Empowering Women Having Children After 40

In 2010, the CDC reported that the only age group in the United States to show a RISE in birth rate were women over 40.

Flower Power Mom is offering advance membership to the first online community to empower women having children after 40, launching USA Mother's Day, May 8th, 2011.

To join now, go to: www.flowerpowermom.com/community

For more information on the A CHILD AFTER 40 campaign video, Pay It Forward Mother's Day Gift Pendant, and online resources, go to: www.flowerpowermom.com/a-child-after-40

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News on FSH levels

Found on Fertility Friend today:

Extract from: Canadian Consensus on Menopause and Osteoporosis (Update Sept 12, 2002)
RECOMMENDATIONS:
A2 Healthcare providers should not use random serum markers of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol E2 for the purpose of predicting menopause since clear markers for predicting menopause are yet to be identified. (II-2)

I'm shocked because I went to the doctor and he did a blood test called FSH which showed I'm menopausal even though I'm having regular periods. How can this be?

Hormonal blood tests are notoriously unreliable as hormone levels vary widely from day to day and even during the day. The FSH test is basically useless for determining what stage of the perimenopausal transition anybody is in. Here are statements from the abstracts of three studies you can find on Medline. You might like to print out the whole abstracts and show them to your doctor if you want to convince him. Of course he *could* simply mean "perimenopausal" - the two words are often used interchangeably (and confusingly!)

http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=6790204&form=6&db=m&Dopt=b
Clin Endocrinol (Oxf) 1981 Mar;14(3):245-255

Pituitary-ovarian function in normal women during the menopausal transition.

It is concluded that the appearance of high levels of FSH and LH is characteristic of the perimenopause and often precedes the sustained loss of sex hormone secretion by the ageing ovary. Postmenopausal biochemical parameters are no guarantee of the postmenopausal state.
________________________________________
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8107620&form=6&db=m&Dopt=b
Maturitas 1993 Dec;18(1):9-20

Perimenopausal patterns of gonadotrophins, immunoreactive inhibin, oestradiol and progesterone.

It was concluded that typical postmenopausal hormone patterns may occur at the time of entry into the normal menopausal transition, and in some women with anovulatory infertility, but may be completely and relatively abruptly reversible. Elevation of serum FSH into the postmenopausal range, with undetectable INH concentrations, does not provide reliable evidence that the menopause (or permanent ovarian failure) has occurred. INH contributes to elevations of serum FSH during the menopausal transition.
________________________________________
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8124478&form=6&db=m&Dopt=b
Eur J Endocrinol 1994 Jan;130(1):38-42

Diagnostic role of follicle-stimulating hormone (FSH) measurements during the menopausal transition--an analysis of FSH, oestradiol and inhibin.

It is concluded that FSH measurement is of little value, if any in the assessment of women during the menopausal transition because it cannot be interpreted reliably and because, apparently, ovulatory (and, presumably, potentially fertile) cycles may occur subsequent to the observation of postmenopausal FSH levels. Both oestradiol and inhibin are important negative feedback regulators of circulating FSH.
________________________________________
extract from Menopause 1999;6:29¬35. © 1999, The North American Menopause Society
http://www.menopause.org/abstract/6129.htm

Among U.S. women aged 35¬60 years, median FSH and LH levels began to increase for women in their late 40s and reached a plateau for women in their early 50s.This study supports the previously reported association between serum FSH and age (i.e., serum FSH and LH levels increase with age) and smoking (i.e., current smoking was associated with an increased level of serum FSH). At FSH levels of = or >15 IU/L or = or >20 IU/L, 70 and 73% of women, respectively, were postmenopausal. Our study also found an interaction between age and oophorectomy. In addition, the present data suggest that women with only one ovary may have higher FSH levels than women with both of their ovaries.
________________________________________
From: Gail Gillespie

This discussion of the FSH test took me back to my menopausal transition, reminding me of some of the more horrifying absurdities foisted on me by the medicalization of menopause. For example, when, at 48, heavy bleeding drove me to the doctor's office, I was given the test - as part of a general check up to see what was going on, or so I thought. When the results came back the doctor told me that they would have to perform an endometrial biopsy to "check for cancer" since my FSH was "similar to a 29 year old's." Great.

So, then, after the (very painful for me) endo. biopsy showed nothing abnormal, they put me on ever-increasing doses of provera to curtail the bleeding - which paradoxically increased to the pointt where I had a 70 day continuous bleed accompanied by cramps just this side of childbirth. Weak from exhaustion/anemia, I dragged myself in again to the same doctor who then gave me a second FSH test. (The fact that I was taking 20 mg of provera a day seemed immaterial to him!)

Studying the new FSH results, he then told me that because of my unexplained POSTmenopausal bleeding I would require a more-or-less immediate hysterectomy. I should sign up right then and there because he was "very busy" in October.

When I reacted with shock, since the biopsy, which was normal, was also based on the FSH results which suggested a NON post-meno. status, the doctor became very condescending. He indicated that this second blood test indicated that my FSH had gone from 9 to 51 (in a couple of months) and suggested that I was now, suddenly, POST menopausal. Then he began to hint darkly at the possibility that I may have cancer or at least fibroids because POST menopausal bleeding is one of the major signals of serious trouble. As angry as it makes me to recount this, it also strikes me that the fact that the doctor was an insensitive jerk helped in the long run since my distrust prompted me to check out things on my own.

