My Doctor Online The Permanente Medical Group

Focus on a Healthy Diet

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Research shows that a balanced diet and an active lifestyle can improve your overall health and prevent some of the most common illnesses among women.

As women get older, they experience an increase in body fat and a decrease in the rate at which they burn calories. Unchecked, this combination is a recipe for weight gain. Good nutrition reduces your risk of developing:

• Heart disease and stroke
• High blood pressure and diabetes
• Breast and colorectal cancers
• Bone loss
• Obesity

Studies have shown that small weight losses of 8 to 10 pounds can significantly improve some medical conditions. For peak health, the most recent studies on women's nutrition suggest the following guidelines:

• Eat lots of vegetables and fruits. Vegetables and fruits are naturally low in fat and can lower your risk of heart disease, hypertension, and cancer. Aim for 5 to 9 servings every day.
• Eat more whole grains. Whole-wheat breads, whole grains (like brown rice), and cereals add vitamins and fiber to your diet. These high-fiber foods may decrease the risks of colorectal cancer and heart disease. Other foods particularly high in fiber include oats, bran, beans, and prunes.
• Eat more fish. Fish is rich in substances that have been found to protect against heart disease. Two to 3 fish-based meals per week, together with a low-fat diet, are beneficial to your health. However, many types of fish contain traces of mercury, which can be harmful when consumed in large amounts. To minimize mercury intake, choose shrimp, canned light tuna (not albacore), salmon, pollock, and catfish. Check epa.gov/waterscience/fish for information about mercury and other pollutants found in seafood.
• Eat foods that are lower in saturated fat and hydrogenated fats (trans fats). Maintaining a low-fat diet will help you control your weight, keep your heart healthy, and reduce your risk of cancer. Animal proteins, including meats and whole-fat dairy products, are high in saturated fats. Check labels on margarines, cookies, crackers, chips, and fried foods, which often contain hydrogenated fat. When you use oil, use small amounts of olive or canola oil (monounsaturated fats) or try cooking with a zero-calorie canola oil spray.
• If you drink alcoholic beverages, do so in moderation. Drinking alcohol can increase your risk of cancer because it increases the levels of some hormones, especially estrogen. If you drink, limit yourself to 1 drink per day.
• Eat foods rich in calcium and vitamin D. Calcium and vitamin D can help reduce the risk of osteoporosis, or thinning bones. For people 50 years of age or older, the recommended daily intake of calcium is 1200 mg to 1500 mg, along with 1000 IU to 2000 IU of vitamin D. Although most people need to take calcium supplements, low-fat dairy products (including low-fat yogurt, cheese, and milk) are good primary sources of calcium. Each serving contains about 300 mg. Other sources include salmon, sardines, almonds, soy products, and green leafy vegetables.
• Go easy on salt and sodium. Diets high in sodium, a component of salt, may cause urinary loss of calcium and increase your blood pressure. The recommended intake of sodium for healthy adults is about 2000 mg (under a teaspoon of salt a day). Women with high blood pressure may need to limit their sodium even more, according to the recommendations of their physicians.
• Try soy foods. Foods made from soybeans, including tofu, tempeh, roasted soy nuts, soy milk, or isolated soy protein, are high in compounds called phytoestrogens, which can help protect against many menopausal symptoms. Soy products are low in fat and can add variety to your diet.

How to Start Eating Healthier

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Make small changes over time. For instance, add 1 serving of fruits or vegetables to any of your meals. Or try having fruit as a snack. Avoid fad diets or big changes in what you eat.

Control portion sizes and choose leaner meat or fish. Choose smaller portions of lean meat (such as tenderloin or bottom round). A healthy portion size is about the size of your palm or of a deck of cards. Try skinless white meats such as turkey or chicken or add some fish to your diet.

Realize that simple changes add up. Switching from whole milk to low-fat milk (1 or 2 percent), or even nonfat milk, can make a difference in your daily intake of calories. Try cutting back on sugar by limiting the amount of soda you drink and switching to sugar-free soda. Use small amounts of healthy oils such as olive or canola oil and try lower fat salad dressings. Drink plenty of water – at least 6 to 8 glasses every day – it is good for the body, and it helps you feel full. Try to eat more slowly. It takes your stomach 20 minutes to signal your brain that it is full.

