HRT raises breast cancer risk for years!

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An analysis of dozens of studies found that women taking the therapy remain at a higher risk for more than a decade after stopping use

A sweeping new analysis adds to the evidence that many women who take hormone therapy during menopause are more likely to develop breast cancer—and remain at higher risk of cancer for more than a decade after they stop taking the drugs.

The study, published recently in the Lancet, looked at data from dozens of studies, including long-term data on more than 100,000 women who developed breast cancer after menopause. Half of those women had used hormone therapy, or HRT. The longer women took the medicine, the more likely they were to develop breast cancer. Experts say the findings could shape how women and their health care providers decide how to manage symptoms of menopause.

“This is a consensus of many researchers and many studies all around the world. These are important new results,” said said Valerie Beral, a cancer epidemiologist at the University of Oxford and one of the lead authors of the new study.

Women have long been prescribed synthetic versions to replace the hormones that decline during menopause. The medications—usually delivered in a pill, but sometimes in a patch, gel, or injection—provide women either estrogen or a combination of estrogen and progestogen, a synthetic form of progesterone. For some women, they may help to tamp down symptoms of menopause.

For years, research has suggested a potential link between HRT and an increased risk of breast cancer. In 2002 and 2004, the Women’s Health Initiative released reports that showed women who used combination HRT were more likely to develop breast cancer. HRT use fell after the reports received widespread coverage. That was followed by a decline in breast cancer rates.

But there wasn’t much information on whether that risk persisted, or how it differed based on the type of HRT a woman took. So an international group of researchers pulled together data from dozens of studies—published and unpublished—to examine the issue more closely. They took a woman’s age at first use of HRT, how long she used the medication, and the time elapsed since she last used it into account. The mean age of women starting menopause was 50, which was also the mean age at which women started using HRT.

The researchers found that compared with women who never used HRT, women who did had a significantly higher risk of developing invasive breast cancer. They estimated that 6.3% of women who never used HRT developed breast cancer, compared to 8.3% of women who used the combination drug continually for five years. That’s roughly one extra cancer diagnosis for every 50 users.

The longer women used HRT, the greater their risk of breast cancer. Women who were no longer using HRT had a lower relative risk than women who were currently using it—but they remained at an elevated risk for more than a decade after they stopped taking the drug. The level of risk was dependent on how long a woman took HRT. The study also found that women who took the combination drug were more likely to develop cancer than women who took the estrogen-only drug.

“The findings are significant,” said Joanne Kotsopoulos, a breast cancer researcher at Women’s College Research Institute in Toronto. “The longer you use it, the higher the risk,” added Kotsopoulos, who wasn’t involved in the research but wrote a commentary on the study, also published in the Lancet. “It’s a balance. Every woman is different, but the risk is high for breast cancer, so they need to take a very serious approach.”

How not to get caught short by the HRT shortage

If you’re in the UK you have probably heard in the news recently that there is a national shortage of hormone replacement therapy due to manufacturing delays.  The appearance of symptoms is due to hormone imbalance at perimenopause in your 40s and 50s. We encourage a natural approach to menopause and managing hormone balance with diet, exercise, avoidance of toxins containing xeno-oestrogens and the use of bio-identical hormone replacement therapy.

What can you do if the HRT shortage affects you?

We encourage you to try alternatives to HRT.  

Diet

A healthy diet can really help to balance your hormones. You can read more about what we recommend diet wise here. In the mean time stick to fresh, unprocessed foods, organic where possible. Sugar should be cut to a minimum or eliminated altogether if you can. Alcohol and caffeine can exacerbate hot flushes, so reduce their intake too.

Exercise

Feel better and protect yourself from osteoporosis by with  regular weight bearing exercise. Exercise also stimulates the production of endorphins so you’ll feel better emotionally too.  There are many menopause symptoms which can be alleviated by yoga and you can find how yoga can help you here.

Avoidance of toxins

Xeno-oestrogens are hormone disruptors which have occurred as a result of industrialization. Xeno-oestrogens mimics oestrogen in the body leading to oestrogen dominance which causes hormone imbalance. They can be found in all sorts of products such as cosmetics, cleaning products, plastics. Our article 10 signs of oestrogen dominance and what you can do about it tells you more about toxins and how to avoid them.

