Menopause and the Mind: The Complete Guide to Coping with the Cognitive Effects of Perimenopause and Menopause Including: +Memory Loss + Foggy Thinking + Verbal Slips

Overview

Are you between the ages of 35 and 60 and having trouble remembering your best friend's phone number? If this sounds familiar to you, take heart: Claire Warga's help and advice are on the way.

In this groundbreaking book, Dr. Warga, a neuropsychologist, identifies the "mind misconnect" syndrome that causes unsettling events during perimenopause and menopause, noting that they are not signs of imminent madness but a natural part of aging.

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Overview

Are you between the ages of 35 and 60 and having trouble remembering your best friend's phone number? If this sounds familiar to you, take heart: Claire Warga's help and advice are on the way.

In this groundbreaking book, Dr. Warga, a neuropsychologist, identifies the "mind misconnect" syndrome that causes unsettling events during perimenopause and menopause, noting that they are not signs of imminent madness but a natural part of aging.

Drawing upon cutting-edge brain research and many never-before-described cases, Warga provides the first scientific explanation for why the symptoms occur and reveals how they can be reversed or alleviated. She provides a self-assessment test to help readers determine whether they are experiencing "mind misconnect" syndrome and offers important information and advice on estrogen replacement therapy as well as non-hormonal treatments that mimic estrogen's mind-boosting effects. Her self-screening test, symptom chart, and treatment measurement technique are important tools every woman can use to assess her condition and progress over time, with or without her ob/gyn.

"...provides the first scientific explanation for why the symptoms of 'mind misconnect' syndrome occur, & reveals how they can be reversed or alleviated...a self-assessment test helps determine if you are experiencing the symdrome."

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Editorial Reviews

From the Publisher
Kirkus Reviews (starred review) A significant heads-up for women over 30, along with reassurance and a detailed action plan....This book offers validation and hope.

Stanley J. Birge, M.D. Associate Professor of Medicine, Division of Geriatrics and Gerontology, Washington University School of Medicine Insightful....Brings [the] emotional and cognitive changes associated with estrogen loss out of the closet, empowering women to seek readily available strategies to modify these changes.

Kate Murphy Zeman
Many well-informed women going through menopause today greet hot flashes without surprise, step up calcium intake to guard against weakening bones, and consider hormone therapy to ease symptoms and protect their hearts. But what most of them never expected are an assortment of behavioral and cognitive effects ranging from memory loss to difficulty concentrating to verbal lapses. Neuropsychologist Claire Warga writes in her new book, Menopause and the Mind, that she first began to notice these behavioral symptoms in her patients; when she started to see them among a wide variety of women she knew socially, she got curious enough to do some research at a medical library on menopause and the mind. She turned up nearly nothing, but when she began to look for information on estrogen's effects on the brain, she hit paydirt -- a wide variety of recent studies that had begun to explore changes in memory and attention caused by estrogen loss. As she began to track down researchers and talk to organizations like the American College of Obstetrics and Gynecology and the North American Menopause Society, she was dismayed to find that while the new research was becoming widely known, the connection with behavioral symptoms during menopause was largely still unrecognized, and that the organizations were waiting for consensus to form before making any recommendations to their members.

Meanwhile, the critical information wasn't making its way to the women suffering the cognitive effects of declining estrogen levels, women who in many cases, Warga reports, had such noticeable lapses that they worried they might have early-onset Alzheimer's or a brain tumor. Warga began to get the message out with a 1997 New York magazine cover story; in her groundbreaking book, she expands on that story to describe in detail the cognitive symptoms that can be associated with perimenopause and menopause, to cover the scientific findings on estrogen and the brain, and to explore treatment options for women experiencing these behavioral effects. An extensive section of the book presents screening techniques and self-tests so readers can determine whether it's likely they are suffering from the syndrome Warga has named WHMS -- Warga's Hormonal Misconnection Syndrome. She emphasizes that though some of these effects are strange, they are normal in the same way that hot flashes are normal, and they need not go unrelieved. Treatment options she discusses include various forms of hormone replacement therapy, dietary changes, and memory enhancement exercises. Menopause and the Mind is at once a wake-up call to a medical establishment that has been woefully slow in responding to what is clearly a serious biological effect of menopause and a survival guide for the women experiencing it; it's an empowering addition to the library of any woman over 30 who wants to take control of her heath and mental well-being for years to come.

--Kate Murphy Zeman

Library Journal
Mood swings and other more severe psychological disorders during perimenopause have already been documented and attributed to estrogen deprivation (Marcia Lawrence's Menopause and Madness, LJ 4/15/98). Here, neuropsychologist Warga focuses on the cognitive deficits that result from estrogen loss, detailing such changes as losing one's train of thought, the "what did I come here for" sensation, having the wrong words pop out, reversing words while speaking, briefly forgetting how to do things, and experiencing erratic fine motor coordination. She postulates the existence of Warga's Hormonal Misconnection Syndrome to describe these symptoms and suggests remedies--hormone replacement therapy as well as nonhormonal approaches involving glucose, antioxidants, anti-inflammatory agents, aerobic exercise, and behavioral training. Although one might chide the author for naming her theory after herself, her book is reassuring and worthwhile. Recommended for consumer health and health sciences collections.--Linda M.G. Katz, Allegheny Univ. of the Health Sciences Lib., Philadelphia
Kirkus Reviews
A significant heads-up for women over 30, along with reassurance and a detailed action plan: yes, there are measurable cognitive changes that occur in midlefe as a result of changing hormone levels, and yes, there are pharmaceutical, dietary, and other measures that can be taken to alleviate or even reverse the changes. Warga, a neuropsychologist, aims this book at educating women and their physicians, as well as pointing health-care researchers in the right direction for more thorough investigation. The root cause of the syndrome (which Warga dubs Warga's Hormonal Misconception Syndrome, WHMS) is dropping estrogen levels. It includes a range of intermittent disturbances or lapses in memory, speech, attention, behavior, or thinking. Part two of this volume looks at the cause: Warga explains clearly the current understanding of the neurochemical interplay between estrogen and the brain. Part three sets out thorough screening tools for self-diagnosis. In part four, Warga gives extensive, thorough advice on alleviating the symptoms and correcting the cause: hormone replacement therapy, glucose, phytoestrogens, antioxidants, antiinflammatories, along with mental exercises and drills, and learning new ways of focusing on tasks. Choosing the right health-care provider is paramount: choose someone who is knowledgeable about the existing evidence, understanding of the problem, and alert to new treatment options. This book offers validation and hope for those affected by the syndrome. A welcome, emminently worthwhile guide.
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Product Details

  • ISBN-13: 9780684854793
  • Publisher: Touchstone
  • Publication date: 4/20/2000
  • Edition number: 1
  • Pages: 416
  • Sales rank: 967,432
  • Product dimensions: 0.93 (w) x 5.50 (h) x 8.50 (d)

Meet the Author

Claire Warga, Ph.D., is a New York State — licensed health psychologist and a researcher in behavioral neuroendocrinology. She trains health and mental health professionals, and women, in midlife research. She lives in Brooklyn, New York.

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Read an Excerpt

Chapter 1

What Are These Strange Symptoms I'm Experiencing in the Middle of My Life?

Mrs. Malaprop: a character in Richard Brinsley Sheridan's 1775 play The Rivals. "A...woman of almost fifty [emphasis added] who...is famous for misusing...long words that sound similar to the correct words."

— Larousse Dictionary of Literary Characters

Malapropisms: the type of verbal errors made by the character Mrs. Malaprop.

There are some topics almost no one talks about till you do first. The stampede for the male impotence drug Viagra unveiled one such topic. This book is about another one: the previously unrecognized cognitive symptoms that are caused by the effects of perimenopause and menopause on the mind.

Sometimes it begins out of the blue with occasional slips of the tongue, meaning to say one word and unexpectedly hearing another pop out. Or when you realize that you, once a champion speller, aren't so sure anymore how to spell "potato" or "forty." Sometimes it begins with uncharacteristically forgetting important appointments or drawing unexpected momentary blanks — total blanks — when it comes to remembering your only child's or best friend's name, or how to turn on the computer you've been using for years. Sometimes with feeling mentally "hazy" "foggy," or "spacey" and not being able to clear things up though you need to be "sharp" at that moment. "What's happening to me" you wonder. "Could this be early, early, early Alzheimer's disease or a brain tumor?"

But it is usually not early Alzheimer's disease or a brain tumor. It is something else, a particular set of symptoms — a syndrome — that can occur in women beginning in their mid to late thirties or in their forties or fifties that more than likely can be halted and even largely reversed according to the best evidence available today. It is a syndrome associated with estrogen loss that is mainly experienced from within, and that until now, amazingly, no one has recognized as common among women or has linked to the wealth of post-1990s research evidence revealing the many important newly discovered roles estrogen plays in the remembering, naming, and attending parts of the brain. This is research that helps explain why the symptoms occur and why they can often be reversed.

"I'm losing it," women say. "I'm going out of my mind," "I'm falling apart at the seams." "I'm flipping out." "I'm cracking up." "I'm having a nervous breakdown," "I'm just not myself." "I don't know what's wrong with me." "I do the strangest things." "I think I'm getting early Alzheimer's."

These are not the hysterical rantings of women with vague psychosomatic complaints but rather the blanket descriptions frequently used by perimenopausal (women experiencing or undergoing changes associated with the shifting hormonal functioning of the ovaries that precedes the last period. Symptoms can begin four to fifteen years before menopause.) and menopausal (women who have had their last period twelve months ago) women to describe the dislocating experience of confronting an assortment of unpredictable mind, speech, and behavioral "flash" symptoms. These are surprising symptoms no one has ever prepared them for. Physicians hearing these dramatic statements over the years have simply had no basis in training for understanding what they were hearing and as a result have been able to offer no, or minimally constructive, help to women who dared to mention them.

dTHE SYMPTOMS OF PERIMENOPAUSE AND MENOPAUSE CAN BE VERY STRANGE BUT NORMAL

Before describing the specific symptoms I am referring to it makes sense first to agree about certain realities of a perimenopausal/menopausal symptom you already do know something about. Hot flashes. Consider this: If we on earth had never heard of hot flashes as a "normal" midlife symptom associated with ovarian and hormonal changes, and a returning astronaut-discoverer of a twin planet to ours reported drenching, unpredictable, overheating episodes as normal in otherwise healthy midlife-and-older women, we would likely say in quick dismissal, "Go away! You must have gotten something wrong there. The women were probably fooling with you in some way. You couldn't be right. That symptom is just too weird to be true of normal people."

And yet the reality is hot flashes are definitely normal but strange symptoms for healthy women to have. The fact that they are so common makes them seem normal to us. What makes them believable apart from their strangeness is the fact that they are also sometimes observable to others, leaving "tracks" of the internal experience visible to those who don't have them and who might otherwise be inclined to dismiss them as "too crazy" to credit as real.

PERIMENOPAUSAL AND MENOPAUSAL SYMPTOMS CAN OFTEN BE CURED EVEN WHEN NOT FULLY UNDERSTOOD

It's also useful to point out that though science does not yet have a clear consensus on what specific sequence of events produces hot flashes in women — beyond the bigger picture of changing ovary and estrogen function during perimenopause and menopause — nevertheless medicine has developed at least one quite effective empirical treatment for hot flashes based on trial-and-error experience, even in the absence of a clear scientific understanding of their basis. Namely, estrogen replacement. (Other remedies that apparently work for some proportion of women have been considerably less tested and proven.) Successful treatment therefore of a symptom associated with ovarian/hormonal changes can precede biological understanding of the full complexity of the symptom.

The broad array of symptoms I have named the WHM Syndrome — for Warga's Hormonal Misconnection Syndrome — may at first, I suspect, appear as strange and bizarre as hot flashes do to those unfamiliar with them. But in the years to come, I believe, it will seem one of the great mysteries of our time that such a common, unusual, but apparently typical set of biologically based symptoms could have been overlooked for so long. Cultural and medical historians of the future, I predict, will long ponder the great divide of female patient/doctor non-communication that is implicit in physicians not having "heard" and detected this set of symptoms and its cause in women for so many years.

What WHMS Is Like

The list of possible symptoms I am specifically referring to is presented in Table 1 to help you better understand the cases you will shortly be reading about. (A fuller description of possible WHMS symptoms with examples of how they actually occur in women's lives follows in chapter 7.) In Table 1, however, I list only the mind/speech/attention/ behavioral symptoms to which I have given the name "WHM Syndrome," or "WHMS." This table does not include any of the mood or physical symptoms that are also frequently but not inevitably associated with menopause and the years preceding menopause. (These are more fully described in Appendix I.)

TABLE 1

The WHM Syndrome: Warga's Hormonal Misconnection Syndrome

As you examine the following chart keep in mind that the symptoms below typically occur as brief come-and-go episodes within the context of a functional ongoing nondisabled life, not unlike the manner of hot flashes. Women who experience some of the symptoms need not experience all of the symptoms or even many of the symptoms. Some symptoms may appear similar but are experienced by women as different from each other and are thus listed as distinct, pending additional research. Implied in each symptom is the sense that it occurs with a greater frequency than it did in the past. The symptoms most typically do not occur continuously but in erratic on-and-off intermittent episodes, in the pattern of occurrence of "hot flashes," so each symptom should be read preceded by the phrase "Flash episodes of." The headings over the symptoms are provisional pending further research, i.e., whether a specific symptom belongs under a speech, memory, or attention category may ultimately change as more is discovered about the symptom's biological basis.

Symptoms of Warga's Hormonal Misconnection Syndrome

THINKING CHANGES

* Losing your train of thought more often than in the past

* Forgetting what you came into a room to get more than in the past

* Not being able to concentrate as well upon demand

* Feeling foggy, hazy, and cotton-headed and not being able to clear it up at will

* Experiencing a thought blockade: an inability to pull ideas out at will

* Fluctuating agility in prioritizing as well as in the past

SPEECH CHANGES

* Naming difficulties for long-known names: children, best friends, things, places

* Finding yourself at a loss for words in how to express something while speaking

* Experiencing "It's on the tip of my tongue but I can't get it out" sensation

* Making malapropisms: saying wrong words that are related some how to the intended one

* Reversing whole words while speaking

* Reversing the first letters of words while speaking

* Experiencing "echo" words as unintentional intrusions into present speech

* Relying on "filler" words more often: "whatchamacallit," "that thing," "you know what I mean"

* Organizing sentences and ideas less efficiently while speaking

CHANGES IN THE "BEAM" OF ATTENTION

* Blinking social attention when interested and interacting: listening but not always attending

* Blanking-out amnesia for what you just did

* Experiencing increased distractability

MEMORY CHANGES: SHORT- AND LONG-TERM

* Forgetting what you just did, or past occurrences, with no threads of association to getting back to what's missing: missing links

* Changing certainty in how words should be spelled in once good or great spellers

* Fluctuating agility in calculating and in "counting with a quick scanning look"

* Experiencing changes in the speed and accuracy of memory retrieval

* Forgetting the content of a movie right after seeing it but remembering your emotional reaction to it

BEHAVIORAL CHANGES

* Making behavioral "malapropisms": unintended slips in behavior that are related to the intended behavior somehow, such as putting shampoo in the refrigerator

* Forgetting briefly how to do things long known, such as where to turn on the computer

* Feeling that automatic skills such as driving for a few moments are not "automatic" in the same way as usual

* Dropping things more often that require fine finger/hand coordination

* Absentmindedly, leaving out or reversing letters in words while writing

* Forgetting how to write a word in the middle of writing and having to leave blanks

* Experiencing "translating" hesitations in converting what's heard into writing

* Not handling the same amount of stress in the same way

SPATIAL SKILLS CHANGES

* Changing skill in remembering and/or recognizing faces (not well-known faces)

* "Looking at but not seeing" what you are looking for when it's right there ultimately, more than in the past

* Changing reading skill in visually "seeing" and comprehending reading material

* Spending less time reading, without difficulties above (for formerly heavy-duty readers)

* Forgetting briefly how to get to long-known landmarks in your life

* Experiencing familiar locales in one's experience as momentarily unfamiliar

ALTERED SENSE OF TIME

* Forgetting appointments more or not anticipating events of personal importance with the same accuracy as in the past

* Forgetting important events in your personal history timeline, i.e., which breast you had biopsied

* "Living more in the moment" out of necessity: a "spliced-film-frames" sense of personal time

WHY IT'S CALLED THE WHM SYNDROME

I have named this set of symptoms the WHM Syndrome, or WHMS, because women who experience the symptoms often feel subjectively as if they are observing their own "bad show," watching their mind behaving whimsically, unexpectedly taking off on a whim with seeming intentions of its own while violating their intent.