Avoid temptation. If it is not in your cupboard, you will not be tempted to eat it. Make a grocery list to help you buy healthier foods and stay away from junk food. Substitute lower fat choices (such as popcorn or reduced fat crackers) for foods with lots of fat and sugar. Read labels. Plan your grocery trips so that you do not end up shopping when you are hungry.

Be Active and Stay Active

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If you are in or approaching midlife, this may be the most important time for you to be active. A healthy routine of activity:

• Lessens your risk for osteoporosis, heart disease, and cancer.
• Helps manage the pain of arthritis.
• Boosts your immune system.
• Raises your self-confidence and self-esteem.
• Helps you feel more energetic and relaxed.
• Improves your sleep.
• Lifts your mood.

Reach or maintain a healthy weight. As you grow older, your body slows down. Your metabolism, the rate at which your body burns calories, naturally decreases. Regular exercise reverses this trend. It increases your metabolism and is one of the best things you can do for your health. Not only will you burn calories while exercising, but your body will continue to burn calories at an increased rate for several hours afterward.

Maintain bone strength. After menopause, women lose strength and density in their bones. Bone loss is a major reason for falls and fractures in older women. These injuries decrease mobility and lead to a lower quality of life. Exercise, particularly weight-bearing exercise, is the best way to maintain bone strength. It can be even more effective than hormone therapy.

Build or maintain muscle mass. After menopause, your weight may shift around your body – usually moving toward the stomach and midsection. You may also lose muscle, which supports bones and joints and keeps your body looking firm. Exercise can help strengthen and tone your muscles, improve your balance, and lift your mood.

Make Time for Exercise

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Look for ways to be more active during the day. It is best to try to be physically active for 30 to 60 minutes on most days. Here are some tips to help you get there:

• Make exercise a priority. Schedule exercise on your calendar and stick to it.
• Pick something you can easily do at home or near home, like gardening or walking.
• Meet a friend for a walk instead of for lunch. Try a walking meeting.
• Buy, borrow, or rent exercise videos. Choose a few different ones that suit your level of fitness so you do not get bored.
• Walk or ride a bike instead of driving. Trips to the bank, the dry cleaner, or the convenience store are perfect times to leave the car behind.
• Fit in mini-workouts whenever you can throughout the day. Lift some light weights first thing in the morning or take a few short walks during the day.
• Dedicate half your lunch break to walking or other exercise.
• Plan longer workouts and active events, such as hikes or longer bike rides, on weekends when you have more time.

How to Keep it Fun

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Mix up your activities to strengthen different body parts and avoid boredom with your routine. Try walking on Monday, aerobics on Tuesday, lifting weights and stretching on Wednesday, etc. Or go out dancing with friends for a change of pace.

Here are some other ideas for keeping it interesting:

• Exercise with a friend. You will be surprised by how many people will want to join you.
• Try starting a neighborhood walking club or a lunchtime walking group at work.
• Walk in beautiful places or on different routes to stay interested and motivated. Try local hiking trails.
• Try new activities that have always sounded like fun. How about jazz dance, tennis, yoga, or biking?
• Listen to music or books on tape while you exercise.
• Concentrate on how good it feels to be fit and active.

Mental Health

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For many women, midlife is a wake-up call to leading a healthier, more reflective life. For others, it seems to heighten emotional and mental challenges, such as:

• Trouble concentrating
• Forgetfulness
• Difficulty sleeping
• Fatigue
• Worsening premenstrual syndrome (PMS) 
• Mood swings
• Irritability
• Depression
• Anxiety

Can antidepressants help with menopause symptoms?

Antidepressants are prescription medications that may treat menopause symptoms (including hot flashes and night sweats) in addition to treating depression. Certain types can be used as an alternative to hormone therapy for some women.

