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Good nutrition and regular physical exercise are thought to improve overall health. Some doctors feel these factors can also affect menopause. Although these areas have not been well studied in women, anecdotal evidence is strongly in favor of eating well and exercising to help lower risks for CVD and osteoporosis.

Nutrition

While everyone agrees that a well-balanced diet is important for good health, there is still much to be learned about what constitutes "well-balanced." We do know that variety in the diet helps ensure a better mix of essential nutrients.

Nutritional requirements vary from person to person and change with age. A healthy premenopausal woman should have about 1,000 mgs of calcium per day. A 1994 Consensus Conference at the National Institutes of Health recommended that women after menopause consume 1,500 mgs per day if they are not using hormonal replacement or 1,000 mgs per day in conjunction with hormonal replacement. Foods high in calcium include milk, yogurt, cheese and other dairy products; oysters, sardines and canned salmon with bones; and dark-green leafy vegetables like spinach and broccoli. In calcium tablets, calcium carbonate is most easily absorbed by the body. If you are lactose intolerant, acidophilus milk is more digestible. Vitamin D is also very important for calcium absorption and bone formation. A 1992 study showed that women with postmenopausal osteoporosis who took vitamin D for 3 years significantly reduced the occurrence of new spinal fractures. However, the issue is still controversial. High doses of vitamin D can cause kidney stones, constipation, or abdominal pain, particularly in women with existing kidney problems. Other nutritional guidelines by the National Research Council include:

• Choose foods low in fat, saturated fat, and cholesterol. Fats contain more calories (9 calories per gram) than either carbohydrates or protein (each have only 4 calories per gram). Fat intake should be less than 30 percent of daily calories.
• Eat fruits, vegetables, and whole grain cereal products, especially those high in vitamin C and carotene. These include oranges, grapefruit, carrots, winter squash, tomatoes, broccoli, cauliflower, and green leafy vegetables. These foods are good sources of vitamins and minerals and the major sources of dietary fiber. Fiber helps maintain bowel mobility and may reduce the risk of colon cancer. Young and older people alike are encouraged to consume 20 to 30 grams of fiber per day.
• Eat very little salt-cured and smoked foods such as sausages, smoked fish and ham, bacon, bologna, and hot dogs. High blood pressure, which may become more serious with heavy salt intake, is more of a risk as you age.
• Avoid food and drinks containing processed sugar. Sugar contains empty calories which may substitute for nutritious food and can add excess body weight.

For people who can't eat an adequate diet, supplements may be necessary. A dietician should tailor these to meet your individual nutritional needs. Using supplements without supervision can be risky because large doses of some vitamins may have serious side effects. Vitamins A and D in large doses can be particularly dangerous.

As you age, your body requires less energy because of a decline in physical activity and a loss of lean body mass. Raising your activity level will increase your need for energy and help you avoid gaining weight. Weight gain often occurs in menopausal women, possibly due in part to declining estrogen. In animal studies, scientists found that estrogen is important in regulating weight gain. Animals with their ovaries surgically removed gained weight, even if they were fed the same diet as the animals with intact ovaries. They also found that progesterone counteracts the effect of estrogen. The higher their progesterone levels, the more the animals ate.

Exercise

Exercise is extremely important throughout a woman's lifetime and particularly as she gets older. Regular exercise benefits the heart and bones, helps regulate weight, and contributes to a sense of overall well-being and improvement in mood. If you are physically inactive you are far more prone to coronary heart disease, obesity, high blood pressure, diabetes, and osteoporosis. Sedentary women may also suffer more from chronic back pain, stiffness, insomnia, and irregularity. They often have poor circulation, weak muscles, shortness of breath, and loss of bone mass. Depression can also be a problem. Women who regularly walk, jog, swim, bike, dance, or perform some other aerobic activity can more easily circumvent these problems and also achieve higher HDL cholesterol levels. Studies show that women performing aerobic activity or muscle-strength training reduced mortality from CVD and cancer.

Just like muscles, bones adhere to the "use it or lose it" rule; they diminish in size and strength with disuse. It has been known for more than 100 years that weight-bearing exercise (walking, running) will help increase bone mass. Exercise stimulates the cells responsible for generating new bone to work overtime. In the past 20 years, studies have shown that bone tissue lost from lack of use can be rebuilt with weight-bearing activity. Studies of athletes show they have greater bone mass compared to nonathletes at the sites related to their sport. In postmenopausal women, moderate exercise preserves bone mass in the spine, helping reduce the risk of fractures.

