Australian Menopause Centre - Ebook

The
Menopause
Booklet
eBook
The MENOPAUSE Booklet
This booklet briefly explains how your treatment program

works. It answers many commonly asked questions about
how soon your menopausal symptoms should subside, how
and when you need to fine tune your treatment, as well as
when you can expect to stop treatment.
Table
of Contents
Welcome to the Australian Menopause Centre (AMC)
Introduction
Phases of Menopause
Getting Started
What to Expect in the First Four Months
How Long Will You Remain On The Program?
10
Your Medical Checklist
11
Compounding Of Hormones
12
Fresh Is Best
12
How to Take Your Medication
13
Prescription Delivery
14
Important Points Regarding Medication
15
Understanding Your Menopause
16
Understanding Your Hormones
24
Bio-identical Natural Hormones - A More Natural Approach
29
The Health Risks of Hormone Replacement Therapy
32
Meet the Bio-Identical Hormones
34
Menopause Lifestyle Eating and Exercise Plan
36
Contributors to Menopausal Symptoms - Lifestyle Tips
38
Exercising Through Menopause
40
Check for Osteoporosis
44
What The Man In Your Life Can Do To Help!
45
We Are Here To Help
46
Private Health Fund Rebate
47
Privacy
47
Our Treatment Program Overview
48
Welcome to the
Australian Menopause Centre (AMC)
Our aim is to provide you with a treatment program of Bio-identical Hormone
Replacement Therapy(BHRT) designed to help your menopausal symptoms subside as quickly as possible. Every woman is physiologically different and will also be
at a different stage of menopause. This is why we individualise our approach on a
person by person basis.
We will recommend a starting point for your treatment based on your medical
history as well as your current symptoms. We may use pathology testing of your
hormones as a helpful diagnostic tool. We encourage your regular feedback so that
we can understand how best to address your symptoms over time.
When you start your treatment program, we will stay in regular contact throughout your time with us. Based on your feedback, relevant medical history and any
investigation results, we will counsel you and if necessary, adjust your medication
dosage to ensure that you gain the best symptom relief with the lowest required
treatment dose.
Our skilled staff are delighted to have the opportunity to assist you and we assure
you that we will endeavour to provide you with our prompt, personal and professional attention.
Kind Regards,
Dr Gary Aaron
MEDICAL DIRECTOR
Australian Menopause Centre
Introduction
What Is Menopause?
Menopause is a natural change that occurs in a woman, marking the end of her
monthly menstrual periods, sometimes referred to as cessation of the menses,
the climacteric or change of life. Menopause is the last stage of a gradual biological process in which the ovaries reduce their production of sex hormones. Most
of the symptoms of menopause come from decreased production of the hormone
oestrogen. This process progresses gradually over a period of time. It is rare for a
woman to be menstruating after the age of 55.
When Will It Occur?

The average age of menopause is 51 however some women can experience symptoms from age 35 or earlier. It is most common for menopausal symptoms to occur
between the mid forties and early fifties. Sometimes a woman will follow the same
course as her mother.
Menopause can be induced by surgically removing the ovaries. Early onset of
menopause may also occur from cancer therapy, certain illnesses or diseases and
smoking.
What Are The Symptoms?

Menopause is an individual experience, therefore symptoms and intensity of symptoms will vary from person to person. Typical symptoms are night sweats, hot
flushes, mood swings, anxiety, depression, insomnia, vaginal dryness (painful intercourse) and loss of libido (low sex drive).
Phases of Menopause
The phases of menopause can be characterised as follows:
1 | Pre Menopause
can occur from age 35 onwards and women may have regular periods but be
experiencing menopausal symptoms.
2 | Peri Menopause
can occur in the middle to late 40s and women may experience irregular menstrual periods and symptoms such as hot flushes, night sweats, mood swings
or depression. Peri-menopause, is perhaps the most difficult to treat and can
require multiple changes in hormonal supplementation. Many women simply
do not cope well with this erratic time in their life.
3 | Menopause
is marked by the end of monthly bleeding and signals a major decline in oestrogen production. It could be said to have commenced when a woman in
her 40s or 50s has not had a period for six months or more. If it has been 12
months since her last period, then menopause is almost certain.
4 | Post Menopause
represents the first five or so years after menopause. The lack of oestrogen
released from the ovaries leads to several changes. These may include decrease in bone density, rising levels of cholesterol and other lipids in the blood,
and other physical changes. Hot flushes, night sweats and mood swings may
occur during this phase, although these generally decrease within one to two
years.
Despite a commonly held belief, menopause is not an end ~ it is a

beginning. Most women will live at least one-third of their lives after
menopause. Menopause can be described as the beginning of a new
phase in a womans life that will bring different expectations,
opportunities and experiences.
Getting Started
This section outlines the steps involved as well as what to expect when you first
commence the treatment program. Also included is some general information and
some useful health and lifestyle tips that may help you minimise your symptoms
and improve your quality of life
Our Goal
Our goal is to provide you with a BHRT treatment program designed to adequately control your menopausal symptoms, and to provide a low dose treatment to
accommodate your bodys requirements. We will assist you in reaching that goal
by us first arriving at a starting point for your treatment and then monitoring your
situation until such time as you are ready to be weaned off the treatment.
Steps In Brief
1
In order for us to arrive at that starting point we will require:

A detailed medical history, where we will ask you relevant questions
pertaining to your health.
A description of your current menopausal symptoms
Results from pathology and or other investigations
Our staff will assist you organising this in advance of your first consultation
with one of our doctors.
2
An initial consultation will then be booked for you with one of our doctors.
Based on the information and the outcome of your first consultation, our
doctors will suggest an appropriate course of action.
Frequent follow up with you by our patient care team during the initial phase
of your treatment.
Continuing regular follow up, providing you with our counsel and assistance
along the way.
Finally assisting you to wean off the treatment.
What to Expect
in the First Four Months
Its important to understand that it may have taken years for your body to become
hormonally imbalanced - its not possible to correct this instantly.
Every woman will respond differently. Response will also be dependent on the particular stage of the menopause a woman is at. Your response will be in accordance
with your bodys natural sensitivity and absorption rate of the various hormones.
You may experience rapid symptom relief or, as is more usually the case, this may
take a number of weeks.
Some women, especially in the first 14 days after starting BHRT, may experience an
increase in hot flushes and night sweats. These may actually increase in intensity
and frequency before they start to reduce. This may be due to what we refer to as
an oestrogen dip - this is when your body reduces production of its own oestrogen in response to the BHRT supplementation.
When you begin your treatment program, you may experience symptoms that reflect insufficient supplementation or over-sensitivity to the hormones. These symptoms may include uncomfortable reactions such as:
Insufficient response to the medication ~ your
symptoms havent completely subsided
Break-through bleeding
Breast tenderness
Bloating
Headaches
Your response to the medication should stabilise over a period of time.
Adjusting Your Initial Dosage