Fortunately, by this time, I'd discovered alt.support.menopause and was reading Susan Love's book as well as a number of books on hysterectomy, including Cutler's. Looking back and checking my "bleeding journal," the entire situation reminds me eerily of childbirth, in which case, the fetal monitor, like the FSH test, is often the excuse for rampant, unnecessary intervention in a normal physiological process....an intervention which may, in the end, have dire consequences (such as the loss of perfectly healthy body parts). Incidentally, this doctor's remark to me when I fired him to get a second opinion, was "don't come crying to me when you get ovarian cancer."
-g
PS. To the newbies: I am doing just fine now. I feel better than I have since my 30s and have not bled for two years. I take no drugs other than the occasional ibuprofen and a multi-vitamin when I think about it. My only "symptoms" (hate that word) were a few hot flashes for several months as I made the adjustment to a drug free state. After what I went through, it was hard to go back to a doctor regularly though I do reluctantly get an annual PAP and mammogram.
________________________________________

So what are "normal" levels for FSH?
Note the wide range and overlap -
http://www.drkoop.com/adam/peds/top/003710.htm#Normal values
Normal values:
male: 4 to 25 U/L
female:
premenopausal: 4 to 30 U/L
midcycle peak: 10 to 90 U/L
pregnancy: low to undetectable
postmenopausal: 40 to 250 U/L
Note: U/L = units per liter
________________________________________

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Sex after 40? Women get a chance to talk about it

Picture by bjearwicke
Here’s a wake-up call for anyone who thinks mature women don’t have to think about unwanted pregnancies.

Half of the pregnancies among women over 40 are unintended and 65 per cent result in abortion, said Kelty Moser, executive director of the Pictou County Centre for Sexual Health in New Glasgow.

Rising divorce rates mean more women in mid-life are encountering new sexual partners than in the past, and they aren’t accustomed to using condoms because the practice wasn’t taught when they went to school more than 20 years ago, Ms. Moser said.

Read more: http://thechronicleherald.ca/NovaScotia/1122584.html

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Calculate probability of spontaneous ongoing pregnancy

I tried doing some calculations for a 48 year old woman (oldest age they list) and got:

The calculated probability of a spontaneous ongoing pregnancy within one year is: 36.1%
__________________________________

Note the page says:
This probability is not reliable in case of :

* - Women with ovulation disorders
* - Men with severe male factor (Total motile sperm count = volume x concentration x % motility <>
* - Women with 2-sided tubal pathology.


Try it out at: http://www.freya.nl/probability.php and let me know what you get!

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LH estrogen decreased in older women

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Luteal phase estrogen is decreased in regularly menstruating older women compared with a reference population of younger women.

Objective: To compare daily reproductive hormone secretion in regularly menstruating older versus younger women.

Results: Daily morning urine samples were obtained from 106 women, 28 of whom were aged between 20 and 34 years (mean: 27.8 +/- 3.7 y) and 78 of whom were aged between 35 and 50 years (mean: 40.3 +/- 3.7 y). Lower luteal estrone-3-glucuronide levels were seen in the older versus the younger group (82.7 vs 93.5 ng/ml, P = 0.035).

The pregnanediol-3-glucuronide levels in the older group were lower than those in the younger group throughout the entire cycle. The median length of the follicular phase was shorter in the older versus younger women (13 vs 14.5 d, P = 0.005). There was no significant difference in the median luteal phase lengths between groups.

Conclusions: We report the new finding that regularly menstruating older women not only have lower pregnanediol-3-glucuronide levels but also have a significant reduction in luteal phase estrone-3-glucuronide compared with a contemporaneous cohort of younger women. This combined deficit may play a key role during the luteal-follicular transition, potentially affecting follicle recruitment and decreasing fecundity in the subsequent cycle.

(C)2008The North American Menopause Society

Full Article: http://www.menopausejournal.com/pt/re/menopause/fulltext.00042192-200815030-00015.htm;jsessionid=Lb8GpBcNZc8LZJDPwtyNYv5Ynp8wzSnkHYzPkY4b1pwXfTcJhKHB!1955444924!181195629!8091!-1

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Delayed Parenting

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A growing number of women across America are having their first babies at age 40 or even older. Overall, first births among women over 30 rose to a record 22% of all births in 1995, as opposed to 5% of births in 1975.


Full article: http://ohioline.osu.edu/hyg-Fact/5000/5305.html

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Journalist needs help

Johanna wrote: I am researching a story about the very thing you wrote about on your blog. The fact that women undergoing menopause can still conceive (though it is more difficult) so they need to keep using birth control if they want to avoid a pregnancy.

I am looking to interview women who either had to deal with an unplanned pregnancy during perimenopause or were surprised to discover they still needed to use birth control. If you know of anyone willing to share their story, could you forward my contact information. Unfortunately, I am under the gun with my deadline. I have to submit the piece to my editor at the Wall Street Journal (it is a freelance story) by April 1. Can you help me?

Johanna Bennett
Barron's Online
(212) 416-2243
johanna.bennett@barrons.com

How old is too old?

Photo by www.bbc.co.uk
Women are leaving it later and later to have children, and thanks to advances in fertility treatments, women in their 60's or older now have the chance of giving birth. But should IVF be used in this way?

Older mothers
No one could deny the joy and love on the faces of Patricia Rashbrook and husband John Farrant as they presented their newborn baby, JJ, to the world in July 2006. A mother for the fourth time, aged 62, she earned the tabloid title of 'Britain's oldest mum'.

In December 2006, a 67-year-old Spanish woman was reported to have given birth to twins, and in January 2005, Romanian academic Adriana Iliescu became a mother at 66.

The verdict from most of the public and media was that sexagenarian parenthood was a step too far.

But whatever your opinion of Dr Rashbrook and Adriana, there's no doubt they're outriders in a growing trend towards late motherhood.

Waiting game
In 2004, more babies were born to women in their early 30s in England and Wales than to any other age group, overtaking 20-somethings for the first time. The birth rate is also rising fastest among women in their late 30s and early 40s.

In 2005, 22,246 women over the age of 40 gave birth, a figure that has almost doubled in a decade. Regardless of doctors' warnings about the risks of delaying childbirth, more women are choosing to fit in having babies when it suits their career and life plans.

As a result, women in their late 40s and 50s are turning to those same doctors for assistance in rewinding the biological clock.

Current age limits
There are no hard and fast rules governing age eligibility for assisted reproduction, and neither is being postmenopausal a barrier. The guidelines simply require clinicians to take account of the welfare of the child.