Natural progesterone cream

Natural progesterone or bioidentical hormone replacement therapy is, for us, the gold standard in hormone balancing for easing symptoms of menopause You can read more here  When buying a natural progesterone cream it is essential to ensure that the cream you buy has the correct amount of the active ingredient. At Menopause Matters Guru we have teamed up with our preferred supplier of the cream and you can find out more by emailing us at info@menopausematters.guru

PREGNANT AT 50! Eeek!

There’s been much in the news lately about how doctors can delay menopause for up to 20 years. One procedure has just become available at a clinic in Birmingham. Doctors at the ProFam (short for Protecting Fertility and Menopause) are able to remove a piece of ovary via keyhole surgery, freeze it and then re-implant it when a woman’s natural menopause occurs.The implanted tissue then produces hormones that reverse the menopause. These grafts can maintain a woman’s youthful hormone production for years.

This procedure has been used before to help young cancer patients who have gone into premature menopause because of chemotherapy, who want to recover their fertility. Now it is being offered to more women who can pay to have their ovarian tissue removed up to the age of 40 and stored for use when they reach menopause. The average age for women to reach menopause is 51. The hormonal changes can affect quality of life and cause adverse effects such as strokes, heart disease, osteoarthritis, not to mention hot flushes, depression, mood swings and memory loss.

So whilst this breakthrough procedure to delay menopause could enable women to have babies into their 50s, it could also benefit women whose menopause triggered health issues and who were reluctant to use HRT because of harmful side effects. Women who did not want to become pregnant could have the ovarian tissue re-implanted anywhere with a strong blood supply, such as the armpit.

Children born in the West today can reasonably expect to live up to 100, so for the first time women will be living for as long after menopause as before it. Medical procedures like these can help women to break free from the constraints of their biology, by calling time on their biological clock.

J is for Juggling!

The Sandwich Generation is a generation of people (usually in their 40’s to 70’s) who care for their ageing parents while supporting their own children; including young adults aged 25 -34, who are staying or returning home in increasing numbers!

Keeping all those balls in the air can be a major problem! A Carers’ UK report in 2012 said that approximately 2.4 million people  aged 40 to 70 are both raising a child and caring for a parent. 

That in itself is stressful, but look at that age group! It is almost precisely the time that women are starting to feel the effects of peri and menopause!

A number of strategies are needed to cope with this situation so that you don’t become overwhelmed.

As with any big goal or change there are lots of actions you can take to reach your goal and it’s best to break them down into small steps. There are lots of changes we recommend. You don’t have to do them all at once. Pick one you like the look of and practice it until you are comfortable with the change you have made, then add another to your repertoire. Make the changes gradually until you feel less stressed.

  1. Make yourself some head space. Take a break and practice meditation. Start with 5 minutes at a time and if you find your mind wandering, focus on your breath. There are several meditation apps. Two of our favourites are One Minute Meditation (https://www.youtube.com/watch?v=F6eFFCi12v8) and Headspace (https://www.headspace.com/headspace-meditation-app)

2.       Exercise. The benefit of exercise to reduce anxiety and also menopausal symptoms cannot be underrated as it helps correct hormone imbalance which is the root of symptoms. Another advantage of exercise is that it results in lower levels of heart failure in post menopausal women. You can read more here.

3.       Manage your mindset. If you expect your menopause to be stressful and difficult then it probably will be. It is important to maintain a positive outlook. There are lots of ways to achieve this. One of our favourites is  use of affirmations. You  can find lots on our Instagram feed

4.       Reduce toxins. This can be the confusing one as we are absolutely  surrounded by toxic substances which disrupt hormones. Industrialisation has been great in so many ways and we as a society have benefitted lots. However many man made materials, cosmetics, household cleaners and products contain toxins which contribute to oestrogen dominance which in turn exacerbates menopause symptoms You can read more about oestrogen dominance in our article here. A great rule of thumb is to use items which are as close to their natural state as possible.

5.       Get good sleep. It’s so much easier to deal with anything if you have had a decent night’s sleep and are full of energy. Go easy on the late nights, and all night parties. Get into good bed time habits and avoid too much stimulation before sleep (sorry that includes your mobile phone)

6.       Eat a good balanced diet. Avoid processed foods and sugar. Focus on plenty of fresh produce like organic meats and fish, fruit and vegetables. Cut down on alcohol – you don’t have to ban it altogether.