If you are experiencing any unwanted symptoms including any of those set out
above, it is important that you contact the AMC help line on 1300 883 405 and
book an appointment as soon as possible.
Regular Follow Up
One of our goals is to provide you symptom relief using the lowest required dose of
BHRT for as short a duration as is required.
In order to fine tune your treatment and reach this goal, your treatment dosage will
from time to time require a review.
If after your initial consultation with one of our doctors, you decide to join our program, we will contact you as follows:
After the date your first medication is dispensed, you will receive a Welcome Call
from us where we will go over the details of your treatment program and establish
that you have received what is needed to start your treatment program. We will
also then schedule follow up clinical reviews with our clinical team. We will then
contact you regularly during this time.
You will also be able to contact us for advice.
At all times it is vital that you take the medication according to the
instructions supplied with the medication and the advice given
by our medical team.
How Long Will You Remain

On The Program?
It is normal for women to remain on the program from anywhere between two and
five years (some women may require treatment beyond five years.)
Treatment duration is determined by your bodys adjustment to the menopause
and its ability to eventually cope without supplementation. With ongoing regular
testing and assessment of your symptoms we will be able to guide you through
your program.
Reducing Your Dependency

The rebalancing process involves two different but equally important hormones.
Oestrogen can be effective for hot flushes, night sweats, low energy, skin dryness
and vaginal dryness but in excess can cause fluid retention.
Progesterone can be effective in reducing anxiety, mood swings and stress. It also
helps release excess fluid from the body and helps with hot flushes and improves
sleep.
While both of those hormones offer positive benefits, the benefit of one hormone
can be offset by the other if dosage levels are not carefully monitored. For example, oestrogen causes fluid retention while progesterone acts like a diuretic and
helps with fluid release. It is important to ensure that while we are weaning you off
your treatment, the correct balance is maintained.
The duration of the complete process of weaning off BHRT may vary but may be
as short as just a few months. Each month during the weaning off process we will
determine from you, based on your feedback, how you are progressing and whether or not any of your symptoms have returned. Together with you, we will consider
each month whether or not to reduce your medication any further. Of course, if
any symptoms return during this process, you should contact the Australian Menopause Centre immediately.
10
Your Medical Checklist

As part of your treatment program, we may recommend that you undertake specific medical tests. These will be advised by our doctor during your consultation. In
addition, we suggest that you consult with your general practitioner and have the
following tests:
Pap Smear - Every 2 years

(unless you have had a hysterectomy or if you are being followed for previous
abnormal smears).
Mammogram - Every 2 years

Especially if over the age of 50. Some women, with a family history of breast
cancer, may require a mammogram yearly and from an earlier age. Regular self
examination of your breasts is also recommended.
Blood Pressure - At least every 12 months

(more regularly if on blood pressure medication).
Cholesterol Levels
Consider an initial assessment of your cholesterol and other blood lipids, especially if you are overweight or you have other risks of having elevated cholesterol, e.g. a family history of heart disease. Further testing will depend on this initial
result.
Blood Sugar Levels

An initial assessment of your blood sugar is advisable. Further testing will depend on this initial result.
Bone Scan
An initial bone scan is advisable. Further bone scans will depend on this outcome.
As a patient of the Australian Menopause Centre we encourage you to maintain
these regular medical checks and also strongly advise that you inform us of your
results. We do recommend a yearly blood test and clinical reviews with our clinical
staff. If you find that you have not had a review or scheduled 12 monthly blood test,
please remind us when you speak with your care consultant.
11
Compounding Of Hormones
Prescribed By Doctors and Compounded To Order
The Hormones used in BHRT have chemical structures identical to those the human body produces naturally and are commonly referred to as being bio identical. Bio identical hormones with the appropriate strength to assist in relieving
your symptoms cannot be dispensed over the counter of a retail pharmacy. They
can only be dispensed by prescription.
Your BHRT medication will be individually compounded as prescribed by our doctors according to the specific dose and combination you require. Because these
hormones are compounded specifically, our doctors can tailor a formulation to
suit. Furthermore, the medication can be finetuned over time to increase or decrease the strength. The pharmacy that compounds the medication is a dedicated compounding pharmacy and uses only British Pharmacopoeia (BP) or United
States Pharmacopoeia (USP) grade products. Good manufacturing practices and
principles, along with using the highest grades of raw ingredients ensure the quality of the medication dispensed.
Fresh Is Best
It is very important that to get the best results from any medication, is to ensure
that it is used before its expiry date. Compounded medication has an expiry date
of 3 months from the date of dispense. We encourage patients to use their medication as prescribed by the doctor and to ensure that they do not use out of date
medication.
This usually means that you will well and truly use your prescribed does well within
the expiry date. Your health is too important to take unwise and unnecessary risks
by using medication that is past its expiry date. You will find us committed to ensuring that you use your medication properly. It is part of our duty of care to continually monitor your progress and to ensure you get the best result from fresh and
effective bio-identical hormones.
12
How to Take Your Medication

Your Starting Dose
Our initial aim with your treatment program is to balance your levels of oestrogen
and progesterone - the two hormones responsible for the majority of your symptoms. To facilitate this goal most patients will initially receive two separate packs of
medication as troches, (most patients are prescribed troches):
one pink pack containing oestrogen (translucent colour)
one blue pack containing progesterone (white colour)
For patients who are prescribed creams or other forms of BHRT, please refer to the
instructions accompanying your medication.
Keeping your dosage of the medication low will be the most desirable outcome for
you. Therefore some dosage adjustments may be required to ensure you get the
most effective result.
The purpose of these separate packages is to allow your doctor or nurse to make
dosage changes as and when required. If you are taking this medication for the first
time, you should have received enough medication to last you approximately 4, 8
or 12 weeks depending on your particular program.
If you experience over-sensitivity to your BHRT, please contact the AMC Helpline
immediately.
It is important to understand that you may have been in a state of hormonal imbalance for many years and correcting these levels may take a few months.
Through the course of the program your doctor may prescribe a change of medication dosage for you.
It is very important that you follow instructions from our medical team in relation to
any changes to your medication and dose.
13
Prescription Delivery
Automatic Monthly Repeats
Medication will automatically be dispatched regularly, either monthly, bi-monthly
or quarterly to patients on a automatic dispense and payment plan (if you are not
on a direct debit payment plan please call the Australian Menopause Centre to arrange one). This is to ensure you never run out of medication. It is vital to maintain
regular daily doses and to ensure you always have a fresh effective supply.
If you are not home at the time of delivery the courier will try to leave the medication at an agreed delivery point (near the front or rear door / veranda and out of
the sun or your local post office for pick up).
It is important to notify AMC immediately if you have changed your address.
What to Do if Your Medication Has Not Arrived

