What’s your advice on the menopause? I have taken HRT for six years now but have decided to stop. I would be grateful for any recommendations. Jane Butler, by email DR DAN RUTHERFORD WRITES: Hormone replacement therapy can significantly reduce the physical symptoms associated with the drop in oestrogen levels that go with the menopause. Hot flushes and night sweats are experienced by about 80 per cent of women at this stage of life. Withdrawing HRT after several years does run the risk of symptoms coming back, but it can help to phase the HRT out rather than stop it suddenly. There is also the option of local treatment such as oestrogen cream for vaginal dryness, rather than full HRT. The pendulum still swings back and forth on the longer-term benefits and risks of HRT. HRT provides extra bone-strength protection for women who go through the menopause at an unusually early age (below 45) but probably does not add much to bone protection for women whose menopause occurs around the average age of 51. Breast cancer risk is higher with HRT, but the effect is small and fades back to normal five years after stopping HRT. Stroke risk is slightly higher for those on HRT, but this is significant only in older women (over 60), for whom HRT is not now recommended. We used to think that HRT protected against heart disease – now it doesn’t seem so. HRT is probably best seen as a potential help through the menopause, taken for a limited period of up to several years. In that time, it is more likely to help than to cause harm – and it’s usually obvious within a few weeks or months if HRT is of real benefit. It’s a complicated topic and one that needs to be tailored to the individual. See www.patient.co.uk/doctor/Hormone-Replacement-Therapy.htm and the NHS website at www.nhs.uk/conditions/hormone-replacement-therapy. SARA STANNER WRITES: With or without HRT, the menopause is a high-risk time for weight gain; the metabolism slows as you age and there is a hormonally-driven shift to pile on pounds around the tummy. While oestrogen deficiency seems to play a role, it is important to exercise and cut calories too. Calcium is lost from bones at a faster rate after the menopause; this can trigger early osteoporosis in those with low bone mass. So adequate calcium (at least 700 mg/day) and vitamin D (to absorb calcium) is needed to protect bones. Vitamin D is formed in the skin by sunlight, but dietary sources include fortified spreads, oil-rich fish and meat. After the menopause, the risk of heart disease increases due to ageing and falling oestrogen levels. Reduce the risk by staying a healthy weight and eating healthily. A low intake of magnesium (found in milk, meat, cereals, potatoes, dark-green vegetables and seeds) can also lead to anxiety and irritability. Many women also take phytoestrogen supplements or eat phytoestrogen-rich foods such as soybean products to help with symptoms. Phytoestrogens (e.g. isoflavones and lignans) occur naturally in soyabeans, chickpeas and other legumes and are similar to the hormone oestrogen – only weaker. Women in Japan and China, who eat diets high in phytoestrogens, have fewer menopausal symptoms and a lower incidence of heart disease and osteoporosis than women in the west. The amount suggested is 30-50mg/day. You can achieve this with a diet rich in soya beans and soya products but it means eating soya foods at most meals so supplements are popular. Other supplements and herbal remedies (e.g. agnus castus and black cohosh) are marketed for symptom relief. There are reports of supplements of vitamin C with bioflavonoids reducing hot flushes and vitamin E supplements – about 400 IU –have been suggested to reduce hot flushes and help with vaginal dryness. TONY GALLAGHER WRITES: I am not certain if you have stopped your HRT yet. Reducing the dose of HRT gradually over several months seems the most appropriate action to help cope with the effects of falling oestrogen levels. The rate will be determined by your symptoms and the form of HRT you are on. It is something you should consider carefully. Exercise is beneficial. It can help relieve and prevent symptoms such as hot flushes, night sweats, depression, insomnia and osteoporosis. It will improve circulation, energy levels, and your ability to handle stress. It is also accepted that weight-bearing exercises help prevent the onset of osteoporosis. You should have a better chance to control your weight and hopefully will sleep better. A Swedish study showed that regular exercise decreases the frequency and severity of hot flushes. Similar results, including mood