Drugs called SSRIs/SSNRIs (selective serotonin or norepinephrine reuptake inhibitors) and other types of antidepressants can also be prescribed to treat irritability, anxiety, depression, insomnia, and moodiness. We can discuss whether antidepressants may be useful or recommended for you.

Know when to seek professional help

Although you can often take steps to improve your mental and emotional states on your own, sometimes you may need assistance. Clinical depression is much more than just feeling sad. Seek out professional help if you have been depressed for 2 weeks or longer and have had several of the following symptoms:

• Persistent feelings of sadness
• Loss of interest in activities that you usually enjoy
• Decreased interest in sex
• Continuous fatigue and/or trouble concentrating
• Excessive feelings of guilt or a sense of worthlessness or helplessness
• Trouble sleeping
• Restlessness
• Change in weight
• Suicidal thoughts and/or plans

Self-Care Tips

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If you notice any troublesome mental or emotional effects of midlife, consider the following self-help tips:

• Work it out. Exercise can decrease depression, stress, and anxiety. It can improve your mood and reduce hot flashes.
• Watch your diet. A balanced low-fat diet that includes plenty of fruits and vegetables will keep your body and emotional state healthy and balanced.
• Practice meditation or yoga. Both are calming and can help you handle stressful situations.
• Find a support group. Join a support group or class at your Kaiser Permanente facility or at a local adult school. Talking to others about the changes you are experiencing and exploring questions together can be reassuring and empowering.
• Pace yourself. Most people have peak times – certain hours of the day when they feel most mentally alert. You may want to try scheduling more challenging brain work during these times.
• Manage stress. Consider ways you can change or avoid stressful situations to lower your anxiety.
• Be prepared. Think of how you might respond to possible situations. This preparation will make the situation seem less overwhelming if it occurs.
• Reward yourself after you cope. A reward can be a personal treat, such as a soak in a bubble bath, a facial, a half-hour with a good book, or a walk in the park.

Healthy Sexuality in Midlife

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The amount of estrogen produced by your ovaries slowly decreases during perimenopause and then drops off steeply at menopause. This hormonal change, as well as other physical changes in midlife, can cause shifts in your sexual desire or create challenges in your lovemaking.

Like many other aspects of the transition through menopause, your reaction to these changes will be individual. You might enjoy sex more after menopause, or you may feel a drop in your sex drive during this time.

Changes in Desire

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Sexual desire is the result of a complex interplay between your psychological makeup, social and cultural background, and hormones. Although estrogen affects sexual desire, the amount of testosterone your body produces has a greater influence. Often, women's testosterone levels do not decline as quickly as their estrogen levels. A higher ratio of testosterone to estrogen after menopause may actually lead to an increase in your sexual desire. Having more time with your partner or having more time for intimacy may also boost desire. However, if intercourse becomes painful, or if you are bothered by symptoms of menopause (including hot flashes, insomnia, or irritability), your desire may lessen. We can help you find ways to treat these symptoms.

Potential challenges

There are many reasons for a decrease in sexual interest:

• Vaginal dryness can lead to painful sex. Dryness is often caused by the drop in estrogen and appears to be one of the main reasons sex may become more difficult.
• Emotional changes, stress, depression, or fatigue.
• Perimenopausal symptoms, including hot flashes, irritability, or sleeplessness.
• A partner's changing sexual abilities.
• A serious illness or surgery.
• Lack of time with your partner.
• Concerns about pregnancy or sexually transmitted diseases.
• Boredom with your sex life.
• Side effects of medications.
• Lack of a partner.

