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  • Midlife often is called "the prime of life," and research suggests it really is. At midlife, you are likely to be healthy and productive. By this stage, you've likely met goals set in your youth and are thinking about where to go next in your life. However, myths about middle age abound. Some people think of it as a dreary stage when the best that life has to offer is over. Nothing is further from the truth. What is true is that midlife is a busy time, full of changes. Maybe your children are older—even living on their own—giving you free time you haven't had in years. You may switch to a new career, go back to school, or take up new hobbies. Your body changes at midlife, too. Around your mid-40s, you enter a transition phase called perimenopause. It is a time of gradual change leading up to and following menopause. In general, perimenopause extends from age 45 years to age 55 years, although the timing varies among women. During this time, the ovaries produce less estrogen. Other changes occur in your body, as well. Because these changes happen slowly over time, you may not be aware of them. Menopause is sometimes called "the change of life." It marks the end of menstrual periods and of your childbearing years. On average, the age at which American women have their last menstrual period is 51 years. First of all, you should know that any post-menopausal bleeding is considered to be abnormal until proven otherwise (think “better safe than sorry”). This approach is a standard of care in mainstream gynecology for good reason; we would hate to miss the early identification of abnormal uterine tissue, precancerous tissue, or even overt cancer of the uterus. Early identification is key here because it saves lives; most uterine abnormalities are easily treatable without major consequence. Some cases are serious and may need prompt attention by a skilled GYN cancer specialist, but certainly not all cases of postmenopausal bleeding or abnormal tissue mean cancer. What would be most unfortunate is for a woman to delay an evaluation out of fear that the bleeding might mean something bad. That is why it is important to make an appointment to see your health care provider promptly if you have any bleeding or spotting after a full year without a period. The standard of care for this situation is a bi manual pelvic examination, Pap smear if due, and an endometrial biopsy as soon as possible. Occasionally a practitioner may find the bleeding is not from the uterus, but from a tear in the vaginal wall or from the urethra (the tube-like passageway through which we urinate). Many practitioners will also order an ultrasound to gauge the thickness of the uterine wall and lining and to verify that the ovaries and fallopian tubes look normal. Common causes of post-menopausal bleeding * Hormonal imbalance Hormonal change or re balancing is one of the primary reasons for post-menopausal bleeding. Women changing, adding, or weaning off their HRT may experience unexpected bleeding events. Any woman with a preexisting build-up of tissue inside the uterus may initially experience new spotting after initiating any kind of progesterone or progestin therapy, including the popular low-dose progesterone creams. This does not mean the cream caused the bleeding, but rather allowed the uterus to shed the build-up that was already there. * Nutrition and insulin resistance Nutrients support the cycle of hormonal balance, so if you’ve been deficient in certain nutrients over the years it will manifest at menopause in the guise of physical symptoms — like bleeding. One of the best natural ways for post-menopausal women to support their evolving hormonal balance is to clean up their diet and add a high-quality daily multivitamin. Optimal nutrition, which includes EFA’s and other essential nutrients, is especially relevant for post-menopausal women who are insulin resistant (for many women, the two go hand-in-hand). Many insulin resistant women tend to be highly estrogenic, converting any mobilized progesterone into estrogen. The ratio of estrogen to progesterone is thrown off, which can lead to a number of symptoms and conditions, including weight gain and unusual bleeding. One thing is for sure, these women see huge improvement when they begin a program of rich nutrition, daily exercise and watch their intake of processed sugar, fats, and simple carbs. * Weight loss Post-menopausal bleeding may also occur with a drastic weight loss and reduction in body fat, which I have seen on occasion with my own patients. Dramatic weight loss can occur when women have gastric by-pass surgery or join an assertive program like Food Addicts Anonymous (FAA) or Over eaters Anonymous (OA). What’s happening here is that estrogen stored in fat tissue becomes liberated into the bloodstream as a woman loses weight. Bleeding may also occur with weight loss as estrogen (E1, one of three main types of estrogen naturally occurring in the body), which relies largely on fat as its source, is reduced as weight loss occurs, resulting in a shift in the relationship between estrogen and progesterone. This re balancing of hormones, among other health reasons, is why we say gradual weight loss is usually best. * Emotional stress Bleeding after menopause can also occur during a particularly stressful or emotional event or due to an unexpected spurt of hormones. I have known some menopausal women to menstruate again when their daughter comes home from college for the summer. I have also known many women in times of extreme grief or anxiety who experience such spontaneous bleeding events. For example, we evaluated an unbelievable number of dysfunctional and post-menopausal bleeding cases in the six months following 9/11. I have not seen that high an incidence of bleeding events since.

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