7.       Balance your hormones. We advocate the use of natural progesterone cream and our favourite one is made by a company called Naturone, as it’s important to ensure you have the correct percentage of progesterone in the cream  To try it follow the link and quote MENOPAUSE MATTERS in the order information

Menopause. Is it a modern myth?

Menopause. Is it a modern myth?

We’re always interested in finding different explanations of menopause, and even more to hear your opinions.

Helen has recently visited a homotoxicologist , a biomedical  therapy based on homeopathy who recommended a book Medical Medium by Anthony William.  The book contains chapters on various conditions and offers explanations for them.  As you can imagine we were fascinated to read his theory of menopause.  

William notes that throughout history menopause has been viewed positively. The medical literature contains few references to menopause particularly in a detrimental way. This all changed around the 1950s. Women born from 1900 on were the first to experience the symptoms we now associate with menopause, hot flushes, mood swings, depression etc. He also noted that men suffer the same symptoms around that age, weight gain, depression forgetfulness and ‘work sweats’.

“Physicians reported the epidemic to pharmaceutical companies and at first the consensus was that it was all in women’s heads – it was just crazy woman syndrome. They had to be making up their symptoms because otherwise it made no sense. It was all a cry for attention, a sign they were bored. Women were told to join the PTA” (WTF?!)

So what changed between 1900-1950 to make menopause the monster it is seen as today? Williams proposes a number of factors which attribute all the blame to menopause when the symptoms are the result of a variety of causes

Epstein Barr Virus

EBV was taking root in the early 1900s. the theory here is that it entered the womens bodies and spends decades building up to the inflammatory condition which causes symptoms and coincides with the onset of perimenopause.

Radiation exposure

Most women of the time were exposed to huge amounts of radiation just through buying shoes. From the 1920s-50s each shoe shop and department contained an ingenious foot measuring device called a fluoroscope. This amazing machine took an x-ray of the foot bones to enable shoe sales people to get an accurate picture of your foot and therefore find and sell the best fitting shoes. The dose of radiation delivered each time was unmeasured and unregulated. Luckily by the 1950s the dangers of radiation had been discovered and the fluoroscope was removed from service. Many women had legs amputated and suffered from related cancers around this time and all were attributed to the menopause rather than the real culprit.

DDT exposure

In the 1940s and 50s DDT was seen as a wonder pesticide. Little was known about the incredible harm it did due to its toxicity. Use of DDT peaked in the 1950s and the central nervous system and liver were overloaded with the toxin.

Williams states that menopause was used as a scapegoat for a variety of reasons and it does not make sense that something which had previous caused no problems should suddenly be the root cause of all the symptoms of menopause.

Now it’s quite possible that these theories do explain some exacerbation in symptoms in women. However, there are other possibilities. Since the turn of the last century there has been a huge increase in the manufacturing industry. We use more artificial chemicals than ever before in cleaning products, cosmetics and industrially. The xeno-oestrogens found in these have a severe effect on hormone and hormone balance. You can read more about oestrogen dominance in our article 10 Signs of Oestrogen Dominance and What You Can Do About It.

What do you think?  What other explanations for menopause and its symptoms have you heard? We’d love to hear  your views. Feel free to comment on this blog. fffff

I is for Inner Bitch…and 11 ways to tame it!

Have you noticed since becoming menopausal that your mood swings all over the place? Without warning you can go from being perfectly happy one moment to ‘screaming bitch from hell’ with a short stop off at tearful and anxious on the way. Fluctuating hormones have a lot to answer for. The first thing you need to know is that mood swings are a well documented symptom of menopause. But we’d like to give you some natural tools to arm yourself with so you can calm down before you find yourself friendless, frustrated and alone.

Handling mood swings naturally

1. Balance your hormones: hormone imbalances around the menopause are the root cause of your mood swings. BHRT, (Bio-Identical Hormone Therapy) is the safe, natural way to get your hormones back in balance using a natural progesterone cream which will elevate your mood and make you less snappy! See our previous article on the benefits of the mother hormone progesterone here: http://menopausematters.guru/wp-admin/post.php?post=660&action=edit

2. Meditation:  Carving out time in your day to meditate really helps quiet your mind and give you personal space. Just 5 minutes of meditation a day will make you calmer, increase feelings of well being and happiness, and help you keep things in perspective.

