Jeanette Winterson: can you stop the menopause?
After two years of mental breakdown, I was physically depleted, unable to sleep and my hair was falling out. Was my only choice HRT? Or was there a natural alternative?
'A woman talks to her GP like a sinner at confession' … Jeanette Winterson. Photograph: Peter Peitsch
Murderous, moody, crazy, depressed, nervous, exhausted, shouty, weepy – even before I get to the word "woman", you know it isn't a man I am talking about, because certain words have stuck to women like wasps in jam. My next word, "hormonal", applies as much to testosterone-spiked banksters and irrational males with machine guns as it does to menstruating or menopausal women, but it's one of those words that has become gendered for social, not scientific, reasons. A mix of confusion and camp comedy, "hormonal" is how we explain and explain away a woman's experience of the changing biochemistry of her body. A woman talks to her GP like a sinner at confession: "It must be my hormones" covers everything from not wanting to sleep with your husband, to wanting to kill him. Meanwhile your waistline expands and your hair falls out. The prescription is likely to be the same: antidepressants or HRT.
Over the last few years I have been trying to find a medical model responsive to the fact that our bodies are not machines made of faulty parts but a process in constant movement and change. And I have been looking for medical practitioners able to discuss the mind-body balance as a synergy, not a confusing, frightening war.
When I was recovering mentally and emotionally from two years of breakdown (which I wrote about in my memoir Why Be Happy When You Could Be Normal?), I knew that my brokenness had damaged the integrity of my body. My mind had healed, but I still had problems sleeping, with low energy levels, with the horrors of my hair falling out. My body felt unpredictable and alien. It was as though my madness had been somatised. My local GP gave me a standard Well-Woman check. She said I was fine, but perimenopausal, so I could have HRT. I was more interested in the fact that my cholesterol was bafflingly high for someone of my weight, with a good diet, taking regular exercise. "Eat less red meat," she said. That means nothing when you don't eat any.
I insisted on a thyroid test. The results came back in the "normal" range. I asked for information about the "range", and I started doing my own research.
Next stop was a fancy nutritionist, who arranged for vitamin and mineral blood tests. My vitamin D was rock bottom, and I wasn't absorbing the B spectrum, even though I was eating well. There were also zinc and magnesium deficiencies, and I wasn't getting enough protein because I wasn't eating enough protein-rich foods. "Eat more red meat," she said.
Greens, grains, fruit, pasta, eggs, chicken twice a week and fish once a week just weren't enough. What is interesting is that my diet had done very well for me for a decade. My weight had been stable and I had plenty of energy. But mental illness had depleted my physical resources in ways I didn't understand – and I was facing the challenge ofmenopause.
Nobody tells you that your body needs different kinds and combinations of foods at different life stages – all we hear is cut the calories, caffeine and booze. And when our body signals that it needs help, the answers contradict each other. The nutritionist gave me a tailor-made cocktail of vitamins and minerals and I began to sleep a bit better, and my energy improved. But my skin was too dry and my hair was still falling out.
Then a friend put me in touch with the Philip Kingsley Trichology Clinic. Philip Kingsley made his name back in the 1960s when he successfully treated Audrey Hepburn for thinning hair brought on by her anorexia. He invented the phrase "Bad Hair Day". Biblically old, he is still the senior consultant at his clinics in Mayfair and New York.
With the Pill to prevent conception, IVF to encourage it and HRT for the menopause, the womb to tomb ambitions of Big Pharma have been realised
Feeling both ridiculous and dejected I booked an appointment at the exclusive Mayfair address, comforting myself that at least I could buy his hair products democratically from his range on sale at Marks & Spencer. The first thing PKT did was to check my levels of stored iron (ferritin), and mercury. Consultant Carole Michaelides said: "Go to New York and look at all those wealthy self-starved women with terrible hair. All they eat is sashimi. Their mercury levels are sky-high."
My mercury levels were too high, but the real problem seemed to be a ferritin count of below 30. That didn't mean I was anaemic – I am not – my functional iron is fine, but the body uses stored iron for hair growth. I called my GP again. Her voice told me I was a time-waster. She assured me that my ferritin was within the "normal" range. "It is nowadays," Michaelides said, "because they keep lowering the range of what is 'normal'. What is certain is that below 80 you won't have healthy hair." Why be healthy when you could be normal?
Michaelides studied my various blood tests and thought she was spotting a pattern of hormonal disruption. "You are listening to your body – which is showing signs of distress – but your doctor isn't listening to you." She suggested I make an appointment with Dr Marion Gluck – a world pioneer in the prescription and preparation of bio-identical hormone therapy for women and men.
I had never heard of bio-identical hormones – and a quick flash round the internet confused me. I could buy off-the-shelf progesterone cream, but what exactly would I be putting into my body? What is the difference between HRT and bio-identicals?
