text:
You're often flushed and feel like you're burning up. You're no longer excited about sex. Your joints seem more achy than usual. And your temper? It's never been so hot. Welcome to menopause.
Find out what's going on with your body and mind and what can you do for yourself during this uncomfortable time. We'll walk you through the basic symptoms and their solutions. Our expert will cover the pros and cons of hormone therapy, diet and exercise tips, what to do about hair loss and fatigue, and more.
Welcome to this HealthTalk show. Before we begin, we remind you that the opinions expressed on this show are solely the views of our guests. They are not necessarily the views of HealthTalk, our sponsors or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you.
Now here's your host, Elizabeth Austin.
Elizabeth Austin:
Hello and thank you for joining us for Menopause 101: A Survival Guide. I'm your host, Elizabeth Austin.
Every woman experiences it differently. For some it's hot flashes, cotton brain and a quick fire temper, while others barely notice it. That's just one of the mysteries of menopause. No matter how it manifests, it's a time of genuine change - physically, mentally and emotionally. In this show, our guest will give expert advice on all questions menopause. She'll discuss a variety of physical symptoms, try to explain the physiology behind extreme emotions and help you understand why your sex drive went MIA. We hope you'll learn how to help manage your symptoms and make treatment choices that are right for you.
Joining us is Dr. Marcie Richardson. Dr. Richardson directs the Menopause Consultation Service and is the assistant medical director for clinical quality in obstetrics and gynecology at Harvard Vanguard Medical Associates. She's a clinical instructor in obstetrics and gynecology at Harvard Medical School. She practices general obstetrics and gynecology at Harvard Vanguard and Beth Israel Deaconess Hospital in Boston. She served on the board of trustees for the North American Menopause Society (NAMS) for nine years, where she sat on the executive committee and was past chair of the NAMS education committee. For the past 15 years she's served on the advisory board of Harvard Women's Health Watch. She was an editorial adviser for the production team of "Our Bodies, Ourselves: Menopause," published in 2006 by the Boston Women's Health Book Collective. Welcome, Dr. Richardson.
Dr. Marcie Richardson:
I'm delighted to be here.
One mystery of menopause is its actual definition. Technically, menopause is the last day of your last period, but the symptoms and conditions caused by menopause can go on for years. Doctor, can you tell us what is happening in our bodies when we experience menopause? Why does the process last so long?
Dr. Richardson:
Well, actually menopause starts when you are in utero, because the ovaries start losing eggs while the fetus is still developing inside his or her mom. And these eggs continue to sort of die off without actually ovulating throughout a woman's life. But as a woman gets into her late thirties and forties, other functions of the ovaries sort of sputter out, if you will, and the regular hormonal monthly ups and downs that we're used to that are responsible for our menses start to change in character. In particular, the first sign that women usually notice is that their cycles get a little shorter, and this will happen in the late thirties and early forties.
The other obvious thing that happens to women as they age is their fertility goes down. And if you look at societies where women are not using any birth control, as women get into their late thirties and early forties they aren't getting pregnant as frequently. But then women start to skip periods, and they develop hot flashes, all as a result of the changes in ovarian function. And women talk about menopause as not just the final menopause - because you don't know at the time of the final menstrual period that it is the final menstrual period - rather, we talk about the changes that we notice in our cycling over the course of the years prior to and after the final menstrual period.
Doctor, at what age does it typically start, and how long does it usually last?
Dr. Richardson:
Well, the average age of menopause, which is the final menstrual period, is 51. Things that make it come earlier include smoking because it's so toxic to the ovaries. Perimenopause seems to have been getting longer and longer in the eyes of scientists. For many women, perimenopause - the years before menopause when she starts to notice symptoms - lasts four to eight years.
Can you explain perimenopause to us in a little more detail? What are the signs that perimenopause is underway?
Dr. Richardson:
Well, I think I've mentioned them, but again women first notice that their periods are coming a little closer together. Lots of women in their forties notice that they have more mood swings associated with their menstrual cycle. Hot flashes are different for every woman, but most are just an incredibly intense sensation of heat that starts as the menstrual cycles start getting more irregular. I think that those are the main things that women notice while they're still menstruating. So symptoms of menopause are menstrual irregularity, hot flashes, up and down moods. Sometimes they'll notice some vaginal dryness. Sometimes they'll notice some sleep disruption.
Okay. So is there a way for a woman to prepare her body for menopause before it happens to sort of ease the experience?
Dr. Richardson:
Well, I think the answer to that is something you've all heard many times, which is I think taking care of yourself by eating well, exercising, not smoking, not drinking too much alcohol and finding ways to dissipate your stress. All of those things are the things that women need to do throughout their whole lives, but especially around the menopause transition.
I've heard some women, young and not so young, blame menopause for a wide variety of emotional symptoms. You mentioned mood swings and sleep disruption. But how can you tell which of those things are related to menopause or perimenopause and which are maybe just symptoms of some other kind of stress? And is it even important to make that distinction?
Dr. Richardson:
I think women are the experts on their own bodies, and when they notice changes associated with the hormonal changes and menstrual changes that we know are from menopause, I believe them. On the other hand, women are also aging, and many of the symptoms that we associate with menopause are also associated with aging. In addition, I think it is a stressful time for women. They have teenage children. Sometimes their relationships are in trouble. Sometimes they have responsibility for the care of their elderly parents. It's a stressful time, and we know well that stress takes a toll on our body. So sometimes I think it is pretty hard to sort out what's what.
I think if your main problem is hot flashes then that's probably related to menopause, and you ought to talk to a clinician who can help you deal with that menopause related symptom. But if it's irritability or mood ups and downs, it's a little less clear where you should seek help for that.
Well, since this program is a survival guide for menopause, let's look at some of the more severe menopause related symptoms. You just mentioned hot flashes, and some people refer to them as night sweats. Are hot flashes and night sweats the same thing? And what's happening in the body that causes this?
