“Hey doc, my face looks like a war zone.  I wouldn’t mind having the complexion of a sixteen year old if I could have the body of one also, but this is ridiculous for a grown woman!”  Gladys was a victim of adult onset acne, and she was not pleased.  She is not alone.  Some experts estimate that up to 50 % of women over 30 suffer from some type of acne or acne like complexion disorders.
     It is not known what triggers adult onset acne. The development of hormonal irregularities in the menstrual cycle may be a factor, or ovarian cysts may cause hormonal abnormalities that increase androgen productivity, resulting in acne breakouts.  The classic situation is one in which a woman experiences irregular cycles, setting up an over production of estrogens and testosterone.  These hormones stimulate oil production in the skin glands which in turn become inflamed and irritated. Sometimes these sebaceous glands continue producing a higher amount of sebum well into adulthood and thus acne infection continues even at that age. Androgens have also been associated with acne flare-up in women before menstrual cycles or sometimes during pregnancy.   Whatever the cause, it is not wanted or welcomed.
     Most acne treatments require prolonged care, from months to years. These treatments include topical creams and gels and/or oral medicines.  Once improvement is achieved, a maintenance dose is usually necessary. Women who develop adult acne typically have the problem for years, frequently through menopause.  The suspected hormonal disruptions that trigger adult onset acne are often treated by attempting to regulate the hormonal imbalance. The modalities used most in hormonal acne treatment are oral contraceptives and antiandrogens. (medicines that counteract the effect of too much testosterone in a woman’s system).
     There are several simple things to do to minimize adult onset acne.  Washing with soap and water once or twice daily is a good way to keep debris and oils from the day accumulating on the skin surface. Salicylic acid and benzoyl peroxide are both common over-the-counter treatments for acne. Benzoyl peroxide exfoliates the skin and the anti-bacterial agents in it clear the excess debris from the skin to help prevent infections.      
     Retinoids are a class of molecules in the vitamin A family. The retinoids are potent against acne because they stabilize abnormal growth and death of cells in the sebaceous follicle. These abnormal growth cycles are believed to play a key role in the formation of blackheads, whiteheads, and other acne. The danger in retinoids is that they cannot be used by pregnant women or women who might be getting pregnant because of the high rate of serious birth defects in unborn children.
     Topical and oral antibiotics are used together with other agents. Topically, antibiotics neutralize the skin-based bacteria and, when used with other agents, help deplete the excess sebum or oil secreted by the sebaceous glands, allowing acne spots to heal without infection.
     Oral contraceptives prescribed for women are based on their ability to regulate hormones.  A birth control pill stimulates the production of a protein that binds testosterone, thus reducing the androgen’s ability to affect oil glands.
     Occasionally, adult onset acne can be confused with a condition known as rosacea.  Although it is not exactly acne, its red-faced, acne like appearance can cause many physical, psychological and social problems if left untreated. In a recent survey by the National Rosacea Society, nearly 70% of rosacea patients said that this skin disorder lowered their self esteem, and 41% of patients said that they avoided social contact or functions because of their skin disease.
     The cause of rosacea in unknown and there is no cure, but with available medical help this skin disorder can be controlled and minimized. Its typical symptoms are redness on the cheeks, nose, chin or forehead, small visible blood vessels on the face, bumps or pimples on the face, and watery or irritated eyes.
    Whatever the cause, whatever the result, if adult onset acne is cramping your style, see your doctor because there is help.
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“I’m sick and tired of being sick and tired!” 
“I just have no energy.”
     One of the most common problems of the 21st century woman is fatigue.  I am not exaggerating by stating that well over 40% of women I see in my office complain at some stage of their life of excessive tiredness.  Lack of energy is not a local phenomenon either (in spite of the claims of one woman who was sure that SRS had something to do with her low energy level.  Of course this was the same gal who had been nabbed by aliens and forced to watch reruns of “Geraldo”).  National statistics are equally as impressive.  One study even went as far to claim that 30.3 % of adolescents experienced excessive fatigue (PEDIATRICS Vol. 119 No. 3 March 2007, pp. e603-e609) 
   