Exercise is also thought to have a positive effect on mood. During exercise, hormones called endorphins are released in the brain. They are "feel good" hormones involved in the body's positive response to stress. The mood-heightening effect can last for several hours, according to some endocrinologists. Consult your doctor before starting a rigorous exercise program. He or she will help you decide which types of exercises are best for you. An exercise program should start slowly and build up to more strenuous activities. Women who already have osteoporosis of the spine should be careful about exercise that jolts or puts weight on the back, as it could cause a fracture.

To gather more data to help women make a well-informed decision regarding hormone therapy, researchers at the National Institutes of Health (NIH) launched the Postmenopausal Estrogen/Progestin Interventions Trial (PEPI) in 1989. With 127 women enrolled at each of seven medical centers, PEPI will address the short-term safety and efficacy of various methods of HRT. The study will compare women who take estrogen by itself to those who take it with different types of progestin. It will also examine the effects of both cyclical and continuous progestin on cardiovascular risk factors, blood clotting factors, metabolism, uterine changes, bone mass, and general quality of life.

Several new studies are looking at normal body changes as women move from pre- to postmenopause. Up to now, the lack of such data has been one problem in assessing the value of HRT. Without knowing what "normal" is, scientists have difficulty judging the effect of a particular treatment. Another problem with past studies is the "healthy user effect." In many trials preceding PEPI, the HRT users studied had freely chosen to begin treatment, with advice from their doctors. In general, most physicians discourage women with a preexisting illness or long family history of breast cancer from taking HRT. This factor could skew study results to appear that nonusers became ill or died more frequently simply because they failed to take estrogen. Only by randomly assigning study participants to the treatment can this bias be overcome. Until more random trials are completed, the jury is still out on HRT.

Another NIH study is the Women's Health Initiative, a multicenter trial involving 70,000 postmenopausal women ages 50 to 79. The study will assess the long-term benefits and risk of hormone therapy as it relates to cardiovascular disease, osteoporosis, and breast and uterine cancer. It will also help determine the effects of calcium supplementation, dietary changes, and exercise on women in this age group. Some of the specific questions to be addressed by the Women's Health Initiative include:

* How long is estrogen effective for each system of the body (skeletal, cardiovascular, nervous, endocrine)?

* What is the best dose and route of administration of estrogen and progestin to prevent side effects yet maintain efficacy?

* How long is estrogen safe to take?

* Does estrogen act the same way in older women as in younger women?

* Are there effective alternatives to HRT?

Clearly, no one has all the answers about menopause. Medical research is beginning to give us more accurate information, but some myths and negative attitudes persist. Women are challenging old stereotypes, learning about what's happening in their bodies, and taking responsibility for their health. The important thing to remember as you go through menopause is to be good to yourself. Take time to pursue your hobbies, be they gardening, painting or socializing with friends. Have a positive attitude toward life. Sharing concerns with friends, a spouse, relatives or a support group can help. Don't fight your body--allow the changes that are happening to become a part of you, a part that is natural and that you accept.

GLOSSARY

angina--a disease marked by brief attacks of chest pain

biopsy--removal and examination of living cells from the body

cardiovascular disease (CVD)--disorders of the heart and circulatory system

ERT--estrogen replacement therapy; the use of estrogen alone for the treatment of menopausal symptoms and the prevention of some long-term effects of menopause.

endometrium--the tissues lining the uterus

estrogen--one of the female sex hormones produced primarily bythe ovaries before menopause and by fat and other tissues after menopause.

