Dr. Michael Goodman 
Caring for Women 
A Specialty Women's Healthcare Practice 
530-753-2787
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1340 E. Covell Blvd., Suite 102 
Davis, California 95616 
Caring for Women

Dr. Goodman received his training from Stanford University and has over 33 years’ experience in the field.  An early pioneer in Family Centered Maternity Care, he was the first doctor in California to include children at in-hospital birth and one of the first in the nation to work with midwives, and to allow fathers into the OR for C-sections.  An accredited Laparoscopic Surgeon, he authored the first published U.S. series on Advanced Operative Laparoscopy and has taught and proctored many courses and seminars on these procedures.

Dr. Goodman is a medical communicator practicing patient-oriented health care and specializes in listening to women.   His empowering book, "The Midlife Bible: A Woman's Survival Guide," published by Robert D. Reed Publishers, San Francisco, is available above.

• How Strong Are Your Bones?
• Breast Cancer
• Updates on Hormone Replacement Therapy
• Migraines?
• Menopause FAQ

“Red Hat”; “Sexy Years”; “Not Your Mother’s Midlife”; “Screaming to be Heard”; “The Midlife Bible”--Books, societies and interest abound about and for “Baby Boomers”.  Here is a bare-bones outline of ideas to help assure vibrancy and health for years to come.

I. Lifestyle Modifications

“If I had known I was going to live this long, I would have taken better care of myself”--Jazz pianist Eubie Blake, upon reaching the age of 100.
 

Hormonal balancing is important:  Herbs, botanicals and supplements are helpful, and  pharmaceuticals can be life-saving, but none will work without a healthy lifestyle--either maintaining (if you already have one) or adapting the following routine:

 A. Eating pattern:  Multiple small complex carb, and protein-balanced meals to maximize caloric expenditure, prevent hypoglycemia and shrink the size of your stomach (fresh fruits and veggies, whole grains and beans are examples of “complex carbohydrates”).
B. Exercise:  You don’t have to like it, you just have to do it.  This is exercise as work--every bit as important (and more) as other “work” you have to do, and you have to do it to stay healthy!  Exercise most days, 20-60 minutes of out-of-breath, sweaty work. 
C. Stress reduction:  Much of the fatigue and depression that accompanies menopause is secondary to adrenal fatigue.  What stress does to you, and specific methods for reducing stress will be discussed later.

II. Hormonal Balancing:  The Role of Botanicals and  Bioidenticals. 

“They are not hot flashes--they are power surges.”--anonymous.

Everyone responds to their environment, and what is a more integral part of a woman’s environment than her hormones!  The headaches, the PMS, the mood changes and depression and the hot flashes, joint aches, poor sleep quality and emotional lability of peri- and post menopause is in large part secondary initially to the fluctuations of estrogen and progesterone in the perimenopause and later to the bottoming out of estrogen and general lowering of testosterone levels as menopause proceeds.

While herbs and botanicals help many women, it is frequently via re-balancing ovarian (and sometimes adrenal) hormones that homeostasis is re-established.

Botanicals that may work:  St. John’s Wort, Black cohosh, chaste berry (Vitex), phytoestrogens (from soy or red clover sources) help take the edge off for many women.  Several amnio acids (Sam-E, L-theanine and others) may also help.  Other supplements (phosphatidylserine, acetyl-L-carnitine and Ginkgo, as well as Vinpocetine may all help enhance cerebral circulation and memory. 

Bioidenticals:  The role of hormone therapy in the peri- and post menopause is to re-establish the balance that has been lost by the body’s bumpy transition from the gently rolling cyclicity of the reproductive years to the lack of estrogen (and frequently testosterone) when the ovaries cease func-tioning.  Many different estrogens, progestogens, combina-tions and delivery systems are available.

In this (usually temporary) replacement, it makes sense to utilize compounds and delivery systems that are best accepted by a woman’s body.

A bioidentical is a compound that is biologically identical to that (previously) produced by the body.  Also erroneously called “natural hormones”, bioidenticals are synthesized in the lab, usually from plant sources (soy beans, wild Mexican 
yam) to be biologically identical to the hormones secreted from a woman’s own ovaries.

Bioidentical hormones include: 
(1)  Estradiol (“E2”)--the primary hormone from the ovary. 
(2)  Estrone (“E1”)--also secreted from the ovary and to a small degree from adrenal glands; very biologically active. 
(3)  Estriol (“E3”)--a byproduct of E1 and E2 metabolism; a weak estrogen.  Estriol is not normally secreted from the ovary. 
(4)  Testosterone. 
(5)  Progesterone. 

Bioidentical Adrenal Hormones: 
(1) Pregnenolone.  (2)  DHEA.

The whole idea of bioidentical hormonal balancing is to   re-establish your individual homeostatic hormonal milieu, regain your strength and confidence and then, at your own pace, manage your hormonal taper down all of the way to “taper off”, if possible. 

III. Hormones forever?  Or Never?  Hormonal Safety.

“One has two duties:  To be worried and not to be worried.”--E. M. Forster

A picture is beginning to emerge from all of the confusing results of recent studies.  (1)  Hormonal therapy is much safer if started at peri-menopause (or early post menopause) rather than many years after menopause.  (2)  The safest way to administer hormone therapy is to utilize the lowest effective dose of estrogen, giving progestagen (bioidentical progesterone or a mild synthetic) intermittently (if at all), utilizing testosterone in low doses.  The testosterone potentiates the action of estrogen and may have (in low doses) an inhibitory effect on cancer-cell proliferation in the breast.  Dormant breast tumors that are hormonally sensitive usually have both estrogen and progesterone receptors, so giving both (whether the synthetic or bioidentical) is potentially more dangerous in the long run.  (3) After stability is obtained, very slowly, and at the individual’s own pace, taper hormone therapy with the goal, after three-seven years, of tapering off all together if tolerated.  (4)  Some women may wish to continue on low-term hormone therapy.  If so, the safest is microdose estrogen, without progesterone, with or without a low dose of testosterone.  There probably is an increased risk of breast cancer, but the numbers are extremely small (and estrogen offers bone and colon cancer protection); many women will elect to take this risk because of quality of life factors. 