Dr. Richardson:
That's a really interesting question. Yes, hot flashes and night sweats are the same thing. Night sweats are just how we refer to hot flashes that are happening at night. And what's happening in the body is still somewhat uncertain, but some interesting work is being done to sort it out. It looks like what happens is that the body's temperature regulation mechanism gets messed up. We have this very finely tuned physiologic process that keeps us at 98.6, because lots of the proteins in our body don't do well at different temperatures.
And what happens in a normal person is if you get overheated, say from running around a track or something, then you start to sweat and your blood vessels dilate, and that's to keep your core temperature normal. And when you're menopausal and having hot flashes, you're going to have that process kick in earlier. So we think your body is thinking you're getting overheated and then your body tries to dissipate heat, so you flush and you sweat and you have a hot flash. And then lots of times after that, women will feel very cold and they'll start shivering because then the body thinks it's underheated, and you shiver so that you'll get back to where you want to be.
So do hot flashes occur with any particular pattern, like six times a day for three years?
Dr. Richardson:
You know, every woman has her own script. And every woman has triggers, and it actually can be helpful to try and pay attention to what your triggers are - triggers such as drinking a cup of tea; I always get hot flashes when I lose my keys. So I'm trying not to lose my keys as often. I think that alcohol can be a trigger; spicy foods can be a trigger. Then some women have hot flashes every hour on the hour, some have them occasionally. On average they last from three to five years. They tend to be the worst in the year following the final menstrual period. I have some bad news, which is that there's a study from Scandinavia that shows that 10 percent of women over the age of 70 are still having hot flashes.
Wow. That's a long time. So you've mentioned some of the things that might trigger hot flashes, but can you tell us about some strategies or treatments to deal with them?
Dr. Richardson:
Sure. I think that these are somewhat self evident but nevertheless worth going over. Wear cotton clothing so that you can breathe through your clothing, or dress in layers so that when you start to get hot you have something to take off and when you get cold you have something to put on. Identifying and avoiding your triggers is helpful. I have one patient who suggested that you put one of those frozen ice pack things under your pillow at night, and then when she wakes up with the night sweats she turns the pillow over and the bottom is nice and cool.
Don't take a hot shower before you go to bed because that heats you up. Sleep in a very cool room, another thing that can help out. I find after I have a hot flash if I go wash my hands with cold water that that kind of settles me down some, and it also makes my hands feel clean after they've been feeling really sweaty and unpleasant. And since I can't jump into the shower during the workday, I've found that washing my hands in cold water makes me feel a little better.
Those are terrific tips. But are there ways to prevent them? I think I've heard that hormone replacement therapy is sometimes used for that. What's your take on that?
Dr. Richardson:
There are a variety of other interventions. In particular, there has been some data suggesting increasing the soy in your diet or increasing the plant-derived estrogen can help. This is supported by the observation that women in countries where they eat a lot of soy don't have hot flashes as often as women in Western countries do. And then there are herbs that have been suggested for preventing hot flashes. The one that has the most data supporting it is a Native American herb called black cohosh. That herb, however, doesn't seem to work universally.
One of the big problems with studying hot flashes and their treatment is that there is a profound placebo effect. And if you give a woman sugar pills, about 30 percent of the time her hot flashes will get better. This can be looked at in another way, which is if a woman waits, her hot flashes in most cases will get better. And then there are prescription drugs which can help with hot flashes. Estrogen, as you said, is certainly far and away the most effective drug for treating hot flashes, although as you all probably realize, estrogen has been shown to have some pretty dangerous side effects.
So why is hormone replacement therapy (HRT) potentially dangerous, and who's at risk for that danger?
Dr. Richardson:
Well, this is a long, complicated story, but briefly, it looks like hormone replacement therapy has a wide range of effects in women. There was the notion in the '90s that hormone replacement therapy reduced the incidence of heart disease in women, and a study was done to support or refute that. And what that study - called the Women's Health Initiative - showed was that women on hormone replacement therapy had more heart disease, more strokes and more breast cancer.
Now, this isn't as straightforward as it seems because the average age of the women in the study was 63. So it's hard to totally justify applying the information from this study to women around the age of menopause, which of course would be 50. Also, it turns out with additional studies that there's evidence to suggest that it wasn't the estrogen that caused all these problems, but some of the problems may have been the result of the progesterone that was given with the estrogen to prevent women from developing cancer of the lining of the uterus.
So when all is said and done I think it is quite clear that estrogen increases the likelihood of a woman having a clotting problem, in particular a stroke or something called a pulmonary embolus where a clot breaks off and moves to the lungs. The relationship between estrogen and heart disease looks a little bit more complicated, and some of us believe that the reason the Women's Health Initiative showed more heart disease than the women on estrogen was because of their age and because of the additive effect of the progesterone.
And lastly, [regarding the risk of] breast cancer, I think that's really confusing to look at the data. And it turns out that women didn't have an increase risk in breast cancer until at least four years on the hormones. On the other hand, there wasn't such an increase in breast cancer in the women on estrogen alone, and I think there are some unsettled questions, although I feel quite certain that there is a relationship between estrogen and breast cancer in some way.
So clearly this is a very complicated issue, and it's complicated still by the fact that it's a viable option for some women. I'm curious, how do you talk to your patients about the risks and benefits, and does it really help anything except hot flashes?
Dr. Richardson:
Well, I talk to my patients about the risks and benefits like I've just talked with you. There's a very good Web site for the Women's Health Initiative (whi.org) with some nice graphs of the information from that study. I try to go over that with my patients. And then I talk with them about what they expect to gain from hormone therapy. I talk with them about the fact that most women can get a lot of relief from lower doses than what was studied in the Women's Health Initiative. And I talk with them about different delivery systems for hormones and the fact that it's possible that the clotting effects aren't as extreme when you use transdermal delivery systems where the hormones go directly into a woman's blood and avoid the liver. I tend to use patches because of that difference.