Off I went from Mayfair to Wimpole Street, thankful to have sold enough books to pay for all this private attention, furious that if I wasn't tenacious, intelligent and solvent, I would gradually be running myself into ill-health and beginning to hate my shedding, tiring, frightening body that had replaced the strong reliable body I used to know.
"Yes, it's about balance," said Gluck. "Women go through a lifecycle of hormonal fluctuations from puberty through menopause. That is perfectly normal and a healthy body will constantly readjust to change. But in the world we live in, environmental toxins, poor nutrition, the fact that even a good diet is often lacking in essentials, plus the stress toll on women, all this means that the body cannot always rebalance itself. Imbalance affects energy, mood, conception, digestion, sleep, sex, everything. Bio-identical hormones can be used at every stage of life – not only during the menopause. And yes, you are right; a mental breakdown does not happen only in the head."
I liked her straight away. "The blood profile will tell me a lot, but the patient will tell me more. Doctor and Patient should be a relationship not a dictatorship," she said.
She explained that hormones are chemical messengers, constantly circulating in the bloodstream, regulating our metabolic processes. For women, the ratio of oestrogen, progesterone and testosterone is crucial – but that ratio changes as we do, according to our age and fertility. "Women didn't used to live much past the menopause – let alone be starting an active and productive second life, as many women do once their children are grown-up. We are asking a huge amount of our bodies, even when they are perfectly well."
Gluck put me on a low dose of oestrogen, progesterone and testosterone and four weeks later my periods started again, one year after what I had thought was the last one. Apparently my body was still producing more than enough oestrogen, but my testosterone was low and my oestrogen/progesterone ratio was out of balance.
Progesterone is the happy hormone. In balance it makes us feel confident and positive. Out of balance, women get weepy and anxious. "So many women are prescribed antidepressants when they need progesterone," said Gluck. "Just as importantly, progesterone is an anabolic steroid – it works in partnership with oestrogen to maintain healthy bones. Oestrogen delays the loss of bone density but progesterone actually builds bone tissue. In the right balance, oestrogen and progesterone offer our best protection against osteoporosis."
So why aren't we all on HRT? And why is BHRT (Bio-identical hormone replacement therapy) so much better, according to its supporters?
In 2002 the Women's Health Initiative released the results of a 10-year study into the effects of conventional HRT on women's bodies. Funded by the US government after years of lobbying by women's groups, the study began in 1991 but had to be halted early as the shocking results became clear. Women on conventional HRT were suffering from a huge increase in heart attacks, blood clots, strokes and breast cancer. The study was a triumph of science over marketing but it left women with an impossible choice: we are living longer but our bodies must do so unsupported by the protecting and vitalising hormones we produce naturally when we are younger. Do we take HRT, and close our eyes to the side effects, or do we take nothing and hope we don't suffer from fragile bones, lack of energy, loss of libido, depression etc?
Gluck was trained in Germany, and subsequently moved to Australia with her family. It was there that she became interested in BHRT because her patients wanted to come off HRT but there was no Big Pharma alternative. "HRT is ham-fisted. It's like trying to perform surgery with a mallet. We don't need to flood our bodies with synthetic hormones."
Hormone replacement therapy tablets Photograph: Alamy
Bio-identicals are made from plant sources – usually wild yams or soya beans, and because they have an identical structure to the hormones our bodies produce, our bodies tolerate them. "Look at progesterone," said Gluck. "Doctors prescribe Provera, which is a progestin, notprogesterone. Provera is a chemical substitute for a naturally occurring hormone, just as Premarin is a chemical substitute for oestrogen. These are drugs, not hormones, and like all drugs they have a side-effects profile."
She got out a pen and paper and drew me the molecular structures of bio-identicals versus synthetics. "Anyone can understand this. You can agree, disagree, argue, but you need the information. If not, so-called choice means nothing."
Criticisms that bio-identicals are unproven or unsafe are ignorant. Big Pharma manufactures its own bio-identicals and sells them under their proprietary brand names such as Testogel, Intrinsa, Estraderm, Vagifem, Utrogest, Oestrogel etc. These brands are made to a uniform prescription using the same tested and approved ingredients that a licensed compounding pharmacy will use to make an individual prescription that is balanced for each person's needs.
"Less is more," said Gluck. "Your own prescription, for instance, is less than half of any standard dose a medical doctor can prescribe for you off the shelf. As for the products you can buy on the internet – it is unwise to self-medicate knowing nothing about the biochemistry of your body or what is actually needed to rebalance it – that is where people rightly criticise BHRT as being unmonitored but that does not mean that the basic ingredients are untested or untried."
Or new. Back in 1950s Britain, Dr Katharina Dalton pioneered the use of natural progesterone to rebalance the female hormone cycle, as a cure for heavy disruptive periods, and to help women through the menopause. She also noticed that progesterone alleviated depression. She didn't have an easy time of it with the mostly male medical profession, who did their best to rubbish her results, but her patients were experiencing symptomatic relief without drugs and without side effects.