In my mind WHM originally stood for the Women's Hormonal Misconnection Syndrome. I felt the acronym in good measure characterized the subjective experience of women who had the symptoms without stigmatizing them. And the words behind the letters described what I believe is going on at the neurophysiological level — namely, cognitive/behavioral/speech episodes that are mis-hits. Episodes that are off the mark misconnections, in which the mind's intentions are not producing the right physiological connections that they used to in the preexisting circuitry and/or chemical flow patterns of the brain. The reason for the misconnections? A body/brain retooling or "retuning" brought on by the effects of declining ovarian function and declining estrogen hormone supplies on a thinking, remembering, attention-creating brain that science has recently learned (see chapter 4) depends heavily on estrogen as a brain "transmission" fluid of sorts, as a fortifying performance-enhancing steroid or multivitamin. (Estrogen is after all a steroid hormone even though it isn't the kind typically used by athletes. I'll explain this more later in chapter 4.)

However, as I continued interviewing women and experts and reviewing the research literature in this area over the span of several years, I came to the conclusion that calling this the Women's Hormonal Misconnection Syndrome would not be prudent. (You'll have to read chapter 14 to find out exactly why.) But for the moment suffice it to say that I learned that science had very recently discovered that male thinking/remembering brains and sex organs also depend on estrogen supplies for their normal function. So for reasons of faltering estrogen hormonal levels in their brains I began to suspect that at least some men too may have similar WHM symptoms at possibly similar ages. What to do?

To preserve the acronym WHM and prevent the syndrome from being called the rather farcical HM(mmm) Syndrome, I have renamed the set of symptoms Warga's Hormonal Misconnection Syndrome. It turns out that naming new medical syndromes and hormonal/behavioral phenomena after their discoverer has a long history, respectively, in both medicine and behavioral neuroendocrinology (the hormones and behavior branch of science), according to the eminent sociobiologist Edward O. Wilson. Describing a series of known behavior-and-hormones effects in the animal kingdom — i.e., the Bruce Effect, the Lee-Boot Effect, the Ropartz Effect, and the Whitten Effect — Wilson in his landmark 1975 book Sociobiology, writes: "In the manner of the medical sciences, the different kinds of physiological change are often called after their discoverers."

Why have I called this set of symptoms a syndrome? Because the set of symptoms occur frequently in association with each other, as a constellation, or sets of subconstellations. Certainly not all women who have some of the symptoms have all of the symptoms, but sufficient cumulative experience interviewing women has persuaded me that the symptoms represent a possible set that are part of the same causative agent.

WHMS SYMPTOMS HAVE TYPICALLY BEEN IGNORED OR WALLPAPERED OVER

Till now in the relatively few instances when popular writers have referred to the above symptoms they have usually used seemingly mild, and nonspecific terms such as "concentration problems," or "forgetfulness," or "memory problems" to refer to women's experiences during these years, without an appreciation of the range of possible "glitches" in speech, behavior, and cognition that women in actuality have been experiencing. Broad-spectrum terms such as "forgetfulness" or "concentration problems," in effect, "wallpapered" or plastered over the variety and the bizarreness of the symptoms women have encountered. The casual, familiar terms masked or obscured the specific reasons why otherwise seemingly normal and healthy women might be inclined to say such phrases as "I think I'm losing it" or "I think I'm flipping out" or "I think I'm cracking up."

If you had occasion to go into major bookstores at the time I am writing this to look in the indexes of the many books now on the shelves currently addressing menopause or perimenopause for such terms as "memory" or "concentration" or "forgetfulness," you would find that in the vast majority there is either no mention of even these broad-spectrum terms or at most a one- or two-line reference to their possibility at this time of life but without much in the way of elaboration. There is virtually no reference in most of these books to the unusual behavioral symptoms listed in Table 1.

HOW DO WHMS SYMPTOMS PLAY OUT IN WOMEN'S LIVES

But how do these symptoms actually play out in the lives of real women? Let's look at three very different women:

Case 1: Katherine Kennedy

Katherine Kennedy (alias) is a thirty-eight-year-old professor of English at an Eastern university who also hosts a weekly talk-radio show. She is married to a scholar, has no children yet, but hopes to have them in the future.

Reproductive state: still gets her period regularly appears to be perimenopausal, though she does not yet realize it.

When I was younger I had the most retentive memory for everything, especially names and faces. Friends in college would say, "Your mind is like a Rolodex." When I entered my thirties I started having these strange symptoms. I would meet people and the next day felt as though I had never seen them before. They'd know me but I had no due as to who they were. Their faces were just not registering. It so happens that I had begun to menstruate copiously around that time, more than before but I did nothing about it. Not recognizing faces still happens. I find that slightly scary because my grandmother was demented; and I sometimes wonder if it's hitting me very early.

What drives me mad is that I now forget the precise names of things, objects, and will end up saying "that thing" instead of "diploma" for example. It's the same with verbs. I will use the word "doing" instead of the verb I actually want to use. I also have the sense that sometimes I'm grasping for a word and I can't get to it. It feels like mental clutter, like I'm shuffling around inside not finding what I want. I find it hard to retrieve things. I'll have a sense of what I want — it's not even the sense of being on the tip of my tongue but rather I can't get it to my tongue. I'll want to say "chair" and will think "something about sitting" but can't fill in what I want. It's like mental miasma. This happens not all the time but intermittently enough so that it concerns me.

I find it [these symptoms] enormously frustrating. One of the ways it affects me is when I'm having a disagreement with my husband. I'll know there's a point I want to make but I can't make my point. Either that or I lose it midstream.

The difficulty in retrieving, to some degree, also overlaps with what I call fog or haziness. My mind sometimes feels foggy, hazy, or cloudy. If it's fog I'm feeling it's more confused, more grasping than when I'm trying to retrieve something. With fog I don't know what I'm looking for — that's the worst — being lost in the fog. When this happens I think I'll end up like my grandmother, not knowing the names of my family and having lost decades. Or like my friend who got ECT [electroconvulsive therapy] and lost decades of her life, big chunks of her brain. At times like this I feel like I'm losing it. And I'll think to myself "I didn't even drink or take drugs and I'm losing it."

In the classroom and when I'm on radio I want to be sharp and alert, and it hasn't happened terribly much, these blunders, when I'm working. In fact when I'm in front of a class or microphone I'm somehow sharper. I have to be really alert and thinking and focused. And when I'm working I'm better than in my private life.

I find now that often when I walk into a room and want to get something, I'm apt not to recall what I went to find. I think it's a little early for this to be happening to me. My mom and grandmother do this. I never did this as much as now.

In my late twenties if I was writing fast I noticed that I started to reverse letters on words. I also used to be a great speller. Now if I see something that's wrong I won't realize what the correct thing should be. Strangely though, I started doing crossword puzzles only recently as a way to reassure myself of my verbal skills, and I can finish The New York Times crossword puzzle pretty easily writing in ink. But at the same time I just feet really stupid. I used to be and probably still am pretty smart. I always did very well in school. Verbal things were very easy for me. Now I'm still strong verbally but I hate any slippage. It might be analogous to being really gorgeous when you're young and now not feeling as radiant.

I don't think others have noticed the verbal changes because I'm still better than most at noticing names. I'm always the first person who knows the name of a writer or actor. At the same time though I will mispronounce words and can't get back to recalling the correct word. Recently, for example, I was trying to say the plural of roof and couldn't recall if it was "roofs" or "rooves." Both sounded wrong. It's this confusion over basics that I find scary. In the past once I learned something I would have remembered it always. I seem to need a lot more reinforcement than I used to, to learn new commands on the computer.

In the last couple of months I've also begun to lose things and I never ever did that before. My wallet, for example. I lost it and I couldn't think at all where I might have lost it. I had absolutely no associations the way I normally would as to where it might have happened. Fortunately a Good Samaritan returned it, I have a special telephone message pad that's been by the phone forever that's got important numbers on it. I just couldn't remember what happened to it in my home office. It's the lack of associative threads that seems so strange.

I'm the treasurer in my family who does all the practical things. My husband is incredibly brilliant but doesn't really live on this planet. He always loses things and people return them. Recently, I thought I had cash in the bank and when I looked I had appreciably less than I recalled. I couldn't think at all where I spent it. Nothing came to mind in the way of any associations. It's as though I had no links to the past when this happens.

I think I tend to compensate for all of this fairly well. I keep lists and write things down and use the mnemonic devices from childhood that I was always great at. But at the same time all these things affect my whole identity. I've always thought of myself as verbally skilled and these episodes affect my sense of self. I met a woman at the radio station a few weeks ago. Then I met her again two nights later and didn't recall her at all.

Another night I asked the same couple twice if I gave them passes to something and they got annoyed with me. I had already given them the passes.

The ironic part is that as a teenager I had unbearable contempt because my mother couldn't recall the names of people. But she could recall other things really well — what she paid for something.

All this makes me feel diminished. I now feel not as sharp as I used to be. I'm not depressed but feel like I'm getting dim, with the foggy, hazy, cloudy episodes.

At the same time I'm probably happier in my life than I've ever been. I'm in a great marriage that's working well. My husband and I have a wonderful relationship. Over the years I have had depressions on and off but things are going well now both in my private and professional life. I love the work I do.

I don't go to doctors unless I'm dying and I wouldn't know who to go to with these symptoms anyway. I just keep hoping they'll go away on their own.

Katherine Kennedy's case is an example of pure WHM cognitive/speech/behavioral symptoms occurring at a rather early age — what I think of as a "one-ring circus" of symptoms — with no body symptoms (i.e., hot flashes or vaginal dryness) or associated mood/emotional symptoms except for her diminished sense of self in reaction to having the symptoms. Her symptoms can't be said to be occurring in reaction to sleeplessness, or hot flash disruptions, or depression because she does not report these. Like many women her age she isn't thinking about hormone changes in relation to these symptoms, but her mention of greater bleeding in her early thirties when her WHM symptoms appeared to her to begin, likely reflects the increased variability of periods (more, less, longer, shorter) that typically characterizes perimenopause. I view her case as being linked to hormone changes because, as you will see with later cases, it echoes in its pattern of specific symptoms so many of the other women whose symptoms did begin in association with hot flashes or vaginal dryness — indicators of hormonal changes. Like many women Katherine Kennedy has not seen a doctor about these symptoms. She has been coping with them in multiple ways. As with many women the symptoms are occurring within the context of a fully lived functional life. They are mainly invisible to others though very noticeable to her.

Case 2: Sherry Strumph

Sherry Strumph (actual name) is the forty-nine-year-old president of a highly successful major office-services company in New York City that now employs over thirty-five people. She has built this company from a one-person venture over a twenty-year period through great initiative, ability, creativity, and sustained directed effort. She owns another unrelated business as well. Sherry is married and the mother of a grown daughter.

Reproductive state: "I'm perimenopausal now. I'm still regular but my periods come for ten minutes. The last one was over before I knew it."

I remember this beginning about two to three years ago when I caught myself saying something wrong to myself. I said to myself, "You used to have a 'photogenic' memory" and then said, "You fool, you mean 'photographic' and now you can't even remember what your husband told you ten minutes ago." This was in response to my husband reminding me that he would be out that evening and my not remembering it at all. He said we spoke about it several times. For me it was the first time. I laughed it off thinking "OK here comes old age." I thought memory problems began around age seventy-five, not in your forties. Another time a friend asked me something and I said I didn't remember; and she said, "But you always remember everything. I can't accept that you say you can't remember." She was so taken aback because my memory had always been phenomenal — everybody relied on it. My husband started saying things like "You used to be so reliable and I used to be able to count on you. Now I never know when you'll do whatever you say you'll do." I realized myself that I wasn't the same as before but I said to myself, "It's the way I am now." I was very accepting. Maybe because I had been so responsible all these years. I used to be so driven to be right. It's kind of refreshing for me not to have to do that.

When this began I had been away from the office for two years. I had excellent management there. I was free as a bird so it wasn't job burnout or stress. My memory lapses created havoc for some of the people around me, but not me. I just accepted it. But then too I didn't know what to do about it and it's not my style to complain to people.

Before I started using estrogen cream nine months ago, I'd say that my worst memory issues were one to two years ago [ages forty-seven to forty-eight]. When I'd forget something I would joke with people and say "Mind-like-a-sieve strikes again."

When this began I had no idea this could even be related to hormonal changes. I learned this from the experience of my friends. I thought menopause was about going through hot flashes. I didn't associate hormonal changes with what I was experiencing. I didn't have any mood swings during this time the way some women do. In fact I was the calmest, most unflappable I'd ever been. Things I had feared doing before I could do now, like driving at night. But my memory was a mess. I'd write things down and forget where I'd put the list.

I thought about going to a doctor but I'm not one to go running to them very readily. I thought maybe I was pre-Alzheimer's but then I said to myself, "No one in my family has ever had it." I did stop using my deodorant, however, because I had read that something in deodorant — aluminum — caused Alzheimer's. I also stopped using aluminum foil and switched to shrink-wrap for that reason.

My concentration also changed. I would start to read a book and pick it up two weeks later and have absolutely no memory of any of it. As though not a trace had stayed with me. However, when I tested myself, by pulling cards from a deck and reading them to myself, to see how many I could remember, I could do it if I tried. This forgetting happens more when I'm on automatic pilot. I need to really pay attention to "get" some things now, more than I used to. And I can but I need to make a conscious effort to do so.

I finally broke down and bought a date book and I'm pretty religious about writing in it but not at all religious about looking at it.

I started to make the connection that the things happening to me were related to hormones when friends started telling me what they were going through. My friend A. said to me one day that she was much more forgetful than I was. She was diagnosed as needing estrogen for her bones and started being treated with it, and she said it was working for all her symptoms. Then another friend said that she'd been put on estrogen and could think like a young girl, meaning that things came easily again. I was percolating on this information and then my friend A. said she was switching to an estrogen cream. She used to be a chemist. After she went on the hormone cream she said she stopped being hot all the time (the way I am too all day without any hot flashes), her memory got better, and amazingly she was able to successfully lose weight.

I started using the [estrogen] cream in August (nine months ago) and they say to give it three months. I've noticed a difference in some things but not a great difference in everything. But I also haven't used it consistently — probably about 50 percent of the time. I forget to. But I'm also afraid of hormones because of my family history. I'm the only one in my family who hasn't had cancer. So I've got a love/hate relationship to taking estrogen. Now at least I know I have a choice in whether I want to stay this way if it lasts.

After I went on estrogen my attention got better. I'm more focused. It might also be because I'm back at work full-time. It kind of forces me to be focused. The result is I appear more focused than I am in my personal life. Besides my husband and good friend, I don't think others noticed any difference in me. The changes weren't blatantly observable.

Did I go to a doctor about this? Yes and no. At regular intervals I would go to my internist and when I told her what I was experiencing she said, "Well, welcome to the club honey." She's only a bit older than me. She didn't offer me anything. She knows better. I'm normally unwilling to take even aspirin. I mentioned the heat thing to my gynecologist. He felt that since it was constant it wasn't likely related to menopause. He did take blood level tests and told me I'm perimenopausal.

I'll do these strange things every now and then. The vice president of my company and I take turns picking each other up on alternate days to drive in to work. One day I left the house, got into the passenger seat, and sat there waiting. When I realized what I'd done I started laughing. Even more recently I unpacked groceries. I put canned tomatoes into the fridge and put fresh lettuce and spinach in the pantry closet where I found them a week later. Other times I'll be cooking and go into the pantry and say, "Now why am I here?" and then realize I meant to go to the freezer or spice shelf. This now happens all the time.