Regarding the benefits, I think things that are proven are that estrogen can help for hot flashes. It can help with vaginal dryness, although there are forms of local estrogen that are good for vaginal dryness, that is, a cream or a ring or some tablets that are put directly in the vagina, and not much estrogen gets into the system that way. And estrogen has been shown to be helpful for some women who have a lot of sleep disruption.
Now, the question of whether estrogen helps for a variety of other things, like mood, like sense of well being, is much more difficult to sort out. Although I personally think for some women estrogen seems to make them feel quite a bit better in a fairly nonspecific way.
I've also read that birth control pills have several times more estrogen in them than most hormone replacement therapies do. So is taking the pill a reasonable alternative to HRT?
Dr. Richardson:
Well, the pill is actually a very reasonable alternative for women who are in perimenopause. When women are in perimenopause, remember their ovaries are still making hormones, and if you put a woman on the pill then you suppress those hormones and the ovaries sort of shut down. So if a woman is having irregular periods and both peaks and valleys of estrogen and you give her the pill, you'll knock out the ovaries and she'll have much more even hormone levels, and she'll oftentimes feel a lot more comfortable.
However, once a woman has gone through the real menopause, you don't usually have to give her as much hormone as there are in birth control pills to give her symptomatic relief, because it's about four times more than are in hormone therapy. And one of the problems is that if you have a woman on the birth control pill, it's hard to tell when she's in menopause because you're giving her hormones.
Right. You're sort of masking the process.
So, Dr. Richardson, what are bioidentical hormones? Do they work as well as synthetic hormones?
Dr. Richardson:
Well, that's another complicated discussion. "Bioidentical hormones" is a term that's not really a technical medical term. But what people usually mean is the hormones have the same chemical makeup as the hormones that the human ovary makes on its own. So those would be estradiol for the estrogen. And it would be progesterone. It would be testosterone. And it might include small amounts of estrone and estriol, which are two other estrogens that the human ovary makes.
There has not been a lot of scientific study of the differences between bioidentical hormones and synthetic hormone therapy. And of course Premarin, which is the most frequently used hormone, is collected from the urine of pregnant mares or horses. So it's not really synthesized, but it's certainly not bioidentical. In any case, there are a lot of claims that have been made that bioidentical hormones are safer, and I think it's largely unproven. I think bioidentical hormones are just as effective in similar doses as nonbioidentical hormones.
Can you explain progesterone and how it affects a woman's hormonal replacement therapy regimen?
Dr. Richardson:
If you give a woman estrogen alone, eventually that will lead to the buildup of the lining of her uterus, and it can eventually lead to a cancer of the lining of the uterus or endometrial cancer. This was figured out in 1974, and since then doctors have been giving women progesterone along with the estrogen largely to prevent endometrial cancer. So that's how progesterone is used in hormone therapy. If women have had a hysterectomy, in general they don't need to take progesterone.
Now, the progesterone challenge test is when we give a woman who is not having periods a course of progesterone. And if this woman is making a lot of estrogen and then when we give her progesterone, she's going to get a period. And if this woman has not been making a lot of estrogen, when we give her the progesterone then nothing will happen. So that's what we call a progesterone challenge test, which is designed to see how much estrogen has been around in this particular woman over the last weeks.
So it's used to determine levels of HRT?
Dr. Richardson:
No, not exactly. It's used more to determine what's happening in a woman's body. Because taking a level of hormones on a woman who is perimenopausal is sort of like taking a picture of the speedometer when the car is in the garage. You have no idea what it did three minutes ago, and you don't know what it's going to do in the next 20 minutes. Because women's hormones are so up and down, doing blood levels is sometimes not very informative. But if you've had a woman who hasn't had a period and you give her progesterone and she has heavy bleeding, that means that she's been exposed to a lot of estrogen in the past few weeks. And if she has no bleeding that means there's no estrogen around.
Thanks for clarifying that. Another hormone you had mentioned earlier was testosterone. When should a woman consider taking testosterone?
Dr. Richardson:
Well, testosterone is the male hormone, but women have small amounts of it around too. And it's thought to be responsible for some of our sexual characteristics, like sexual desire and our ability to be aroused and our orgasmic function, although there's not a ton of scientific evidence about this. Over the course of a woman's lifetime her testosterone levels slowly go down. They don't dramatically fall off at the menopause the way estrogen does, but associated with the menopause transition some women do notice a loss of libido and a loss of the ability to be orgasmic, and we think at least in some cases this is associated with changing testosterone levels.
A special example of a problem in this area is women who have had their ovaries removed, because the female ovaries do make testosterone even in the postmenopausal woman. So when a woman has her ovaries removed they're not there to make any more testosterone.
So now who should consider taking it? Well, first of all, there are no FDA approved testosterone products in the United States for treating sexual dysfunction. There is one combined product with estrogen and an oral testosterone called Estratest, and that's approved for treating recalcitrant hot flashes. However, because testosterone is available, it's possible to have testosterone gels made up at a compounding pharmacy, and some women find that it can be helpful in dealing with their sexual dysfunction. As I say, this is especially true for women who have had their ovaries removed.
But I think it's really important to remember that the most important female sex organ is the brain. And for women who are experiencing sexual difficulties, it's key for them to think over what is going on in their lives that may be contributing to this. And furthermore, it's important to remember that there's not very much long term data on the safety of testosterone for women.
And do we know what some of the side effects are for using testosterone?
Dr. Richardson:
Well, if you end up using large amounts it can cause hair growth, it can cause acne. It can cause angry, aggressive behavior.
I want to ask about another symptom of menopause that can get in the way of a healthy sex life. And you mentioned this a little bit earlier, and that's the issue of vaginal dryness. What can women do about this condition?
Dr. Richardson:
Well, vaginal dryness is, again, probably a combination of aging and the absence of estrogen. And there are tons of lubricating products available over the counter. The one I usually send people to get is one called Astroglide. Or there's another one called Silk e. I think you have to try them and see what works for you. There is a moisturizing product called Replens, which is not used at the time of intercourse the way the lubricants are, but it increases the moisture in the vagina.
