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Menopause

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Menopause

Midlife is a challenging time for most women. At this time women's bodies undergo the hormonal changes of menopause, just as they do when we enter puberty. These changes are more dramatic for some women than for others, and do not necessarily account for all the stress we feel at this time of our lives.

Our changing bodies demand that we pay attention to them. The average age for menopause is 52, but menopause commonly happens anytime between the ages of 42 and 56. According to Amy Eyler, PhD, of the Saint Louis University School of Public Health about 1.5 million American women reach menopause each year, at an average age of 52, and 80 to 85% experience unpleasant symptoms such as hot flashes, night sweats, irritability, anxiety or emotional instability.

Lorna Vanderhaeghe states in her book, No More HRT Menopause: Treat the Cause (2002), “Women who have uncomfortable menopause symptoms or are preparing for menopause should become as knowledgeable as possible about the choices that are open to them. Talk to health-care providers and read more about menopause, its effects, and treatment options." Learning about exercise techniques, relaxation opportunities and various herbs' physiological actions, including side effects and contraindications, can help women decide the best way to deal with the physical and emotional changes.

What Is Menopause ?

There is significant disagreement about the definition of menopause. Some confusion exists because there are several stages of the natural menopause process. Technically, natural menopause is the transition between perimenopause and postmenopause, the entire process culminating with the ceasing of the menses, generally around age 50 for most women. During the time, called perimenopause, which can last anywhere from five to fifteen years, the brain continues to send out hormones trying to stimulate the development of ovarian follicles, and it is common for a woman's ovaries to respond erratically, so that her hormones fluctuate a great deal from month to month. These fluctuations are responsible for many of the symptoms of perimenopause.

This natural menopause process itself is usually identified retrospectively, when it's been a year since a last period. Susan Weed, in her book Menopausal Years: The Wise Woman Way, describes natural menopause as a metamorphosis, a change from one person to another, similar to puberty. It can be viewed as a hormonal shift mirroring puberty. The natural smooth hormonal rises and falls in our monthly cycle can become more like the waves of a rough sea, with pronounced peaks and valleys. Natural menopause occurs when the monthly cycle of ovulation comes to an end. This occurs because the ovarian supply of follicles and eggs decline sharply as a woman approaches menopause.

Eventually, though, the ovaries are no longer able to develop an egg for ovulation. Ovarian production of estrogen goes into a permanent decline, and progesterone is no longer produced. The lining of the uterus thins, since it isn't being stimulated by high estrogen levels each month and monthly bleeding stops. At this time menopause has occurred, however, most refer to the term ‘menopause' for both the perimenopausal years as well as the few years following menopause.

We cannot discount the importance of the postmenopausal ovary as it continues to produce hormones even after ovulation ends, producing some estrogen and also androgens (male hormones) including testosterone. Some of the androgens are converted to estrogen (estrone) in a woman's fat tissue.

The 35 Symptoms of Menopause

This list of common symptoms that occur during perimenopause and menopause was developed from the real-life experiences of hundreds of women. All symptoms were experienced by numerous women (but not all women) and were either cyclical in nature or responded to treatments (both traditional and alternative) known to address hormonal imbalances.
  • Hot flashes, flushes, night sweats and/or cold flashes, and clammy feeling
  • Irregular heart beat
  • Irritability
  • Mood swings and sudden tears
  • Trouble sleeping through the night (with or without night sweats)
  • Irregular periods; shorter, lighter periods; heavier periods, flooding; phantom periods, shorter cycles, and longer cycles
  • Loss of libido
  • Dry vagina
  • Crashing fatigue
  • Anxiety and feeling ill at ease
  • Feelings of dread, apprehension, and doom
  • Difficulty concentrating, disorientation, and mental confusion
  • Disturbing memory lapses
  • Incontinence, especially upon sneezing, laughing; urge incontinence
  • Itchy and crawly skin
  • Aching, sore joints, muscles and tendons
  • Increased tension in muscles
  • Breast tenderness
  • Headache change: increase or decrease
  • Gastrointestinal distress, indigestion, flatulence, gas pain, and nausea
  • Sudden bouts of bloat
  • Depression
  • Exacerbation of existing conditions
  • Increase in allergies
  • Weight gain
  • Hair loss or thinning, head, pubic, or whole body; increase in facial hair
  • Dizziness, light-headedness, episodes of loss of balance
  • Changes in body odor
  • Electric shock sensation under the skin and in the head
  • Tingling in the extremities
  • Gum problems and increased bleeding
  • Burning tongue, burning roof of mouth, bad taste in mouth, and change in breath odor
  • Osteoporosis (after several years)
  • Changes in fingernails: softer, crack or break easier
  • Tinnitus: ringing in ears, bells, 'whooshing,' buzzing etc.