3. Tapping or EFT (emotional freedom technique): Tapping is a great ways to reduce feelings of despair, anxiety, anger and many other negative emotions. Measure your feelings of an emotion on a scale of 1-10 before you start and when you’ve finished and you will see a reduction in that feeling.

(You can learn more about EFT here. Tap your way to emotional freedom)

4. Exercise: Exercise increases endorphins and makes you feel better, particularly in relation to mood swings. For menopausal and peri-menopausal women there is the added benefit of improving bone health and helping to eliminate that menopause middle. If you’re feeling uptight, vigorous exercise such as the 4 minute Nitric Oxide Dump (www.nitricoxidedump.com/) will help you work it off. A session of yoga can calm you and reduce anxiety, and walking is also a great exercise and stress reliever.

5. Supplements: Ginseng, Agnus Caestus, St Johns Wort and magnesium are among the supplements which help mood swings. Do your research carefully and make sure there are no adverse effects when mixed with other medications or conditions.

6. Healthy diet: cut down or avoid sugar which can give you extreme highs and lows. Try and ensure that the food you eat is as close to its natural state as possible. Processed foods should be kept to a minimum as they contain all sorts of additives and chemicals. Whenever possible eat organic foods.

7. Sleep: a lack of sleep will make anyone feel cranky. Add that to hormone imbalance and you have a perfect storm for mood swings. Check out our recent post for ways to get a good nights sleep

8. Eliminate caffeine and alcohol: excessive caffeine intake can lead to irritability, insomnia, anxiety and restlessness, so you should at least reduce your intake. Wean yourself off caffeine as you can experience adverse symptoms with sudden withdrawal. Regular alcohol intake reduces your serotonin (the happy hormone) levels which affects your mood. Reduction or elimination of either or both will help reduce your mood swings.

9.  Figure out your triggers: identifying your stressors will help you take actions to avoid or reduce them. Whether it’s certain situations, people or even foods you are intolerant of, working out what causes you stress encourages you to take measures to alleviate the effects. For example if a particular person upsets you and you have no option but to see them try promising yourself a little reward afterwards or use EFT.

10. Get support: don’t go it alone. You are not the only one prone to mood swings. If your friends are of a similar age to you they will no doubt be experiencing the same things, and make sure your family are aware of what you’re going through. We’re always available for help and support, so join our FB group and get involved in lively discussions with members going through the same problems. And you can always email us, Helen & Caroline at info@menopausematters.co.uk

11. Be kind to yourself: sometimes you just need to take time out for yourself and relax. Book a massage, read that book you’ve been meaning to get round to or just take a bubbly bath.   

G is for Good Habits!

While hormones play a vital part in a healthy life-style, there’s a lot more to do! The no. 1 mistake a lot of people make is being unaware. Be vigilant about anything that you put in or on your body. Toxic substances in food, creams, shampoos, cleaning products, all add to the xeno-oestrogen overload polluting Mother Earth, that you can eliminate. Learn their names and read the labels. Eliminate sugar from your diet, especially high fructose corn syrup. According to nutrition experts, it’s as addictive as cocaine and heroin, and there’s  new research on how sugar fuels cancer cells, which is their only source of energy. Deprive them of that and they die! Also avoid all artificial sweeteners like Aspartame and the like. There are natural plant based alternatives such as xylitol and stevia.  A good rule of thumb is put nothing on your body that you wouldn’t put in your mouth! There is always a healthy alternative.

More than 84,000 chemicals are used in household products, cosmetics, food, and food packaging, and a majority of these have never been tested for safety. The overuse of anti-bacterial soaps and cleaning products can reduce the amount of healthy bacteria on a person’s skin, which can make antibiotics less effective in the fight against new strains of bacteria, called superbugs.

Healthy, organic eating is vital for good health. Far too many people eat anything unquestioningly as long as it tastes good. Fortunately, people are waking up, and there’s now a big move to healthy, organic eating.