Spelling too is strange. I used to be a great speller. I didn't have to think about it. Now I have to think about it. The other day I couldn't remember if the word "comrade" had an e at the end. Working with language has been my business so this is not like me. I'll also now substitute short words for the ones I can't think of. I also have more difficulty prioritizing things than before. I'm still very good at it but I feel there's a change in the directness with which I organized a task before.

I used to be able to compute things mentally and now I have to write them down. I sometimes have someone check it for me. I now blank out on phone numbers and names that I've known forever. I never needed a phone book but I think now I should start writing them down. I've also blanked out on mail I received at home that I acted on. I wouldn't remember having talked to anyone about what was involved but then they would tell me I had already.

I'll also catch myself now half focusing on things. People will be speaking and I'll have no idea what we just spoke of. My friend M. was speaking the other day and I realized I had no idea what the conversation was about. I've also stopped carrying keys. Keys no longer exist in my consciousness. I have given new meaning to the phrase "living in the moment." I own a house and two businesses but I no longer carry any keys. They were gone all the time. I had a garage opener built into my car for that reason. It's funny because my husband always relied on me for locking everything up. Now he does it all. I used to be obsessive about it. Now I'm cavalier about it, nonchalant. I'm also not as suspicious as I used to be. I'm more trusting of people. In the past if I got on a train I used to automatically size people up and think "Do I want to be caught in an alley with this person?" Now I don't look for traits in that way anymore. I'm less mistrusting of the looks of someone.

Would I rather go back to the way I was? I don't seem to feel as much need to control everything. To me I think estrogen is like the fuel that wants me to try to get big bites out of life and my appetite has diminished somewhat with the diminishing of the estrogen.

Sherry is an old friend who was unaware of what I had been doing the last several years. When she read the New York magazine article I had written in the summer of 1997 and my allusions to WHM symptoms in the article, we spoke. She said, "That's me," and proceeded to tell me her story.

Like many women Sherry did not connect the symptoms she was experiencing with hormonal factors, but instead attributed them vaguely to aging or the possibility of developing early Alzheimer's disease and went so far as to make changes in her life. Like many women with WHMS she did not run to a doctor after experiencing the symptoms or get much specific help from doctors in response to describing some of them. What stands out about her case to me is the atypical equanimity with which she accepted the cognitive/behavioral symptoms she watched herself exhibit, the attributions she ascribes speculatively to her reproductive hormones, the motivational drives she suspects they impelled her to, and the diminished vigilance around safety she describes in herself, i.e., less suspiciousness, diminished fears around driving at night, less compulsiveness around keys, locking up, etc. Are these new traits unique to her? Is there something here to follow up? I'm not sure. Sherry was experiencing what I think of as a "two-ring circus" of symptoms associated with hormonal changes. She experienced the cognitive/speech/behavioral changes — the mind changes, and one physical change — she was hot all the time.

Like many perimenopausal or menopausal women with erratic memory who take hormones, Sherry's symptoms lead her to sometimes forget to take medications consistently (although in her case, ambivalence due to fears of cancer related to her family history may partially account as well for her forgetting). Product manufacturers need be mindful of memory as a basis for noncompliance with prescribed and nonprescribed treatments.

Case 3: Quiana Mortier

Quiana Mortier (an alias) was referred to me by one of the menopause experts I had come across in my research. He had recently started to treat her at the time of our interview. Ms. Mortier is widowed, the mother of a daughter now twenty-one, and supports herself in a position she has long held, working in the billing department of a physician.

Reproductive state: now fifty-two and in menopause.

I'm now fifty-two but my symptoms started when I was forty. I was perimenopausal then. I went to the doctor because I wasn't feeling right. Weird words were popping out of my mouth that I hadn't intended to say, and I'd cry constantly. I thought I was cracking up. This had been going on for a couple of months and my husband and I went to our internist. I told him about the wrong words that would come out. And I told him it felt like I was seeing things. I'd go to take something that I was sure was there before. And then it wasn't there when I went to look for it again. He diagnosed me as having paranoid schizophrenia. He told my husband that in private and my husband was very upset. He told me that night what the doctor had said. I was very upset and called the doctor and said, "Did you really say that?" He denied he told my husband that. But I believe my husband more than I believe him.

I was so upset with what he said that I went to another doctor, a psychiatrist, to check it out. After telling him the same things, he said it wasn't schizophrenia or paranoia. He didn't know what it was.

Then I started getting hot flashes. My body started to change. My periods came real heavy. Then they didn't come. I never knew what was going to happen from month to month. When I was forty-three or forty-four my memory started to get even worse. I thought it might be due to stress. Frustrating things would happen. I was going into the bank to pay my bank mortgage one day and parked my car and saw the meter maid behind me. I had the coin in my hand and intended to put it in the meter, but I forgot in a second what I was going to do and went into the bank holding it. When I came out the meter maid was writing the ticket. I was so mad. Things that frustrated me like that kept on happening. In a second I'd forget what I was going to do. I'd misplace things I'd kept in the same place forever. This happens with keys, money, earrings. I'll look in the refrigerator and think "Who ate this?" You know you brought it in and you can't find the food. At one point there was a reason for this happening — my daughter had a girlfriend living here, and she was hiding her. But this happened before and after that too.

But you become paranoid. You suspect people because you are missing things, misplacing things. At times I'd say to myself, "This must be Alzheimer's."

I did speak to another doctor about this. He said it was probably related to stress and never related it to menopause.

This has gotten better though — the misplacing things. I just take Rejuvex and I think it's helped me. It relaxes me. But even now I still come into a room and don't remember what for. I have trouble with speaking. It's as if you don't remember any words in a sentence. If the sentence I wanted to say was "The cow jumped over the moon," I couldn't remember the word for cow. Even now, I have difficulty repeating a sentence back. It's like the recall button takes longer to bring things to the mental screen. Names escape me the minute I hear them. I still have difficulty with my memory. If I don't write things down, forget it — which is usually what I do. But I forget to write things down. I have only short-term memory now. I thought it was just aging.

I didn't know this could possibly be related to menopause until Dr. D. told me that it could. Before him I went to an Italian gynecologist about all of this, and he just didn't believe in taking hormones. The speech difficulties he said were due to stress! He said to relax, which didn't help much.

For the last seven to ten years I've felt like I was in a bubble. I've only recently come out of that bubble. I felt like I was in a vacuum and certain things weren't important to me, like the silver candelabra my mother left me when she died. My family thought I was crazy. "Leave her alone," they would say. My daughter would say this too. My sister even tried to take advantage of my memory problems. She thought I had forgotten that she had the candelabra and acted surprised when I asked about it a year later.

But other times if something wasn't directly in front of me it was out of my mind, as if I had amnesia or something. At different times I've forgotten my ATM code, my social security number, my family's birthdays, which I've had in my mind forever. They just flew out and later just flew back in. That's what it feels like. It feels like you are going crazy. You don't know what's going to happen next.

How did I manage at work? My husband is dead now and I work in a doctor's office on billing. The computer has a format for what I do so I can handle it. I have to focus in on it but I do OK. I've been at it a long time. At home I studied to become a travel agent a couple of years ago when it was really bad and things would just go out of my head, I have to read something over and over and over to retain it and within a week it's gone. I'll forget it like I never read it before. It all feels brand new if I read it again.

Now it's a lot easier. Whatever was going on with me the last ten or so years has leveled off. It was a really bad time. I just recently went to Dr. D. He wants me to take estrogen. He's for it but I went to two other gynecologists who were against my taking estrogen. They still don't relate any of this to menopause. Dr. D. knew what I was talking about and said it's related to menopause, but nobody else ever said that. I'm still not sure of taking it [estrogen-progesterone hormone replacement therapy (HRT)], even though nobody in my family ever had breast cancer. The other doctors said not to. So I'm not sure yet what I'll do.

What is revealing about Quiana Mortier's case is the many years that this syndrome can apparently persist and that it can become better with time; also, that verbal and perceptual (cognitive) errors together with reduced control over her emotions were Ms. Mortier's earliest symptoms, preceding hot flashes and menstrual irregularity. What stands out too is the misdiagnosis of her symptoms as "paranoid schizophrenia" by an internist, and complete unawareness of the basis for her symptoms by other physicians, except for Dr. D., a male ob/gyn who specializes in treating perimenopausal and menopausal women and has been correctly sensing what women have been trying to communicate to him about their experiences over the years.

WOMEN, WHMS, AND DOCTORS: WHAT HAPPENS NOW WHEN WOMEN REPORT THEIR SYMPTOMS TO DOCTORS

The bigger picture at present is that most physicians know very little if anything about the specific mind/speech/behavioral symptoms I have named the WHM Syndrome. They haven't been taught of their possibility during medical training. They may have learned something about these symptoms if they have been carefully listening to some of their patients over the years. However, some women, as we've seen, don't go to physicians about these symptoms for multiple reasons, but some women do speak up about their symptoms.

At present when women go to their ob/gyns or other physicians with their symptoms here is what may happen:

1. Women are told to relax more, or to take a vacation, that the symptoms are probably stress-related. The cost of following this seemingly innocuous advice, however, can sometimes be high. A woman with multiple WHM symptoms, for example, was led by her doctor to believe her symptoms were due to stress. She quit an exciting, demanding job she loved, only to discover her symptoms did not improve at all with a less stressful job, but got worse. They did improve significantly after she was put on a three-month diagnostic test-trial of estrogen alone to see if estrogen decline was the basis for them. When she had determined that her symptoms were related to estrogen loss, wary of estrogen for family history reasons, she then went off the pharmaceutical estrogen her doctor had prescribed and turned instead to weaker plant-based estrogens, phytoestrogens. And it worked in her case. The three months of estrogen was used as a diagnostic tool, to identify the cause of her symptoms. (See chapter 10 on treatments.)

2. Women are told the symptoms are the result of aging and to "accept it" as inevitable.

3. Doctors, like many other human beings, tend to deny or dismiss what they don't understand. And their training to date hasn't included any grounded scientific rationale that would logically explain the basis for the symptoms. So women are given "It's probably nothing" admonitions, or quizzical looks that imply they don't know what they're talking about. The tone of these encounters is "if the doctor hasn't heard about it, it is probably nothing too important, or it doesn't exist."

4. Women who show up in doctors' offices with WHMS can be misdiagnosed as having a psychotic condition. You saw that this is what happened to Quiana Mortier. Describing her WHM symptoms as best she could, "strange words popping out" and "things being there and then not being there," Mrs. Mortier's internist attributed her strange unfamiliar symptoms to a psychotic condition, paranoid schizophrenia, and gave this diagnosis to her husband but not to her directly. But what if her job had depended on this diagnosis? What if this diagnosis unbeknownst to her became part of a permanent HMO medical record made available to others? Mrs. Mortier's prudent decision to see a psychiatrist for a second opinion paid off in her case, when the psychiatrist was forthright enough to say he didn't know what disorder she had. But do all psychiatrists exercise this option? How often can they say "I don't know" to those who refer patients to them for a diagnosis? I don't know.

5. Sometimes women with WHMS symptoms are diagnosed as having Attention Deficit Disorder (ADD). Two women with WHMS symptoms I interviewed were given this diagnosis, one by a psychologist, the other by a psychopharmacologist she was referred to. Both were advised to take Ritalin, the stimulant drug used to help focus attention in youngsters with ADD. Taking Ritalin helped one of the two women with WHMS symptoms. (Might this be a potential form of treatment for some women with WHMS attention changes?) Both women had no prior history of attention, reading, or word-reversal difficulties.

After interviewing these women I decided to interview several experts on ADD. I asked if ADD ever manifested with adult onset — if the disorder could show up initially in adulthood without a prior history in childhood. I was told that in instances where ADD is first detected in adulthood, the assumption commonly made is that it was likely present in childhood but not detected or diagnosed at that time! It is my suspicion that in some women with WHMS an intermittent ADD-like disorder can show up in adulthood for the first time as one possible subset of WHMS symptoms in association with estrogen loss. It's important to be aware, however, that not all women with WHMS symptoms have ADD-like symptoms.

6. Sometimes women with WHMS who insistently pursue their quests for diagnosis at memory or Alzheimer's disease research centers within major medical centers are suspected of having early Alzheimer's disease and given this tentative diagnosis. Though they test normal on the battery of cognitive tests they are given, the symptoms these women describe lead clinicians to suspect a diagnosis of Alzheimer's disease, since the symptoms outwardly can sometimes appear to overlap. The women are then asked to return at regular intervals for follow-up testing and evaluations, to see what happens to their symptoms — if they progress with time, stay stable, or disappear. What happens over time helps the experts clarify the diagnosis. Imagine, however, being told by experts that your WHMS symptoms might indeed be Alzheimer's disease! You might very well redirect the whole course of your life or live in a bubble of suspended anxiety if you thought your remaining cogent time on earth was likely very limited.

The reality is that Alzheimer's disease researchers know very little as yet about how true instances of Alzheimer's disease begin in very specific detail — how they play out in everyday life. As a former Alzheimer's disease researcher, I know. I would often ask the relatives of patients I was evaluating what were the earliest signs they saw. Typically the first signs were only recognized in retrospect, after the full-blown picture of Alzheimer's had later emerged. "So that's why he acted so funny back then two years ago," they would say.

Alzheimer's disease researchers aren't yet aware of WHMS as a distinct set of symptoms among perimenopausal and menopausal women, even though they may be aware overall of the neuroscience research showing a connection between estrogen loss and changes in the structure and chemistry of the brain, and recent research on Alzheimer's disease and estrogen (see chapter 7). Alzheimer's disease experts are reading about the existence and details of the WHM Syndrome at the same time you are reading this. They aren't yet prepared to diagnose WHMS. They can't diagnose what they don't yet know. But they might mistakenly diagnose WHMS symptoms in relation to what they are familiar with and unintentionally derail the course of a life. I have nothing against the clinicians who diagnose memory disorders or Alzheimer's disease. I am merely cautioning women with WHMS symptoms about what could theoretically happen. Hopefully WHMS will be given the attention it deserves in research efforts so that memory and Alzheimer's diagnostic centers will be aware of it soon. Without intending to add to the fears of women with WHMS, I feel it would be negligent of me not to add that some true cases of Alzheimer's disease can occur within the age range of the forties and fifties. The youngest presumed Alzheimer's patient I ever tested was a forty-two-year-old male. It is my belief, however, that the preponderance of cases of WHMS in women are not manifestations of early Alzheimer's disease cases. As anchoring points for this view, I use as evidence the absence of droves of sixty-year-old Alzheimer's-like women wandering the streets of major cities. (If WHM symptoms are present to one degree or another in a significant proportion of fifty-year-old women, then if it truly represented the beginning of Alzheimer's disease, ten years should be sufficient time for the condition to "bloom" into Alzheimer's disease.) Also in my experiences as a health psychologist treating patients with chronic disease sometimes in rehabilitation and nursing home settings, I found few sixty-year-old women or men with Alzheimer's disease. For very specific reasons that will become clearer in a later chapter, I believe that WHMS in most women represents a "normal," though until now undetected, series of changes.

More Encounters with Doctors

Here are two more experiences of women with self-described WHMS symptoms and encounters with their doctors. They are letters to the editor that arrived in response to publication of my August 1997 article on "Estrogen and the Brain" in New York magazine.

Thank you for validating the absolute nightmare I lived for at least four years. I make a living as a salesperson on the wholesale level. I have always thought on my feet and counted on doing several things at one time. Words cannot express the sheer terror I lived through, losing my quick thinking and my memory, being depressed, and going to doctor after doctor who had no idea what was wrong — and I was already taking estrogen.

Fortunately, I found a new gynecologist and she picked up my symptoms. My body was not absorbing enough [estrogen] to get me back on track mentally. [Women can differ biologically in their reaction to the same drugs.] Everything is now pretty much back to the way it was — except that I lost a job that I loved and was working at for fourteen years.

(Name listed in the article, Manhattan)

Here is another:

How good to read [my article]. In my early thirties, I went into premature menopause. With it came what I call "teflon brain" and aberrant bouts of halting speech. Pieces of simple information would fly through my brain, skipping over a slick surface....No small problem for a television-news producer. Of course, when I would tell this to my doctors — and then add that it had to be because my brain was malnourished from lack of estrogen — they determined that lack of estrogen had rendered me daft, not forgetful. Now, it seems medicine is wiser....