A courier delivers your medication to you, but occasionally a batch does get lost.
It is important to contact us immediately if you have only seven days or less medication left and have not received the next months supply. Please do not leave
notifying us to the last minute as it does take 2-3 days to arrange replacement
dispenses.
Each prescription is individually compounded to order at a specialised pharmacy.
It can therefore take approximately five working days from the time you contact
us until your medication actually arrives at your requested delivery location. It may
take slightly longer for remote areas.
14
Important Points
Regarding Medication
If you have been late in starting your medication, please call us so

that we can resynchronise the delivery of your next batch.
If you have not received your expected delivery of medication,

and you have only 7 days medication left, please urgently call us on
1300 883 405. We will need to follow up to ensure that you
do not run out.
Whilst you are on our program we strongly suggest that you

do not take any other forms of hormone therapy unless
specifically advised by our Clinical team.
15
Understanding
Your
Menopause
Menopause is literally the cessation of your menses,
and the end of your menstrual cycles.
16
17
Understanding Your Menopause

Prior to this occurring many women experience menopause like symptoms well
before the actual last period as the body undergoes various hormonal changes
and fluctuations. This is often referred to as the climacteric or change of life.
We are born with approximately 2 million egg follicles. By the time we reach puberty there are about 750,000 and by the age of around 45, only 10,000 may be
left. The rest may have disintegrated over the years. Menopause occurs when your
store of eggs run dry.
During the transition to menopause most women will experience at least one of
the following phases.
Read on to identify where you may be at this very moment?
Pre-Menopause
Peri-Menopause
Menopause
Post Menopause
Early Menopause
Surgical Menopause
Pre-menopause
The pre-menopause can be characterised when a woman begins to experience
menopausal symptoms whilst still having a regular monthly cycle. This indicates
the hormones are beginning to change.
Pre-menopausal symptoms can occur for a woman as early as the age of 30 but
tend to occur more commonly around the mid to late 40s. They may include hot
flushes, sweats, emotional swing.
18
Peri-menopause
The peri-menopause is the next stage following the pre-menopause. During
peri-menopause the ovaries begin to decline in the production of hormones and
the menstrual period become irregular. The changes in the cycle may be subtle or
very dramatic. Women may notice a slightly lighter flow, or slightly heavier flow.
The duration of the cycle may differ too, going from a 28 day cycle to a 33 day
cycle, followed by a 31 day cycle.
Alternatively, the changes may be more dramatic. It is not uncommon to skip a
period completely, or cease having periods for a few months at a time then recommence two weekly or monthly. Women often say they experience the heaviest
periods of their entire reproductive life or alternately their menstrual flow may be
significantly lighter. Regardless, this is a time when changes are noticed within the
cycle whether they be subtle or dramatic.
Generally speaking, the symptoms during the Peri-menopause will be

more severe than those experienced during the pre-menopause and
normally occur around the mid 40s but can occur as early as the late
30s early 40s and for other women as late as the early 50s.
Most women experience what is termed a natural menopause, which occurs

gradually. Many women begin noticing changes in their menstrual cycle and/or
mood, years before they actually have their final period. It is not uncommon for a
woman to experience irregular cycles with associated symptoms sometimes up to
5-10 years prior to complete cessation of the menses. For other women their periods suddenly stops one month and they never menstruate again.
Progesterone is generally the primary female hormone to decline during the pre/
peri-menopausal stage whilst oestrogen can remain stable or even increase. This
ultimately creates an imbalance between the two hormones. This state of low
progesterone to oestrogen ratio is commonly referred to as oestrogen dominance. Testosterone levels may also start to decline well before the last menstrual
cycle.
19
Oestrogen production during the peri-menopausal stage may become erratic

with surges of inappropriately high levels alternating with irregular low levels. This
helps to explain periods of hot flushes and night sweats coupled with oestrogen
dominant symptoms (high ratio of oestrogen to progesterone) such as breast
tenderness, headaches, fluid retention and cravings. In many cases, women can
successfully manage these symptoms effectively with the support and balancing
effects of natural progesterone alone. Ideally both hormones work best when they
are in balance and harmony with each other.
As progesterone is an important hormone involved with building bone, bone loss
is accelerated during the first 5 years after a woman enters her menopause.
Therefore, it is important to adopt healthy lifestyle factors to further prevent the
risk osteoporosis. These include regular weight-bearing exercise such as walking
or jogging, enjoying a healthy diet with an adequate supply of calcium, avoiding
foods and substances that compromise bond health, such as smoking or drinking
soft drink that contain substances known to strip calcium from the bones.
Symptoms of Peri-menopause
Symptoms of Peri-menopause will generally be the result of low levels of progesterone, potentially coupled with oestrogen dominant symptoms and symptoms associated with low levels of testosterone. Oestrogen levels during this
stage can be quite erratic hence your symptoms may reflect this.
Symptoms of a lack of progesterone
Mood swings, depression, anxiety, feeling emotional or more vulnerable, sore
breasts, bloating, hot flushes/sweats, tiredness, insomnia, weight gain, forgetfulness, lack of concentration, reduced capacity to deal with stress, aching in
the muscles and joints, irritability, reduced sex drive, lack of energy, fibrocystic
breast, period problems and fibroids, endometriosis, low metabolism, cravings
(particularly for sweet things), sluggishness in the mornings.
Oestrogen Dominant Symptoms
Headaches/migraines, recurrent vaginal yeast infections, breast swelling and
tenderness, depression, nausea, vomiting, bloating, leg cramps, yellow tinged
skin, excessive vaginal bleeding, possible weight gain irritability, cravings particularly for sweet things, fatigue.
20
Low Testosterone Symptoms