While the NHS imposes an age limit of 39, the financial reality is that only about 25 per cent of fertility treatments are state-funded. So it comes down to biology and finance - can the woman cope with the rigours of pregnancy and can she pay?

In vitro fertilisation (IVF) success rates decline with age and most clinics won't treat patients over 45, but a handful of British units take a more flexible approach. Since the 1990s, there has been a dramatic rise in IVF mums over the age of 50. Just three were treated in the UK in 1992, but by 2002 that figure had jumped to 96, resulting in 24 births. Women treated overseas aren't included in these figures.

Playing catch-up
While society is getting used to an increase in 40-something childbearing, it's the postmenopausal pregnancies that stir up media commentators. But are these women really going against the natural order, or is it Mother Nature who's failing to keep up with the pace of human development?

That's the argument of Mr Laurence Shaw from The Bridge Centre, a London fertility clinic. He points out that 150 years of improved nutrition, hygiene and medicine have extended our lifespan well beyond the menopause, to 80 and older.

But while our longevity has increased, the reproductive cut-off remains stalled at 50. "It's the menopause that's not natural," Mr Shaw argues. "Before we criticise 62-year-old women who want babies, we should remember that not so long ago women would only have had about 20 or 30 years to care for their offspring.

"Nowadays, 60-year-old women in many industrialised countries have a life expectancy of 80 or 90 [the average is 82], so there's no difference in terms of length of their survival after the birth of the baby."

News: Surge in older women seeking IVF
HFEA
NICE
British Fertility Society

Full article: http://www.bbc.co.uk/health/fertility/bigissues_age1.shtml

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Pregnancy After 35: Better ways to track ovulation

Photo by www.fertile-focus.com
If you're in your late 30s or 40s and trying to conceive, ovulation-predictor kits might be steering you wrong -- or driving you crazy.

In a US study of 848 women, researchers found that the hormonal surge that usually signals "It's time!" may not really announce ovulation if you're perimenopausal and your period is irregular. (Perimenopause can start in your late 30's or early 40's.)

"Levels of luteinizing hormone, the hormone measured by most ovulation kits that use a urine sample, may be high and produce a falsely positive color change on test strips," says lead researcher Nanette Santoro, MD, an OB/GYN at Albert Einstein College of Medicine. "A woman thinks she's ovulating, but in fact, two other key hormones -- estrogen and progesterone -- may be so low that ovulation isn't really possible."

Santoro's team is developing a mathematical formula that pinpoints ovulation based on the ratio of estrogen to progesterone. A home version of their ovulation detector is years away, but these steps can help you pinpoint a ready egg:

Are you ovulating at all? If you have irregular periods or have tried to conceive for 6 months, your doc can order lab tests to assess ovulation.

Buy two ovulation test kits. Women over 35 may have late-in-the-month hormone surges. "If you start checking on day 10, and you don't ovulate until day 20, you'll run out of strips if you have just one five-strip pack," says Santoro.

Switch to a saliva test. These kits ($25 to $60) detect the pre-ovulation estrogen surge.

Source: http://www.prevention.com/cda/article/pregnancy-after-35/fb279c777f803110VgnVCM20000012281eac____/health/healthy.living.centers/ob.gyn.health

Ovulation Predictor Kit Frequently Asked Questions: http://www.fertilityplus.org/faq/opk.html


How to use ovulation kits: http://www.babycenter.ca/preconception/suspectingaproblem/howovulationkitswork/

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Scientists discover enzyme that controls ovulation

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A cause of premature menopause has been found which could pave the way to new treatments and also help improve the success of test tube baby fertility treatments.

An international team that includes British scientists has discovered an enzyme that controls the rate at which women ovulate and believe that when this process goes awry it can lead to menopause occurring years earlier than normal.

At birth, the ovaries of women contain about 300,000 - 400,000 unripe eggs, her lifetime's complement, each held in a tiny sac or follicle.

But in adulthood only ten or so follicles grow each month and of these, only one goes on to deliver an egg bursting to release its ripened egg into the fallopian tube.

However, around one woman in every hundred runs out eggs before her 40th birthday, triggering early menopause, so she is no longer able to have children naturally.

Today, in the journal Science, Dr Kui Liu of Umeå University, Sweden, Prof Ilpo Huhtaniemi of Imperial College London and colleagues in China and America report that the enzyme PTEN keeps immature eggs from ripening prematurely. "It is a kind of brake," says Prof Huhtaniemi.

The team finds that in mice lacking PTEN in their eggs, the entire pool of immature eggs is activated prematurely, becoming ripe so the mouse uses up it store of eggs more rapidly..

Prof Huhtaniemi says that PTEN works in humans too and that the team is now going to investigate whether mutations in the PTEN gene are linked with premature menopause in women. "We have one good candidate to explain why some women develop premature menopause," he says.

A drug to mimic the effects of PTEN could be used to prevent or treat premature menopause when combined with new tests that can show how quickly a woman's biological clock is ticking. By the same token, a way to block the effects of PTEN could lead to new ways to ripen eggs for IVF, notably if eggs fail to ripen in the first place, says Dr Liu.

To overcome how women only make one egg each month and obtain more for IVF treatments, or to create embryos if they are to undergo fertility threatening cancer treatments, doctors have used expensive hormones to stimulate them to ripen multiple eggs, which does carry some risks.

But some women seeking to preserve their child-bearing capacity may not have enough time to undergo ovarian stimulation or may have a condition that makes it dangerous, such as hormone-sensitive breast cancer.

Lab-dish or "in vitro" egg maturation has produced hundreds of babies worldwide, though is still experimental.

Now PTEN offers another way to ripen eggs, says Dr Liu. "With the knowledge that PTEN suppresses follicle activation, it is in theory possible to culture a piece of the ovaries in the petri-dish and trigger the follicle growth with a synthetic PTEN inhibitor, which we have started to try".

Such a method will enrich the source of eggs for IVF or who want to freeze their embryos before going to have chemotherapy or radiation therapy for cancer, says Dr Liu.