(Name, Manhattan)

THE WHM SYNDROME PARALLELS HYPOTHYROIDISM

In many ways the WHM Syndrome parallels, in its effects on thinking and behavior, an established hormone-deficiency syndrome that is also known for having cognitive/behavioral consequences — hypothyroidism.

In those with hypothyroidism, the very basic hormonal "fuel" that "drives" the body's metabolism efficiently — thyroid hormone — becomes deficient for one of several reasons. People with insufficient supplies of the hormone can experience not just mood and physical symptoms such as bone-wearying fatigue and a persistent cloud of depression (as do some women with WHMS), but also well-established cognitive-deficit symptoms ranging from subtle to very serious, in memory, attention, and the fine-tuning of thinking and speaking. The precedent thus exists for a known hormone-deficiency state producing cognitive symptoms in the manner of WHMS. It is even possible that hypothyroidism and WHMS may be related, i.e., that estrogen loss may trigger changes in thyroid function. While little is known about the relationship of estrogen changes on thyroid changes, it is known that changes in thyroid functioning often increase significantly in frequency among women during intervals of rapid hormonal shifts — e.g., following the birth of a child and around perimenopause and menopause. Some clinicians who treat menopausal women have observed that in association with menopausal symptoms often thyroid disregulation of one kind or another is not an uncommon finding. Moreover it has been discovered in recent years that the respective receptors that bind thyroid hormones and estrogens are part of the same superfamily of steroid receptors and may have evolved in tandem and work in tandem. Both are hormonal systems in charge of major, basic life-sustaining functions — thyroid hormones for driving the metabolism of cells for daily living and estrogen for underwriting and "fueling" the survival of the species and directly or indirectly affecting many brain, bone, heart, and other body-system functions. Just as the symptoms of hypothyroidism are now known to be readily correctable with thyroid hormone replacement therapy, in the years to come, the cognitive and behavioral symptoms of the WHM Syndrome, I believe, will be formally recognized as a comparably correctable hormone-deficiency state reversible with estrogen hormone replacement or custom-designed drugs or products mimicking estrogen's effects in the brain.

WE DON'T CREDIT HOW MUCH NORMAL WOMEN CAN DIFFER FROM EACH OTHER BIOLOGICALLY AROUND REPRODUCTIVE HALLMARKS

It is my goal in this book to communicate what the WHM Syndrome is and what it feels like, but it is also my express goal not to do harm, not to paint all women broadly with the same brush since WHMS symptoms affect some women not at all, some only mildly, and some seriously. I believe that central to any woman's or health expert's understanding of WHMS symptoms, perimenopause, menopause, research on menopause, and the treatment of menopausal symptoms is a considerably heightened appreciation of how much normal women can differ from each other with respect to any of the stages on the time line of women's reproductive events.

Consider for the moment what you already know about otherwise healthy normal women. Some have a monthly momentary twinge that announces their period is coming, whereas some go through days of premenstrual syndrome (PMS) agony with intense and disruptive mood and physical symptoms hammered in often by grueling migraine headaches. I have treated such women. Some women during pregnancy are sick to their stomachs practically every day while others fall in love with the psychological state pregnancy induces and keep wanting to repeat it over and over. Some women suffer postpartum effects that lead to thoughts of suicide and infanticide while others experience postpartum euphoria and bliss.

When I first heard about PMS and later postpartum depression as states that could induce dire mood alterations in women the truth is I suspected that some poor male psychiatrists had had the wool pulled over their eyes by females who were malingering for some unknown reason. I doubted that women could experience such intense reactions since I was a woman, after all, and assumed I knew what the universal experience of having a period was like. It was a "nothing" experience for me. Nothing to balk about. Only with time have I come to truly appreciate how diverse and divergent the experiences of women in this regard normally can be.

Let me share with you one moment of insight when this appreciation forcefully embedded itself in my psyche. Since graduate school I have used medical/science journalism as a means for extracurricular graduate study, for developing expertise by getting paid access to experts I wanted to interview in relation to my work as a research psychologist and later as a clinical health psychologist. I could ask the experts "up close and personal" what I wanted to know. When I was working with patients with chronic pain I proposed to the editors of Psychology Today doing a profile of one of the leading research psychologists of our day, Dr. Ronald Melzack. Melzack and a colleague, Patrick Wall, had put forth an important theory on pain — the gate control theory — that ultimately stimulated generations of research and progress in the field of pain. Melzack had studied the experience of pain in women during childbirth and had earlier developed a novel pain questionnaire that helped in the communication of a difficult topic — how much and what kind of pain a person had. When I interviewed him at McGill University in Montreal, Canada, he told me that the pain of giving birth could be compared to the acute pain of having a finger cut off. On the other hand he said there were some women who gave birth with no pain whatsoever. "No pain whatsoever?" I asked in amazement. "No pain whatsoever," Melzack said. I just couldn't believe such a thing was true so I asked the same question again in an even higher-pitched tone: "No pain whatsoever?" "No pain whatsoever," he said. Melzack indulged me this back-and-forth dance several times till I finally desisted and decided to store the information away, uncredited, in the back of my mind for some other day. It just seemed too amazing to be true.

Then one day into my office walked a woman who came to see me in my role as a health psychologist. In taking a history somehow the fact emerged that she had given birth with no pain whatsoever. "No pain whatsoever?" I again asked incredulously. "No pain whatsoever," she answered. I asked if this had ever occurred to anyone else in her family and she said, "Yes, to my grandmother. Maybe it skips a generation." At that pivotal moment of confirmation I "got it" — the bigger picture about the variability among normal women. I accepted as true what Melzack had told me and what this woman had told me. More important I "got" the message that a rose is not a rose is not a rose. Menstruation is not menstruation is not menstruation in the same way for every woman; pregnancy is not pregnancy is not pregnancy for all women; delivery is not delivery is not delivery for every woman; that menopause and perimenopause are often far from the same experiences from woman to woman to woman. I realized that these reproductive biological hallmarks can and often do vary enormously among women so that, to overstate the case somewhat, there are virtually different species of women when it comes to the "fine-tuning" of their brain and body's reproductive infrastructure.

The morals: (1) You can't know the interior experience of the woman sitting next to you by knowing your own. (2) You shouldn't be intolerant of women whose experiences in this regard differ from your own. (3) You can't characterize the experiences of all women by knowing the individual experiences of some women. Some women first experience WHMS symptoms in their thirties, some in their sixties. Some never do.

The existence of many distinct biological subgroups of women means in terms of research on perimenopausal and menopausal women that very large-size samples are needed to get accurate findings that detect accurately what is true in nature about women. Small-size sample studies may obscure and find insignificant what may be very true in nature. What this means in terms of treatments for perimenopausal and menopausal women is that possibly very different forms or intensities of treatment may be needed to help women with different biological natures.

I became familiar with the research literature on menopausal women only after first detecting the symptoms of the WHM Syndrome via interviews with women. What I discovered in my interviews with ultimately some 160 perimenopausal and menopausal women did not correspond with what I later read in the professional "menopause research literature." I had interviewed women who reported being hot all the time, like Sherry Strumph and her friend. The menopause literature made no mention of such women — though they might be in there somewhere I haven't yet read. Menopause experts I interviewed about such symptoms didn't know what I was talking about. Some even told me that women only developed hot flashes during menopause, not during perimenopause, which entirely defied what informants had told me.

I discovered there were more than a few women who were now menopausal who had never had a hot flash or only one to date, but who had lots of WHMS symptoms to one degree of intensity or another. These women didn't have physical symptoms to speak of. Their memory wasn't blinking from nighttime awakenings. Their relationships, their diet, and their exercise were essentially the same. Their ability to recall where they had just put something down wasn't. The menopause field said women with lots of complaints around the time of menopause who went to menopause clinics for help were having secondary reactions to their body symptoms and tended to overuse the mental health and health systems altogether, i.e., they were crackpots, so to speak, and couldn't be assumed to be representative of most menopausal women who didn't go to doctors. To the contrary, I discovered that quite a few women with many WHMS symptoms and other mood complaints rarely or never went to doctors for help and that women who did seek out help were not typically crazy; but likely resourceful or desperately bothered by biological systems, which weren't doing what they expected them to.

This insufficiently recognized biological variability among women with regard to perimenopause and menopause, together with the lack of awareness of the biological effects of estrogen loss on behavior, thinking, and physiology, has rendered invalid, to my mind, many of the present "findings" produced to date by the professional menopause survey research literature. Researchers haven't asked the right questions of women so they haven't learned sufficiently what is happening to them and what is affecting them. Though this may sound like criticism my intention is not to be carping. It is my intention to spotlight what needs to be added to future research. Anyone involved in science long enough knows from personal experience that most knowledge in science is provisional, that etched-in-stone dogmas diligently learned in graduate school or medical school can be overturned in a night. Future research in this field, I hope, will routinely acknowledge women's evident biological diversity and work toward finding markers that predict that diversity. The field of menopause research needs to first observe women better and describe women's perceptions of change no matter the political fallout from either those who don't want menopause "medicalized" or from women fearful of finding biological differences among women or between women and men. It is time to acknowledge that not only do the sexes differ from each other in some important ways but that women can differ from each other in important ways. Understanding those differences, and in medical terms learning how to accommodate individual needs dependent on such differences, is where we should be heading.

Copyright © 1999 by Claire Warga

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Table of Contents

Contents

Acknowledgments

Introduction

PART I

Identifying the Problem

1. What Are These Strange Symptoms I'm Experiencing in the Middle of My Life?

2. Why the Syndrome Has Been Overlooked for So Long

PART II

What Causes the Syndrome?

3. Why Does WHMS Occur?

4. Estrogen and Alzheimer's Disease Research Evidence

5. Evidence the Symptoms Can Be Reversed

PART III

Do You Have the Syndrome?

6. Who Suffers from Warga's Hormonal Misconnection Syndrome (WHMS)?

7. The Symptoms: Warga's Hormonal Misconnection Syndrome

8. WHMS Screening Instrument and Measuring Tools

PART IV

What to Do If You Have WHMS

9. Doctors, Women, and WHMS Symptoms

10. If You Choose Estrogen and Progesterone to Treat WHMS

11. Non-hormonal Approaches for Working with WHMS

12. Behaviors That Can Boost Your Mind or Brain Power

13. Coping with WHMS

PART V

The Big Picture

14. WHMS Symptoms and Men

15. The Big Picture

Appendix I

Appendix II

Notes

Index

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First Chapter

Chapter 1

What Are These Strange Symptoms I'm Experiencing in the Middle of My Life?

Mrs. Malaprop: a character in Richard Brinsley Sheridan's 1775 play The Rivals. "A...woman of almost fifty [emphasis added] who...is famous for misusing...long words that sound similar to the correct words."
-- Larousse Dictionary of Literary Characters

Malapropisms: the type of verbal errors made by the character Mrs. Malaprop.

There are some topics almost no one talks about till you do first. The stampede for the male impotence drug Viagra unveiled one such topic. This book is about another one: the previously unrecognized cognitive symptoms that are caused by the effects of perimenopause and menopause on the mind.


Sometimes it begins out of the blue with occasional slips of the tongue, meaning to say one word and unexpectedly hearing another pop out. Or when you realize that you, once a champion speller, aren't so sure anymore how to spell "potato" or "forty." Sometimes it begins with uncharacteristically forgetting important appointments or drawing unexpected momentary blanks -- total blanks -- when it comes to remembering your only child's or best friend's name, or how to turn on the computer you've been using for years. Sometimes with feeling mentally "hazy" "foggy," or "spacey" and not being able to clear things up though you need to be "sharp" at that moment. "What's happening to me" you wonder. "Could this be early, early, early Alzheimer's disease or a brain tumor?"

But it is usually not early Alzheimer's disease or a brain tumor. It is something else, a particular set of symptoms -- a syning and as a result have been able to offer no, or minimally constructive, help to women who dared to mention them.

THE SYMPTOMS OF PERIMENOPAUSE AND MENOPAUSE CAN BE VERY STRANGE BUT NORMAL

Before describing the specific symptoms I am referring to it makes sense first to agree about certain realities of a perimenopausal/menopausal symptom you already do know something about. Hot flashes. Consider this: If we on earth had never heard of hot flashes as a "normal" midlife symptom associated with ovarian and hormonal changes, and a returning astronaut-discoverer of a twin planet to ours reported drenching, unpredictable, overheating episodes as normal in otherwise healthy midlife-and-older women, we would likely say in quick dismissal, "Go away! You must have gotten something wrong there. The women were probably fooling with you in some way. You couldn't be right. That symptom is just too weird to be true of normal people."

And yet the reality is hot flashes are definitely normal but strange symptoms for healthy women to have. The fact that they are so common makes them seem normal to us. What makes them believable apart from their strangeness is the fact that they are also sometimes observable to others, leaving "tracks" of the internal experience visible to those who don't have them and who might otherwise be inclined to dismiss them as "too crazy" to credit as real.

PERIMENOPAUSAL AND MENOPAUSAL SYMPTOMS CAN OFTEN BE CURED EVEN WHEN NOT FULLY UNDERSTOOD

It's also useful to point out that though science does not yet have a clear consensus on what specific sequence of events produces hot flashes in women -- beyond the bigger picture of changing ovary and estrogen functio n during perimenopause and menopause -- nevertheless medicine has developed at least one quite effective empirical treatment for hot flashes based on trial-and-error experience, even in the absence of a clear scientific understanding of their basis. Namely, estrogen replacement. (Other remedies that apparently work for some proportion of women have been considerably less tested and proven.) Successful treatment therefore of a symptom associated with ovarian/hormonal changes can precede biological understanding of the full complexity of the symptom.

The broad array of symptoms I have named the WHM Syndrome -- for Warga's Hormonal Misconnection Syndrome -- may at first, I suspect, appear as strange and bizarre as hot flashes do to those unfamiliar with them. But in the years to come, I believe, it will seem one of the great mysteries of our time that such a common, unusual, but apparently typical set of biologically based symptoms could have been overlooked for so long. Cultural and medical historians of the future, I predict, will long ponder the great divide of female patient/doctor non-communication that is implicit in physicians not having "heard" and detected this set of symptoms and its cause in women for so many years.

What WHMS Is Like

The list of possible symptoms I am specifically referring to is presented in Table 1 to help you better understand the cases you will shortly be reading about. (A fuller description of possible WHMS symptoms with examples of how they actually occur in women's lives follows in chapter 7.) In Table 1, however, I list only the mind/speech/attention/ behavioral symptoms to which I have given the name "WHM Syndrome," or "WHMS." This table does not includ e any of the mood or physical symptoms that are also frequently but not inevitably associated with menopause and the years preceding menopause. (These are more fully described in Appendix I.)

TABLE 1
The WHM Syndrome: Warga's Hormonal Misconnection Syndrome

As you examine the following chart keep in mind that the symptoms below typically occur as brief come-and-go episodes within the context of a functional ongoing nondisabled life, not unlike the manner of hot flashes. Women who experience some of the symptoms need not experience all of the symptoms or even many of the symptoms. Some symptoms may appear similar but are experienced by women as different from each other and are thus listed as distinct, pending additional research. Implied in each symptom is the sense that it occurs with a greater frequency than it did in the past. The symptoms most typically do not occur continuously but in erratic on-and-off intermittent episodes, in the pattern of occurrence of "hot flashes," so each symptom should be read preceded by the phrase "Flash episodes of." The headings over the symptoms are provisional pending further research, i.e., whether a specific symptom belongs under a speech, memory, or attention category may ultimately change as more is discovered about the symptom's biological basis.