Loss of sex drive, decreased sexual response, decreased sensitivity in your
erogenous zones, decreased sense of well-being, energy and ambition, depression, loss of or thinning of pubic hair.
Menopause
Menopause is your very last period and officially classified as such once your periods have completely ceased for a full 12 months. The average age of menopause is
51 years, give or take 5 years.
For some women the full symptoms of menopause do not kick in until after this 12
month period, indicating a dramatic drop in circulating oestrogen leading to the
more common symptoms associated with menopause such as hot flushes, night
sweats, dryness of the skin and dry vaginal tissue.
Symptoms of menopause can last on average between 4-6 years. In saying this,
some women breeze through menopause with few or no symptoms at all, where
as others, when you include the pre and peri-menopausal stages, may experience
symptoms for up to 20 years.
Symptoms of Menopause
Symptoms of menopause include many of the symptoms associated with
peri-menopause, coupled with the symptoms of a lack of oestrogen.
Lack of Oestrogen Symptoms

Increase in hot flushes, night sweats, vaginal dryness, vaginal wall thinning,
decreased sexual response, dry skin, crawling or itching sensations under the
skin, dry hair and possible hair loss, ageing skin, mental fuzziness, urinary frequency, vaginal and/or bladder infections, infection, incontinence, recurrent
urinary tract infections, difficulty sleeping, lack of esteem, osteoporosis
21
Post Menopause
The post menopause follows on from the menopause. Oestrogen and progesterone levels are still low but the body has learned to cope with these lower levels
and most of the symptoms disappear. There is still an ongoing concern about osteoporosis so weight bearing exercises and good dietary habits need to be maintained. Vaginal dryness and low libido are symptoms that often require ongoing
attention.
Menopause affects each woman differently and every woman may be experiencing different symptoms at different stages of menopause. We are all unique and
while the symptoms of menopause, maybe similar to that of other women, everyone will travel their own journey.
Other considerations that may affect the severity of your symptoms include lifestyle factors such as diet, nutrition, exercise, other prescription medications, other
health concerns, stress levels and relationship issues.
Early Menopause
Menopause before the age of 40 is called an early or premature menopause. It
may occur naturally when the ovaries have stopped working, surgically when a
woman has her ovaries removed or chemically from chemotherapy/radiotherapy
for cancer.
Smokers tend to have an earlier menopause by about 2 years on average because
smoking diminishes the secretion of oestrogen in the ovaries.
A hysterectomy, even without the removal of the ovaries can lead to the earlier
onset of menopause by about five years. It is believed this happens due to the
change in blood supply to the ovaries after surgery. A tubal ligation may also
bring on an earlier menopause for some women.
22
Surgical Menopause
Surgical menopause is when the ovaries are removed prior to a natural menopause (known as an oophorectomy). This causes a sudden and permanent drop of
the ovarian hormones, oestrogen, progesterone and testosterone.
The surgical procedure may include the removal of the uterus - when both are
removed, this is termed a total hysterectomy.
An oophorectomy or total hysterectomy will lead to an instant menopause and
often the symptoms are intense unless treatment is initiated immediately.
We are more than just our hormones hence this is why an integrated
and individualised approach to managing your symptoms will offer
the best possible outcomes.
23
Understanding
Your
Hormones
In order to fully understand the hormonal changes that
the body may be experiencing as it enters menopause
we must first understand the monthly cycle.
24
25
Understanding Your Hormones

During the reproductive years women produce a number of hormones. These
include oestrogen, progesterone, follicle-stimulating hormone (FSH) and luteinising hormone (LH). Each of these hormones has a specific role to play during the
various stages of your monthly menstrual cycle.
On the first day of the menstrual period, FSH is released from the pituitary gland.
FSH stimulates the growth of a group of follicles on the surface of the ovary.
These follicles will eventually produce eggs. Over the next two weeks (the follicular phase) the eggs will develop and mature. At the same time, your levels of oestrogen (the primary female hormone) will increase.
As your oestrogen level increase, the pituitary gland decreases its production of
FSH. At this stage another hormone comes into play, known as luteinising hormone, LH surges at mid cycle and triggers the release of an egg (ovulation). The
egg enters the fallopian tube and is carried into the uterus.
The empty follicle (corpus luteum) begins to produce progesterone, as the second
half of the cycle commences - this is termed the luteal phase. If fertilization does
not occur the lining of the uterus (endometrium) is shed, resulting in a menstrual
period. At the same time there is a dramatic fall in both oestrogen and progesterone levels, which in turn triggers FSH and the cycle starts all over again.
A sign that menopause is approaching is a surge of FSH. In the lead up to menopause, the number of cycles in which eggs are NOT released increase. Oestrogen
rather than increasing begins to decline during the first two weeks and ovulation
is less likely to occur, although women can still experience a period. The chance of
falling pregnant diminishes, though it is still possible.
Without the rising levels of oestrogen to send back a message to the pituitary to
produce smaller amounts of FSH, the levels of FSH in the blood stream keep rising
as the body registers that ovulation is not happening.
26
Increases in FSH can be measured via a blood test to help detect the onset
of menopause. Women begin to notice a difference internally; signs and the
symptoms normally experienced with ovulation may now be absent. This may
be replaced by the onset of experiencing menopausal symptoms, such as mood
swings, hot flushes, night sweats, bloating, fluid retention, to name a few.
Your adrenal glands and other hormone producing sites such as the fatty tissues
now take on a more significant role to minimise symptoms and support a woman
throughout the transition of menopause.
Conventional HRT (Hormone Replacement Therapy) and the Womens Health

Initiative (WHI)
Hormone replacement took hold in the 1960s with the introduction of unopposed
oestrogen in the form of pregnant horses urine (Premarin) to manage the disease
of menopause.
It soon became fashionable to take as women were sold and marketed the promise of remaining young forever. With the release of the book Feminine Forever by
Dr Robert Wilson, Premarin soon became the standard treatment for women going
through The Menopause and quickly became the number one selling drug in the
United States.
By the 1970s it was discovered that oestrogen alone increased the risk of uterine
endometrial cancer, so a synthetic progestin was added to stop this danger. However, in avoiding HRT induced uterine cancer, we then induced even more dangers
namely an increased risk of breast cancer, cardiovascular disease and blood clots
were induced.
Well before the WHI study confirmed the above risks, a number of short term clinical studies indicated the carcinogenic (cancer causing) properties and risk of blood
clots of these synthetic hormones.
27
Potential Risks of Taking Conventional HRT as Revealed by the WHI Study