Most Common Symptoms of Menopause

Hot flashes, night sweats and difficulty sleeping, headaches, variability of menstrual cycle, decreased bone density, vaginal dryness and thinning, emotional unrest, urinary tract infections, mood changes, anxiety, forgetfulness or problems with focus and concentration. This article will elaborate on the common symptoms and provide some solutions.

Hot Flashes and Night Sweats

Hot flashes are very common among women undergoing menopause affecting up to 85% of women. A hot flash is a feeling of warmth (sudden heat surges) that spreads over the body and is often most pronounced in the head and chest. A hot flash is sometimes associated with flushing usually; lasting from 30 seconds to several minutes, and is sometimes followed by perspiration. Hot flashes can be accompanied by anxiety and palpitations (a fluttering sensation in the chest). Sometimes they're followed by "the chills".

Although the exact cause of hot flashes is not fully understood, hot flashes are likely due to a combination of hormonal and biochemical fluctuations brought on by declining estrogen levels. Sometimes hot flashes are accompanied by night sweats (episodes of drenching sweats at nighttime). Hot flashes cause major problems with sleep and daily activities for about 15% of women. This may lead to awakening and difficulty falling asleep again, resulting in un-refreshing sleep and daytime tiredness. The hot flashes often begin before a woman's periods have stopped.

Hot flashes occur in up to 40% of regularly menstruating women in their forties, so they may begin before the menstrual irregularities characteristic of menopause even begin. About 80% of women will be finished having hot flashes after five years. Sometimes (in about 10% of women), hot flashes can last as long as 10 years. There is no way to predict when hot flashes will cease, though they tend to decrease in frequency over time. On average, hot flashes last about five years.

Urogenital Changes

Dropping hormone levels can affect our vagina, our sexuality and our bladder. The vagina may become drier and its walls thinner. This can lead to discomfort during intercourse. Many women experience a drop in their sexual desire. The inability to hold urine within the bladder until you want to urinate (urinary incontinence) also affects many midlife and older women. There are different forms of urinary incontinence. Stress incontinence is caused by stress on the bladder opening. Urge incontinence (also called overactive bladder) is caused by involuntary bladder contractions. The incontinence can result from a strong, sudden urge to urinate or may occur during straining when coughing, laughing, or lifting heavy objects.

Insomnia is a very common symptom. The fatigue from lack of sleep can also worsen emotional symptoms such as irritability, a depressed mood, and difficulty concentrating. Self-help techniques can be very useful in managing your problems.

Emotional Unrest

Estrogen has been associated with the production of substances responsible for regulating mood in the brain. When estrogen levels change, our mood and thinking, perceiving, and memory (cognitive functions) can be affected. Women in perimenopause often report a variety of cognitive (thinking) and/or emotional symptoms, including fatigue, memory problems, irritability, and rapid changes in mood. It is difficult to precisely determine exactly which behavioral symptoms are due directly to the hormonal changes of menopause. We may have trouble concentrating and feel irritable. Stress can also worsen emotional symptoms, and so it's a good idea to find ways to ease the stress in your life.

Research in this area has been difficult for many reasons. Emotional and cognitive symptoms are so common that it is sometimes difficult in a given woman to know if they are due to menopause. The night sweats that may occur during perimenopause can also contribute to feelings of tiredness and fatigue, which can have an effect on mood and cognitive performance. Finally, many women may be experiencing other life changes during the time of perimenopause or after menopause. There are responsibilities of children, grandchildren and aging parents and other stressful life events such as money and work that may also cause emotional symptoms.