Source: http://www.telegraph.co.uk/earth/main.jhtml?view=DETAILS&grid=&xml=/earth/2008/01/31/scimeno131.xml

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From 'menopause' to baby for mum

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A 40-year-old woman told by a doctor she was starting the menopause gave birth to a baby seven hours later after having had no idea she was pregnant.

Amanda Morgan, from Neath, gave birth to her 5lb 6oz (2.43kg) daughter Caitlin after leaving the surgery.

She was told she was having the "classic signs of early menopause", but her condition had been misdiagnosed.

The Royal College of Midwives said cases like hers were very rare, but fast labours were often uncomplicated.

The legal secretary, who already had two sons aged 13 and 10 from a previous relationship, described how she gave birth to Caitlin at home 11 months ago.

"It was a complete shock to me," she said. "I'd had no morning sickness or tiredness and had absolutely no bump at all.

"I'm 40 and had decided not to have any more children. I thought my baby-making days were long gone.

"I had only put on about a pound in weight but just thought I'd been snacking too much in the run-up to Christmas."

She gave birth within minutes of breaking the news to her partner Chris Grinter, 42, of the menopause diagnosis after she had seen her doctor.

'Overjoyed'

"My mum died from cancer so I worried there might be something seriously wrong.

"But I was very reassured when my doctor said I was experiencing the classic signs of the menopause. She then booked blood tests at hospital to check my hormone levels."

She returned home after the appointment and complained of feeling "exhausted". She had gone to the bathroom when she felt a "crippling pain".

"There was no time to even shout out to Chris - it was that quick.

"A strange calm took over and with one push Caitlin was out. She barely cried, just wriggled.

"I grabbed a towel and wrapped her in it. I was in a state of shock but also quite calm."

She said her partner's "face went white" when he saw the baby. "He was just gobsmacked - I don't think he could take it all in and I can't blame him."

Mr Grinter dialled 999 and paramedics arrived to cut the cord as she lay in the bathroom.

They were taken to Singleton Hospital, Swansea, and she was told she was six months into her pregnancy when Caitlin was born. The baby was in a ventilator and allowed home after five weeks.

The family are ready to celebrate her first birthday on 19 February.

"Caitlin is Chris's first baby so he's particularly thrilled. We had discussed having a baby - but decided against it because of my age.

"Even now I look back on photos just a few weeks before I had her and cannot believe I was pregnant.

"But Caitlin is the most adorable baby and we are all overjoyed to have her. She is also the easiest baby - a bit like my pregnancy."

Sue Jacobs of the Royal College of Midwives said: "This is only the third time I've come across one like this in my 25 years as a midwife.

"But women do occasionally experience what seem like periods in pregnancy.

"In such cases it's because the bleeding is caused by the placenta and just happens to coincide with period dates.

Source: http://news.bbc.co.uk/2/hi/uk_news/wales/south_west/7211940.stm

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The vagaries of FSH as a "test" for menopause

QUESTION: I'm shocked because I went to the doctor and he did a blood test called FSH which showed I'm menopausal even though I'm having regular periods. How can this be?

ANSWER: Hormonal blood tests are notoriously unreliable as hormone levels vary widely from day to day and even during the day. The FSH test is basically useless for determining what stage of the perimenopausal transition anybody is in. Here are statements from the abstracts of three studies you can find on Medline. You might like to print out the whole abstracts and show them to your doctor if you want to convince him. Of course he *could* simply mean "perimenopausal" - the two words are often used interchangeably (and confusingly!) - Pat

http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=6790204&form=6&db=m&Dopt=b
Clin Endocrinol (Oxf) 1981 Mar;14(3):245-255
Pituitary-ovarian function in normal women during the menopausal transition.

It is concluded that the appearance of high levels of FSH and LH is characteristic of the perimenopause and often precedes the sustained loss of sex hormone secretion by the ageing ovary. Postmenopausal biochemical parameters are no guarantee of the postmenopausal state.

http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8107620&form=6&db=m&Dopt=b
Maturitas 1993 Dec;18(1):9-20
Perimenopausal patterns of gonadotrophins, immunoreactive inhibin, oestradiol and progesterone.

It was concluded that typical postmenopausal hormone patterns may occur at the time of entry into the normal menopausal transition, and in some women with anovulatory infertility, but may be completely and relatively abruptly reversible. Elevation of serum FSH into the postmenopausal range, with undetectable INH concentrations, does not provide reliable evidence that the menopause (or permanent ovarian failure) has occurred. INH contributes to elevations of serum FSH during the menopausal transition.

http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=8124478&form=6&db=m&Dopt=b
Eur J Endocrinol 1994 Jan;130(1):38-42
Diagnostic role of follicle-stimulating hormone (FSH) measurements during the menopausal transition -- an analysis of FSH, oestradiol and inhibin.

It is concluded that FSH measurement is of little value, if any in the assessment of women during the menopausal transition because it cannot be interpreted reliably and because, apparently, ovulatory (and, presumably, potentially fertile) cycles may occur subsequent to the observation of postmenopausal FSH levels. Both oestradiol and inhibin are important negative feedback regulators of circulating FSH.

extract from Menopause 1999;6:29­35. © 1999, The North American Menopause Society
http://www.menopause.org/abstract/6129.htm

Among U.S. women aged 35­60 years, median FSH and LH levels began to increase for women in their late 40's and reached a plateau for women in their early 50's.This study supports the previously reported association between serum FSH and age (i.e., serum FSH and LH levels increase with age) and smoking (i.e., current smoking was associated with an increased level of serum FSH). At FSH levels of = or >15 IU/L or = or >20 IU/L, 70 and 73% of women, respectively, were postmenopausal. Our study also found an interaction between age and oophorectomy. In addition, the present data suggest that women with only one ovary may have higher FSH levels than women with both of their ovaries.