The most comprehensive evidence about the risks and benefits of taking hormones
after menopause to prevent disease comes from the Womens Health Initiative research program. This research program examined the benefits of menopausal hormones on womens health.
The WHI research program involved two studies - the use of conjugated oestrogens plus progestin for women with a uterus and the use of conjugated oestrogens
alone for women without a uterus. In both hormone therapy studies, women were
randomly assigned to receive either the hormone medication being studied or the
placebo.
The WHI conjugated oestrogens plus progestin study was stopped in July 2002,
when investigators reported that the overall risks of conjugated oestrogens plus
progestin outweighed the benefits. The news made headlines around the world. Ultimately, the study showed an increased risk of breast cancer, heart disease, stroke
and blood clots. However, the risk of colorectal cancer and hip fractures was lower
on HRT than those on placebo.
A subgroup of women in the WHI research program participated in the WHI Memory study. This showed that conjugated oestrogens plus progestin doubled the
risk for developing dementia in postmenopausal women age 65 and older. The risk
increased for all types of dementia, including Alzheimers disease.
The WHI conjugated oestrogens alone study, was stopped in February 2004, when
the researchers concluded that conjugated oestrogens alone increase the risk of
stroke and blood clots.
The risk of breast cancer on oestrogen decreased in comparison to women on placebo. Similar to the results of oestrogen plus progestin, oestrogen alone decreased
the risk of urinary incontinence and showed a decreased risk of hip fractures.
28
Bio-identical
Natural
Hormones
A More Natural Approach
29
Bio-identical Natural Hormones - A More

Natural Approach
Bio-identical hormones have been in use for over 30 years and are used extensively throughout Europe, the US, Canada, the UK and Australia. They are fast becoming the preferred choice for many women as they seek more natural alternatives to managing their symptoms of menopause.
What Are Bio-Identical Natural Hormones?

The term bio-identical means bio-logically the same as. From a medical perspective, bio-identical hormones share a similar bio-chemical and molecular structure
to that of a hormone the human body naturally produces.
We call a human hormone a natural hormone and hence the reason why
bio-identical hormones are also commonly referred to as natural hormones in
that they match that which the body naturally produces.
Bio-identical hormones offer a more natural approach in that the hormones are
plant derived. They are extracted predominantly from the wild yam plant and a
smaller percentage from soy. Research has shown that bio-chemically the hormones produced by these plants share a similar bio-chemical structure to that of
a human hormone.
The molecular structure is then slightly modified, in specialised labs, to match that
of a human hormone.
In Dr Sandra Cabots book Hormones the Real Truth she states: natural hormones are chemically identical to the hormones produced by your own glands,
which means that your body cannot tell the difference between your own hormones and a natural hormone... These natural hormones are called bio-identical
hormones
30
Dr Christianne Northrup in Wisdom of Menopause states: In contrast to premarin, Provera and Prempro, the hormones that I recommend are exactly the same
as those found in the female body. Though they are synthesized in the lab from
hormone precursors found in soy beans or yams, their molecular structure us designed to be an exact match of the hormones found in the human body. Hence we
call them Bio-indentical....
Because Bio-identical hormones are just like the hormones that our bodies were
designed to recognize and utilize, their effects are more physiologic-consistent
with our normal biochemistry - with less chance for unpredictable side effects at
low replacement doses than with synthetic, non bio-identical hormones
We now have a hormone that is plant derived, bio-chemically and

molecularly similar to a human hormone. The idea being that the body
recognises the hormone as though it is one of its very own thus
converts it into a hormone to work similar to its own hormones.
Natural or bio-identical hormones are commonly used for peri-menopausal and

menopausal women and include progesterone and the natural oestrogens (oestradiol, oestrone and oestriol), DHEA and testosterone.
The beauty of natural hormones is that they can be created and tailored to each
individual woman in unique doses and combinations, in a variety of applications
to meet the needs of each woman. This allows for an individualised approach and
considers such factors as: body weight, emotional and sexual needs, personal
history, medical conditions and risk factors, unique metabolic and hormonal characteristics whilst evaluating the results of blood and salivary tests.
Over the past decade, millions of women have used bio-identical hormones with
great success and improvement in health. Research studies done in the US and
Europe on bio-identical hormones have confirmed this. Since 2003, the Australian
Menopause Centre has had over 50,000 women complete our treatment program.
31
The Health Risks of

Hormone Replacement Therapy
Breast Cancer
Studies including the Womens Health Initiative, a large pharmaceutical trial, have
indicated that conventional Hormone Replacement Therapy (HRT) is linked to a
small but significant increase in breast cancer, such that taking the therapy for 5
years or more can result in approximately 4 extra cases of breast cancer per 1000
women. At the time there were no equivalent research studies done specifically on
BHRT (bio-identical hormone replacement therapy) so the risks associated with
BHRT had not been proven.
However, more recent studies1;2 which included bio-identical hormone treatment
and in particular the use of micronized bio-identical progesterone have documented that there appears to be no increased concern regarding breast cancer risk.
If you have at least one first degree relative (i.e. mother or sister) who has developed breast cancer, then you are at a slightly increased risk of developing breast
cancer relative to the average population.
The effect of hormone replacement therapy on breast cancer risk for women who
have a history of breast cancer (mother or sister) appears to be the same as for
women who have no family history of breast cancer
1 | Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study, Agns Fournier, FrancoBerrino and Franoise Clavel-Chapelon Postgrad Med. 2009 Jan;121(1):7385. doi: 10.3810/pgm.2009.01.1949.
2 | The bioidentical hormone debate: are bioidentical hormones (estradiol,

estriol, and progesterone) safer or more efficacious than commonly used
synthetic versions in hormone replacement therapy? Holtorf K
32
How to deal with the risk of breast cancer:

It is important to be vigilant with breast monitoring throughout your life, as
at no stage of your life are you ever free from the risk of breast cancer. You
should have regular mammograms (at least every 2 years) and regular self
examination of your breasts. This should be done regardless of whether or not
you are at an increased risk of breast cancer.
Other Risks
There is an increased risk of venous thrombosis (blood clots in the veins) in women using hormone therapy, however the incidence is very low and more likely in
the first year of therapy. The Womens Health Initiative also concluded that women
receiving HRT have a risk of suffering side effects such as fluid retention, headaches, irregular bleeding, weight gain and breast pain. BHRT or HRT may therefore not be advisable in particular if the following affects you:
Breast Cancer
Women who have had breast cancer in the past are at a greater risk of developing a recurrence of breast cancer.
Blood Clot
Women who have had a blood clot in the past are at a greater risk of a recurrence of a blood clot. If you have had a blood clot in the past, you will need
blood tests to assess this risk.
Stroke
Women who have had a stroke in the past are at a greater risk of a further
stroke in the future. If any of these groups apply to you, your situation will be
considered after specific blood testing and may require discussion with your
specialists.
In keeping with good medical practice, we also recommend that you have your
blood pressure checked by your GP at least once a year (more frequently if
you have high blood pressure) and if you have not had a hysterectomy, you
should have a pap smear test every 2 years. (Refer toYour Medical Checklist).
33
Meet the Bio-Identical Hormones

Oestrogens
Bi-oestrogen (Bi-Est), a combination of oestriol and oestradiol.
80% of Bi-Est is oestriol, which has been shown to protect against
breast cancer in animal studies. Oestriol causes little or no stimulation to the uterine lining and is clinically effective for the treatment
of symptoms caused by oestrogen deficiency, such as vaginal dryness and atrophy, painful intercourse, and urinary tract disorders
(incontinence, frequent urinary tract infections). Oestradiol relieves
symptoms such vaginal thinning dryness. It decreases hot flushes and night sweats; improves mood, energy level, sleep patterns,
memory, cognitive function; and reduces bone loss. It may also help
to lower blood pressure. Tri-oestrogen (Tri-Est), a combination of
80% oestriol, and 10% oestradiol, and 10% oestrone. Oestrone is the
primary oestrogen produced after menopause. It is produced from
hormone precursors in peripheral fat tissue.
Progesterone
Progesterone is a hormone commonly prescribed for women with too much
oestrogen relative to the level of progesterone produced by the body. Progesterone minimises the stimulating effects of oestrogen on coronary arteries, and when given alone or combined with oestrogen, it may improve bone
mineral density. Progesterone improves sleep, may increase libido, act as a
diuretic, lowers blood pressure and improves the insulin-glucose balance to
facilitate blood glucose control.
Special Note: Progestins are sometimes erroneously referred to as progesterone. A Progestin is very different and is not a bio-identical hormone.
It is a synthetic hormone made to mimic the effects of progesterone. Some
practitioners do not make the distinction between progestin and progesterone, which has caused much confusion. For example progestins are given to
women to prevent pregnancy, whereas progesterone is used to assist fertility.
The two could not be more different. Since progestins are foreign to a womans body, sometimes they create adverse effects on a womans body and
sometimes they create adverse effects on a womans brain, blood vessels,
skin, heart and breast.
34
DHEA
DHEA is prescribed for women whose hormone profile as
determined by blood testing, indicates a low level of DHEA.
DHEA enhances libido, helps to build bone mass, lowers the
levels of cholesterol and triglycerides, improves the sense of
well-being and increases alertness. Please note in Australia,
DHEA is not registered with the TGA. Overseas DHEA is approved and is commonly purchased as an over the counter
nutritional supplement.
Testosterone
Testosterone is present in women too, not just males. Testosterone is prescribed for women whose pathology suggests a
deficiency in the hormone. It can help to improve libido, help
to build bone mass, improve mood and the sense of well-being, increase muscle mass and strength, lower levels of cholesterol and triglycerides, normalize blood glucose levels, and
decrease body fat.
Melatonin
Melatonin is a naturally occurring compound found in humans, animals, plants and microbes. In humans, circulating
levels of melatonin vary in a daily cycle, thereby regulating
the circadian rhythms of several biological functions. It also
has a role as a pervasive and powerful antioxidant with a
particular role in the protection of nuclear and mitochondrial DNA. Melatonin signals the part of the body system that
regulates the sleep wake cycle by chemically causing drowsiness. It is used to help improve sleep and get back into a regular routine of sleep.
Pregnenolone
Pregnenolone is a pre hormone involved in the production of
progesterone, mineralocorticoids, androgens and oestrogens.
Pregnenolone may be considered a good brain enhancer in
those who are deficient. In some people pregnenolone improves energy, memory, clarity of thinking, wellbeing, and
often sexual enjoyment or libido.
35
Menopause Lifestyle Eating

and Exercise Plan
Lose Weight And Feel Great
One of the many ways you can take charge of your own health and wellbeing
throughout menopause is to adopt a healthy eating approach used in conjunction
with undertaking a regular (daily) exercise regime. The benefits of nutrition and
exercise are numerous and studies have indicated by purely changing your eating
habits for the better you can significantly reduce your risk of breast cancer, heart
disease, osteoporosis and many other ageing ailments whilst promoting energy,
wellbeing and further supporting the reduction of menopausal symptoms.
Menopause is a time of change women will need to embrace with an open mind
and educated brain. Certain dietary and lifestyle habits will need to be adjusted to
suit their hormonal changes. Left unchanged, menopause can often lead to weight
gain.
General Dietary Tips:

Avoid
Refined sugars Treat treats as a treat, and not a regular thing
Refined carbohydrates and many packaged items, including soft drinks and
refined fruit juices
eat
Protein (meat, tofu, eggs etc.) with each meal. A portion would be considered
100g of meat or 200g of tofu.
Good fats regularly. Cook with olive oil or coconut oil.
A rainbow of vegetables, and lots of them.
A maximum of 2 pieces of fruit daily.
Snack on fresh fruit, unsalted nuts, a tin of tuna etc.
be
Conscious of your daily calcium intake; food or supplement.
Wary of your carbohydrate intake; this commonly encourages weight gain
during menopause.
36
Tips To Promote Optimal Digestion

To ensure that you are getting the
most from your food, proper digestion
and absorption must be addressed.
Eat in a relaxed environment
Chew you food slowly
Eat in moderation
Avoid multi-tasking at meal times
Try fresh lemon juice in warm water
before meals to aid digestion
Specific Dietary Strategies For