IV. Sexual Health:  Testosterone, Estrogen, Vaginal Health and  Couple’s Issues.

“Sex is one of the nine reasons for reincarnation...the other eight are unimportant” --Henry Miller in “Big Sur and the Oranges of Hieronymus Bosch.

“Use it or lose it...”, as the saying goes, is true for sexual satisfaction and intimacy in women.
Waning sexual desire, vaginal dryness and diminished intimacy and coital frequency seem to be the norm at midlife, but that does not have to be the situation.  This state of affairs stems from a combination of low estrogen (and frequently concomitant low testosterone) levels, leading to diminished desire, a dry vagina and other symptoms (moodiness, poor sleep quality, hot flashes, etc.), which make sex less than appealing.  Men often forget that while a man may be easily aroused at any time in his life, women (and midlife women in particular) frequently desire intimacy first, which then may lead to desire and arousal.
Additionally, frequently male issues such as erectile diffi-culties or the sexual desire and energy loss caused by low testosterone levels serve to further push sex “off the table”. 

Local (vaginal) estrogen, systemic estrogen, and testosterone all have their place in promoting vaginal health and increasing dormant desire.  Frequently the same medications (Viagra, etc.) that have erected many a man’s penis can be used successfully in women to aid in arousal and orgasmic intensity. Midlife women’s vaginas should be used (via intercourse, devises or self pleasuring) to maintain optimal health.  Some sex begets more sex. Arranging one or two “physical dates” (in bed, minimal clothing, good atmosphere) each week at a time when both partners aren’t tired works wonders and diffuses the angst of the “should I approach her” situation.  In-bed cuddling puts intimacy first, and frequently “...the rest will follow”.  The use of fantasy, erotica and “...implements of pleasure” can all help to increase arousal and spice up an old relationship. 

V. Stress and the Immune System

“There is nothing on my mind that couldn’t be expressed by a long, insane burst of hysterical rage”--Ashley Brilliant

Stress colors everything we do, who we are, and how we act/react to our surroundings.  It plays a very major role in disease states from fatigue to irritable bowel to cancer to heart disease.  Constant, even low level unrecognized stress “wears out” the adrenal glands, leading to difficult-to-manage fatigue states. Stress reduction techniques including meditation exercise and limiting over extension and stressful situations are imperative.  Frequently supplementing adrenal hormones, (especially DHEA, occasionally pregnenolone and cortisol) may work wonders. 

VI. Keeping Your Bones Strong:  Preventing Osteoporosis.

“It wasn’t raining when Noah built the arc”--Howard Ruff

You don’t want to get osteoporosis!  You want to prevent it.  How do you do that? 
Your bones are dynamic, constantly “remodeling”.  Building up, breaking down.  The idea is to build up as much (or more) as you break down!  A good 20-25% of the female population is “challenged” in the bone density department, either secondary to genetic factors, poor intake of protein and calcium during maximal bone-forming years (ages 14-24) or chronically lowered estrogen levels.  It is important to find out if you are “one of that 20-25%”!  If you are Caucasian or Asian, slender, perhaps small breasted, a smoker, had a history of missing periods when you were younger or have a family history of osteoporosis or have taken a lot of cortico-steroids in your life, you may be at increased risk.

A heel or wrist screen can give you a general idea of where you are at, but it is only a screen.  If your bone density is “okay” (a T-score of better than -1.0) odds are 95% you are okay; if it is lower than -1.0, odds are 40% you are not okay.  These odds increase to 75-80% for T-scores of -2.5 or lower.  The only way to know for sure, as well as follow improvement (or deterioration), is a study of your hip and spine by dual-energy x-ray absorptiometry (“DXA or DEXA”).

How do you build up bone?  You need adequate protein in your diet, adequate calcium (1200-1500 mg a day), some magnesium (400-600 mg a day) adequate Vitamin D (600-800 mg a day) as well as weight-bearing exercise.  If you do have evidence of early bone loss, it is important as well to prevent loss, and many different hormonal substances and pharmaceuticals are available. This is the place for estrogen, testosterone, progesterone, flouride, non-estrogen pharmaceuticals. Actonel and Fosamax as well as newer compounds) and SERM’S (“selective estrogen receptor modulators”) such as Reloxefine (“Evista”). and others about-to-be-available will be discussed.

If you are not “challenged” in this department, it is a nonissue.  But if you are, it is very important to understand that the greatest bone loss in women occurs in the two to three years after menopause or after they discontinue hormone therapy.  It is important to know this before it happens; it is difficult to regain bone mass once it has been lost.

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Michael Goodman, M.D., is a 30-plus-year experienced gynecologist and perimenopausal practitioner, director of “Caring for Women” in Davis California.  He is a Certified Menopause Practitioner, Certified Menopause Clinician and Certified Clinical Bone Densiometrist.  Dr. Goodman sits on the Consumer Education Committee for the North American Menopause Society.  He works with women to develop individualized programs to aid and enliven the midlife passage, and to assure aging fearlessly.  Dr. Goodman speaks frequently at gatherings from small groups to large seminars.  His new book, “The Midlife Bible, A Woman’s Survival Guide” is available on his website, www.caringforwomyn.com and at bookstores.