However, for women who are really having difficulty with their sexual activity because of the changes associated with menopause, local estrogen products are wonderful, and there are three different kinds. There's a ring called the Estring that can be inserted into the vagina and left in for three months. And then there are estrogen tablets or Vagifem, which you do usually once or twice a week. And then lastly, there are estrogen creams that can be inserted into the vagina. I tend to encourage the first two because they put less estrogen in the system.
And the last thing I want to say about it is that there is some data to suggest that women who continue to be sexually active after menopause are less likely to have problems with vaginal dryness than those who don't, although I always sort of wonder whether part of that is that the women who are having bad vaginal dryness aren't sexually active because it hurts.
Right. Hard to tell what's the cart and what's the horse in that case.
Dr. Richardson:
I want to ask you about another symptom that can be embarrassing and concerning, and that of course is incontinence. What causes incontinence and what can women do to treat it?
Dr. Richardson:
Well, the relationship between incontinence and menopause is somewhat uncertain, but incontinence is caused by changes in the function of the bladder and the nerves and muscles that are associated with it that can be worsened by traumatic childbirth and probably are somewhat just related to aging. And I think what woman can do about it is to practice good voiding habits, which is to keep their bladder somewhat empty and avoid foods that are bladder irritants, such as cranberry juice and coffee. There are some exercises called Kegel exercises, which seem to help some women. And then there are some increasingly fine tuned surgical techniques to help for incontinence.
And I think the important thing about this is to consult an expert in the area. And there's a specialty now of gynecology called urogynecology, where people are especially interested in continence. And I think it's great if women can see one of those urogynecology specialists if incontinence is an issue for them.
Well, you mentioned surgery as a possible treatment. What kind of surgery is that? What does that mean?
Dr. Richardson:
There are a ton of different kinds of surgeries that are done for incontinence, but recently there is one that is being finely tuned called the transvaginal tape, where they put a little tape inside the vagina and tie it up, and it elevates the urethra, which is the tube connecting the bladder to the outside world. And that's an outpatient procedure that really doesn't have terrible side effects and usually goes quite well. But not everybody is a candidate for that. It's called TVT.
So I want to move on now to some of the heightened emotions that some women experience - like rage or depression or anxiety - during menopause. And I'm wondering, what's happening in the brain and the body that causes these emotional reactions?
Dr. Richardson:
Well, again, I think you bring up a question that there are lots of answers to. I'd like to start by saying that even though I see myself as a feminist, I feel strongly that women are, to a certain extent, victims of their hormone ups and downs and that anybody who is a woman or lives with a woman knows that she does feel different at different times of the month when she's menstruating. But most of us get pretty comfortable with our regular menstrual changes, and we know that the day before we get our period that we're not going to feel very well and we may not sleep very well, so we can look forward to the next day being a better day.
Part of the problem in perimenopause is that our hormones are all over the map. So on any given day we can't really know where they're going to be. And I think that that is really hard for women. We also know, for instance, that some women get a severe postpartum depression when there are hormone changes, so there are other examples of the relationship between hormones and kind of mental health or sense of well being in women.
So while we're going through perimenopause and menopause and experiencing these untrackable shifts in hormones, do diet and exercise help with that? I'm thinking about the way with regular exercise you get that endorphin rush. Can that be a good balance?
Dr. Richardson:
Exercise has been shown to help with PMS. Exercise has been shown to help with depression. And I think the answer to that is absolutely. The data are a little bit less clear to make specific dietary recommendations for depression or mood lability, but in general I think the main thing is to eat a healthy diet; it always makes you feel better. I think there are some data about using long-chain fatty acids to improve mood, and some people think fish oil can help with that.
What if the difficult emotional symptoms and sleep distress go beyond what exercise and diet can do to help? Are anti-depressants or anti-anxiety medications helpful? And can you give us a couple of examples of where they might be?
Dr. Richardson:
I think you bring up an interesting point. I'm glad you mentioned sleep, because I do think if women start sleeping poorly that that has an incredible negative mood effect, and so it's an important thing to keep in mind.
Right. It can compound everything else.
Dr. Richardson:
It can compound everything else. I think the question of when to use anti-depressants or anxiolytics [anti-anxiety medicines] is an age old question. And I always say that if you go to your gynecologist you'll get hormones, and if you go to your therapist you'll get anti-depressants. I think that if sleep disruption and hot flashes are a big part of the picture, then using hormones makes sense to me. I think if it's all truly emotional, then it may need some kind of an anti-depressant.
In the introduction we mentioned the symptom "cotton brain," and that was a new term to me. What is cotton brain, and when your patients say they have it, what are they talking about? Is it another hormone related thing?
Dr. Richardson:
No. I don't know whether it was your writer or me that brought this up, but cotton brain just refers to not being able to focus and just not being able to retrieve memories, and just feeling like you're not sure where your brain is. And it's certainly not a true medical term.
Well, I've also heard that referred to as "mommy brain," so maybe that's not a strictly menopause thing.
Dr. Richardson:
Again, the relationship between estrogen and cognitive function has been studied quite a bit. There are some relationships, but it's not as closely linked as some people would lead you to believe. Again, if you're not sleeping, your brain isn't at its best performance. But I do definitely think women complain of difficulty concentrating and difficulty with focus associated with the menopause transition, and it's hard to know how much of this is sleep deprivation, how much of this is all of the different stresses in your life and how much of it is additional hormone changes? We don't really know.
And so what do you recommend for treatment?
Dr. Richardson:
For cotton brain?
Uh huh.
Dr. Richardson:
I recommend the things that we've talked about, which is taking care of yourself. And if somebody is having a lot of hot flashes and not sleeping well, I might talk with them about hormone therapy.
So you'd treat it in the context of other symptoms?
Dr. Richardson:
So one thing we haven't talked about yet is joint pain, which is often part of aging but not necessarily something we associate with menopause, although some women have seen a connection. Can you tell us more about that?