Symptoms of Warga's Hormonal Misconnection Syndrome

THINKING CHANGES

* Losing your train of thought more often than in the past
* Forgetting what you came into a room to get more than in the past
* Not being able to concentrate as well upon demand
* Feeling foggy, hazy, and cotton-headed and not being able to clear it up at will
* Exper iencing a thought blockade: an inability to pull ideas out at will
* Fluctuating agility in prioritizing as well as in the past

SPEECH CHANGES

* Naming difficulties for long-known names: children, best friends, things, places
* Finding yourself at a loss for words in how to express something while speaking
* Experiencing "It's on the tip of my tongue but I can't get it out" sensation
* Making malapropisms: saying wrong words that are related some how to the intended one
* Reversing whole words while speaking
* Reversing the first letters of words while speaking
* Experiencing "echo" words as unintentional intrusions into present speech
* Relying on "filler" words more often: "whatchamacallit," "that thing," "you know what I mean"
* Organizing sentences and ideas less efficiently while speaking

CHANGES IN THE "BEAM" OF ATTENTION

* Blinking social attention when interested and interacting: listening but not always attending
* Blanking-out amnesia for what you just did
* Experiencing increased distractability

MEMORY CHANGES: SHORT- AND LONG-TERM

* Forgetting what you just did, or past occurrences, with no threads of association to getting back to what's missing: missing links
* Changing certainty in how words should be spelled in once good or great spellers
* Fluctuating agility in calculating and in "counting with a quick scanning look"
* Experiencing changes in the speed and accuracy of memory retrieval
* Forgetting the content of a movie right after seeing it but remembering your emotional reaction to it

BEHAVIORAL CHANGES

* Making behavioral "malapropisms": unintended slips in behavior that are re lated to the intended behavior somehow, such as putting shampoo in the refrigerator
* Forgetting briefly how to do things long known, such as where to turn on the computer
* Feeling that automatic skills such as driving for a few moments are not "automatic" in the same way as usual
* Dropping things more often that require fine finger/hand coordination
* Absentmindedly, leaving out or reversing letters in words while writing
* Forgetting how to write a word in the middle of writing and having to leave blanks
* Experiencing "translating" hesitations in converting what's heard into writing
* Not handling the same amount of stress in the same way

SPATIAL SKILLS CHANGES

* Changing skill in remembering and/or recognizing faces (not well-known faces)
* "Looking at but not seeing" what you are looking for when it's right there ultimately, more than in the past
* Changing reading skill in visually "seeing" and comprehending reading material
* Spending less time reading, without difficulties above (for formerly heavy-duty readers)
* Forgetting briefly how to get to long-known landmarks in your life
* Experiencing familiar locales in one's experience as momentarily unfamiliar

ALTERED SENSE OF TIME

* Forgetting appointments more or not anticipating events of personal importance with the same accuracy as in the past
* Forgetting important events in your personal history timeline, i.e., which breast you had biopsied
* "Living more in the moment" out of necessity: a "spliced-film-frames" sense of personal time

WHY IT'S CALLED THE WHM SYNDROME

I have named this set of symptoms the WHM Syndrome, or WHMS, because women who experience t he symptoms often feel subjectively as if they are observing their own "bad show," watching their mind behaving whimsically, unexpectedly taking off on a whim with seeming intentions of its own while violating their intent.

In my mind WHM originally stood for the Women's Hormonal Misconnection Syndrome. I felt the acronym in good measure characterized the subjective experience of women who had the symptoms without stigmatizing them. And the words behind the letters described what I believe is going on at the neurophysiological level -- namely, cognitive/behavioral/speech episodes that are mis-hits. Episodes that are off the mark misconnections, in which the mind's intentions are not producing the right physiological connections that they used to in the preexisting circuitry and/or chemical flow patterns of the brain. The reason for the misconnections? A body/brain retooling or "retuning" brought on by the effects of declining ovarian function and declining estrogen hormone supplies on a thinking, remembering, attention-creating brain that science has recently learned (see chapter 4) depends heavily on estrogen as a brain "transmission" fluid of sorts, as a fortifying performance-enhancing steroid or multivitamin. (Estrogen is after all a steroid hormone even though it isn't the kind typically used by athletes. I'll explain this more later in chapter 4.)

However, as I continued interviewing women and experts and reviewing the research literature in this area over the span of several years, I came to the conclusion that calling this the Women's Hormonal Misconnection Syndrome would not be prudent. (You'll have to read chapter 14 to find out exactly why.) But for the moment suffice it to say that I learned that science had very recently discovered that male thinking/remembering brains and sex organs also depend on estrogen supplies for their normal function. So for reasons of faltering estrogen hormonal levels in their brains I began to suspect that at least some men too may have similar WHM symptoms at possibly similar ages. What to do?

To preserve the acronym WHM and prevent the syndrome from being called the rather farcical HM(mmm) Syndrome, I have renamed the set of symptoms Warga's Hormonal Misconnection Syndrome. It turns out that naming new medical syndromes and hormonal/behavioral phenomena after their discoverer has a long history, respectively, in both medicine and behavioral neuroendocrinology (the hormones and behavior branch of science), according to the eminent sociobiologist Edward O. Wilson. Describing a series of known behavior-and-hormones effects in the animal kingdom -- i.e., the Bruce Effect, the Lee-Boot Effect, the Ropartz Effect, and the Whitten Effect -- Wilson in his landmark 1975 book Sociobiology, writes: "In the manner of the medical sciences, the different kinds of physiological change are often called after their discoverers."

Why have I called this set of symptoms a syndrome? Because the set of symptoms occur frequently in association with each other, as a constellation, or sets of subconstellations. Certainly not all women who have some of the symptoms have all of the symptoms, but sufficient cumulative experience interviewing women has persuaded me that the symptoms represent a possible set that are part of the same causative agent.

WHMS SYMPTOMS HAVE TYPICALLY BEEN IGNORED OR WALLPAPERED OVER

Till now in the relatively few instances when popular writers have referred to the above symptoms they have usually used seemingly mild, and nonspecific terms such as "concentration problems," or "forgetfulness," or "memory problems" to refer to women's experiences during these years, without an appreciation of the range of possible "glitches" in speech, behavior, and cognition that women in actuality have been experiencing. Broad-spectrum terms such as "forgetfulness" or "concentration problems," in effect, "wallpapered" or plastered over the variety and the bizarreness of the symptoms women have encountered. The casual, familiar terms masked or obscured the specific reasons why otherwise seemingly normal and healthy women might be inclined to say such phrases as "I think I'm losing it" or "I think I'm flipping out" or "I think I'm cracking up."

If you had occasion to go into major bookstores at the time I am writing this to look in the indexes of the many books now on the shelves currently addressing menopause or perimenopause for such terms as "memory" or "concentration" or "forgetfulness," you would find that in the vast majority there is either no mention of even these broad-spectrum terms or at most a one- or two-line reference to their possibility at this time of life but without much in the way of elaboration. There is virtually no reference in most of these books to the unusual behavioral symptoms listed in Table 1.

HOW DO WHMS SYMPTOMS PLAY OUT IN WOMEN'S LIVES

But how do these symptoms actually play out in the lives of real women? Let's look at three very different women:

Case 1: Katherine Kennedy

Katherine Kennedy (alias) is a thirty-eight-year-old professor of Eng lish at an Eastern university who also hosts a weekly talk-radio show. She is married to a scholar, has no children yet, but hopes to have them in the future.

Reproductive state: still gets her period regularly appears to be perimenopausal, though she does not yet realize it.

When I was younger I had the most retentive memory for everything, especially names and faces. Friends in college would say, "Your mind is like a Rolodex." When I entered my thirties I started having these strange symptoms. I would meet people and the next day felt as though I had never seen them before. They'd know me but I had no due as to who they were. Their faces were just not registering. It so happens that I had begun to menstruate copiously around that time, more than before but I did nothing about it. Not recognizing faces still happens. I find that slightly scary because my grandmother was demented; and I sometimes wonder if it's hitting me very early.

What drives me mad is that I now forget the precise names of things, objects, and will end up saying "that thing" instead of "diploma" for example. It's the same with verbs. I will use the word "doing" instead of the verb I actually want to use. I also have the sense that sometimes I'm grasping for a word and I can't get to it. It feels like mental clutter, like I'm shuffling around inside not finding what I want. I find it hard to retrieve things. I'll have a sense of what I want -- it's not even the sense of being on the tip of my tongue but rather I can't get it to my tongue. I'll want to say "chair" and will think "something about sitting" but can't fill in what I want. It's like mental miasma. This happens not all the time but intermittently enough so that it concerns me.

I find it [these symptoms] enormously frustrating. One of the ways it affects me is when I'm having a disagreement with my husband. I'll know there's a point I want to make but I can't make my point. Either that or I lose it midstream.

The difficulty in retrieving, to some degree, also overlaps with what I call fog or haziness. My mind sometimes feels foggy, hazy, or cloudy. If it's fog I'm feeling it's more confused, more grasping than when I'm trying to retrieve something. With fog I don't know what I'm looking for -- that's the worst -- being lost in the fog. When this happens I think I'll end up like my grandmother, not knowing the names of my family and having lost decades. Or like my friend who got ECT [electroconvulsive therapy] and lost decades of her life, big chunks of her brain. At times like this I feel like I'm losing it. And I'll think to myself "I didn't even drink or take drugs and I'm losing it."

In the classroom and when I'm on radio I want to be sharp and alert, and it hasn't happened terribly much, these blunders, when I'm working. In fact when I'm in front of a class or microphone I'm somehow sharper. I have to be really alert and thinking and focused. And when I'm working I'm better than in my private life.

I find now that often when I walk into a room and want to get something, I'm apt not to recall what I went to find. I think it's a little early for this to be happening to me. My mom and grandmother do this. I never did this as much as now.

In my late twenties if I was writing fast I noticed that I started to reverse letters on words. I also used to be a great speller. Now if I see something that's wrong I won't realize what the corre ct thing should be. Strangely though, I started doing crossword puzzles only recently as a way to reassure myself of my verbal skills, and I can finish The New York Times crossword puzzle pretty easily writing in ink. But at the same time I just feet really stupid. I used to be and probably still am pretty smart. I always did very well in school. Verbal things were very easy for me. Now I'm still strong verbally but I hate any slippage. It might be analogous to being really gorgeous when you're young and now not feeling as radiant.

I don't think others have noticed the verbal changes because I'm still better than most at noticing names. I'm always the first person who knows the name of a writer or actor. At the same time though I will mispronounce words and can't get back to recalling the correct word. Recently, for example, I was trying to say the plural of roof and couldn't recall if it was "roofs" or "rooves." Both sounded wrong. It's this confusion over basics that I find scary. In the past once I learned something I would have remembered it always. I seem to need a lot more reinforcement than I used to, to learn new commands on the computer.

In the last couple of months I've also begun to lose things and I never ever did that before. My wallet, for example. I lost it and I couldn't think at all where I might have lost it. I had absolutely no associations the way I normally would as to where it might have happened. Fortunately a Good Samaritan returned it, I have a special telephone message pad that's been by the phone forever that's got important numbers on it. I just couldn't remember what happened to it in my home office. It's the lack of associative threads that seems so strange.< P>I'm the treasurer in my family who does all the practical things. My husband is incredibly brilliant but doesn't really live on this planet. He always loses things and people return them. Recently, I thought I had cash in the bank and when I looked I had appreciably less than I recalled. I couldn't think at all where I spent it. Nothing came to mind in the way of any associations. It's as though I had no links to the past when this happens.

I think I tend to compensate for all of this fairly well. I keep lists and write things down and use the mnemonic devices from childhood that I was always great at. But at the same time all these things affect my whole identity. I've always thought of myself as verbally skilled and these episodes affect my sense of self. I met a woman at the radio station a few weeks ago. Then I met her again two nights later and didn't recall her at all.

Another night I asked the same couple twice if I gave them passes to something and they got annoyed with me. I had already given them the passes.

The ironic part is that as a teenager I had unbearable contempt because my mother couldn't recall the names of people. But she could recall other things really well -- what she paid for something.

All this makes me feel diminished. I now feel not as sharp as I used to be. I'm not depressed but feel like I'm getting dim, with the foggy, hazy, cloudy episodes.

At the same time I'm probably happier in my life than I've ever been. I'm in a great marriage that's working well. My husband and I have a wonderful relationship. Over the years I have had depressions on and off but things are going well now both in my private and professional life. I love the work I do.

I don't go to doctors unless I'm dying and I wouldn't know who to go to with these symptoms anyway. I just keep hoping they'll go away on their own.


Katherine Kennedy's case is an example of pure WHM cognitive/speech/behavioral symptoms occurring at a rather early age -- what I think of as a "one-ring circus" of symptoms -- with no body symptoms (i.e., hot flashes or vaginal dryness) or associated mood/emotional symptoms except for her diminished sense of self in reaction to having the symptoms. Her symptoms can't be said to be occurring in reaction to sleeplessness, or hot flash disruptions, or depression because she does not report these. Like many women her age she isn't thinking about hormone changes in relation to these symptoms, but her mention of greater bleeding in her early thirties when her WHM symptoms appeared to her to begin, likely reflects the increased variability of periods (more, less, longer, shorter) that typically characterizes perimenopause. I view her case as being linked to hormone changes because, as you will see with later cases, it echoes in its pattern of specific symptoms so many of the other women whose symptoms did begin in association with hot flashes or vaginal dryness -- indicators of hormonal changes. Like many women Katherine Kennedy has not seen a doctor about these symptoms. She has been coping with them in multiple ways. As with many women the symptoms are occurring within the context of a fully lived functional life. They are mainly invisible to others though very noticeable to her.

Case 2: Sherry Strumph

Sherry Strumph (actual name) is the forty-nine-year-old president of a highly successful major office-services company in New York City that now employs over thirty-five people. She has built this company from a one-person venture over a twenty-year period through great initiative, ability, creativity, and sustained directed effort. She owns another unrelated business as well. Sherry is married and the mother of a grown daughter.

Reproductive state: "I'm perimenopausal now. I'm still regular but my periods come for ten minutes. The last one was over before I knew it."

I remember this beginning about two to three years ago when I caught myself saying something wrong to myself. I said to myself, "You used to have a 'photogenic' memory" and then said, "You fool, you mean 'photographic' and now you can't even remember what your husband told you ten minutes ago." This was in response to my husband reminding me that he would be out that evening and my not remembering it at all. He said we spoke about it several times. For me it was the first time. I laughed it off thinking "OK here comes old age." I thought memory problems began around age seventy-five, not in your forties. Another time a friend asked me something and I said I didn't remember; and she said, "But you always remember everything. I can't accept that you say you can't remember." She was so taken aback because my memory had always been phenomenal -- everybody relied on it. My husband started saying things like "You used to be so reliable and I used to be able to count on you. Now I never know when you'll do whatever you say you'll do." I realized myself that I wasn't the same as before but I said to myself, "It's the way I am now." I was very accepting. Maybe because I had been so responsible all these years. I used to be so driven to be right. It's k ind of refreshing for me not to have to do that.

When this began I had been away from the office for two years. I had excellent management there. I was free as a bird so it wasn't job burnout or stress. My memory lapses created havoc for some of the people around me, but not me. I just accepted it. But then too I didn't know what to do about it and it's not my style to complain to people.

Before I started using estrogen cream nine months ago, I'd say that my worst memory issues were one to two years ago [ages forty-seven to forty-eight]. When I'd forget something I would joke with people and say "Mind-like-a-sieve strikes again."

When this began I had no idea this could even be related to hormonal changes. I learned this from the experience of my friends. I thought menopause was about going through hot flashes. I didn't associate hormonal changes with what I was experiencing. I didn't have any mood swings during this time the way some women do. In fact I was the calmest, most unflappable I'd ever been. Things I had feared doing before I could do now, like driving at night. But my memory was a mess. I'd write things down and forget where I'd put the list.

I thought about going to a doctor but I'm not one to go running to them very readily. I thought maybe I was pre-Alzheimer's but then I said to myself, "No one in my family has ever had it." I did stop using my deodorant, however, because I had read that something in deodorant -- aluminum -- caused Alzheimer's. I also stopped using aluminum foil and switched to shrink-wrap for that reason.

My concentration also changed. I would start to read a book and pick it up two weeks later and have absolutely no memory of any of it. As though not a tr ace had stayed with me. However, when I tested myself, by pulling cards from a deck and reading them to myself, to see how many I could remember, I could do it if I tried. This forgetting happens more when I'm on automatic pilot. I need to really pay attention to "get" some things now, more than I used to. And I can but I need to make a conscious effort to do so.