The classification of fatigue runs the gamut from a transient mild tiredness to a debilitating lack of energy.  One of the inherent problems in studying a condition such as this is the subjectivity of the diagnosis.  Those who suffer with chronic fatigue are often perceived as malingerers and patronizingly dismissed.  There is still reluctance on the part of many medical practitioners to legitimize chronic fatigue syndrome, the most extreme form of tiredness, as a genuine entity; however, this appears to be an area where the science is finally catching up with the clinical observation.  As with any medical problem that is poorly understood, the treatment of excessive fatigue is varied, sometimes unconventional, and often unsuccessful.  It is important to distinguish chronic fatigue syndrome from “garden variety” tiredness as they differ in numbers of symptoms and degree of disability.  For many sufferers it comes down to how much the lack of energy interferes with normal day to day activities.  The Center for Disease Control in Atlanta has set down certain criteria for physicians and researchers to use in making the diagnosis of chronic fatigue syndrome.  A CFS diagnosis should be considered in patients who present with six months or more of unexplained fatigue accompanied by other characteristic symptoms. These symptoms include:
  • cognitive dysfunction, including impaired memory or concentration
  • exhaustion and increased symptoms for more than 24 hours following physical or mental exercise
  • non-refreshing sleep
  • joint pain (without redness or swelling)
  • persistent muscle pain
  • headaches of a new type or severity
  • tender lymph nodes
  • sore throat
  You can see from these symptoms that there is tremendous overlap with other common problems.  We all may experience some of these problems some of the time. The key is the
persistence and intensity of the problem and, importantly, no other medical or emotional troubles that serve as a cause.
   There is hope!  Since becoming a more universally defined syndrome, additional research has been done on ways to thwart this bothersome illness.  Many of these treatments and suggestions also apply to the woman who has only mild symptoms.  So whether you are unable to get out of the bed or just collapse at the end of a busy day, these pointers may be worthwhile pursuing.
     First and foremost, get a good checkup by your doctor.  Many medical conditions such as hypothyroidism, menopause, Lupus, depression, anemia, and sleep apnea have fatigue as a primary symptom.  If you check out well with your doc, consider the following:
1.  Check your sleep habits.  We are a culture of sleep deprivation.  It makes logical sense that if we don’t sleep restfully we will be tired the next day.  I am amazed at the number of folks that forget this simple connection.  Improve your sleep and your energy will rebound.
2.  Force yourself to get off the couch.  Multiple studies show the positive effect of exercise on energy level.  You may be saying, “I would exercise if I wasn’t so darn tired!” It is tough, but forcing yourself to do something, even a good walk, will, over time, improve your energy level.
3.  Garbage in equals energy gone.  We are what we eat, and this applies to energy level.  In fact, energy derives from the body’s ability to metabolize food.  If we put molasses in our car’s gas tank, it won’t go far.  If we put junk in our gas tank, we won’t go far!
4. Reduce stress.  Stress magnifies everything!  The more stress, the more your lack of energy.  It’s as if the body tries to shut down to save itself from the stress. The more you can minimize stress, the more energy you will have.
  I realize this is a very superficial treatment of very complex solutions, but maybe it can stimulate you to investigate these approaches on your own. 
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  Aileen blew into my office like a Summer storm.  “Help me, I’m a poster child for Hormones from Hell!”  After catching my breath, I assured her that there were many ways of dealing with the ravages of hot flashes, dry skin, mood changes and forgetfulness.  I started by reinforcing that menopause is not a disease. Inaccurately and unfortunately there is a pervasive sense that menopause is the “ultimate and inevitable bad experience” for aging women.  I jokingly explained that women were not designed to self-destruct at fifty!   
          
     Menopause is a normal, natural transition, and it is vital for women to view it with a positive perspective.  That simple understanding is the cornerstone in building a plan to thwart the symptoms of “the change.”  But it is equally important to realize that not everyone has a problem with menopause. 
      
     As a physician, my experience treating menopausal women is that there are some universal similarities in women’s experiences, but because of every person’s unique physiology and life journey, this time in a woman’s life is very individualized.

      I am a “recovering traditionalist”.  I was trained in the old school approach to menopause (which means drugs, and if that didn’t work, more drugs). In almost twenty years of practice I have found that many women are not satisfied with their options and many discover that their “treatments” are worse than their symptoms.  Especially in this age of “estrogen panic” where the media (and many physicians) has touted misleading and confusing advice on hormones, many women are looking towards alternative treatments for their symptoms. One woman put it well.  She said, “Physicians have a duty to give a woman the best care they can provide, especially their options.  However each person is ultimately responsible for his or her own health.  We, the patients, need help, guidance, and a listening ear.” Those were powerful and challenging words.
   
     The general dissatisfaction among women is amplified by the observation that only 17% of eligible women in the US are taking some type of hormone replacement and up to 80% of women who start on hormones stop them after two years!  The needs of women are not being met!  This problem with compliance is due to poor communication and fear.  After all, treatment of symptoms is not limited to simply taking a drug.  Successfully navigating the potentially turbulent waters of menopause requires a more comprehensive approach.  Herbs, complimentary teachings, diet, and exercise all should be discussed along with hormones. The main caveat surrounding these modalities is that they must be held to the same standard and scrutiny that safeguards traditional hormone replacement. The major problem in meshing the traditional and complimentary approaches to health is a mistaken perception of mutual exclusivity.  These treatments can coexist and be complimentary.

      I am saying that choice and personal responsibility are keys to unlock a joyous menopause. 
      
     This is an opportunity to live with passion and fulfill your life mission. This is a time to take stock of the past and choose your path for the future. The choice is yours. It is a choice that is difficult if not impossible to make wisely without sound information and guidance. 