Full article: http://www.geocities.com/menobeyond/fsh.html

Effects of Melatonin in Perimenopausal and Menopausal Women: Our Personal Experience

The purpose of this clinical trial on possible effects of nocturnal MEL administration in perimenopausal women was to find if MEL by itself modifies levels of hormones and produces changes of any kind, independently of age (42-62 years of age) and the stage of the menstrual cycle.

It is accepted that a close link exists between the pineal gland, MEL, and human reproduction and that a relationship exists between adenohypophyseal and steroid hormones and MEL during the ovarian cycle, perimenopause, and menopause.

Subjects took a daily dose of 3 mg synthetic melatonin or a placebo for 6 months. Levels of melatonin were determined from five daily saliva samples taken at fixed times. Hormone levels were determined from blood samples three times over the 6-month period. Our results indicate that a cause-effect relationship between the decline of nocturnal levels of MEL and onset of menopause may exist.



The follow up controls show that MEL abrogates hormonal, menopause-related neurovegetative disturbances and restores menstrual cyclicity and fertility in perimenopausal or menopausal women.

At present we assert that the six-month treatment with MEL produced a remarkable and highly significant improvement of thyroid function, positive changes of gonadotropins towards more juvenile levels, and abrogation of menopause-related depression.

Source: http://www.annalsnyas.org/cgi/content/abstract/1057/1/393

Perimenopause is a time of “Endogenous Ovarian Hyperstimulation”

“Perimenopausal endogenous ovarian hyper-stimulation” is the exact opposite of “The Myth of the Shriveling Ovary”: High estrogen levels during perimenopause, coupled with characteristically intermittent ovulation, can explain much of the misery of perimenopause.

My hypothesis is based on the assumption that inhibin production decreases while there are still viable follicles (capable of producing both estrogen and eggs) in the ovaries and that this in turn stimulates FSH to increase the production of estrogen in the follicles. I offer five pieces of evidence for this hypothesis:

Perimenopausal changes are similar to changes caused by some infertility treatments.

In vitro fertilization (IVF) requires laparoscopic surgery (through a small tube in the abdomen) to suck up ovarian egg cells that are nearly ready to ovulate so they can be grown and fertilized in a laboratory and then injected into the woman’s uterus. In order to collect the maximum number of eggs, gynecologists override inhibin using a technique called “ovarian hyper-stimulation.” The woman is given daily injections of FSH until many follicles have been stimulated and estrogen levels are very high. She is then injected with another hormone (much like luteinizing hormone [LH], another pituitary hormone that stimulates the ovary) to mimic the normal mid-cycle HL surge and this triggers ovulation.

A rare pituitary tumor causes higher-than-normal FSH levels, resulting in hormone levels and symptoms similar to those experienced in menopause.

In an “experiment of nature,” a 36-year-old woman with a tumor on her pituitary gland complained of very heavy menstrual flow. An ultrasound of her pelvis showed seven ovarian cysts and an unusually thick endometrium (lining of the uterus). Her bleeding was successfully treated with medroxyprogesterone (Provera) for ten days each month. This woman’s FSH levels were increased, but only to a level commonly found in perimenopausal woman during the five or more years before the last menstrual period. Her inhibin level was in the normal range, but her estrogen levels during days four to eight of her cycle, were about 12 times higher than normal for the early follicular phase.

More ovarian follicles are used up each year during a woman’s late 30s and early 40s, as compared to earlier in her life.

Pathologists have observed that there is a steady decrease in the numbers of ovarian follicles as women age. (The highest number of follicles is present before birth). This gradual loss takes place during adolescence and young adulthood without any perceptible influence of FSH. The marked increase in the rate of decline in midlife is an indication that more follicles are being stimulated.

Women in their forties are more likely than younger women to be pregnant with non-identical twins (i.e. from two different eggs).

Many women try unsuccessfully to get pregnant for years and then are suddenly successful: compared to younger mothers, these women in their 40s are more likely to bear non-identical twins. In these cases, two ovarian follicles are stimulated, both ovulate and both are fertilized. This could well be due to lower levels of inhibin and higher FSH levels.

Average estrogen levels in perimenopausal women are higher than in younger women.

Although perimenopausal women often believe their estrogen levels to be high, scientists have been slow to acknowledge this possibility. However, two recent studies may change this. One study (subtitled “hyperestrogenism in the perimenopause”) compared the amounts of estrogen (estrone in urine, during one cycle) in two groups of regularly cycling women — one group aged 47 or over and another aged 19 to 38. Ovulation occurred in some cycles and not in others. The older women not only had higher levels of estrogen but also had lower levels of progesterone.

Another study involved a large, randomly selected group of women aged 45 to 55 in Melbourne, Australia. During the early follicular phase, these women showed unexpectedly high estrogen levels (averaging 226 pmol/L) as compared to the expected average of 175 pmol/L. Forty-two per cent of women in a subgroup who had skipped periods for three to 11 months, had levels higher than normal for that phase of their cycle and eight per cent had levels higher than the usual mid-cycle estrogen peak.

[I was gratified to find that high estrogen levels during the perimenopause had been found in a large, well-designed study. However, when I read the authors conclusion that the menopausal transition was characterized by “an increase in serum FSH and decrease in estrogen,” I felt I had to write. The authors subsequently acknowledged that I was probably right about high estrogen levels in the perimenopause.]

Women’s experience and “perimenopausal ovarian hyper-stimulation”
In the book Women of the 14th Moon, nurse practitioner Maura Kelsea says, “At [peri]menopause* life can turn into one long premenstrual experience. Hormones slap you up against the doors of your unfinished business.” Her description of “one long premenstrual experience” aptly describes the physical and emotional upset related to abnormally high estrogen levels. If a woman is to differentiate between moods caused by the social stress of the menopausal transition, and moods caused by high estrogen levels, it helps to be able to recognize the effects of abnormally high estrogen.