Osteoporosis

Osteoporosis is the deterioration of the quantity and quality of bone that causes an increased risk of fracture. The density of the bone (bone mineral density) normally begins to decrease in women during the fourth decade of life. However, that normal decline in bone density is accelerated during the menopausal transition. As a consequence, both age and the hormonal changes due to the menopause transition act together to cause osteoporosis. The process leading to osteoporosis can operate silently for decades. Women may not be aware of their osteoporosis until suffering a painful fracture. The symptoms are then related to the location and severity of the fractures. It lowers estrogen levels, which can worsen symptoms and menstrual problems

The goal of osteoporosis treatment is the prevention of bone fractures by slowing bone loss and increasing bone density and strength. Although early detection and timely treatment of osteoporosis can substantially decrease the risk of future fracture, none of the available treatments for osteoporosis are complete cures for the condition. Therefore, the prevention of osteoporosis is as important as treatment. Osteoporosis treatment and prevention measures include lifestyle changes such as: cessation of cigarette smoking, curtailing alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D. Medications that stop bone loss and increase bone strength include: alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), raloxifene (Evista), and calcitonin (Calcimar). Teriparatide (Forteo) is a medication that increases bone formation.

If You Smoke, Quit

Smoking is perhaps the single worst thing you can do for your health. About 15,000 women die of smoking-related causes in Canada each year. Smoking also has several other negative effects. It increases the risk of osteoporosis, heart disease and stroke, lung disease and many cancers, of such as those of the cervix, lung, mouth, larynx, and bladder. It lowers estrogen levels, which can worsen symptoms and menstrual problems.

Ask your health care provider about ways to help you quit smoking successfully, such as nicotine replacement medications (Nicoderma, Nicorettea, NicotrolB) and support groups in your neighborhood. There is, also, excellent information to obtain through the Heart and Stroke Foundation of Canada, the Canadian Cancer Society, and the Canadian Lung Association.

Other Physical Changes Reported Frequently

Many women report some degree of weight gain along with menopause. The distribution of body fat may change, with body fat being deposited more in the waist and abdominal area than in the hips and thighs. Skin becomes drier, thinner, changes in skin texture, including wrinkles, may develop along with worsening of adult acne because the loss of estrogen leads to a decrease in natural substances important to skin's appearance. These substances are called collagen and elastin. Long-term sun exposure also plays a major role in skin aging in those affected by this condition. Since the body continues to produce small levels of the male hormone testosterone, some women may experience some hair growth on the chin, upper lip, chest, or abdomen.

Dry skin and aging can be prevented or slowed down by: a) wear a sunscreen with a sun protection factor (SPF) of 15 or more, b)don't smoke, c) drink plenty of water, and d) stay active. Exercise improves blood circulation and the skin's appearance.

What are the Treatment Options for Menopause?

Menopause itself is a normal part of life and not a disease that requires treatment. However, treatment is possible if the symptoms of menopause become substantial or severe.

Prescribed Menopause Treatment:



  • Estrogen and Progesterone Hormone Therapy

    Hormone therapy (HT), also referred to as hormone replacement therapy (HRT) or postmenopausal hormone therapy (PHT), consists of estrogens or a combination of estrogens and progesterone (progestin). Hormone therapy has been used to control the symptoms of menopause related to declining estrogen levels such as hot flashes and vaginal dryness, and HT is still the most effective way to treat these symptoms. But long-term studies (the NIH-sponsored Women's Health Initiative (WHI) of women receiving combined hormone therapy with both estrogen and progesterone were halted when it was discovered that these women had an increased risk for heart attack, stroke, and breast cancer when compared with women who did not receive HT. Later studies of women taking estrogen therapy alone showed that estrogen was associated with an increased risk for stroke, but not for heart attack or breast cancer.

    Estrogen therapy alone, however, is associated with an increased risk of developing endometrial cancer (cancer of the lining of the uterus) in postmenopausal women who have not had their uterus surgically removed. The decision about hormone therapy is very individual decisions in which the patient and doctor must take into account the inherent risks and benefits of the treatment along with each woman's own medical history. It is currently recommended that if hormone therapy is used, it should be used at the smallest effective dose for the shortest possible time. The WHI study findings do not support the use of HT for the prevention of chronic disease.


  • Oral Contraceptive Pills

    Oral contraceptive pills are another form of hormone therapy often prescribed for women in perimenopause to treat irregular vaginal bleeding.

