, Dearest.  But such a diet is difficult for most Westerners 
to adhere to.  


Dearest: 	The soy shakes are delicious :) I have no problem with one shake per 
day.    


Annetteb2:	I am 49, perimenopausal on natural progesterone. At this time 
is testosterone indicated for loss of libido(which may be caused by a medication 
I am on and would taking soy protein at this point be detrimental?


Dr. Goldstein and Ms. Ashner:	But what drug are you on that is affecting libido? Discover that 
rather than adding more irons to the fire.  


Annetteb2:	I am on Effexor however Dr. thinks the libido more than likely is 
hormonal.


Dr. Goldstein and Ms. Ashner:	Have your doctor recommend something other than effexor. I have 
no data on how testosterone might interact with effexor.  


Lrj48:	You seem to think testosterone basically unnecessary; even if no ovaries?  
Is it only sex drive--I thought it might help w/overall energy level. 


Dr. Goldstein and Ms. Ashner:	I don't think testosterone is unnecessary, and I am saying the jury 
is still out.  Pharmaceutical grade testosterone is only available with estrogen.  
Testosterone creams have poor quality control.  I'm hoping that in the years that 
follow research will show better ways to administer testosterone if research 
shows it to be of value.  The research on testosterone is really lacking.  I can't 
really comment any further than what I've already said.  


Lrj48:	You said 200 mg B6 before, isn't that a lot?  I looked at my multi-vitamin, 
and it is has only 5 mg.  What does B6 do for you?


Dearest: 	  200 mg. B-6 is not a lot. I take 100 mg. B-6 3x per day


Sealoom:	Dr. I took birth contol pills for 3 weeks when I was 19. They made me 
sick too.  If I can put in my body enough soy isn't that enough?


Dr. Goldstein and Ms. Ashner:	This is a main theme of my book, Could It Be...Perimenopause?.  
The pills you took had FOUR TIMES the hormone of the ultra low dose pill we're 
speaking about today.  Take vitamin B6, restrict your salt, and give them a two 
month trial.  


Dearest: 	Dr. Goldstein and Laurie Ashner,thanks for joining us in Power Surge 
and fielding our questions about perimenopause, HRT, SERMs and your wonderful 
new book, "Could It Be....Perimenopause?" Thank you, too, for the wonderful chapter on 
Power Surge in your book. We hope you'll come back and visit with us 
again very soon. 


Dearest:  	Dr. Goldstein, Laurie, please share the name of the newest book, too.


Dr. Goldstein and Ms. Ashner:"The Estrogen Alternative" 


Dearest:  Thanks and thank you for a wonderful chat tonight. 


Dr. Goldstein and Ms. Ashner:	It was our pleasure.  Thanks to all!




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Dearest
aka Alice Stamm
Power Surge
Founder, Facilitator, Host


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