For women who menstruate, there are two accurate signs of high estrogen levels that normally occur for a day or two at the middle of a menstrual cycle: front-of the-breast tenderness and stretchy cervical mucus. If estrogen remains high for several days, then the breasts also swell, become firmer and may develop the kind of tenderness often characteristic of early pregnancy. Stretchy mucus is caused by estrogen stimulation of the glands of the cervix (the mouth of the uterus). This mucus is clear and slippery (like raw egg white), can be stretched in a long thread 5-7 cm (2-3" long) and acts to assist sperm traveling into the uterus to fertilize an egg. This type of mucus disappears after mid-cycle when progesterone comes on the scene. Therefore, not only is mucus a sign of high estrogen levels, its disappearance is good evidence of ovulation.

Many perimenopausal women have a high estrogen mid-cycle peak without ovulation. FSH then stimulates another follicle to make high estrogen levels that peak a week or so later. At that point the endometrium has become thickened, is over stimulated and begins to bleed. Thus a common menstrual pattern in the perimenopause is for front-of-the-breast tenderness and stretchy mucus to begin in the middle of the cycle, but then to continue and be at their maximum at the start of a period. Menstrual blood mixed with this mucus may resemble currant jelly. When these signs are present, it is clear evidence that ovulation did not occur. It may also be associated with heavy flow, increased premenstrual moodiness, fluid retention, bloating, and sometimes with menstrual cramps.

What is the significance of these high estrogen levels – aside from breast tenderness and stretchy mucus? According to one recent study, estrogen serves to amplify our body’s hormonal responses to any kind of stress. This was demonstrated by randomizing young men to wear either a high-dose estrogen or a placebo patch and then subjecting all of them to a standard stress test (speaking and doing math problems in front of an audience). Those who were receiving estrogen were found to produce higher levels of the kinds of hormones manufactured in response to stress (i.e. ACTH, cortisol and norepinephrine).

Daytime hot flashes and night sweats are usually interpreted as indicators of low estrogen, despite the fact that they occur in response to rapidly decreasing estrogen levels. Many women who experience flashes find that they start while they are still menstruating regularly – before estrogen could be low. There is now good evidence that hot flashes are related to at least two conditions:

The brain must have been exposed to high estrogen levels at some time, and
The level of estrogen has to be decreasing. The brains of women who have regular periods and mid-cycle estrogen surges will become used to high estrogen levels.


When estrogen decreases – even from high to normal — hot flushes are triggered. Two studies have now shown that severe hot flushes can occur concurrently with either very high or normal estrogen levels.

Treating “perimenopausal endogenous ovarian hyperstimulation”
This picture of erratic (and explosive) estrogen levels in perimenopause not only can help us to make sense of our experiences. It can also guide us toward appropriate treatment choices, including the avoidance of supplementary estrogen until flow has been gone for a year and the possible use of cyclic progesterone.

In the normal course of events a 47-year-old woman seeing her doctor about night sweats, heavy flow and PMS would likely be given combined hormone (estrogen/progestin) therapy or the oral contraceptive pill. (She might even be told that she is too young to be menopausal and scheduled for a D & C). She is not likely to be told that there are many things she could do to help herself.



She could find and talk to other women who have come through the perimenopause; she could get more information about perimenopause at community seminars and read about perimenopause. She could also help herself by exercising regularly. Walking (or more strenuous exercise) for 30 minutes a day may not alleviate all premenstrual symptoms but will help reduce stress, control weight, allow more sound sleep, possibly relieve hot flushes and be good for both bones and heart. The hot flushes can also be helped by a daily dose of vitamin E (400-800 IU) and even more so, by relaxation training. Finally, she could use vitamin B6, oil of evening primrose and herbal remedies like black cohosh to see if they help.

If perimenopause is a time of high estrogen and low progesterone, a logical treatment is supplementary natural oral micronized progesterone or medroxyprogesterone, provided that the progesterone and/or progestin produce adequate physiological blood levels to be effective. At the outset, progestin/progesterone may briefly (for one cycle) exacerbate estrogen-related mood symptoms, migraines or breast tenderness. But if you persist, progesterone will block these unpleasant symptoms.

Progestin/progesterone therapy is certainly indicated when estrogen excess (relative to progesterone) causes spotting, heavy flow (defined as more than 16 soaked pads/tampons a period), periods too close together (e.g. two periods within the same month) or endometrial hyperplasia (over-stimulation of the cells lining the uterus). These situations are so common in the perimenopause that physicians or nurse practitioners should feel comfortable prescribing this therapy; gynecological consultation is rarely necessary and endometrial biopsies or ultrasounds are usually not needed.



The treatment involves either oral micronized progesterone (Prometrium®) in a dose of 300 mg at bedtime because of its drowsy side-effect, or medroxyprogesterone acetate (MPA) in a dose of 10 mg per day for 16 days – on days 12 to 27, counting from the first day of the menstrual period. This will usually bring flow back to normal.

To ensure an adequate counterbalance to the high estrogen, each 16-day course of progestin/progesterone must be completed, even if bleeding starts. In other words, the woman should finish the 16 days but – at the same time – start counting towards day 12 and the next dose from the beginning of flow. This means that during some cycles, she may be off progesterone for only a few days. Cyclic progesterone therapy should be continued for at least six months.

In some situations, if excess estrogen symptoms are severe, if flow starts before the ninth day of the progestin/progesterone therapy, or if breakthrough bleeding occurs, higher doses of progesterone may be needed. For instance, I have used cyclic natural progesterone (300 mg per day for days 12 to 27 of the cycle) and added daily progestin (Provera®) at 5 or 10 mg per day every day. The daily dose of progestin can be stopped when flow becomes scant or some periods are skipped, but the progestin/progesterone taken on days 12 to 27 should be continued for another six months.

We know that several old controlled studies showed that hot flushes were relieved by progestin treatments. So the cyclic progestin/progesterone treatment I recommend will not only control heavy bleeding, but also alleviate night sweats that often begin before flow. We also know that in premenopausal women experiencing abnormal cycles, ten days a month of Provera can increase spinal bone density by a high significant 2 per cent. Best of all is the knowledge that cyclic progestin/ progesterone therapy can bring estrogen and progesterone back into a healthy balance. You can monitor your feelings and bodily changes, as well as therapy, using a Daily Perimenopause Diary®.