    Prior to treatment, a doctor must exclude other causes of erratic vaginal bleeding. Women in the menopausal transition tend to have considerable breakthrough bleeding when given estrogen therapy. Therefore, oral contraceptives are often given to women in menopause transition to regulate menstrual periods, relieve hot flashes, as well as to provide contraception. The list of contraindications for oral contraceptives in women going through the menopause transition is the same as that for premenopausal women.
  • Local (vaginal) Hormone Treatments
  • Antidepressant Medications The class of drugs known as selective serotonin reuptake inhibitors (SSRIs) and related medications has been shown to be effective in controlling the symptoms of hot flashes in up to 60% of women. Most literature research discourages the use of antidepressants due to the many side effects.

Alternative Menopause Treatment Options

The most effective treatment for hot flashes is prescribed estrogen. However, the risks and benefits of this therapy must be carefully considered by a woman and her physician.

Because each woman experiences menopause differently treatment is directed toward the particular symptoms that are present. While "natural" menopause remedies may be effective, there is a lack of research on the safety and effectiveness of many of these remedies. A physician should be consulted regarding symptoms that are new or of unknown cause.

Plant Estrogens (Phytoestrogens and Isoflavones)

Isoflavones are chemical compounds found in soy and other plants that are phytoestrogens, or plant-derived estrogens. They have a chemical structure that is similar to the estrogens naturally produced by the body, but their effectiveness as an estrogen has been estimated to be much lower than true estrogens. Their estrogen potency has been estimated to be only 1/1000 to 1/100,000 of that of estradiol, a natural estrogen.

Non-prescription products that have been used to treat hot flashes include phytoestrogens (plant estrogens), black cohosh, and vitamin E. However, studies that attest to their effectiveness and long-term safety are lacking.

Vitamin E

Some women report that vitamin E supplements can provide relief from mild hot flashes, but scientific studies are lacking to prove the effectiveness of vitamin E in relieving symptoms of menopause. Taking a dosage greater than 400 international units (IU) of vitamin E may not be safe, since some studies have suggested that greater dosages may be associated with cardiovascular disease risk.

Black Cohosh

Black Cohosh is an herbal preparation that has been popular in Europe for the relief of hot flashes. This herb is becoming more and more popular in the U.S., and the North American Menopause Society does support the short-term use of black cohosh for treating menopausal symptoms, for a period of up to six months, because of its relatively low incidence of side effects when used short term. However, there have still been very few scientific studies done to establish the benefits and safety of this product. Research is ongoing to further determine the effectiveness and safety of black cohosh.

Other Alternative Therapies

There are many supplements and substances that have been advertised as "natural" treatments for symptoms of menopause, including licorice, dong quai, chasteberry, and wild yam. Scientific studies to prove the safety and effectiveness of these products have not been performed.

Non-Pharmaceutical Therapies

In women for whom oral or vaginal estrogens are deemed inappropriate, such as breast cancer survivors, or women who do not wish to take oral or vaginal estrogen, there are a variety of over-the-counter vaginal lubricants. However, they are probably not as effective in relieving vaginal symptoms as replacing the estrogen deficiency with oral or local estrogen.

Controversy Regarding Menopause

This paper would not be complete without mentioning the controversy in literature regarding what happens during menopause.

Most conventional doctors still tell women that menopause and all the menopause and pre-menopause symptoms are the result of a drop in estrogen production. In their view the solution is estrogen supplementation, or HRT, usually with synthetic hormones. In contrast, many alternative practitioners believe that women have too much estrogen, leading to a condition known as “estrogen dominance.” The late healthcare pioneer Dr. John Lee broke new ground when he claimed that estrogen dominance was the real cause of menopause and pre-menopause symptoms, especially in younger women. In his view the obvious solution was to rebalance the ratio of estrogen to progesterone through progesterone supplementation.

John R. Lee, M.D. was an international authority and pioneer in the use of natural progesterone cream and natural hormone balance. He was a sought-after speaker, as well as a best-selling author and the editor-in-chief of a widely read newsletter. John R. Lee, M.D. was internationally acknowledged as a pioneer and expert in the study and use of the hormone progesterone, and on the subject of hormone replacement therapy for women. He used transdermal progesterone extensively in his clinical practice for nearly a decade, doing research which showed that it can reverse osteoporosis. Dr. Lee, who passed away in 2003, also famously coined the term "estrogen dominance," meaning a relative lack of progesterone compared to estrogen, which causes a list of symptoms familiar to millions of women.

What is Estrogen Dominance?