Dr. Richardson:
Oh, I think that's a very interesting area, because so many women do experience an increase in stiffness and pain in their joints associated with menopause transition. And my own physician told me that the several months after the Women's Health Initiative came off and a lot of her patients went off hormones, she had a ton of people coming in with new onset of joint pain, and she thought that this was not some special arthritis but just osteoarthritis that's exacerbated by women going off hormones. I don't have much to say about the notion of etiology or the notion of how to prevent it. I personally think there is a component of hormone deficiency related to this increase in joint pain, although some people think it's purely aging.
Well, that makes me think about osteoporosis, which is another condition that women may be vulnerable to both during and after menopause. And the media doctor tells us that this is totally preventable and advertises a lot of different products. Is osteoporosis preventable? And if it is, what are some of the best ways to do that?
Dr. Richardson:
Well, I think osteoporosis is somewhat preventable. I think we have to remember that in terms of these medications that are being pushed, most of them have only been around for 10 to 15 years, and at the age of 80 about half of women will have osteoporosis. But nobody who's 80 now was taking these medications in their 50s. So I feel that this is another area where we don't know as much as we'd like to. It does look like calcium intake is related to osteoporosis. Also exercise is incredibly important, and in particular weight bearing exercise. Swimming is not weight bearing exercise. Walking slowly is not really weight bearing exercise.
Another thing that's become increasingly clear over the last couple of years is that getting enough vitamin D is important, and that a lot of women, especially in the Northeast where there aren't enough sunlight hours, are vitamin D deficient.
You mention calcium supplements a moment ago. Suppose a woman doesn't start taking calcium supplements until she's well into menopause. Is that too late, or is it ever too late to start?
Dr. Richardson:
No, it's never too late to start. And some women won't have bad bones, but it's absolutely never too late to start.
Well, you mentioned when we were talking about testosterone a few minutes ago the possibility of extra hair growth related to that, but something many women experience with menopause is hair loss. And is that a side effect of prescription medicines or is there a physiological reason that that happens at menopause?
Dr. Richardson:
I think that that represents a readjustment of the balance of the particular woman's hormones. I think some women find that hormone therapy helps with hair loss and some women don't. I think as the ovary is making less estrogen sometimes testosterone becomes more dominant, and that may be a factor in this. But again, this is one of those changes that have not been very clearly documented. But I'm convinced that the menopause transition has an effect on hair in some women.
After everything we've discussed, it seems like finding a great doctor that a woman feels comfortable talking to is key, because you've raised some very complex issues. So how does a patient find a doctor that suits her needs and personality? What kind of questions should she ask?
Dr. Richardson:
Well, I'd like to start off by saying it doesn't necessarily have to be a doctor and that there are a lot of very good nurse practitioners out there who know a lot about menopause. Secondly, I'd like to say the North American Menopause Society - which, as you know, I was on the board of - does certify people as menopause experts, and they post the people who are certified on their Web site. So I think looking into that is something that might be helpful.
I think choosing a doctor is an incredibly challenging thing. And also, different doctors are good for different parts of your life or aspects of your health. I think that getting information from professional societies and your friends is going to put you in the best position to find the right person.
So doing some research.
Dr. Richardson:
Right. I also think it's very important to feel like you can go find someone else if it's not working for you with whoever you're seeing. I think sometimes people don't even think about going to find someone else, and that's certainly acceptable and appropriate. In addition, having your questions organized, having a good sense of what you want to get out of the visit with the doctor and putting that out there in the very beginning can help the interaction be more satisfying for both of you.
Well, I guess I'd ask you this: I think about when you're weighing your options with the doctor or a nurse practitioner of someone being an expert and then someone being a really good communicator. I know that it's not always either/or, but as you think about specifically dealing with menopause, where do you think the weight should go with that?
Dr. Richardson:
Well, I have to say that you've got to have both, because I do think that a lot of physicians and nurse practitioners don't know that much. Actually, let me take a step back and say one thing, which is that menopause is normal. And 90 percent of women are going to go through menopause without any major problems. They'll have some bumps in the road. They'll have some changes in their body, which they'll have to get used to, but it's not going to totally disrupt their lives. And that's a good thing.
That's very reassuring.
Dr. Richardson:
But for those women, being knowledgeable and knowing what's going to happen is probably sufficient. And then there's the 10 percent of people who are going to have a really tough time. And since 100 percent of women go through menopause, that represents a lot of women. And I think for those of you who are having a hard time, finding somebody who both has some expertise in the menopause transition and is a good communicator is worth waiting for.
So I think what I hear you saying is that women, if they're in that 10 percent that are struggling a bit with menopause, that they should keep looking for a doctor or a nurse practitioner until they find one that they're really comfortable with that really works for them.
Dr. Richardson:
That's right. And somebody who they can tell has some expertise.
And then what about if it's important to a woman to include treatments from a naturopath or an acupuncturist into her traditional menopause regimen? Are medical doctors, in general, open to that kind of collaboration?
Dr. Richardson:
It varies enormously, and I think that many of them are, but some of them aren't. But I do think it's important for women to let their traditional doctors know what kind of help they're getting in these other more alternative settings.
So how important do you think natural remedies are in the whole picture of menopause treatment?
Dr. Richardson:
I think that lifestyle is really important. I think in terms of natural remedies, I'm not sure what you mean. Do you mean that if I go into my local drugstore there's like a whole shelf of various things that are available over the counter to treat menopausal symptoms? I'm not sure any of those work that much. But I do know that taking care of yourself and getting enough sleep and enough exercise and reducing the stress in your life will make you feel better.
So I was just about to ask you to list your top five coping skills for menopause, and I think I heard at least two of them: A good diet and exercise. Are there a few more that you'd like to leave our listeners with?
Dr. Richardson:
Yeah. I think that taking time for yourself and taking time to evaluate what's happening in your life is another important piece of managing the menopause transition. Taking time to examine what the meaning of this transition has for you in terms of not being able to have children anymore, or perhaps feeling like your life is two thirds over and you haven't accomplished what you'd like to accomplish. I think it's important for women to realize that this physical transition has a lot of psychological meaning and that they need to do that.