Self-Care Tips

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There are many ways to overcome sexual difficulties and enjoy a fulfilling sex life. If you are experiencing vaginal changes or decreased desire, try the following self-help measures:

• Increase the time you and your partner spend in foreplay. This can help with vaginal lubrication and increase your desire.
• For vaginal dryness, use one of the many nonhormonal vaginal lubricants or moisturizers available without a prescription. Lubricants are water-based and must be applied every time you have intercourse. Moisturizers are applied just 2 or 3 times a week. Avoid petroleum jelly or creams and lotions not specifically intended for vaginal moisturizing. These products can introduce bacteria and infection into the vagina.
• Kegel exercises are simple exercises that can improve your sexual function and improve bladder control at the same time. We recommend that all women do Kegel exercises.
• Start an exercise program. Physical activity can increase blood flow to the vagina and improve body image.
• Enjoy sex in the morning or afternoon rather than at night when you and your partner are tired.
• Make dates to spend time with your partner. Take a walk, go out for dinner and a movie, or just relax and talk. Experiencing emotional intimacy and closeness can help with sexual intimacy.
• Do not give up on sex. Regular sexual activity, alone or with a partner, can strengthen the vaginal walls and decrease vaginal discomfort.
• Consider estrogen. Some women find that estrogen creams, applied in and around the vagina, increase muscle tone and lubrication. Others prefer an estrogen-filled vaginal ring or tablet to help increase vaginal lubrication.
• Consider testosterone. Before menopause, your ovaries produce small amounts of testosterone, the "desire" hormone in both men and women. With aging, a decrease in testosterone may mean that desire also decreases. Sometimes, adding testosterone to your hormone therapy is helpful. We can discuss whether testosterone might be a good option for you.

Complementary and Alternative Approaches

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Scientists are just beginning to document the benefits of mind-body and herbal approaches for women in midlife. You can try some complementary and alternative approaches to see if they help reduce symptoms of menopause and improve your sense of well-being.

We recommend that complementary and alternative approaches be combined with a healthy diet and regular exercise routine. Women who make regular exercise a priority and who maintain a normal body weight fare best in regard to midlife changes.

Mind-Body Approaches to Health

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• Prayer, meditation, and relaxation can improve your health and well-being. There are hundreds of prayer, meditation, and relaxation methods. Tapes and videos are available to guide you in these practices. Contact your local Kaiser Permanente Health Education Department for more information.
• Yoga, when practiced regularly, is beneficial to your health. It helps keep you strong and flexible and may change your responses to stress.
• Cognitive restructuring is a practice based on the idea that the way you think about something can affect the way you experience it. In other words, the more you think about menopause in a neutral or positive way, the more likely you are to have a positive experience.
• Humor can reduce stress-related chemicals in the body and boost your immune system's ability to resist disease. Watch a funny movie and let yourself laugh.
• Aromatherapy is the therapeutic use of oils and extracts from plants, like lavender, to promote relaxation and help reduce a variety of symptoms.
• Visualization or guided imagery involves focusing on a mental image or imagining you are in a peaceful place. This practice promotes relaxation. Tapes are available to help in visualization and guided imagery.
• Music can influence body, mind, and emotions. Put on your favorite music. Relax and enjoy.
• Massage therapy involves the use of healing touch to relieve pain, stimulate circulation, release tension, and reduce stress.
• Acupressure and acupuncture involve applying pressure to, or inserting very thin needles in, specific points on the body to help restore the balance of energy.
• Take time for yourself and enjoy regular quiet time. When we care for everyone else, sometimes we can forget ourselves. Take a walk or a bath, or have a cup of tea.

Herbs and Supplements

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It seems there is a new suggestion at least every week for over-the-counter herbs, supplements, and techniques to control menopausal symptoms and manage midlife changes to your mind and body. Although it can be difficult, it is important to try and await the results of good scientific studies before trying a remedy with unknown risks and uncertain benefits.

Before using herbs and supplements, consider:

• The Food and Drug Administration (FDA) does not regulate herbs and dietary supplements, so it is hard to tell what you’re getting.
• Amounts of active ingredients may differ depending on the products, and some products may contain contaminants from the production process.
• Some herbs are not compatible with other herbs, medications, or over-the-counter drugs. We can discuss your options if you are taking medications and wish to start herbs, or vice versa.
• If you want to do your own research about a product, try to use reliable sources without financial motives, such as National Center for Complementary and Alternative Medicine.