HDL--high density lipoprotein cholesterol, the "good" cholesterol thought to have a cleansing effect in the bloodstream

HRT--hormone replacement therapy; the use of estrogen combined with progestin for the treatment of menopausal symptoms and the prevention of some long-term effects of menopause.

hysterectomy--surgical removal of the uterus

IUD--intrauterine birth control device, which prevents implantation of an embryo into the uterus should fertilization occur

LDL--low density lipoprotein cholesterol, the "bad"cholesterol believed to be linked to fat accumulation in the arteries

menopause--the point when menstruation stops permanently

oral contraceptives--pills which usually consist of synthetic estrogen and progesterone that are taken for three weeks after the last day of a menstrual period. They inhibit ovulation, thereby preventing pregnancy.

osteoporosis--a disease in which bones become thin, weak and are easily fractured

perimenopause--the time around menopause, usually beginning 3 to 5 years before the final period.

progesterone--one of the female sex hormones produced by the ovaries

progestin--the synthetic form of progesterone

tubal ligation--a surgical procedure in which the uterine tubes are cut and tied to prevent pregnancy

urinary incontinence--loss of bladder control

National Institute on Aging (NIA) 9000 Rockville Pike Bethesda, MD 20892 800-222-2225 North American Menopause Society (NAMS) University Hospitals Department of OB/GYN 2074 Abington Road Cleveland, OH 44106 fax: 216-844-3348 (written requests) National Women's Health Network 1325 G Street, NW Washington, DC 20005 202-347-1140 American College of Obstetrics and Gynecologists (ACOG) 409 12th Street, SW Washington, DC 20024 202-638-5577 Alliance for Aging Research 2021 K Street, NW, Suite 305 Washington, DC 20006 202-293-2856 Older Women's League (OWL) 666 11th Street, NW Suite 700 Washington, DC 20001 202-783-6686 National Women's Health Resource Center (NWHRC) 2440 M Street, NW Suite 201 Washington, DC 20037 202-293-6045

Wider Opportunities for Women (WOW) National Commission on Working Women 1325 G Street, NW Lower Level Washington, DC 20005 202-638-3143 American Dietetic Association (ADA) 216 West Jackson Boulevard Suite 800 Chicago, IL 60606 312-899-0040 American Heart Association (AHA) 7320 Greenville Avenue Dallas, TX 75231 214-373-6300 National Heart, Lung, and Blood Institute (NHLBI) 9000 Rockville Pike Bethesda, MD 20892 301-496-4236 National Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse Box AMS 9000 Rockville Pike Bethesda, MD 20892 301-495-4484 National Osteoporosis Foundation (NOF) 2100 M Street, NW Suite 602 Washington, DC 20037 202-223-2226

Sex Information and Education Council of the U.S. (SIECUS) 130 West 42nd Street Suite 2500 New York, NY 10036 212-819-9770 DEPRESSION Awareness, Recognition, and Treatment Program National Institute of Mental Health D/ART Public Inquiries 5600 Fishers Lane Room 15C-05 Rockville, MD 20857 301-443-4513 National Mental Health Association (NMHA) Information Center 1021 Prince Street Alexandria, VA 22314-2971 703-684-7722/800-969-6642 National Cancer Institute Cancer Information Service 9000 Rockville Pike Bethesda, MD 20892 800-4-CANCER (800-422-6237) American Cancer Society National Headquarters 1599 Clifton Road, NE Atlanta, GA 30329 800-ACS-2345 (800-227-2345)

RESOURCES

The Change: Women, Aging and the Menopause, Germaine Greer. New York: Knopf/Random House, 1992.

Choice Years, Judith Paige and Pamela Gordon. New York: Villard Books, 1991.

Managing Your Menopause, Wulf H. Utian, M.D., Ph.D., and Ruth S. Jacobowitz. New York: Prentice Hall/Simon & Schuster, 1990.

The Menopause, Hormone Therapy, and Women's Health--Background Paper. Congress of the United States, Office of Technology Assessment, May 1992.

Menopause and Midlife Health, Morris Notelovitz and Diana Tonnesen. New York: St. Martin's Press, 1994.

Menopause News, ed. Judy Askew, 2074 Union St., San Francisco, CA 94123.

The Menopause Self-Help Book, Susan M. Lark, M.D. Berkeley: Celestial Arts, 1990.

The New Ourselves Growing Older, Paula Brown Doress and Diane Laskin Siegal. New York: Simon and Schuster, 1994 (in cooperation with the Boston Women's Health Book Collective).

The Silent Passage; Menopause, Gail Sheehy. New York: Random House, 1991.

Who, What, Where? Resources for Women's Health & Aging, National Institute on Aging, March 1992.