Food production is one of the basic fundamentals of our society, and if we change our mindset, eating habits and  consumer patterns, corporations will have to respond and adapt to a new market.The small farmer is getting back to being relevant to the whole chain of production and people are even growing plants and seeds in their homes.

habits for a healthy menopause

Your diet should consist of as much raw organic food as possible, especially vegetables, plus beef from grass fed cows, free range organic chicken and eggs and out-door reared pork. Above all, avoid all processed foods. They are the source of most of the inflammation we suffer from.  For the updated 2019 list of “Dirty Dozen” and “Clean green” vegetables and fruit, got to the EWG (Environmental Working Group) link https://www.produceretailer.com/article/news-article/2019-dirty-dozen-and-clean-15-lists-released

G is also for gut! We now know that 80% of our immune system resides in our gut, and research shows that your gut flora can affect numerous processes in your body, including your metabolism, energy production, nutrition, and genetic expression. Your intestinal microflora is unique. Choice of foods can alter your microflora in a matter of days, for better or worse. The ideal way to optimise your gut flora is to include fermented foods in your daily diet. While most probiotic supplements contain no more than 10 billion colony-forming units, one serving of fermented vegetables such as sauerkraut,  can contain 10 trillion colony-forming units of bacteria, and give you a wider variety of beneficial bacteria, so all in all, it’s your most cost effective alternative.

Exercise is also vitally important. Use it or lose it is the key, but it doesn’t have to be time consuming. Many of us lead very busy lives, and if you have trouble incorporating exercise into your daily schedule, then you should try the Nitric Oxide Dump. Developed by Dr. Zach Bush, it is a new version of high-intensity interval training (HIIT) that is designed to stimulate the release of nitric oxide, which can catalyse and promote health. http://www.nitricoxidedump.com/

The Nitric Oxide Dump uses simple movements done in quick succession, providing benefits similar to longer workouts, but accomplished in just a very small fraction of the time. The Nitric Oxide Dump only takes a small amount of your time, with one session lasting between three to four minutes. Since it’s ideally repeated three times a day, you’ll be using a total of around 15 minutes. Bush calls it one of the best ways to start toning your body’s systems.

Hormone balance is also vital, and you simply cannot enjoy good holistic health if your hormones are out of balance The key to this is to make sure you are not deficient in the mother hormone progesterone, which declines drastically during peri and menopause. For more information, go to our blog http://menopausematters.guru/wp-admin/post.php?post=660&action=edit

Learn also how to make use of the incredible power that natural herbs and plants can bring, and the benefits of meditation, and a positive mindset. Together with a healthy, balanced, organic diet and exercise, this can go a long way towards addressing many of your body’s problems.

Can you reverse Menopause?

Is menopause reversal possible?

Although emerging research suggests that it could be, at least temporarily, many women would react with horror, especially at the thought of going through it all again at a later date! Scientists are looking at potential treatments, one of which is melatonin therapy, which can reduce the symptoms of menopause and revive natural ovulation.

For years, researchers have been investigating the connections between menopause and melatonin. Melatonin, the sleep hormone, is produced in your pineal gland. Older research shows that the pineal gland begins to shrink as you approach menopause.

Researchers believe melatonin plays an important role in the production of reproductive hormones. Without it, reproductive hormone levels begin to plummet.

One study found that a nightly dose of 3 milligrams of melatonin restored menstruation in participants ages 43 to 49. These participants were either in peri-menopause or menopause. No effects were seen in participants ages 50 to 62.

Clinical trials have also found a nightly dose of melatonin may reduce feelings of depression and improve overall mood for women in menopause. This treatment may be suited for someone looking to minimise menopause symptoms rather than restore fertility.

Melatonin may also have protective effects for older women against some cancers — including breast cancer — and certain metabolic disorders. It’s also been shown to improve the immune system.

Although more research is required, melatonin could be a natural and safe way of delaying, or potentially reversing, menopause, and at the very least helping to alleviate anxiety and depression.

F is for flushes!

Hot flushes (or flashes) and night sweats are a very well known symptom of menopause. They happen when blood vessels close to the skin dilate to cool.

The root cause of hot flushes is not clear. What is known is that the part of the brain that senses and controls body temperature (and other body functions) is the hypothalamus.

During the menopause, hormone levels are disrupted, particularly falling progesterone levels. Although not fully understood, scientists think that this fall causes a glitch in the way the hypothalamus senses body temperature, making it think that you are too hot.

This causes a response designed to cool the body down. More blood goes to the skin (one of the causes of hot flushes and reddening of the skin) and sweat glands start working (the menopausal sweat).