One thing we haven't talked about very much is weight gain, and a lot of women gain weight in their late forties and mid fifties. That's because of the metabolic changes associated with menopause, and I think it also has something to do with the way our society uses food and that you don't go to a restaurant without being served about two to three times as much as you should be eating for any given meal. I think this is a very important time for women to start examining their eating habits and figuring out how to be disciplined about it on a daily basis.
A lot of women gain weight very slowly, but if you gain two pounds a year for 10 years, that's 20 pounds. And women are unhappy to find that none of their clothes are fitting. So I think that this is a time when it's very important as your metabolism is dialing down a little bit to start noticing ways in which you can decrease your caloric intake, like drinking skim milk or being careful about portion size, or the day after Thanksgiving not eating nearly as much as you did the day before. And I've started talking with my patients about this in their forties much more, because I realized that it was sort of self defeating to wait until they were 52 and already had gained the weight.
So making some subtle changes before it really becomes a problem can help keep that from happening later as the metabolism slows down.
Dr. Richardson:
I want to go back to something you mentioned briefly, which were over the counter drugs related to menopause. Can you tell us about any cautions or concerns you want to pass on about treating menopause with those over the counter products?
Dr. Richardson:
I can tell you what I tell my patients - and I think that to a certain extent this is a no data zone - but I tell my patients who want to try black cohosh to use a product called Remifemin, because that's a standardized product that's made in Germany, and at least its different batches are tested for the ingredients and we know that they fulfill what's written on the package. I'm not a big fan of taking a lot of soy or what we call phytoestrogens or isoflavones, which are weak estrogens available from food. I think if you're going to do that you're better off to eat more soy products or flaxseed oil and get your phytoestrogens in your diet.
So if a woman isn't having such difficulty with menopause that she's needed to go find a doctor to work with on it, is there anything on those labels that she should look for, or specific kinds of products she should avoid if she's doing this on her own and looking at those over the counter options?
Dr. Richardson:
Well, as I said, I don't recommend large amounts of isoflavones in the over the counter medications. Another thing is that there is an herb called kava, which has been shown to cause liver problems. And it is still available in the United States, and I think it should be avoided.
Otherwise, there's a whole bunch of stuff out there that hasn't been shown to do anything.
And I think you're wasting your money.
We're almost out of time, Dr. Richardson, but before we go I'd like to get some final words from you for our listeners. What would you like to leave our listeners with?
Dr. Richardson:
Oh, I think menopause is, as I said a few minutes ago, not a big problem for most women. I think it's an opportunity to reassess where you are in life and take care of yourself both physically and psychologically. And I'll tell you, a lot of women feel really great in the years when they're not having periods and they're not having the emotional ups and downs. I do think perimenopause is a tough time for some women, but again, I can say with conviction that they'll feel better afterwards.
I think the last thing I would say also is that to remember if they're having problems with their sexuality or with vaginal dryness that they should try to find a clinician who can help them with those.
Great. Thank you for leaving us with those optimistic notes. I want to thank my guest, Dr. Marcie Richardson and you, the audience, for joining us.
And if you have a topic we didn't address, check out our Reference feature for more treatment and coping information - or our Ask the Doctor feature to ask a question of your own. Just go to healthtalk.com/menopause and click on 'Ask the Doctor.'
Many of you have been asking for podcasts of our shows, and we now have them. Just click on the orange podcast link on the HealthTalk Menopause home page, and you'll go right to the available HealthTalk Menopause podcasts on iTunes. You can also go to itunes.com and search for HealthTalk to find all of our podcasts.
From HealthTalk, I'm Elizabeth Austin.


text:
Taking the time to use Facebook hashtags can effectively help to boost the kind of response your brand receives from a variety of different sectors. As with Twitter, Facebook hashtags are a short word or phrase that identifies content as related and enables it to be highly searchable. Making use of them can have a variety of benefits for your brand with:
Campaigns – A corporate campaign that's promoted with a hashtag to be used on social media sites can help to connect consumers to the source and others who are also participating in the conversation. A campaign hashtag is a choice method for community managers to easily track the kind of results that it's getting and to quickly respond to relevant postings.
Image tracking – Attaching a hashtag to your brand's image means being able to track mentions in real time. A consumer using your brand's hashtag might be directly related or simple in passing, but what's key is the ability to see what's being said, by who and where in the world it's getting the most responses.
Maximizing SEO – Taking the time to use Facebook hashtags means contributing even more to your brand's SEO in the grand scheme, which can be beneficial for driving searchers in the right direction. Essentially, a brand that contributes positively, hashtags accordingly and responds respectfully can become more relevant in the grand sceme.
Taking the time to track changes and innovation is a key step towards getting the kind of results a brand is looking for. Trend Hunter's Social Media Trend Report details ample information that can help a brand identify areas for opportunity and growth, so check it out.
References: trendreports and trendreports

subset: commoncrawl


text:
Chelys was established in 2002 and its core business focuses on software development and supplying services in the Earth Observation sector as a provider of processing stations for Earth observation satellites. In the beginning our personnel worked on the development, integration and maintenance of the ESA/Envisat PDS (payload data segment) on behalf of Thales Alenia Space, and then on the development of test tools and integration of the Eumetsat/EPS GS (ground segment). These experiences allowed us to become specialized in satellite data management and to concentrate on real time satellite (raw) data processing, data quality control, image generation, projection and mosaics (composite satellite images).
Our main product, Satellite Rapid Response System, a multimission real-time data processing and quality control system that is able to simultaneously process data coming from several different missions. It can be used to process data from the following satellite instruments:
The SRRS system used by ESA, MIRAVI, has been installed in all Envisat satellite acquisition stations and has been delivering thousands of images per month since June 2006, processing the Envisat/MERIS Full Resolution raw data as soon as they are acquired.