I finally broke down and bought a date book and I'm pretty religious about writing in it but not at all religious about looking at it.

I started to make the connection that the things happening to me were related to hormones when friends started telling me what they were going through. My friend A. said to me one day that she was much more forgetful than I was. She was diagnosed as needing estrogen for her bones and started being treated with it, and she said it was working for all her symptoms. Then another friend said that she'd been put on estrogen and could think like a young girl, meaning that things came easily again. I was percolating on this information and then my friend A. said she was switching to an estrogen cream. She used to be a chemist. After she went on the hormone cream she said she stopped being hot all the time (the way I am too all day without any hot flashes), her memory got better, and amazingly she was able to successfully lose weight.

I started using the [estrogen] cream in August (nine months ago) and they say to give it three months. I've noticed a difference in some things but not a great difference in everything. But I also haven't used it consistently -- probably about 50 percent of the time. I forget to. But I'm also afraid of hormones because of my family history. I'm the only one in my family wh o hasn't had cancer. So I've got a love/hate relationship to taking estrogen. Now at least I know I have a choice in whether I want to stay this way if it lasts.

After I went on estrogen my attention got better. I'm more focused. It might also be because I'm back at work full-time. It kind of forces me to be focused. The result is I appear more focused than I am in my personal life. Besides my husband and good friend, I don't think others noticed any difference in me. The changes weren't blatantly observable.

Did I go to a doctor about this? Yes and no. At regular intervals I would go to my internist and when I told her what I was experiencing she said, "Well, welcome to the club honey." She's only a bit older than me. She didn't offer me anything. She knows better. I'm normally unwilling to take even aspirin. I mentioned the heat thing to my gynecologist. He felt that since it was constant it wasn't likely related to menopause. He did take blood level tests and told me I'm perimenopausal.

I'll do these strange things every now and then. The vice president of my company and I take turns picking each other up on alternate days to drive in to work. One day I left the house, got into the passenger seat, and sat there waiting. When I realized what I'd done I started laughing. Even more recently I unpacked groceries. I put canned tomatoes into the fridge and put fresh lettuce and spinach in the pantry closet where I found them a week later. Other times I'll be cooking and go into the pantry and say, "Now why am I here?" and then realize I meant to go to the freezer or spice shelf. This now happens all the time.

Spelling too is strange. I used to be a great speller. I didn't have to think about it . Now I have to think about it. The other day I couldn't remember if the word "comrade" had an e at the end. Working with language has been my business so this is not like me. I'll also now substitute short words for the ones I can't think of. I also have more difficulty prioritizing things than before. I'm still very good at it but I feel there's a change in the directness with which I organized a task before.

I used to be able to compute things mentally and now I have to write them down. I sometimes have someone check it for me. I now blank out on phone numbers and names that I've known forever. I never needed a phone book but I think now I should start writing them down. I've also blanked out on mail I received at home that I acted on. I wouldn't remember having talked to anyone about what was involved but then they would tell me I had already.

I'll also catch myself now half focusing on things. People will be speaking and I'll have no idea what we just spoke of. My friend M. was speaking the other day and I realized I had no idea what the conversation was about. I've also stopped carrying keys. Keys no longer exist in my consciousness. I have given new meaning to the phrase "living in the moment." I own a house and two businesses but I no longer carry any keys. They were gone all the time. I had a garage opener built into my car for that reason. It's funny because my husband always relied on me for locking everything up. Now he does it all. I used to be obsessive about it. Now I'm cavalier about it, nonchalant. I'm also not as suspicious as I used to be. I'm more trusting of people. In the past if I got on a train I used to automatically size people up and think "Do I wa nt to be caught in an alley with this person?" Now I don't look for traits in that way anymore. I'm less mistrusting of the looks of someone.

Would I rather go back to the way I was? I don't seem to feel as much need to control everything. To me I think estrogen is like the fuel that wants me to try to get big bites out of life and my appetite has diminished somewhat with the diminishing of the estrogen.


Sherry is an old friend who was unaware of what I had been doing the last several years. When she read the New York magazine article I had written in the summer of 1997 and my allusions to WHM symptoms in the article, we spoke. She said, "That's me," and proceeded to tell me her story.

Like many women Sherry did not connect the symptoms she was experiencing with hormonal factors, but instead attributed them vaguely to aging or the possibility of developing early Alzheimer's disease and went so far as to make changes in her life. Like many women with WHMS she did not run to a doctor after experiencing the symptoms or get much specific help from doctors in response to describing some of them. What stands out about her case to me is the atypical equanimity with which she accepted the cognitive/behavioral symptoms she watched herself exhibit, the attributions she ascribes speculatively to her reproductive hormones, the motivational drives she suspects they impelled her to, and the diminished vigilance around safety she describes in herself, i.e., less suspiciousness, diminished fears around driving at night, less compulsiveness around keys, locking up, etc. Are these new traits unique to her? Is there something here to follow up? I'm not sure. Sherry was experiencing what I think of as a "two-ring circus" of symptoms associated with hormonal changes. She experienced the cognitive/speech/behavioral changes -- the mind changes, and one physical change -- she was hot all the time.

Like many perimenopausal or menopausal women with erratic memory who take hormones, Sherry's symptoms lead her to sometimes forget to take medications consistently (although in her case, ambivalence due to fears of cancer related to her family history may partially account as well for her forgetting). Product manufacturers need be mindful of memory as a basis for noncompliance with prescribed and nonprescribed treatments.

Case 3: Quiana Mortier

Quiana Mortier (an alias) was referred to me by one of the menopause experts I had come across in my research. He had recently started to treat her at the time of our interview. Ms. Mortier is widowed, the mother of a daughter now twenty-one, and supports herself in a position she has long held, working in the billing department of a physician.

Reproductive state: now fifty-two and in menopause.

I'm now fifty-two but my symptoms started when I was forty. I was perimenopausal then. I went to the doctor because I wasn't feeling right. Weird words were popping out of my mouth that I hadn't intended to say, and I'd cry constantly. I thought I was cracking up. This had been going on for a couple of months and my husband and I went to our internist. I told him about the wrong words that would come out. And I told him it felt like I was seeing things. I'd go to take something that I was sure was there before. And then it wasn't there when I went to look for it again. He diagnosed me as having paranoid schizophrenia. He told m y husband that in private and my husband was very upset. He told me that night what the doctor had said. I was very upset and called the doctor and said, "Did you really say that?" He denied he told my husband that. But I believe my husband more than I believe him.

I was so upset with what he said that I went to another doctor, a psychiatrist, to check it out. After telling him the same things, he said it wasn't schizophrenia or paranoia. He didn't know what it was.

Then I started getting hot flashes. My body started to change. My periods came real heavy. Then they didn't come. I never knew what was going to happen from month to month. When I was forty-three or forty-four my memory started to get even worse. I thought it might be due to stress. Frustrating things would happen. I was going into the bank to pay my bank mortgage one day and parked my car and saw the meter maid behind me. I had the coin in my hand and intended to put it in the meter, but I forgot in a second what I was going to do and went into the bank holding it. When I came out the meter maid was writing the ticket. I was so mad. Things that frustrated me like that kept on happening. In a second I'd forget what I was going to do. I'd misplace things I'd kept in the same place forever. This happens with keys, money, earrings. I'll look in the refrigerator and think "Who ate this?" You know you brought it in and you can't find the food. At one point there was a reason for this happening -- my daughter had a girlfriend living here, and she was hiding her. But this happened before and after that too.

But you become paranoid. You suspect people because you are missing things, misplacing things. At times I'd say to myself, "This must be Alzheimer's."

I did speak to another doctor about this. He said it was probably related to stress and never related it to menopause.

This has gotten better though -- the misplacing things. I just take Rejuvex and I think it's helped me. It relaxes me. But even now I still come into a room and don't remember what for. I have trouble with speaking. It's as if you don't remember any words in a sentence. If the sentence I wanted to say was "The cow jumped over the moon," I couldn't remember the word for cow. Even now, I have difficulty repeating a sentence back. It's like the recall button takes longer to bring things to the mental screen. Names escape me the minute I hear them. I still have difficulty with my memory. If I don't write things down, forget it -- which is usually what I do. But I forget to write things down. I have only short-term memory now. I thought it was just aging.

I didn't know this could possibly be related to menopause until Dr. D. told me that it could. Before him I went to an Italian gynecologist about all of this, and he just didn't believe in taking hormones. The speech difficulties he said were due to stress! He said to relax, which didn't help much.

For the last seven to ten years I've felt like I was in a bubble. I've only recently come out of that bubble. I felt like I was in a vacuum and certain things weren't important to me, like the silver candelabra my mother left me when she died. My family thought I was crazy. "Leave her alone," they would say. My daughter would say this too. My sister even tried to take advantage of my memory problems. She thought I had forgotten that she had the candelabra and acted surprised when I asked about it a year later.

But o ther times if something wasn't directly in front of me it was out of my mind, as if I had amnesia or something. At different times I've forgotten my ATM code, my social security number, my family's birthdays, which I've had in my mind forever. They just flew out and later just flew back in. That's what it feels like. It feels like you are going crazy. You don't know what's going to happen next.

How did I manage at work? My husband is dead now and I work in a doctor's office on billing. The computer has a format for what I do so I can handle it. I have to focus in on it but I do OK. I've been at it a long time. At home I studied to become a travel agent a couple of years ago when it was really bad and things would just go out of my head, I have to read something over and over and over to retain it and within a week it's gone. I'll forget it like I never read it before. It all feels brand new if I read it again.

Now it's a lot easier. Whatever was going on with me the last ten or so years has leveled off. It was a really bad time. I just recently went to Dr. D. He wants me to take estrogen. He's for it but I went to two other gynecologists who were against my taking estrogen. They still don't relate any of this to menopause. Dr. D. knew what I was talking about and said it's related to menopause, but nobody else ever said that. I'm still not sure of taking it [estrogen-progesterone hormone replacement therapy (HRT)], even though nobody in my family ever had breast cancer. The other doctors said not to. So I'm not sure yet what I'll do.


What is revealing about Quiana Mortier's case is the many years that this syndrome can apparently persist and that it can become better with time; also, that verbal and perceptual (cognitive) errors together with reduced control over her emotions were Ms. Mortier's earliest symptoms, preceding hot flashes and menstrual irregularity. What stands out too is the misdiagnosis of her symptoms as "paranoid schizophrenia" by an internist, and complete unawareness of the basis for her symptoms by other physicians, except for Dr. D., a male ob/gyn who specializes in treating perimenopausal and menopausal women and has been correctly sensing what women have been trying to communicate to him about their experiences over the years.

WOMEN, WHMS, AND DOCTORS: WHAT HAPPENS NOW WHEN WOMEN REPORT THEIR SYMPTOMS TO DOCTORS

The bigger picture at present is that most physicians know very little if anything about the specific mind/speech/behavioral symptoms I have named the WHM Syndrome. They haven't been taught of their possibility during medical training. They may have learned something about these symptoms if they have been carefully listening to some of their patients over the years. However, some women, as we've seen, don't go to physicians about these symptoms for multiple reasons, but some women do speak up about their symptoms.

At present when women go to their ob/gyns or other physicians with their symptoms here is what may happen:

1. Women are told to relax more, or to take a vacation, that the symptoms are probably stress-related. The cost of following this seemingly innocuous advice, however, can sometimes be high. A woman with multiple WHM symptoms, for example, was led by her doctor to believe her symptoms were due to stress. She quit an exciting, demanding job she loved, only to discover her symptoms did not improve at all with a less stressful job, but got worse. They did improve significantly after she was put on a three-month diagnostic test-trial of estrogen alone to see if estrogen decline was the basis for them. When she had determined that her symptoms were related to estrogen loss, wary of estrogen for family history reasons, she then went off the pharmaceutical estrogen her doctor had prescribed and turned instead to weaker plant-based estrogens, phytoestrogens. And it worked in her case. The three months of estrogen was used as a diagnostic tool, to identify the cause of her symptoms. (See chapter 10 on treatments.)

2. Women are told the symptoms are the result of aging and to "accept it" as inevitable.

3. Doctors, like many other human beings, tend to deny or dismiss what they don't understand. And their training to date hasn't included any grounded scientific rationale that would logically explain the basis for the symptoms. So women are given "It's probably nothing" admonitions, or quizzical looks that imply they don't know what they're talking about. The tone of these encounters is "if the doctor hasn't heard about it, it is probably nothing too important, or it doesn't exist."

4. Women who show up in doctors' offices with WHMS can be misdiagnosed as having a psychotic condition. You saw that this is what happened to Quiana Mortier. Describing her WHM symptoms as best she could, "strange words popping out" and "things being there and then not being there," Mrs. Mortier's internist attributed her strange unfamiliar symptoms to a psychotic condition, paranoid schizophrenia, and gave this diagnosis to her husband but not to her directly. But what if her job had depended on this diagnosis? What if this diagnos is unbeknownst to her became part of a permanent HMO medical record made available to others? Mrs. Mortier's prudent decision to see a psychiatrist for a second opinion paid off in her case, when the psychiatrist was forthright enough to say he didn't know what disorder she had. But do all psychiatrists exercise this option? How often can they say "I don't know" to those who refer patients to them for a diagnosis? I don't know.

5. Sometimes women with WHMS symptoms are diagnosed as having Attention Deficit Disorder (ADD). Two women with WHMS symptoms I interviewed were given this diagnosis, one by a psychologist, the other by a psychopharmacologist she was referred to. Both were advised to take Ritalin, the stimulant drug used to help focus attention in youngsters with ADD. Taking Ritalin helped one of the two women with WHMS symptoms. (Might this be a potential form of treatment for some women with WHMS attention changes?) Both women had no prior history of attention, reading, or word-reversal difficulties.

After interviewing these women I decided to interview several experts on ADD. I asked if ADD ever manifested with adult onset -- if the disorder could show up initially in adulthood without a prior history in childhood. I was told that in instances where ADD is first detected in adulthood, the assumption commonly made is that it was likely present in childhood but not detected or diagnosed at that time! It is my suspicion that in some women with WHMS an intermittent ADD-like disorder can show up in adulthood for the first time as one possible subset of WHMS symptoms in association with estrogen loss. It's important to be aware, however, that not all women with WHMS symptoms have ADD-l ike symptoms.

6. Sometimes women with WHMS who insistently pursue their quests for diagnosis at memory or Alzheimer's disease research centers within major medical centers are suspected of having early Alzheimer's disease and given this tentative diagnosis. Though they test normal on the battery of cognitive tests they are given, the symptoms these women describe lead clinicians to suspect a diagnosis of Alzheimer's disease, since the symptoms outwardly can sometimes appear to overlap. The women are then asked to return at regular intervals for follow-up testing and evaluations, to see what happens to their symptoms -- if they progress with time, stay stable, or disappear. What happens over time helps the experts clarify the diagnosis. Imagine, however, being told by experts that your WHMS symptoms might indeed be Alzheimer's disease! You might very well redirect the whole course of your life or live in a bubble of suspended anxiety if you thought your remaining cogent time on earth was likely very limited.

The reality is that Alzheimer's disease researchers know very little as yet about how true instances of Alzheimer's disease begin in very specific detail -- how they play out in everyday life. As a former Alzheimer's disease researcher, I know. I would often ask the relatives of patients I was evaluating what were the earliest signs they saw. Typically the first signs were only recognized in retrospect, after the full-blown picture of Alzheimer's had later emerged. "So that's why he acted so funny back then two years ago," they would say.