Healthy Hormones
Foods to aid hormone production and
communication Food can be a medicine
for your hormones. Specific foods can
affect chemical processes within the body,
by reducing excessive production of oestrogens, stimulating hormone detoxification and clearance and/or competitively
and beneficially binding to oestrogen receptors. The foods listed below have been
shown to benefit women through their
menopausal journey.
Enjoy at least 1 from each group daily
Herbs and Spices
Nuts and Seeds
Grains and Legumes
Ginger, rosemary,
turmeric, coriander, dill,
fennel, parsley
Pumpkin seeds, sesame

seeds, sunflower seeds,
almonds, cashews,
Brazil nuts
Soy, chickpeas, quinoa,

millet, bulgur,
buckwheat, brown rice
Fruits and Vegetables
Meat,
poultry, fish and dairy
Beverages
Blueberries, strawberries, oranges, grapes,

avocado, banana, figs,
blackberries
Broccoli, cauliflower,
Brussel sprouts, kale,
spinach, cabbage,
mushrooms, celery,
onion, alfalfa sprouts
Milk, cheese and

yoghurt (calcium-rich
alternative may be
substituted), deep-sea
fish
Water, green tea, dandelion tea, chamomile

tea, spearmint tea
37
Contributors to Menopausal Symptoms Lifestyle Tips

Stress Can Significantly Impact Your Menopause Symptoms
The amount of stress within your life, and the way that you react to that stress
can play a large role in how you experience menopause. Tips to reduce your stress
include:
Regular aerobic and weight bearing exercise
Time out for yourself
Relaxation techniques
Play a musical instrument
Learn to draw, paint, knit or crochet
If you cannot change the stress, change

the way you view the stress.
Alcohol Intake
Clinical observation has showed us that alcohol intake
can exacerbate hot flushes/night sweats.
Studies have shown moderate to high levels of alcohol
consumptions to result in an increased risk of breast
cancer. Increased risk was also noted at lower levels of
consumption, equivalent to 1-2 drinks/day.
38
Recognise Bad Plastics

The use of toxic plastics can interrupt, aggravate and mimic hormone communication within the body. Exposing your body to these toxic chemicals should be actively avoided. While no plastic can be considered 100% safe, we have provided a
guide for which plastics to strictly avoid and which plastics have no known health
effects (green). Avoiding plastics as much as possible and using glass alternatives
is the best option.
39
Exercising
Through
Menopause
Although the research doesnt directly show that exercise
reduces menopausal symptoms, it has been shown to reduce
stress, increase energy and reduce your waist line.
The benefits obtained from regular exercise can indirectly support and
ease your transition through menopause. In addition to this, certain
types of exercise can reduce your risk of osteoporosis and heart disease.
Starting an exercise program can be difficult, especially when you are
facing hormonal symptoms, but the key is to remember that your main
goal is to boost your health on multiple levels, whilst supporting your
transition through menopause.
40
Often the trick is to pick a sport/

exercise that you actually like.
41
Australias Physical Activity And

Sedentary Behaviour Guidelines For Adults
(18-64years)
Physical Activity Guidelines
Doing any physical activity is better than doing none. If you currently do no
physical activity, start by doing some, and gradually build up to the recommended amount.
Be active on most, preferably all, days every week.
Accumulate 150 to 300 minutes (2 to 5 hours) of moderate intensity physical
activity or 75 to 150 minutes (1 to 2 hours) of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each
week.
Do muscle strengthening activities on at least 2 days each week
Sedentary Behaviour Guidelines

Minimise the amount of time spent in prolonged sitting.
Break up long periods of sitting as often as possible
Australias Physical Activity

Recommendations For Older Australians
(65years And Older)
Being physically active and staying fit and healthy will help you to get the most
out of life, whatever your age. These recommendations are designed to help older
Australians achieve sufficient physical activity for good health as they age.
Physical Activity Recommendations

1 | Older people should do some form of physical activity, no matter what their
age, weight, health problems or abilities.
42
2 | Older people should be active every day in as many ways as possible, doing
a range of physical activities that incorporate fitness, strength, balance and
flexibility.
3 | Older people should accumulate at least 30 minutes of moderate intensity

physical activity on most, preferably all, days.
4 | Older people who have stopped physical activity, or who are starting a new
physical activity, should start at a level that is easily manageable and gradually
build up the recommended amount, type and frequency of activity.
5 | Older people who continue to enjoy a lifetime of vigorous physical activity

should carry on doing so in a manner suited to their capability into later life,
provided recommended safety procedures and guidelines are adhered to.
Good Exercises For Peri- And Post- Menopausal Women

Moderate to brisk walking. Experts agree that walking is the best form of exercise for post-menopausal women as it can be done anywhere, anytime and
promotes social interaction.
Light to moderate weight training. This will help to build muscle mass and keep
muscle tone. This can also help to support metabolism, improve body composition and increase overall health.
Moderate to low impact aerobics. This is great for increasing heart and respiratory rates, which helps to keep the vital organs healthy.
Light to moderate resistance training. Particularly for women worried about
their bone health. An improvement to bone strength is site-specific; those
bones attached to the exercised muscles are affected. Choose exercises to
strengthen the small and large muscle groups of the spine and hip, the most
common sites of osteoporotic fractures.
Relaxation based exercise (e.g. yoga), especially for those with hot flushes. Relaxation based exercises with paced respiration may significantly reduce objectively measured hot flush occurrence.
For both cardiovascular and strength training exercises, remember to increase the
amount of exercise gradually, starting with realistic amounts and moving towards
achieving the guidelines stated above. Exceeding the minimum recommendations
further reduces the risk of inactivity-related chronic disease and may be helpful in
improving symptoms of menopause.
43
Check for Osteoporosis