Our current areas of activity are:
We also provide services such as:
Guidelines Regarding the Use or Reproduction of Chelys Material Obtained From a EOSNAP Web Pages
Chelys generally has no objection to the reproduction and use of Chelys material (e.g., still or motion picture photography; or World Wide Web pages), subject to the following conditions:
For answers to additional questions, please contact:
CHELYS srl
Via Erasmo Gattamelata, 3
00176 Rome
Internet: [email protected]
MERIS images are generated from Level-0 (raw) data; ASAR images are generated from Level-0 and Level-1 products. MODIS images are generated from Level-1a products. All types of images are from the Chelys SRRS (Satellite Rapid Response System). Envisat source Level-0 and Level-1 products are provided by ESA. Terra and Aqua source products are provided by NASA. AVHRR source products are provided by Eumetsat.
Unless indicated otherwise, the written information on this website comes from the following sources:


text:
The first chapter of the Huangdi Neijing contains the essential way of how we can balance and harmonize our lifes! It is timeless in it´s meaning, what was important thousands of years ago is still actual more then ever!
During his reign, Huang Di discoursed on medicine, health, lifestyle, nutrition, and Taoist cosmology with his ministers Qi Bo, Lei Gong, and others. Their first discussion began with Huang Di inquiring, "I've heard that in the days of old everyone lived one hundred years without showing the usual signs of aging. In our time, however, people age prematurely, living only fifty years. Is this due to a change in the environment, or is it because people have lost the correct way of life?"
Qi Bo replied, "In the past, people practiced the Dao, the Way of Life. They understood the principle of balance, of yin and yang, as represented by the transformation of the energies of the universe. Thus, they formulated practices such as Daoyin, an exercise combining stretching, massaging, and breathing to promote energy flow, and meditation to help maintain and harmonize themselves with the universe. They ate a balanced diet at regular times, arose and retired at regular hours, avoided overstressing their bodies and minds, and refrained from overindulgence of all kinds. They maintained well-being of body and mind; thus, it is not surprising that they lived over one hundred years.
"These days, people have changed their way of life. They drink wine as though it were water, indulge excessively in destructive activities, drain their jing—the body's essence that is stored in the kidneys—and deplete their qi. They do not know the secret of conserving their energy and vitality. Seeking emotional excitement and momentary pleasures, people disregard the natural rhythm and order of the universe. They fail to regulate their lifestyle and diet, and sleep improperly. So it is not surprising that they look old at fifty and die soon after.
"The accomplished ones of ancient times advised people to guard themselves against disease-causing factors. On the mental level, one should remain calm and avoid excessive desires and fantasies, recognizing and maintaining the natural purity and clarity of the mind. When internal energies are able to circulate smoothly and freely, and the energy of the mind is not scattered, but is focused and concentrated, illness and disease can be avoided.
"Previously, people led a calm and honest existence, detached from undue desire and ambition; they lived with an untainted conscience and without fear. They were active, but never depleted themselves. Because they lived simply, these individuals knew contentment, as reflected in their diet of basic but nourishing foods and attire that was appropriate to the season but never luxurious. Since they were happy with their position in life, they did not feel jealousy or greed. They had compassion for others and were helpful and honest, free from destructive habits. They remained unshakable and unswayed by temptations, and they were able to stay centered even when adversity arose. They treated others justly, regardless of their level of intelligence or social position."
- Excerpt from the Book Huang Di Nei Jing


text:
Source: Video and Images Created by Amanda Soderlind
Welcome to this lesson on the urinary system. Today we are going to be discussing how the body maintains homeostasis of its body fluids. So basically, the urinary system helps to maintain homeostasis of extracellular fluids. And remember, extracellular fluids are fluids found on the outside of cells, such as blood, for example. So these fluids, these extracellular fluids, have a tendency to change as our body intakes water and solutes or loses water and solutes. So in order to maintain homeostasis, our body has to try and maintain these extracellular fluids at a certain level and a certain concentration and pH.
So as you intake water and solutes and lose water and solutes, as I mentioned, these extracellular fluids will change. So when I talk about intaking water and solutes, this could be through food, liquids. So food and liquid that you intake or that you ingest. It could be through respiration. And it could be through metabolism. These are all ways that water and solutes can be added to your system.
And when I talk about losing water and solutes, the way that you can lose water and solutes is through urination, feces, sweat, and evaporation. So these are all ways in which your extracellular fluids can change. You can either lose those extracellular fluids or gain water and solutes in the extracellular fluids. So the kidneys play a really important role in homeostasis of these extracellular fluids by forming urine. So urine is produced and excreted by the body. And hormones also play a role in this process as well in helping to form urine and maintain homeostasis of these fluids.
So basically, the kidneys can conserve or excrete fluids as necessary. And they can produce concentrated or diluted urine. So these are some of the ways that that homeostasis of extracellular fluids is maintained as it forms urine. So if there needs to be more water in the extracellular fluid, maybe the water level of extracellular fluids is low, and we need to increase that, then the body can produce more concentrated urine and allow there to be more water in the system than would otherwise be. So these are just some different ways that the body maintains that homeostasis. And if you're interested in more detail about how this process of urine formation occurs, you could look up the steps of urine formation.
But basically here just to give you a quick overview, these are the kidneys. We have two of them. So that's actually where urine is produced, is in the kidneys. And then we have the ureter, the urinary bladder, and the urethra. So urine is produced in the kidneys, will move down the ureter to be stored in the urinary bladder, and then is expelled from the body through the urethra.
So this lesson has been an overview on the urinary system and how the urinary system contributes to maintaining homeostasis of extracellular fluid.


text:
Women's Lacrosse Ball Bags
Women's Lacrosse Ball Bags
(4 Products)
Why Do You Need A Lacrosse Ball Bag?