Alzheimer's disease researchers aren't yet aware of WHMS as a distinct set of symptoms among perimenopausal and menopausal women, even though they may be aware overall of the neuroscience research showing a connection between estrogen loss and changes in the structure and chemistry of the brain, and recent research on Alzheimer's disease and estrogen (see chapter 7). Alzheimer's disease experts are reading about the existence and details of the WHM Syndrome at the same time you are reading this. They aren't yet prepared to diagnose WHMS. They can't diagnose what they don't yet know. But they might mistakenly diagnose WHMS symptoms in relation to what they are familiar with and unintentionally derail the course of a life. I have nothing against the clinicians who diagnose memory disorders or Alzheimer's disease. I am merely cautioning women with WHMS symptoms about what could theoretically happen. Hopefully WHMS will be given the attention it deserves in research efforts so that memory and Alzheimer's diagnostic centers will be aware of it soon. Without intending to add to the fears of women with WHMS, I feel it would be negligent of me not to add that some true cases of Alzheimer's disease can occur within the age range of the forties and fifties. The youngest presumed Alzheimer's patient I ever tested was a forty-two-year-old male. It is my belief, however, that the preponderance of cases of WHMS in women are not manifestations of early Alzheimer's disease cases. As anchoring points for this view, I use as evidence the absence of droves of sixty-year-old Alzheimer's-like women wandering the streets of major cities. (If WHM symptoms are present to one degree or another in a significant proportion of fifty-year-old women, then if it truly represented the beginning of Alzheimer's disease, ten years should be sufficient time for the condition to "bloom" into Alzheimer's disease.) Also in my experiences as a health psychologist treating patients with chronic disease sometimes in rehabilitation and nursing home settings, I found few sixty-year-old women or men with Alzheimer's disease. For very specific reasons that will become clearer in a later chapter, I believe that WHMS in most women represents a "normal," though until now undetected, series of changes.

More Encounters with Doctors

Here are two more experiences of women with self-described WHMS symptoms and encounters with their doctors. They are letters to the editor that arrived in response to publication of my August 1997 article on "Estrogen and the Brain" in New York magazine.

Thank you for validating the absolute nightmare I lived for at least four years. I make a living as a salesperson on the wholesale level. I have always thought on my feet and counted on doing several things at one time. Words cannot express the sheer terror I lived through, losing my quick thinking and my memory, being depressed, and going to doctor after doctor who had no idea what was wrong -- and I was already taking estrogen.

Fortunately, I found a new gynecologist and she picked up my symptoms. My body was not absorbing enough [estrogen] to get me back on track mentally. [Women can differ biologically in their reaction to the same drugs.] Everything is now pretty much back to the way it was -- except that I lost a job that I loved and was working at for fourteen years.
(Name listed in the article, Manhattan)

Here is another:

How good to read [my article]. In my early thirties, I went into premature menopause. With it came what I call "teflon brain" and aberrant bou ts of halting speech. Pieces of simple information would fly through my brain, skipping over a slick surface....No small problem for a television-news producer. Of course, when I would tell this to my doctors -- and then add that it had to be because my brain was malnourished from lack of estrogen -- they determined that lack of estrogen had rendered me daft, not forgetful. Now, it seems medicine is wiser....
(Name, Manhattan)

THE WHM SYNDROME PARALLELS HYPOTHYROIDISM

In many ways the WHM Syndrome parallels, in its effects on thinking and behavior, an established hormone-deficiency syndrome that is also known for having cognitive/behavioral consequences -- hypothyroidism.

In those with hypothyroidism, the very basic hormonal "fuel" that "drives" the body's metabolism efficiently -- thyroid hormone -- becomes deficient for one of several reasons. People with insufficient supplies of the hormone can experience not just mood and physical symptoms such as bone-wearying fatigue and a persistent cloud of depression (as do some women with WHMS), but also well-established cognitive-deficit symptoms ranging from subtle to very serious, in memory, attention, and the fine-tuning of thinking and speaking. The precedent thus exists for a known hormone-deficiency state producing cognitive symptoms in the manner of WHMS. It is even possible that hypothyroidism and WHMS may be related, i.e., that estrogen loss may trigger changes in thyroid function. While little is known about the relationship of estrogen changes on thyroid changes, it is known that changes in thyroid functioning often increase significantly in frequency among women during intervals of rapid hormonal shifts -- e.g., f ollowing the birth of a child and around perimenopause and menopause. Some clinicians who treat menopausal women have observed that in association with menopausal symptoms often thyroid disregulation of one kind or another is not an uncommon finding. Moreover it has been discovered in recent years that the respective receptors that bind thyroid hormones and estrogens are part of the same superfamily of steroid receptors and may have evolved in tandem and work in tandem. Both are hormonal systems in charge of major, basic life-sustaining functions -- thyroid hormones for driving the metabolism of cells for daily living and estrogen for underwriting and "fueling" the survival of the species and directly or indirectly affecting many brain, bone, heart, and other body-system functions. Just as the symptoms of hypothyroidism are now known to be readily correctable with thyroid hormone replacement therapy, in the years to come, the cognitive and behavioral symptoms of the WHM Syndrome, I believe, will be formally recognized as a comparably correctable hormone-deficiency state reversible with estrogen hormone replacement or custom-designed drugs or products mimicking estrogen's effects in the brain.

WE DON'T CREDIT HOW MUCH NORMAL WOMEN CAN DIFFER FROM EACH OTHER BIOLOGICALLY AROUND REPRODUCTIVE HALLMARKS

It is my goal in this book to communicate what the WHM Syndrome is and what it feels like, but it is also my express goal not to do harm, not to paint all women broadly with the same brush since WHMS symptoms affect some women not at all, some only mildly, and some seriously. I believe that central to any woman's or health expert's understanding of WHMS symptoms, perimenopause, menopause, resea rch on menopause, and the treatment of menopausal symptoms is a considerably heightened appreciation of how much normal women can differ from each other with respect to any of the stages on the time line of women's reproductive events.

Consider for the moment what you already know about otherwise healthy normal women. Some have a monthly momentary twinge that announces their period is coming, whereas some go through days of premenstrual syndrome (PMS) agony with intense and disruptive mood and physical symptoms hammered in often by grueling migraine headaches. I have treated such women. Some women during pregnancy are sick to their stomachs practically every day while others fall in love with the psychological state pregnancy induces and keep wanting to repeat it over and over. Some women suffer postpartum effects that lead to thoughts of suicide and infanticide while others experience postpartum euphoria and bliss.

When I first heard about PMS and later postpartum depression as states that could induce dire mood alterations in women the truth is I suspected that some poor male psychiatrists had had the wool pulled over their eyes by females who were malingering for some unknown reason. I doubted that women could experience such intense reactions since I was a woman, after all, and assumed I knew what the universal experience of having a period was like. It was a "nothing" experience for me. Nothing to balk about. Only with time have I come to truly appreciate how diverse and divergent the experiences of women in this regard normally can be.

Let me share with you one moment of insight when this appreciation forcefully embedded itself in my psyche. Since graduate school I have use d medical/science journalism as a means for extracurricular graduate study, for developing expertise by getting paid access to experts I wanted to interview in relation to my work as a research psychologist and later as a clinical health psychologist. I could ask the experts "up close and personal" what I wanted to know. When I was working with patients with chronic pain I proposed to the editors of Psychology Today doing a profile of one of the leading research psychologists of our day, Dr. Ronald Melzack. Melzack and a colleague, Patrick Wall, had put forth an important theory on pain -- the gate control theory -- that ultimately stimulated generations of research and progress in the field of pain. Melzack had studied the experience of pain in women during childbirth and had earlier developed a novel pain questionnaire that helped in the communication of a difficult topic -- how much and what kind of pain a person had. When I interviewed him at McGill University in Montreal, Canada, he told me that the pain of giving birth could be compared to the acute pain of having a finger cut off. On the other hand he said there were some women who gave birth with no pain whatsoever. "No pain whatsoever?" I asked in amazement. "No pain whatsoever," Melzack said. I just couldn't believe such a thing was true so I asked the same question again in an even higher-pitched tone: "No pain whatsoever?" "No pain whatsoever," he said. Melzack indulged me this back-and-forth dance several times till I finally desisted and decided to store the information away, uncredited, in the back of my mind for some other day. It just seemed too amazing to be true.

Then one day into my office walked a woman who came to see me in my role as a health psychologist. In taking a history somehow the fact emerged that she had given birth with no pain whatsoever. "No pain whatsoever?" I again asked incredulously. "No pain whatsoever," she answered. I asked if this had ever occurred to anyone else in her family and she said, "Yes, to my grandmother. Maybe it skips a generation." At that pivotal moment of confirmation I "got it" -- the bigger picture about the variability among normal women. I accepted as true what Melzack had told me and what this woman had told me. More important I "got" the message that a rose is not a rose is not a rose. Menstruation is not menstruation is not menstruation in the same way for every woman; pregnancy is not pregnancy is not pregnancy for all women; delivery is not delivery is not delivery for every woman; that menopause and perimenopause are often far from the same experiences from woman to woman to woman. I realized that these reproductive biological hallmarks can and often do vary enormously among women so that, to overstate the case somewhat, there are virtually different species of women when it comes to the "fine-tuning" of their brain and body's reproductive infrastructure.

The morals: (1) You can't know the interior experience of the woman sitting next to you by knowing your own. (2) You shouldn't be intolerant of women whose experiences in this regard differ from your own. (3) You can't characterize the experiences of all women by knowing the individual experiences of some women. Some women first experience WHMS symptoms in their thirties, some in their sixties. Some never do.

The existence of many distinct biological subgroups of women means in terms of research on perimenopausal and menopausal women that very large-size samples are needed to get accurate findings that detect accurately what is true in nature about women. Small-size sample studies may obscure and find insignificant what may be very true in nature. What this means in terms of treatments for perimenopausal and menopausal women is that possibly very different forms or intensities of treatment may be needed to help women with different biological natures.

I became familiar with the research literature on menopausal women only after first detecting the symptoms of the WHM Syndrome via interviews with women. What I discovered in my interviews with ultimately some 160 perimenopausal and menopausal women did not correspond with what I later read in the professional "menopause research literature." I had interviewed women who reported being hot all the time, like Sherry Strumph and her friend. The menopause literature made no mention of such women -- though they might be in there somewhere I haven't yet read. Menopause experts I interviewed about such symptoms didn't know what I was talking about. Some even told me that women only developed hot flashes during menopause, not during perimenopause, which entirely defied what informants had told me.

I discovered there were more than a few women who were now menopausal who had never had a hot flash or only one to date, but who had lots of WHMS symptoms to one degree of intensity or another. These women didn't have physical symptoms to speak of. Their memory wasn't blinking from nighttime awakenings. Their relationships, their diet, and their exercise were essentially the same. Their ability to recall where they had just put something down wasn't. The menopause field said women with lots of complaints around the time of menopause who went to menopause clinics for help were having secondary reactions to their body symptoms and tended to overuse the mental health and health systems altogether, i.e., they were crackpots, so to speak, and couldn't be assumed to be representative of most menopausal women who didn't go to doctors. To the contrary, I discovered that quite a few women with many WHMS symptoms and other mood complaints rarely or never went to doctors for help and that women who did seek out help were not typically crazy; but likely resourceful or desperately bothered by biological systems, which weren't doing what they expected them to.

This insufficiently recognized biological variability among women with regard to perimenopause and menopause, together with the lack of awareness of the biological effects of estrogen loss on behavior, thinking, and physiology, has rendered invalid, to my mind, many of the present "findings" produced to date by the professional menopause survey research literature. Researchers haven't asked the right questions of women so they haven't learned sufficiently what is happening to them and what is affecting them. Though this may sound like criticism my intention is not to be carping. It is my intention to spotlight what needs to be added to future research. Anyone involved in science long enough knows from personal experience that most knowledge in science is provisional, that etched-in-stone dogmas diligently learned in graduate school or medical school can be overturned in a night. Future research in this field, I hope, will routinely acknowledge women's evident biological diversity and work toward find ing markers that predict that diversity. The field of menopause research needs to first observe women better and describe women's perceptions of change no matter the political fallout from either those who don't want menopause "medicalized" or from women fearful of finding biological differences among women or between women and men. It is time to acknowledge that not only do the sexes differ from each other in some important ways but that women can differ from each other in important ways. Understanding those differences, and in medical terms learning how to accommodate individual needs dependent on such differences, is where we should be heading.

Copyright © 1999 by Claire Warga

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Introduction

Introduction

This book is intended for women in their thirties, forties, fifties, and beyond who may be experiencing unusual come and go memory, speech, attention, behavior, thinking, and time-tracking symptoms no expert ever prepared them for and who want help in understanding and possibly treating such symptoms. It is for all women who may in the future experience such symptoms and prefer to be forewarned and forearmed rather than be caught helpless. It is for women who want to know the latest research news on the estrogen and Alzheimer's disease evolving frontier.

This book is also for women's physicians who want to understand the plausible basis for cognitive, speech, and behavioral symptoms women experiencing perimenopause, menopause, or estrogen loss for any reason may be reporting to them.

Lastly, this book is for neuroscientists eager to mine not merely a good but a "great" research topic rife with the potential for yielding not only major pure science discoveries about the mind and brain but discoveries that will have life altering applications for millions and millions of women now and in the future.


In this book I make a rather dramatic revelation, I report that there is something new under the sun about women's biology that has been missed before: a set of interior, sometimes visible symptoms that frequently occur in association with menopause and perimenopause in many but not all women that are as common, normal, similar in cause, and variable in pattern as hot flashes are. These symptoms have been previously overlooked because no one asked women the right questions. Most of the health and mental experts women see today, I maint to those who have them. When the stakes of reproducing the species, i.e., species survival, are no longer an issue, "nature," I contend, pragmatically draws an exhaling breath of relaxation and says in effect, "You no longer need to be as tightly tuned for hypervigilance as before. It's OK to just 'be' during this time." The subtle symptoms of what I have named the WHM Syndrome (WHMS), for Warga's Hormonal Misconnection Syndrome, I contend, are the outward signs of that relaxation, of that altered biological agenda.

For modern women who intend to live long and well beyond the end of their fertility and whose quality of life is affected by these symptoms, biology need not be destiny I say. I point to plausible ways for living longer well, presenting the input of neuroscientists, menopause, and memory experts, who offer scientific rationales for treatments. I offer self-help behaviors that can have neurological/physiological consequences, along with practical little-known self-help aids and tools.

I argue that these symptoms are now epidemic among women because the first waves of the baby boom generation have reached the maturational landmarks of perimenopause and menopause and will continue to hit those markers in great numbers for some two decades to come. Ignoring women who suffer most with this syndrome, I suggest may have important public health consequences now and quite possibly for the future of our nation.

My goals in this book are:

* First and foremost to help women with these symptoms understand what they are experiencing now
* To educate the medical and mental health professionals women see so they can help women now
* To put this syndrome on the scientific map so tha t researchers can investigate all facets of its basis and devise multiple safe strategies for helping women now
* To offer researchers a testable scientific rationale for the syndrome that has heuristic value, that can be aimed at and validated, or if need be, shot down
* To draw attention to an as yet unrecognized major public health epidemic affecting the lives of millions of women now that may have important long-term consequences.

BACKGROUND

In this book I report on a discovery I made in the fall of 1996 -- the WHM Syndrome -- after several years of initially detecting "glitches" in speech and behavior in women I knew very well in diverse settings.

Some of the women I knew well from my work as a New York state-licensed psychologist treating patients with health and stress-related problems with the tools of health psychology and behavioral medicine. They told me things, which at first I didn't understand, but which I mentally tucked away somewhere.

Some of the women I knew well from belonging to two reading groups that met monthly for over a decade -- that still meet -- and that included, on average, eighteen to twenty women, some my age, some older, and some younger, spanning in recent years ages from about thirty-eight to sixty-two. I knew these women to be highly bright and verbal. And the monthly spacing of our meetings provided sufficient distance to "see" changes in some of them over time. The intimate familiar nature of these groups also made it possible for me during my initial inklings of discovery to get individual confirmation from more than a few women in private about the reality of the symptoms I was detecting. I received more of the same confirmation from inter views with women I had come to know while living outside of New York City for a number of years, who were, on average, four to seven years older than me. The women I collectively observed in these settings were all either perimenopausal or menopausal. Considerable trust I believe is essential for discussing these symptoms, though sometimes need alone will suffice.

Confirmation of what I was detecting fueled my later drives to obtain interviews with many women I did not know about what cognitive or behavioral or speech symptoms they associated with perimenopause and menopause. I solicited interviews with these women through advertisements and referrals made by ob/gyns. I also interviewed women I did not know who responded to an article I wrote in New York magazine in 1997. But I am getting ahead of myself.