The sudden feeling of heat appears from nowhere and  seems to spread through your body. They can appear at any time and if they turn up at night are known as night sweats. A flush can cause redness, sweating and sometimes palpitations. The incidence and severity, like all menopause symptoms, varies from woman to woman.

Hot flushes are at best slightly inconvenient, and at worst so severe that they cause serious disruption for some women. They can occur as often as several times an hour – not good for that silk blouse, but there are plenty of natural ways you can try to reduce them.

Keep a diary of your hot flushes and see if there are any patterns or you notice any triggers. These may be caffeine, hot and spicy foods, alcohol or stress. Smoking may also trigger hot flushes.

Lifestyle

Cut down on caffeine and hot spicy foods.

Wear clothes and choose bedsheets that wick away sweat, particularly those night sweats which leave you feeling cold and clammy afterwards. For natural fabrics try bamboo yarn which is naturally wicking. Avoid cotton as the moisture stays close to your skin.

Keep your rooms cool and sleep with a window open if possible

If you are a smoker then giving up the habit will benefit you in more ways than just hot flushes.

Other remedies

Natural progesterone cream. I am a huge fan of this and know from experience that it is extremely effective in getting rid of hot flushes

Red clover provides a rich source of isoflavones (water soluble chemicals which act like oestrogen – known as phytoestrogens). It is available in tablet form, tea bags and dried flowers which can be taken as an infusion

Black cohosh used by native Americans for many years since it was discovered it can help reduce menstrual cramps and menopause symptoms

Sage has been used for medicinal purposes since ancient times. Sage tea has may uses not least of which is to reduce hot flushes and menopausal sweats. Sage is also available in tablet form.

Evening primrose oil  has many benefits for menopausal women including lessening the effects of hot flushes

Meditation, yoga and breathing exercises all help reduce the stress that can be a trigger for hot flushes. Try a minute of slow deep breathing. 6-15  breaths per minute is ideal. We are great fans of Tapping, also known as Emotional Freedom Technique (EFT) helps and there is now an excellent app you can download for free that helps to deal with stress. Nick Ortner, who is The Tapping Solution founder, and a favourite of ours, posted the following;

“The easiest way to start tapping and to always have it right at your fingertips is to download our free app. Seriously, it is free – and there is a ton of free content available as soon as you sign up.”

E is for eggs

Women are born with about a million eggs in each ovary. By puberty about 300,000 eggs remain, and by menopause there are no active eggs left.

On average, a woman will have 400-500 periods in her lifetime. From about 35-40 years of age, the number of eggs left in your ovaries decreases more quickly and you ovulate (release an egg from the ovary) less regularly until your periods stop. Menopause means the end of ovulation.The transition or lead-up to menopause (running out of eggs)

Peri-menopause

  • Lasts an average of 4-6 years, but can be as short as one year or as long as 10 years
  • Periods start to ‘wind down’ and become less regular
  • Periods can be lighter or heavier, last for longer or finish earlier than they used to
  • Menopausal symptoms often gradually begin during this time.

  Many women talk of peri-menopause as a time of hormonal ‘chaos’. Hormone levels can swing erratically from high to low. This is because the ovaries are beginning to run out of eggs, which affects hormone levels. The pituitary gland produces higher levels of signalling hormones – follicle-stimulating hormone (FSH) and luteinising hormone (LH) – to the ovaries in an effort to keep the ovaries producing eggs and oestrogen levels normal. During this time, ovulation (the release of an egg) might occur twice in a cycle, the second time during a period. This can lead to very high hormone levels. In other cycles, ovulation might not occur at all.

There is no test to diagnose peri-menopause. It is best identified by considering:

  • Changes in the nature of your periods, such as:
    • how frequent they are now and if that has changed
    • how long they last and if that has changed
    • how light or heavy they are and if that has changed

Because of the hormonal swings during peri-menopause, this is the time many women experience the most symptoms. Symptoms of peri-menopause – are you experiencing:

hot flushes?

mood changes (low or swinging mood/irritability/anxiety)?

decreased ability to do your normal activities/inability to cope?

Talk to your doctor if you experience:

  • increasingly heavy periods
  • long periods of more than 8 days
  • periods that come less than 3 weeks apart
  • periods that come more than 2-3 months apart
  • painful periods causing you to stay home
  • bleeding between or after periods, or after sex
  • any of the above listed peri-menopausal symptoms.