Estrogen and progesterone are two of the primary female sex hormones. During a normal menstrual cycle, they take turns driving the process of maturing and releasing an egg and preparing the uterus for possible pregnancy: estrogen rises in the first half of the cycle, peaks at ovulation, then falls in the second half as progesterone rises. Progesterone is released by the rupturing of the egg follicle during ovulation. If there is no pregnancy, you have a period and the whole cycle begins again. When estrogen and progesterone are doing their jobs, they work together.

During pre-menopause it's common for estrogen levels to decrease slowly while progesterone levels plummet — a natural result of fewer ovulations, fewer burst follicles and less progesterone. This can cause many of women's worst symptoms. How much or how little of each hormone is made at any one time relies on a complicated feedback system between the brain: specifically the hypothalamus and the pituitary gland, which release LH (luteinizing hormone) and FSH (follicle stimulating hormone), and the ovaries. Stress and diet affect that feedback system and so directly impact your hormonal balance.

What are Some Solutions for a Better Quality of Life During Perimenopausal and Menopausal Years?

Exercise Regularly

Exercise is proven to reduce the risk of cardiovascular disease and osteoporosis. Aerobic exercise is best for lowering the risk of heart disease. Weight-bearing exercise enhances well-being, promotes balance and agility, has positive effects on cardiovascular function and is most effective for preserving bone health. Talk to your doctor before you start any exercise program. Lorna Vanderhaeghe agrees with the importance of exercise to decrease menopausal symptoms. She stresses that women work towards reducing stress, get plenty of sleep, and practice relaxation techniques such as visualization, biofeedback, yoga, and deep-breathing exercises. Go for regular massages.

Listening to music while you exercise may improve your fitness, commitment, and enjoyment. Music enhances a workout, it makes you work harder without realizing it, and it makes the workout go by faster. Music takes exercise from just being exercise to being an experience. And music may do more than that. A study in 2005 found that listening to music while exercising boosted participants' enjoyment and helped exercisers stay consistent. Therefore, music promoted better compliance. Researcher Christopher Capuano, PhD. adds that music can make exercise seem easier or at least keep you from thinking about how hard it is. The women in the study were also more consistent with their exercise.

Eat a Healthy Diet

An optimal diet is proven to reduce the risk of cardiovascular disease and osteoporosis. The cardioprotective and anticancer effects of a diet low in saturated and transaturated fats and high in fibre cannot be overemphasized. Learn to love fruit and vegetables. Most of us don't eat enough of them. By upping your intake you can get many valuable nutrients while lowering your fat intake. Limiting fat is an important way to lower blood cholesterol, maintain a healthy weight, and decrease heart disease risk.

Limit Your Alcohol Intake

Alcohol intake can worsen hot flashes because of its effect on blood vessels. Heavy alcohol use is also a risk factor for osteoporosis and other health problems. If you drink, it's wise to limit your intake to no more than one drink a day.

Manage Your Stress

Stress plays a major role in estrogen overproduction by triggering an elevated level of cortisol, which interrupts the feedback loop between the brain, pituitary, and the ovaries that regulates hormones. Not only can stress over a long period of time worsen hot flashes, it can have other physical effects. For example, uncontrolled stress can cause the ongoing release of stress hormones from the body. Left unchecked, these hormones can raise blood pressure and damage the lining of the arteries to the heart (coronary arteries).This increases the risk of heart disease. If stress is a problem in your life, try some of the stress management techniques below.

Relaxation Techniques

Learn relaxation and sleeping techniques (yoga, meditation, deep breathing, etc.)

Exercise regularly

Exercise can help you deal with stress and improve your sense of well-being.

Gardening

Working with plants and the earth can be very soothing.

Listen to Music

Choose your favorite CD, sound or tape and relax for 30 minutes.

Avoid Stimulants

Avoid stimulants such as caffeine and tobacco.

Other Ways

Keep a journal in which you can air your worries, sources of stress, and feelings. Also, talk to a friend.

Physical activity such as walking and yoga cannot be stressed enough in helping ease symptoms and increase quality of life during menopause, according to a new study. "The surprising aspect of the study is the fact that we found a significant association between changes in cardio-respiratory fitness and changes in menopausal symptoms," said lead author Steriani Elavsky, PhD, of Penn State University (March 22, 2007). "This is contrary to other studies, which previously reported no associations." One hundred sixty-four sedentary menopausal women were randomly assigned to a walking program, a yoga program or a control group that did no additional exercise for four months.