At some point in the fall/winter of 1996 I could stand it no longer and set off one evening to find out if science knew anything about the symptoms I was detecting in women. I went to do a computer search at the medical library of New York University Medical Center, where for three years I had done research on Alzheimer's disease years before, as a clinical research psychologist testing Alzheimer's patients on a neuropsychological test battery before and after experimental treatment with hyperbaric oxygen.

I loved the medical library and knew it well. Fishing to see what would turn up, I typed into the computer such paired terms as "menopause" and "mind" and came up with very little if anything. I persisted typing in different terms until I suddenly hit gold. I had typed in "estrogen" and the "brain" and out poured a wealth of references and abstracts mainly from the 1990s from leading research laboratories that represented a virtual revolution in prior thinking about both the brain and the roles of estrogen.

Estrogen loss, some of the studies noted, could produce detectable changes in parts of the brain having to do with memory and attention and could affect multiple neurotransmitter systems involved in thinking and memory. Other clinical studies found small but consistent (reliable) evidence of changes in verbal memory and learning in women with estrogen loss. I'll let you read about these discoveries in chapters 3, 4, and 5.

I didn't initially understand the overall significance of many of these studies, but what I did understand was that they could easily dovetail with the observations about unusual symptoms I had made in women -- they dealt with overlapping areas of function. In my readings later I discovered that neuroscientists had actually been wondering how their basic-science discoveries in animals about the potential effects of estrogen loss on the brain would show up in women.

After reading through these studies, facilitated by my earlier study of the neurophysiology of sleep and wakefulness with the eminent scientist Dr. Raul Hernandez-Peon, and later research on the psychophysiology of sleep, dreams, and sexual arousal, I next started calling for interviews with the experts who had published the research I had discovered in the medical library. I had learned that I could pretty much call any expert for an interview, when I had adventitiously stumbled into a side career as a medical/science broadcast and print journalist, during a return to graduate school for a doctorate in psychology at New York University, after a near decade engaged in exciting research as an experimental psychologist. (I had a master's degree in experimental psychology and additional graduate courses.)

My interviews with these experts convinced me that the symptoms I thought I had detected were not merely a figment of my imagination and that there was a plausible scientific basis for them. Dr. Bruce McEwen, an eminent research psychologist and neuroscientist who had done much of the important research in this area with students and colleagues at Rockefeller University and was president of the Neuroscience Society that year, in particular, surprised me by being aware that women were having these difficulties. He urged me on in my efforts.

I wanted to find out if women were being told by anyone about these possible symptoms, since the research evidence supporting their existence was "out there." And so I next called officers of the American College of Obstetrics and Gynecology and the North American Menopause Society to see if their organizations formally recognized any speech, memory, attention, or cognitive/behavioral symptoms in women, in the educational materials they made available to women patients in doctor's offices. They didn't, I soon learned. I decided to find out why. So I called the presidents or scientific directors of these organizations to find out if they were aware of the estrogen/mind/brain research. They were, I discovered. Why then, I asked, weren't they informing women that cognitive changes could be associated with the hormonal changes of perimenopause and menopause. "It was too soon," the leader of one group said. They were waiting "to develop consensus," a leader of the other group said. Meanwhile, as I saw it, millions of perimenopausal and menopausal baby boomer women in the midst of high-demand lives were floundering in the dark, silently wondering what was happening to them. I felt I had to act in some way.

I contacted the director of the New York City branch of the Women's Health Initiative, the huge government-sponsored national study assessing among other things the effects of estrogen on women, and met with her, presenting a list of the symptoms I had by then enumerated. She was very interested in what I had to say, appeared to recognize the merits of what I was describing, and suggested I write up an "ancillary study" for her to submit for review to the national head of the Women's Health Initiative Study at their upcoming meeting in two weeks. The ancillary study was submitted and ultimately rejected.

I decided to use my sideline skills as a published medical/science journalist to get word out to women about these possible symptoms, which I had discovered could vary in intensity and inconvenience in different women in much the same way that hot flashes did. On August 11, 1997, I succeeded in having published a cover article in New York magazine titled within the magazine "Estrogen and the Brain" and "Can Estrogen Make You Smart?" on the cover. The focus of the article was the little-known new research on estrogen and the brain and a conference titled "Estrogen and the Brain" that had been held recently at Mount Sinai Medical Center to present the new research. At that conference the president of the Mount Sinai School of Medicine and the Mount Sinai Hospital, Dr. John Rowe, himself a leading researcher on aging, had opened the proceedings by saying that on the basis of the new research "The equation for taking estrogen has now cha nged....We know now that women taking estrogen after menopause reduce their chances of getting cognitive impairments" -- not a wishy-washy statement.

My article alluded briefly to the symptoms perimenopausal and menopausal women were experiencing and that I describe in detail for the first time in this book. After the article was published, I received countless phone calls from friends and friends of friends -- total strangers -- who said they were so relieved that there was a basis for their symptoms and that they didn't, as feared, have Alzheimer's disease or a brain tumor. For months after the article came out, at parties and meetings, women with the symptoms came up and told me conspiratorially what had happened to them. The president of the Ms. Foundation, Marie Wilson, who had experienced some of the symptoms I described, reported that friends of hers too feared they were developing early Alzheimer's disease or a brain tumor, in a letter to the editor at New York magazine published September 9, 1997, in response to my article. (In my article, the president of the National Organization for Women, Patricia Ireland, also had acknowledged experience with word loss and uncharacteristic scheduling errors -- WHMS symptoms -- before treatment reversed her symptoms.) Shortly after the article came out, when I attended a meeting of the North American Menopause Society in early September in Boston that year, I was amazed to discover how many people there were suddenly familiar with the article. At a party at the New York Academy of Sciences I discovered that copies of the article had been distributed by the academy at a fall meeting on estrogen and the brain. I was delighted that the message I h ad sent out was finding an audience. That message is presented in much greater detail in this book.


Looking back it seems to me now that virtually everything I have ever done professionally as a basic sciences researcher, and as a clinician interested in seeing how "adaptation to stress" really works in people from the "laboratory" vantage point of a private practice (in health psychology), has been relevant to my detecting these symptoms and what I suspect they mean. Even many of the readings I did as a science journalist in preparation for radio interviews with leading scientists, while working toward my doctorate in psychology were interviews in the fields of sociobiology, evolutionary psychology, anthropology, and physiology: interviews with Edward O. Wilson, Donald Symons, Niles Eldredge, Donald Johanson, Mary and Richard Leakey, Tim White, Rene Dubos, Sir John Carew Eccles, and others. Even the many articles I wrote for medical and popular magazines on women's reproductive lives, infertility treatments, and other aspects of women's health have proven relevant.

Reviewing the work I have been engaged in most of my adult life has revealed to me that unwittingly I have been virtually "tap dancing" around topic areas that border on the study of the science of perimenopausal and menopausal women in virtually a connect-the-dot fashion that leads to the present picture. In the study of adult life development my life would make an interesting case example of something, I'm not certain what, since not only self-direction but factors I had no control over -- the deaths of two relatively young people I worked for -- shaped the course of my work.

My earliest research was at Bar Harbor's Jackson L aboratory for Mammalian Genetics Research. There under a National Science Foundation fellowship I independently studied what pregnancy, over its course, does to the self-regulation skills of the body -- its bounce-back ability (homeostasis). I examined the effects of different stages of pregnancy on the ability of mice to get their body temperature back to normal after exposure to cold, a stressor. For this research I studied reproductive endocrinology and the physiology of temperature regulation, both areas that prefigured my present interest in the effects of hormonal changes in women (hot flashes). I later did research on the psychophysiology of sleep, dreams, sexual arousal during sleep, insomnia, and the effects of different emotions on the body at the Psychophysiology Laboratory of what was then Downstate Medical Center and is now known as SUNY Health Sciences Center in Brooklyn.

After the fifty-three-year-old leader of our research group unexpectedly died, I studied sleep and dreams again in research at New York University's Research Center for Mental Health. Both research positions again entailed study of topics that bear directly on the many mysteries that still surround the experience of perimenopause and menopause for many women: potential sleep disruptions, potential changes in sexual arousal, potential changes in emotional lability and baseline mood.

When yet again the relatively young leader of our research team died unexpectedly at fifty-four, I became involved in research on an experimental treatment for Alzheimer's disease and studied the research literature on memory, aging, and Alzheimer's at NYU Medical Center's Rusk Institute for Rehabilitation Medicine. I observed "up close and personal" all the cognitive/behavioral/speech "glitches" of patients in different stages of decline during lengthy hours of testing and of interviewing them and their relatives, before and after treatment with hyperbaric oxygen.

Familiarity with these patients primed me for "thinking about thinking" and for detecting WHM Syndrome symptoms. Familiarity with Alzheimer's patients also prepared me for noting the distinctions between Alzheimer's disease and WHMS symptoms even when they appear related.

A return to graduate school for a doctorate after this research led to my doing a doctoral dissertation in the field of neuropsychology on the role of the two hemispheres of the brain in the expression of positive and negative emotions and how these can show up in subtle differences between the two sides of the face during the expression of emotions. The topics of brain-control-over-emotion and neuropsychology again bear upon issues central to my interests in understanding perimenopausal and menopausal women.

After receiving my doctorate from NYU in 1982 1 became director of research programs at the new Institute for the Advancement of Health, then in New York City. It was devoted to funding and giving prominence to the then-emerging interdisciplinary mind/body/health field of psychoneuroimmunology. I began to fund research, organize and attend conferences, and write about developments in different facets of psychoneuroimmunology. At that time psychologists/psychiatrists didn't know or read much about immunology, and immunologists didn't know or read much about the mind and brain. I loved my work and in relation to it even studied immunology at Mount Sinai's School of Medicine. I was immersed dai ly in research findings that described the negative compromising effects of stress on different aspects of the body, brain, and mind. But while the research was highly credible and intriguing intellectually, the fact was that it didn't mesh with my personal experience in living. I had long thrived on stress. Stress made me feel intensely alive, and I enjoyed rising to the occasion of it, having "Mission Impossible" tasks to accomplish in "x" number of minutes or hours. I enjoyed the "rush" of skiing and even liked to play the piano and type fast, even if I did both badly. I had long enjoyed the excitement of working on multiple projects at once, e.g., the science journalism while in graduate school.

Intrigued by conferences I had been part of, and experts I had heard, to make sense of it all, I decided to become retrained in the "applied" end of psychoneuroimmunology, the then also emerging fields of health psychology and behavioral medicine, and see how life really played itself out in relation to stress. My prior research in psychophysiology related directly to this new work. Over the course of three years I received training in biofeedback; cognitive therapy; hypnosis; pain management; and the self-regulation tools of progressive relaxation training, imagery, breathing and meditation techniques (initially being as much of a skeptic and an unrelaxed person as one could be). Before starting my own private practice I trained in the offices of a neurologist who had many car accident patients suffering profound headaches, backaches, and post-traumatic stress reactions. My main interest was in wanting to hear and understand what happened to people with life stresses -- acute and chronic illnesses, pa in states, panic attacks, headaches, irritable bowel problems, upcoming surgery -- how they managed, what they said to themselves, what made things better, what made them worse.

I was very interested in what happened to patients' lives around their symptoms, and over time, I became adept at teaching and applying the tools of health psychology and behavioral medicine and looking for patterns. You could say I became a sick person's delight. I didn't easily tire hearing the details of symptoms. I wanted to understand their subtleties, detect their sequence in relation to other events, understand what thoughts and feelings they triggered. I enjoyed demonstrating how even a fast-talking, hyper child of wound-up Holocaust survivors could relax in an instant, becoming a puppeteer over my nerves and muscles and mind when I needed to. I enjoyed teaching patients how they could make use of a "medicine shelf" of behavioral tools that could be "popped" in an instant, anywhere, once learned, that could adjust and "tune down" their physiology and mind efficiently and with multiple levels of "payoff."

The relevance of this work to the present is that I became a fairly good listener and observer tuned into observing people and trying to understand the subtleties of their symptoms from their perspective. Biofeedback, for example, taught me not to trust my first impressions. From working with it I learned that people who could look outwardly cool and calm could be highly tense when measured with muscle-tension and temperature-monitoring devices.

So here I am.

It is my hope that this book helps many women now and over the long run. In the course of researching it I have also come to the suspicion that for simi larly hormonal reasons, having to do with estrogen's newly discovered roles in both men's brains and bodies, that some men at similar ages also experience at least some WHMS symptoms. In chapter 14 of this book I explain what I have uncovered in this regard.

I also believe that WHMS symptoms are "normal" in the way that hot flashes are "normal" and use new evidence I present of WHMS symptoms existing in estrogen-deprived breast-feeding women in chapter 6 to frame the claim of "normality." I also propose that the experience of women with WHMS symptoms may offer us a novel perspective on one possible basis for the symptoms of attention deficit disorder in children. So stay tuned. This is an evolving story that will have many ramifications.


The postwar population boom we commonly refer to as the baby boom generation lasted for an amazing length of time -- twenty years according to some sources, eighteen according to others. In 1997 the first wave of baby boomer women reached the average age of menopause. For the next eighteen years millions of baby boomer women will be hitting that marker if they haven't already. Many of these women during years of perimenopause have already been experiencing in great perplexity the on-and-off array of intermittently flashing symptoms I have named the WHM Syndrome, without knowing what was happening to them or who they could turn to for help.

These women need to understand now what is happening to them. Before they give up careers and jobs they have often spent long years training for and striving at. Before they start sidelining themselves out of dreams and plans and hopes from a sense of despair and hopelessness. Before others needlessly sideline the m out of a salary they and their families may be depending on for survival.

At present, as I see it, the world of science knows virtually nothing about the many kinds of WHMS symptoms that are possible with estrogen loss. The research "pipeline" of science could take years to investigate and credit this syndrome with the gold-standard imprimatur of double-blind, placebo-controlled trials. The results of the Women's Health Initiative Study will not be out until the year 2008. And at present in this study the effects of estrogen on some aspects of cognitive functioning are only being examined in women sixty-five years and older. While interest in women of menopausal age is growing at the research level, it will take a long long time, I fear, before researchers in turn discover that some proportion of women, even in their thirties, can be affected cognitively by hormonal loss (as you will see in this book).

It is my belief that the converging evidence on what estrogen does, in different animal models, in women deprived of estrogen for different reasons and given replacement hormones, in women at different hormonal tides in their menstrual cycle, in cell culture, from epidemiological studies of the effects of estrogen therapy on the risk of developing Alzheimer's, collectively offers a sufficient basis for alerting women now to what may be happening to them and to their options, particularly since estrogen replacement therapy is already an available treatment with many other proven benefits to women.

In view of the epidemic number of women potentially affected by WHMS symptoms today and in the near future, in view of the evidence of the potential reversibility of the symptoms by estrogen and in th e future likely with yet-to-be designed estrogen substitutes, in view of the fact that knowledge alone can relieve the suffering of women fearful about the meaning of WHMS, and in view of the potential personal and public health costs of not doing so, I believe women need to be informed of their options now so that they can become health research advocates acting to secure the research they need now. So they can educate each other and, if necessary, their doctors. To do otherwise, to not inform women in light of what I know, for me would constitute neglect.

Lastly, as you read this book I ask you to ponder, as I often have, the question "How could this syndrome have been kept a secret for so long?"

Claire L. Warga, Ph.D.

Copyright © 1999 by Claire Warga

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  • Anonymous

    Posted October 31, 2000

    At last ! Menopause as understood by a women

    After spending numerous trips to the doctor, and seeking help with a neurologist, therapist and being tested for ADD, I find this book and at last I found relief & answers for those women who are afflicted with short term memory loss, fogging thinking and the feeling that you are losing your mind. This women has the credentials, interest and 20 years experience in women's health...FROM ALL ASPECTS OF MEDICINE...to explain at least what I had been suffering. This book discusses in great lengths what is available now, whether it is Hormonal Therapy ( pro's & con's )as well as non-hormonal approaches. In medical school the topic of menopause gets two hours of discussion, and yet women can be in perimenopause or menopause anywhere from 3 to 10 years...We need more scientific research and more books like this for women, to explain this baffling cognitive disorder.

    2 out of 2 people found this review helpful.

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