Popular Herbs, Foods, and Supplements

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We recommend:

Soy. Soy has some positive effects on health. Soybeans and soy products contain isoflavone, which studies have shown to decrease the risk of heart disease by lowering cholesterol. Research results about whether soy can decrease hot flashes are mixed. Some studies show a small decrease in women who take soy protein supplements but not in women who take isoflavone alone in a pill. Research does support consuming a daily serving of soy (25 grams of soy protein) as part of a low-fat, well-balanced diet.

Progesterone cream. Studies have shown that creams containing progesterone may reduce hot flashes. Never use creams in place of prescription progesterone medication.

Bioidentical, natural, or alternative hormones. The term "bioidentical" describes hormones that are chemically identical to those we make naturally in our bodies. These hormones are made from soy and yams. They come as pills, patches, creams, and sprays and act like regular hormones. Here are some things to consider about these products:

• No studies so far have proven that one hormone is safer or more effective than another.
• Concerns regarding breast cancer, stroke, and heart disease risks apply to all forms and types of hormones.
• The hormones estrogen and progesterone are available in FDA-approved products (including estrogen pills and patches and progesterone capsules). These products have been tested for effectiveness, purity, and consistency.
• Non-FDA-approved compounded hormones are no more natural than most of the prescription estrogens. The same prescription estrogens and progesterones can be purchased from compounding pharmacies. 

We do not recommend:

Black cohosh. This is the most widely studied herb in menopause treatment. There have been recent reports of liver problems in women taking black cohosh. For this reason we do not recommend this supplement at this time.

Dong quai. The first study on the use of dong quai for hot flashes took place at Kaiser Permanente. It showed that dong quai was no more helpful for hot flashes than a placebo, or sugar pill.

DHEA. This hormone changes into estrogen and testosterone when it enters the body. DHEA can cause acne, voice deepening, and liver problems, and it may decrease HDL (good) cholesterol. Women with high levels of DHEA seem to have more heart attacks. There is no evidence that DHEA is effective in improving well-being or health, and the long-term effects are unknown.

Not enough evidence to determine effectiveness:

Evening primrose oil. There is no scientific evidence that evening primrose oil can reduce hot flashes.

St. John's wort. Studies have shown that St. John's wort may relieve symptoms of mild depression. However, it is not effective in treating major depression and usually is not recommended beyond 2 years. Side effects may include stomach upset, fatigue, and increased sensitivity to sunlight. It should not be used with anticlotting drugs or with prescription antidepressants.

Your Care with Me

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To help you be your healthiest in midlife, I encourage you to take advantage of the resources we offer for women before, during, and after menopause. Mammograms and routine Ob/Gyn appointments are important to your health in midlife, and they may be booked online or by calling the Appointment and Advice line.

In addition to our online resources, our Health Education center offers:

• Classes on healthy lifestyle, weight management, and tobacco cessation, all of which may relieve your menopause symptoms and improve your overall health.
• Copies of our Kaiser Permanente Menopause Guidebook for Women, a comprehensive reference to help you manage your symptoms and decide on treatment options.

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Contacting Me

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You can connect with me in a variety of ways, depending on the situation and what is most convenient for you at the time. I am available online, by telephone, or in person.

• For nonurgent questions or concerns, you can e-mail me using this site. You can also book an appointment online to see me in person.
• If your concerns are immediate, or you simply prefer to use the telephone, please call our Appointment and Advice line, which is available 24 hours a day, 7 days a week. Our advice nurses can give you immediate advice, and our telephone staff can send me a message or book an appointment for you. 

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How We Coordinate Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay current on your health status and to collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments as needed. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to a specialist

My specialty colleagues are readily available to assist me if I need additional advice about your condition. In some cases, I may contact them during your visit, so we can discuss your care together. If we decide you need a specialty appointment after that discussion, we can often schedule it the same day or soon thereafter.

If you are due for preventive screenings or tests

As part of our commitment to prevention, additional members of our health care team may contact you to come in for a visit or test. We will contact you if you are overdue for cancer screenings or conditions which may require monitoring.

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Convenient Resources for You

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As your personal physician, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available 24/7 so that you can access and manage your care where and when it is most convenient. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions and schedule appointments.
• View your past visits and test results.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at our medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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