Then in the mid 60s, Dr Robert Wilson, an American gynaecologist, published a book with the astonishing title Feminine Forever – declaring that the menopause was an oestrogen deficiency disease, and recommending the drug Premarin to treat it. Premarin became America's fifth largest prescription order.
Many feminists have written about the male view of woman as a disorder in need of treatment. The Pill, Valium and Premarin are swinging 60s drugs. By the early 80s and the rise and rise of HRT, the drug companies' new slogan was Hormones for All Women for the Rest of Their Lives. Today, with the Pill to prevent conception, IVF to make it happen, Provera for heavy periods, antidepressants and HRT for the menopause – plus the ever-popular hysterectomy and the blast of synthetics that follow it, it reads as though the womb to tomb ambitions of Big Pharma have been realised.
Recently, Big Pharma announced as a breakthrough the use of kisspeptin, a naturally occurring hormone, to stimulate the ovaries during IVF treatment. It is much less aggressive and invasive than the synthetics they have been using. So why doesn't Big Pharma encourage BHRT and individually prescribed bio-identicals?
"Money," said Gluck emphatically. "The medicalisation of women's bodies is the biggest land-grab on the planet. Any doctor can refer to me, and on the NHS, but bio-identicals aren't part of the National Institute for Health and Care Excellence guidelines. Sadly doctors are being trained as the robot arm of the drug companies."
If you have ever wondered how oestrogen synthetics are manufactured, pour yourself a stiff drink and Google Premarin. The name is a shortened version of Pregnant Mare's Urine. Critics claim the mares are permanently indoors in stalls where they cannot lie down, with a heavy rubber bag attached to their groin day and night. They are kept thirsty to make their urine richer. When they give birth their foals are taken away at once and the mares are reinseminated as soon as possible to begin another 11-month cycle. When their bodies break down, the mares are shot and knackered into the horsemeat market. If you are an ethical vegetarian on HRT you might as well eat fois gras every day.
So will the new focus on menopause reversal mean that women must be forever fertile, forever slim and forever youthful until we drop dead?
Ask your doctor for the information leaflet about Premarin manufacture: there isn't one. But what if you are not facing menopause but trying to get pregnant? Can bio-identicals help?
"A lot of women with fertility issues come to us. The thyroid is often implicated. The NHS thyroid test is not sufficient, especially for borderline cases. A properly functioning thyroid has an effect on fertility. We should consider treatable causes before advocating IVF. We have noticed that when women contemplating IVF come to us, some find that they fall pregnant naturally after using BHRT. Proper research needs to be done here."
Fertility problems are rising fast among women. The new phenomenon of early ovarian withdrawal (failure, as the medical profession prefers to call it, just in case a woman might mistake her body for a success story) means that some women in their 30s and 40s are experiencing what previous generations typically faced in their 50s. The reasons are complex – environmental as well as endocrinal. The latest medical research is aimed at reversing menopause in those women who are experiencing premature infertility. Again, Gluck would prefer to begin by treating the whole woman and give the body a chance to work with itself in the healing process, before focusing obsessively on what appears to be the dominant symptom.
And what about age-related infertility? If science cracks menopause reversal for younger women, won't we be back where we were with IVF, as older women seek to outwit their bodies, whatever the cost?
Gluck acknowledges that women carry a heavy cultural load that comes with ageing. Men mature, women get old. Men leave their wives for a younger model. Women hate the creasing and wrinkling, the vaginal dryness and loss of libido that seems to be part of the aging process – and the fact that there is only a limited amount of time in which to bear children.
"Hormone treatment is not a miracle cure for misogyny. Society does not value older women, and often, older women do not value themselves. I do not believe that we can be forever young – or even that we should want to be – nor do I believe that bearing children late in life is healthy for women's bodies."
So will the new focus on menopause reversal mean that women must be forever fertile, forever available, forever slim and forever youthful until we drop dead? Cosmetic procedures are rising even faster than the infertility figures. Women are less comfortable in their bodies than ever before. Bio-identical hormone therapy seems safe and sane, but does it also play on the endless anxiety women experience about their bodies?
"Self-esteem and contentment can't be compounded in a cream to use twice daily," said Gluck, "but as a doctor with thousands of hours of clinical experience, working with women across the spectrum of age and health and fertility, I know that BHRT can improve a person's total wellbeing. And wellbeing has mental, as well as physical, benefits."
Gluck would like to see a holistic health model become the norm – where regular blood tests, advice on diet and exercise, and psychotheraputic interventions sit within medical practice.
"Depression is a killer just like heart disease. And we are only just beginning to research the mind-body relationship as a wellness relationship."
My last blood test results showed a steady-state system fluctuating within its optimum range. Gluck is pleased.
"How do you feel?" she asks.
I feel at home in my body again.
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