THE 4 “A”s
    Many of the lifestyle choices you make, such as diet and exercise, can dramatically affect your menopausal experience. It is not a time to be complacent or anxious.  It is a time- a season- to rejoice and celebrate the joy of living.  
Following the four “A”s,   Attitude, Action, Aptitude and Apothecary, can be the prescription for menopausal merriment.     

Attitude- what we believe is our reality, what we know is our truth.  Belief plays a major role in the symptoms of menopause.  Our thoughts become our actions, our actions become our deeds, our deeds become our habits, our habits become our character, and our character becomes our legacy.  In many instances, if you anticipate a horrible experience, you will be right!

Action- this involves two levels.  First, acting on your knowing.  The key to any successful person, whether it’s in business, raising a family, or celebrating menopause is taking action. There is nothing more sad than a good idea that dies from loneliness or lack of attention.  Whether that’s using hormones, herbs, massage therapy or exercise, you have to take action to achieve results. 
     The second part of action is exercise.  It is the fountain of youth and can help in reducing both weight and hot flashes!  

Aptitude- educate yourself, learn your options.  Ask questions, talk to others, and take responsibility. Through knowledge about menopause, you eliminate fear and create opportunities.  M.D. does not mean menopause director!  Learn so you can be a partner in your health care.

Apothecary- We have a plethora of medicines and natural substances to treat the symptoms of menopause.  These are merely tools; however, they cannot stand alone.  
Explore your options and live joyously and healthy. 

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     Men and women are different.  I realize this may not be a ground breaking revelation but aside from certain anatomical variations, the differences are not always noticeable.  

     Women certainly have a different hormonal milieu than men, and some of the internal variations can be directly attributed to such; however, laying everything at the feet of the hormonal hooligans is both simplistic and unfounded.  In other words, men and women are not solely their hormones, but a complex interaction of gender specific, unique physiology.  Let’s look at some examples.
Women are at a greater risk of developing problems from alcohol use than men.  This applies to simple health risks as well as severe consequences.  The National Institutes of Health state that, based on current research, female alcoholics have death rates 50 to 100 percent higher than those of male alcoholics, including deaths from suicides, alcohol-related accidents, heart disease and stroke, and liver cirrhosis.  Even though there are more male alcoholics than female, the women fare worse overall.  This is related to how alcohol is metabolized in the female system.  Women are more likely to develop liver damage from excessive alcohol consumption even when compared to similar intake for males.  In addition, having more than 2 drinks a day can increase the risk for breast cancer for a woman.  Why do these differences exist?  In general women have less body water than men of similar body weight, so that women achieve higher concentrations of alcohol in the blood after drinking equivalent amounts of alcohol.  In addition, women have smaller quantities of the enzyme dehydrogenase that breaks down alcohol in the stomach. A woman will absorb about 30% more alcohol into her bloodstream than a man of the same weight who has consumed an equal amount.  There is a push by many organizations, especially on college campuses to educate women as to these differences.  The consequences later in life can be substantial.

     For years medical research on heart disease and risk factors was done exclusively on men.  The vast majority of major work done in the earlier decades purposely excluded women for reasons ranging from potential pregnancy to volunteer recruitment.  What resulted is a plethora of data that is extremely useful, but biased.  Only with the advent of multiple studies including women have researchers realized that heart disease risk factors, occurrence, and prognosis are different for men and women.  Heart disease has taken a back seat to breast cancer, for example, largely due to media attention and breast cancer awareness programs; however, heart disease is the leading cause of death in women over 50.  A woman is more than ten times as likely to die of cardiovascular disease as she is to die of breast cancer. This is partly due to the fact that the survival rate for breast cancer is quite high, whereas over 40% of women do not survive their first heart attack.   Women’s hearts are anatomically different from men, and they also function differently.  A woman’s heart on average is smaller than a man’s, and it also tends to have smaller blood vessels supplying it.  Researchers from Columbia University and New York Presbyterian Hospital believe that women also have a different rhythmicity to the pacemaker of their hearts, which causes them to beat faster. These same researchers believe that it may take a woman's heart longer to relax after each beat. Some surgeons also hypothesize that the fact that women have a 50 % greater chance of dying during heart surgery than men could be related to some fundamental difference in the way women's hearts work.   These differences have led to a bias in how physicians viewed heart symptoms in women.  Several studies indicated that if a woman and a man presented to an emergency room with identical symptoms, the man would be more likely to be evaluated for heart problems than the woman.  Luckily with the new data, this trend is reversing and early disease is being suspected and detected in women, hopefully reducing both death and disability.

     Most would agree that men and women think differently.  This may have a physiologic basis as research indicates that men’s and women’s brains are structurally different.  There are variations in grey and white matter, which leads to differences in things such as verbal abilities and connectivity between the two sides of the brain.  These anatomical peculiarities can lead to a number of behavioral differences once thought to be social or environmental. 


     It’s important to understand there is no advantage or disadvantage with these variations, it’s just that being aware of the differences may help in promoting each individual's health. 
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