The majority of women are at risk for osteoporosis during and after the menopause. You may have a higher risk of suffering the effects of osteoporosis if you:
have a family history of osteoporosis
do little or no physical activity
are a current cigarette smoker
have a high alcohol intake
have a low body weight
if you are Caucasian or Asian
had delayed puberty
had early onset of menopause
had a previous osteoporotic fracture
over 60 years of age
have chronic liver disease, rheumatoid arthritis or kidney failure
have a history of over-active thyroid or parathyroid glands or past treatment
with thyroid hormones
have had long term treatment with corticosteroids
we recommend that you have a baseline bone scan early on in your menopause,
especially if there is a family history of osteoporotic fractures.
The bone scan is called a DEXA scan (Dual Energy Xray Absorptiometry scan)
and is similar to having a normal X-ray (with no pain). Thereafter, and in consultation with your general practitioner, a scan every two to three years should be sufficient to monitor your progress.
Because it is better to prevent a serious fracture

than to treat one
44
What The Man In Your Life

Can Do To Help!
Menopause is a defining moment in a womans life. Sure, it has its ups and downs
but with a positive outlook it can be a time of empowerment. But most women
cannot do it alone. They need the support of their family and friends ~ and in particular the men in their lives. For those men, we have come up with the following
list of useful tips:
Put yourself in her position
Imagine what it would be like to go through times of sleepless nights, hot
flushes, and the like. I suspect your mood would not be great all the time.
Your marriage is not falling apart
For a time it may seem your wife is no longer the woman you married. Not
true! Appreciate that this roller coaster will pass and that you will both come
out the other side much closer.
Sex? It still exists. Just dont panic
While her sex drive may dip a little, it does not have to be dormant. Now there
are many ways to deal with it. Be resourceful, be creative, keep it fun, and do
not be judgmental or rush to conclusions.
Educate yourself
Imagine how impressed your partner would be if you knew that the reason she
was having hot flushes is most likely because her oestrogen levels are low. Find
some literature and read it. Remember, education is empowerment!
Duck and swerve
This is the perfect time in your life together, to encourage her to seek out
womens groups, new friendships and old friends going through the same experience.
Keep your sense of humour
It may not be politically correct but menopause can be funny. Try and make
her laugh and see the lighter side of things. After all, laughter is the best medicine.
45
We Are Here To Help

At AMC we view ourselves as your resource for advice and counsel at this important stage of your life. Moreover, we understand that every woman is different
which is why we place high importance on ongoing patient communication, evaluation and support.
We have a full-time clinical team. They are trained and familiar with the program
and are available for phone appointments. You can make an appointment them to
discuss your medication dosages or treatment program.
Following is a summary of the support we offer Australian Menopause Centre
patients:
Patient Care Call

We will be in regular contact with you. This will be your opportunity to provide us
with valuable feedback on the progress of your treatment program. If required,
your AMC consultant will book a time for a medical review.
AMC Help Line - 1300 883 405

Call this number if you have any questions about your medication, side-effects that
you may be experiencing or any other question about your treatment program.
Our AMC hotline is staffed by trained patient care representatives. They can refer
you to our clinical staff who have extensive experience in womens health issues.
You can call this number Monday to Friday between the hours of 8.30am and
5.30pm (EST time) to schedule an appointment (a medical advisor will then call
you back at a mutually convenient time).
You can email any time and expect a response sometimes beyond these hours.
We provide clinical appointments from 8.00am EST until 6.30pm EST as well as
Saturdays from 9.00am 1.00pm.
46
Private Health Fund Rebate

If you belong to a private health fund you may be eligible for a rebate on the medical component of your treatment program. Please contact your health fund to
receive the most up to date listing of claimable medications.
Privacy
Your Privacy Is Important To Us
We collect personal information (including health information) about you in various
ways to enable us to provide you with our services, and need you to consent to us
disclosing it. For example, we collect information when you request an appointment with one of our doctors; this will allow them to provide you with medical
advice. We only collect the information we need to fulfill the purpose of collection,
and if we do not receive it we will not be able to provide you with our services. You
have the right to access the information we hold about you at any time.
There is no fee for access, but we may charge reasonable expenses of supplying
information depending on the request. If you would like access please call our help
line on 1300 883 405. We take all reasonable steps to ensure your health and other
personal information is kept secure from unauthorised access or disclosure, up-todate and accurate.
We will not sell your personal information to anyone, but in providing you our
services we may disclose it as required to others (including transmitting electronically). When we do so they are we required to handle the information in the same
way we do. For example we may disclose your personal information:
To enable the pharmacy to prepare and dispense your medication;
When another organisation helps us process transactions, store or access data
or provide services to you so they can perform their role;
Where laws require or allow us to provide information to a government agency
or organisation.
We may write or email you about additional services we or other organisations
offer if we think they might benefit you. If you do not want us to communicate in
that way please let us know by calling our help line on 1300 883 405.
47
Our Treatment Program Overview

Our comprehensive program has thought of everything to help you through
your journey.
48
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The

The MENOPAUSE Booklet

This booklet briefly explains how your treatment program

The MENOPAUSE Booklet

What to Expect in the First Four Months

How Long Will You Remain On The Program?

Your Medical Checklist

How to Take Your Medication

Important Points Regarding Medication

Understanding Your Menopause

Understanding Your Hormones

Bio-identical Natural Hormones - A More Natural Approach

The Health Risks of Hormone Replacement Therapy

Meet the Bio-Identical Hormones

Menopause Lifestyle Eating and Exercise Plan

Contributors to Menopausal Symptoms - Lifestyle Tips

Exercising Through Menopause

Check for Osteoporosis

What The Man In Your Life Can Do To Help!

We Are Here To Help

Private Health Fund Rebate

Our Treatment Program Overview

The MENOPAUSE Booklet

The MENOPAUSE Booklet

When Will It Occur?

What Are The Symptoms?

The MENOPAUSE Booklet

Despite a commonly held belief, menopause is not an end ~ it is a

The MENOPAUSE Booklet

In order for us to arrive at that starting point we will require:

Finally assisting you to wean off the treatment.

The MENOPAUSE Booklet

Your response to the medication should stabilise over a period of time.

The MENOPAUSE Booklet

Adjusting Your Initial Dosage

The MENOPAUSE Booklet

How Long Will You Remain

Reducing Your Dependency

The MENOPAUSE Booklet

Your Medical Checklist

Pap Smear - Every 2 years

Mammogram - Every 2 years

Blood Pressure - At least every 12 months

Blood Sugar Levels

The MENOPAUSE Booklet

The MENOPAUSE Booklet

How to Take Your Medication

The MENOPAUSE Booklet

What to Do if Your Medication Has Not Arrived

The MENOPAUSE Booklet

If you have been late in starting your medication, please call us so

If you have not received your expected delivery of medication,

Whilst you are on our program we strongly suggest that you

The MENOPAUSE Booklet

The MENOPAUSE Booklet

The MENOPAUSE Booklet

Understanding Your Menopause

The MENOPAUSE Booklet

Generally speaking, the symptoms during the Peri-menopause will be

Most women experience what is termed a natural menopause, which occurs

The MENOPAUSE Booklet

Oestrogen production during the peri-menopausal stage may become erratic

The MENOPAUSE Booklet