By dispensing with “The Myth of the Shriveling Ovary” and learning the secrets of “perimenopausal endogenous ovarian hyperstimulation,” we can make sense of the chaotic physical and emotional changes of perimenopause.

by Dr. Jerilynn C. Prior, Scientific Director, Centre for Menstrual Cycle and Ovulation Research

Source: http://www.cemcor.ubc.ca/articles/misc/perimenopause_endogenous_ovarian_hyperstimulation.shtml

The approach of menopause: a New Zealand study.

N Z Med J 1988 Mar 9;101(841):103-106

The approach of menopause: a New Zealand study.

Metcalf MG
Department of Endocrinology, Princess Margaret Hospital, Christchurch.

Once weekly observations of the excretion of FSH, LH, oestrogens and pregnanediol have been used to monitor the changes which occur as New Zealand women approach and pass through the menopause. There were 3 patterns of hormone excretion. (1) Premenopausal women (aged 40-51 yr) had regular menstrual cyclicity with hormone patterns similar to those seen in the ovulatory cycles of fertile young women. (2)



Women in the menopausal transition (40-55 yr) had irregular menstrual cyclicity with erratic hormone fluctuations. There were ovulatory cycles, postmenopausal episodes in which amenorrhoea was associated with high gonadotrophin levels and low urinary oestrogens, and times when the excretion of both gonadotrophins and oestrogens soared.



Ovarian activity did not cease at the menopause, and postmenopausal women in the 6 months following final menstruation (44-55 yr) had hormone patterns which were indistinguishable from those observed in the long anovulatory cycles of the menopausal transition. (3) Older women (57-67 yr) had senescent ovaries with the unvarying high gonadotrophin and low oestrogen levels which are a consequence of ovarian failure.

Source: http://www.wdxcyber.com/mperimen.htm

An analysis of FSH, oestradiol and inhibin.

Eur J Endocrinol 1994 Jan;130(1):38-42

Diagnostic role of follicle-stimulating hormone (FSH) measurements during the menopausal transition--an analysis of FSH, oestradiol and inhibin.

Burger HG
Prince Henry's Institute of Medical Research, Clayton, Victoria, Australia.

This review examines the role of follicle-stimulating hormone (FSH) measurement in assessing the significance of symptoms and possible continuing fertility during the menopausal transition. Follicle-stimulating hormone measurement is advocated frequently as a useful diagnostic tool in perimenopausal patients. Several investigators have shown that the serum FSH level increases in the early--mid-follicular and early postovulatory phases in women over the age of 40 years who continue to experience regular menstrual cycles.

The serum oestradiol level may fall (although this is controversial) and the immunoreactive inhibin level falls, being inversely correlated with the rising FSH level. When alterations in menstrual cyclicity or flow commence, signalling the onset of the menopausal transition, FSH levels may change abruptly, rising into the normal postmenopausal range and falling again into the range normally seen in young fertile women.

Oestradiol and inhibin generally fluctuate in parallel with each other but inversely to FSH, although at times oestradiol in particular may be increased markedly. Postmenopausal FSH levels may be followed by endocrine evidence compatible with normal ovulation. After the menopause, FSH levels rise 10-15-fold, with low oestradiol and undetectable inhibin levels.

It is concluded that FSH measurement is of little value, if any in the assessment of women during the menopausal transition because it cannot be interpreted reliably and because, apparently, ovulatory (and, presumably, potentially fertile) cycles may occur subsequent to the observation of postmenopausal FSH levels. Both oestradiol and inhibin are important negative feedback regulators of circulating FSH.

Source: http://www.wdxcyber.com/mperimen.htm

Estrogen pretreatment can help restore fertility

Thursday, May 3, 2007

NEW YORK (Reuters Health) - In women who stop ovulating before reaching the age menopause would normally begin, a condition referred to as "premature ovarian failure," who want to become pregnant, pretreatment with estrogen before stimulation of the ovaries improves the likelihood of ovulation, according to a report in the journal Fertility and Sterility.

The results of treatment to induce ovulation in women with premature ovarian failure have been poor, explain Dr. Massimo Tartagni and colleagues from Universita di Bari, Italy. The researchers explored the hypothesis that treatment with estrogen before ovarian stimulation could improve the response of the ovarian follicles.

Among 25 women pretreated with estrogen, 9 developed a follicle at least 18 mm in diameter before human chorionic gonadotropin was administered to stimulate ovulation, the researchers report. Eight of these patients ovulated.

In contrast, only 3 of the 25 women who were not pretreated with estrogen (the control group) showed scant follicular growth during ovarian stimulation and none of them ovulated.

Four of the 8 estrogen-pretreated women who ovulated were able to conceive, the researchers note, and all 4 delivered at the end of pregnancy.

Twenty women who were in the control group were then pretreated with estrogen, and 4 ovulated. Therefore, the overall ovulation rate was 32.4 percent among 37 patients who had not ovulated for more than 6 months.

The researcher suggest that for women with premature ovarian failure, ovulation induction after estrogen pretreatment should be attempted before they're referred to an egg donor program.

SOURCE: Fertility and Sterility, April 2007.
http://www.nlm.nih.gov/medlineplus/news/fullstory_48753.html

About the Symptoms of Early Menopause

As symptoms of the early menopause we can find physical signs and emotional signs. In the category of the physical signs, we can mention irregular periods, infertility, vaginal dryness, bladder control problems, hot flashes and night sweats, weight gain, palpitations, headaches, breast tenderness, bloating, gastrointestinal distress and nausea. There can also appear increase in facial hair, changes in body odor, dry mouth and other oral symptoms, dizziness and sore joints.In what concerns the emotional signs, there can appear irritability, mood swings, anxiety, confusion, lack of concentration, memory lapses, lowered libido, and extreme fatigue.