The women who walked or took yoga classes reported a better quality of life and reduced negative effects of menopause compared to the no-exercise group. The women who walked or took yoga classes reported improvements in mood and menopause-related quality of life compared to the no-exercise group. The women, whose average age was nearly 50, completed body composition and fitness assessments along with a battery of psychological tests at the beginning and end of the study, which appears in the April issue of the Journal Annals of Behavioral Medicine.

Walking was chosen for the study because it is an aerobic activity, while yoga was chosen because it is not aerobic, said Elavsky, an assistant professor of kinesiology. The results showed that both walking and yoga were effective at enhancing quality of life. Whether menopausal symptoms improved or worsened appeared to be determined by increases or decreases in cardio-respiratory fitness. Women who experienced decreases in menopausal symptoms in the study also experienced improvements in all positive mental health and quality of life outcomes.

Conclusion

To conclude, menopause can be viewed as a beginning rather than an end; and a perfect time to have a change in lifestyle. Women must try things that you have always wanted to do but had no time for when you were raising young children and building your career. Start with self-care strategies that you have control of. Fortunately, many of the signs and symptoms associated with menopause are temporary. Take these steps to help reduce or prevent their effects:

Cool Hot Flashes

If you're experiencing hot flashes, get regular exercise, dress in layers and try to pinpoint what triggers your hot flashes. For many women, triggers may include hot beverages, spicy foods, alcohol, hot weather and even a warm room.

Optimize Your Sleep

If you have trouble sleeping, avoid caffeinated beverages and exercise right before bedtime. Practicing relaxation techniques, such as deep breathing, guided imagery and progressive muscle relaxation, can be very helpful. You can find a number of books and tapes on different relaxation exercises.

Strengthen Your Pelvic Floor

Pelvic floor muscle exercises, called Kegel exercises, can improve some forms of urinary incontinence.

Eat Well

Eat a balanced diet that includes a variety of fruits, vegetables and whole grains and that limits saturated fats, oils and sugars. Aim for 1,500 milligrams of calcium and 400 to 800 international units of vitamin D a day. Ask your doctor about supplements to help you meet these requirements, if necessary.

Don't Smoke

Smoking increases your risk of heart disease, stroke, cancer and a range of other health problems. It may also increase hot flashes and bring on earlier menopause. It is never too late to benefit from stopping smoking.

Exercise Regularly

Get at least 30 minutes of moderate-intensity physical activity on most days to protect against cardiovascular disease, diabetes, osteoporosis and other conditions associated with aging. More vigorous exercise for longer periods may provide further benefit and is particularly important if you are trying to lose weight. Exercise can also help reduce stress. Try a combination of weight-bearing aerobic activities such as walking, jogging and dancing and strength training exercises. Just staying physically active each day by taking stairs instead of an elevator or by parking farther away and walking to your destination also can make a difference.

Schedule Regular Checkups

Talk with your doctor about how often you should have mammograms, Pap tests, lipid level (cholesterol and triglyceride) testing and other screening tests.

Books and Other Resources

The following books will offer a starting place in research on menopause and treatments for its associated discomforts. Many can be found in local libraries or bookstores.

Gladstar, R. (1993). Herbal Healing for Women. New York: Simon and Schuster.

Griggs, Barbara. (1993). The Green Witch: A Modern Woman's Herbal. London: Vermillion

Henkel, Gretchen. (1992). Making the Estrogen Decision. Los Angeles: Lowell House.

Hopkins V. & Lee, J. et.al. (1999). What your Doctor may not tell you about Premenopause: Balance Your Hormones and Your Life from Thirty to Fifty. Warner Books.

Soule, Deb. (1995). The Roots of Healing: A Woman's Book of Herbs. New York: Citadel Press.

Vanderhaeghe, L. (2002) No More HRT Menopause Treat the Cause. Publisher. Fitzhenry and Whiteside Ltd.

Weed, Susan. (1992). Menopausal Years: The Wise Woman Way. Woodstock, New York: Ash Tree.

Wolfe, Honora Lee. (1995). Menopause, a Second Spring: Making a Smooth Transition with Traditional Chinese Medicine. Boulder, Colorado: Blue Poppy Press.

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