elevation in exercising, have been reported in other studies. Importantly, the benefits of exercise were experienced in women both on and off HRT. Try taking regular exercise in the fresh air, practising yoga, doing breathing exercises (twice a day for five minutes) and massaging the neck and shoulders twice a week (this can help improve blood flow to the brain, improving hormonal balance and sleep). My new sister-in-law, who is coming to stay, is very allergic to strawberries. Is there anything else risky in the same category? Sara Clark, by email SARA STANNER WRITES: Strawberries are part of the Rosaceae botanical family and cross reactivity may occur with other members of this group (apricots, almonds, plums, apples, peaches and pears). The most common adverse reaction to strawberries is oral allergy syndrome; it usually occurs in those who suffer from hay fever. Symptoms include itching, irritation and mild swelling of the lips, tongue, palate and throat. These usually subside in minutes but some people experience symptoms like hay fever, dermatitis or hives and, in severe cases, breathing problems and anaphylactic shock. Those with oral allergy syndrome might react to other fruits and vegetables. Some research suggests that the allergen may be tied to a protein involved in ripening (Fragaria allergen 1). Similar proteins are found in birch and apple. As well as avoiding strawberries – including products that use them for colour or sweetness – ask if she is aware of reactions to other foods. I suffer from bouts of sciatica. Is there anything that might prevent it? P Price, by email ATONY GALLAGHER WRITES: Sciatica is a term given to any pain caused by irritation or compression of the sciatic nerve, the longest nerve in the body. It runs from the lower back through the back of the leg, and to other parts of the leg and feet. Exercise, painkillers and hot or cold packs can help. Specific exercises will depend on the underlying cause. Generally, active back exercises and gentle stretching help decrease pain and prevent flare-ups. I suggest Pilates, yoga or Tai Chi, under instruction, which will stretch the soft tissues. It may take months to mobilise the spine and soft tissues, but will be worth it, since you will have attained increased mobility and reduced the chance of symptoms recurring. Low-impact cardiovascular exercise will increase the flow of blood and help alleviate pain. Try walking, for two or three miles, a couple of times per week or performing exercises in the water – like hip abduction lifts, bicep curls and arm circles. For a good overview of exercises, see http://tinyurl.com/4xra3k2. SECOND OPINION Dr James LeFanu The stability of body weight is a most extraordinary phenomenon where, despite fluctuations in the amount of food consumed and exercise taken, it can remain virtually unchanged over decades. The reason why this should be so remains, surprisingly, a mystery. Or as Professor of Nutrition John Durnin, of Glasgow University, expressed it in the journal Nature: “The energy requirements of man and the balance of intake and expenditure are not known.” It must be presumed there is some “thermostat” in the brain which subtly alters the metabolic rate ensuring that any excess calories are “burnt up”, converted into heat and dissipated out through the skin. The corollary necessarily holds that any sudden, or unintentional, weight loss of half a stone or more needs to be accounted for, being perceived as a sign of something sinister warranting numerous tests to discover what is amiss. And indeed this proves to be the case for about one patient in four, but as Dr Jenna McMinn of Glasgow’s Southern General Hospital points out in a review in the British Medical Journal, for the majority it is possible to identify some remediable explanation. This could be, for example, an overactive thyroid, inflammation of the lining of the stomach (gastritis) or problems with the absorption of food. It is, she suggests, important to pay attention to the factors which may lead to a loss of enthusiasm for eating, and here commonly prescribed drugs may be implicated, resulting in loss of appetite, altered taste or smell and difficulty in swallowing. The possibility of a depressive illness also needs to be considered as this can result in a loss of motivation for buying and preparing food. But, even when all these have been considered, it is not possible to pinpoint the cause in around a quarter of patients. Here the best policy is to do nothing for at least three months, during which, not infrequently, the weight returns to normal.