When the irregular periods appear, that means that the periods will come later then usual, or will come more frequently – every 24 days instead of every 28. There can also happen for you to skip a month and then go back to normal for several months, then skip two periods in a row and so on. You may also experience a light period that lasts only few days, and then, the next month, a very heavy bleeding. Shorter cycles come because the follicles are developing faster.

This happens because you produce lower levels of estrogen during your preovulatory stage, and the FSH levels are higher than normal. Because you don’t produce enough estrogen to build up your uterine lining, extremely light periods can come, but this can be also because of an anovulatory period. Extremely heavy bleeding is a sign of an anovulatory period, but estrogen builds up the uterine lining in the absence of enough progesterone. The uterine lining keeps building up until the production of estrogen drops off and the lining is shed.

You must know that as you get closer to menopause, your menstrual cycle usually lengthens, you may begin skipping periods, and, the bigger change that may happen – you will stop having periods altogether. It is important to know that cancer, polyps, non-malignant tumors, or fibroids can provoke some irregularities in your menstrual cycle.

In premature menopause, there can appear infertility problems. This may happen even if you still have your period, and believe everything is perfect normal.

Hot flashes, also known as the trademark symptom of menopause are estimated to affect 75 to 85% of American women when they are in menopause. It is known that hot flashes can start with a hot, prickly feeling in the middle of your back, the skin temperature can rise up to 8 degrees, your pulse shoots up, and you start sweating as your body tries to cool itself down. Sometimes, your face, neck and chest turn pink or deep red, and you may also get the night sweats, which is the nighttime version of hot flashes.

Hot flashes can be controlled by HRT, by herbs, vitamins, natural supplements, and other methods, but you should also try to reduce stress, limit the intake of caffeine, alcohol and spicy foods, exercise, wear natural fibers, layered and loose-fitting clothing, and in order to stay cool at night, drink cold water at the first time of a sweat, and use cotton sheets and cotton nightclothes. Vaginal tissues start drying and become less elastic when your estrogen levels drop. Sex becomes uncomfortable and you may become more prone to infections. The vagina will take longer to become lubricated and it may atrophy. You may also find that it takes longer to get sexually aroused, and that sexual stimulation may become unpleasant. Sex can become uncomfortable, and even painful. It is important to know that this symptom of the menopause is treatable, and it’s often completely reversible.

To deal with this problem, you can start the standard estrogen replacement therapy, you can use an estrogen ring designed to help with vaginal dryness and atrophy, a vaginally-inserted estrogen cream, but you can also have more sex, use a lubricant to help with the loss of lubrication (vitamin E – a capsule inserted in the vagina helps with lubrication), and avoid antihistamines and certain decongestants and anything that can irritate or dry your vagina.

Like your vagina loses muscular tone and elasticity when estrogen production lags, the same thing happens to the lower urinary tract. You may have to urinate more frequently or you may have urinary stress incontinence. Because the lining of the urethra becomes thinner and the surrounding muscles weaker, when you press stress on your bladder- for example when you cough, sneeze, laugh- you may release a tiny bit of urine. It is important to visit your doctor if you experience severe incontinence.

Sometimes, a great degree of bladder control difficulty can be related to another problem that has nothing to do with the early stages of menopause, and we can also mention that frequent urination can appear because of a bladder infection or diabetes. That is why, it is important to be consulted by a doctor to see exactly what you are dealing with.

If you are having this bladder control problem, you can take estrogen, try Kegel exercises, which will strengthen the muscles around the vagina and bladder opening, and also reduce the intake of caffeine and alcohol. It is known that insomnia may be connected to the menopause. Scientists say that the frequency of insomnia doubles from the amount you may have had before you entered premature menopause, and also women begin to experience restless sleep 5 to 7 years before entering menopause.

HRT and alternative therapies work well in dealing with this symptom, and you can also drink herbal tea before going to bed, avoid alcohol, caffeine and cigarettes before bedtime, and keep your bedroom cool. Even if some doctors say that menopause has nothing to do with weight gain, there are studies that indicate hormone levels are tied to weight gain and redistribution of fat. In order to cope with this symptom, you can opt for HRT or other natural alternatives, and also changes in diet and exercise can do well.

Because your estrogen levels drop, the collagen production slows down too, and as a result, you will see that your skin gets thinner, drier, flakier, and less youthful-looking. Unfortunately, this sign often shows up early in menopause, so you may look a little older than you used to. In order to see a definite improvement, you must increase your estrogen levels through HRT or phytoestrogens like soy or flaxseed. You must also remember (in what concerns the so-called collagen enriched crèmes) that collagen must come from within in order to work on your skin, and not to be applied from without.

Because of the dropping estrogen levels, there can appear headaches, and many women with regular menstrual cycles get headaches just before their periods or at ovulation. So, because the production of estrogen slows down due to premature menopause, you may experience these hormonally- induced headaches, but you can also experience that if the progesterone levels are too high in relation to your estrogen levels.

If low estrogen causes the headaches, you should take estrogen, and you can also try anti-inflammatories, certain herbs, and if the headaches are crippling the doctor may prescribe anti-migraine medication. There can appear breast tenderness, which can last for days and weeks and you will feel your breasts tender to the touch and swollen.

You may also experience gastrointestinal distress and nausea - which can manifest with gas, indigestion, heartburn, and you can also experience tingling or itchy skin - you will have a feeling like some bugs are walking all over you, or you will have a burning sensation like an insect sting.Connected to the estrogen deficiency is the hair loss or thinning - you will notice hair in your brush, your hair will get drier, or you will notice a thinning or loss of pubic hair. Because of low estrogen levels, the mucous membranes will dry, and there can appear a bitter taste in your mouth and bad breath.

For more resources about menopause or about male menopause please review http://www.menopause-info-guide.com/male-menopause.htm

Article Tags: Menopause, Male Menopause

Author: Groshan Fabiola

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For more resources about menopause or about male menopause please review http://www.menopause-info-guide.com/male-menopause.htm

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