You can't play lacrosse without lacrosse balls but more importantly you need a way to transport and store them. Cue in a lacrosse bag specifically for game balls. You have plenty of options for bags to carry balls. A simple and affordable option is a mesh equipment bag, holds approximately three dozen balls. This is an ideal choice for minimal transport of sports balls. Most lacrosse coaches purchase balls by the case which is ten dozen balls. These individuals need an extra large carrying capacity, opt-in for a Bucket Style Ball Bag. The bottom of the bag is typically plastic for durability and can hold up to six dozen or 72 lacrosse balls. Sporting gear works great when your gear is organized. Do not skimp out with a lacrosse backpack or a player style lacrosse equipment bags for your game balls. Purchase gear designed for your needs and the gear you will be transporting.
Not sure what to get, contact our Customer Support Team at 800-335-4670 and we can guide you into the right bag for you. Orders placed by 3pm EST Monday-Friday offer same day shipping and orders over $49 Qualify for Free Standard Shipping. We want your experience to be ideal every time!
Check out these other awesome categories.


text:
For Financial Advisors
Blue Water believes the most successful advisor client relationship is built on trust and expertise. Financial advisors who work with Blue Water get to experience more time focusing on their client relationships while leaving the investment management and back office back office operations to us.
Managed Portfolios
With 15+ portfolios based on income, total return, tax awareness, active or passive management, there is a solution that fits your clients' needs.
Advisors can utilize Blue Water's platform to implement many different types of strategies and account structures.
Retirement Plans
Blue Water can assist you in the design and management of qualified retirement plans. We're more than just a portfolio manager.


text:
Also in Diaspora Banking:
Fixed deposit
Our CBA Deposit Accounts are designed to offer maximum return on investment. They offer flexible investment periods with interest that is paid upon maturity or at predetermined times of the year. We give you the choice of investing in both local and designated foreign currencies.
The Call Deposit Account is ideal for the saver who wants to earn high interest over a short term and still have funds to use as needed. With the Call Deposit you may invest for a minimum period of 48 hours (2 days) onwards. You may make partial withdrawals from your deposit account subject to a 24 hour notice period. In addition, the principal, plus interest, is paid upon notice of withdrawal.
The Time Deposit Account offers a high-yield return and allows you to determine how long you want to invest. You may choose to invest for 1-12 months with the option to roll the account over after that time. With this option you get interest paid upon maturity or at designated intervals (at a market rate).
How much do I need to start?
The minimum deposit amount for local currency is KShs. 100,000 / USD 10,000 or the equivalent in foreign currency.
More about the Deposit Accounts
- The interest rate is fixed and guaranteed for the term of the investment, so you don`t have to worry about declining interest rates
- Interest payment options are flexible, allowing interest to be paid monthly, quarterly, half-yearly, annually or upon maturity
- You may use any of these deposit accounts as security against a loan or overdraft
- CBA will automatically re-invest/roll over your funds after the maturity date, unless you instruct us otherwise
- Should you wish to change your investment period, just inform us before the date of maturity
- In addition you will receive a free advice slip in the mail upon maturity or on request


text:
Do you think you will need some extra cash before you get paid? Do you think a payday loan is something you should consider? Continue reading this piece in order to determine whether a payday loan is right for you.
There are times when individuals would find themselves needing money and there's no other choice but to take a payday loan. If necessary, then check into getting a payday loan. If there is family or a close friend that will loan you money, talk to them before getting a payday loan.
Not all cash advance loans are on par with each other. Check into the rates and fees of as many as possible before making any decisions. A bit of research can go a long way for you.
Take the time to look for the most suitable interest rate. There are online lenders available, as well as physical lending locations. Payday lending is a highly competitive industry, with lenders trying to undercut each other on price. Many will also give you a deal if you have not borrowed before. Review multiple options prior to making your selection.
Payday Loan
Have enough money in your account to repay your payday loan when it is due. The payday lender will pursue payment aggressively if you don't repay your payday loan as agreed. You will also get a NSF charge from your bank as well as extra charges from the loan company. Budget your finances so that you have money to pay back the loan.
You may be required to provide bank account information when you apply for a payday loan. Lots of people wanting payday loans don't get one due to the fact that they feel uncomfortable providing their bank information to the payday loan companies. This information will be needed to collect your loan if you fail to pay on time.
Be aware of any payday loan that is automatically set to roll over. Sometimes lenders utilize systems that renew unpaid loans and then take fees out of your bank account. You could find yourself in such a situation without ever doing anything more than filling out the initial loan application. By your loan automatically rolling over each due date, it can be easy to forget to repay the loan, resulting in extremely high fees. Make sure you research what you're doing before you do it.
Research lending companies prior to agreeing to their terms. Although a payday loan may seem like your last resort, you should never sign for one without knowing all the terms that come with it. The more you know about the company, the less likely you will be to get into trouble.
Stay away from payday loans that are too high for you to pay back. There are many companies that will give you a higher amount than you can afford. When you do not pay the loan back on time, you will continue accruing interest and fees.
Don't let an eager loan rep convince you to borrow more money than you really really need. Lenders do this since it means they can make more from interest and fees. Only get the money you need from the company.
Keep going and decide if you want to investigate further. Always take the time to carefully consider your options when it comes to payday loans. Just remember to make use of the things written in this guide to help you make proper decisions so that you wont be clueless when the time comes.
Feel Free to visit our website for any kind of query Click here.


text:
Comfortable Rooms
some with a view
Warm temperatures continue well into fall, but nights are cooler. Remember whenever you visit, to wear layered clothing, bring plenty of water and solid walking shoes. The best way to enjoy our national parks is by following the rules laid out for their preservations and your safety.
This family-oriented lodge is situated at the South Rim of the Grand Canyon. The Thunderbird Lodge is conveniently located between El Tovar and Bright Angel Lodge in the heart of the Grand Canyon Village Historic District. Thunderbird Lodge offers a contemporary style with architecture that blends in with its rocky and majestic surroundings. Many of the rooms include a partial canyon view making this a perfect place to stay. There's no air-conditioning, but evaporative coolers keep the heat at bay.
Rooms here include either two queen beds or one king bed, television, telephone, in-room coffee, refrigerator, safe, and full bath. In keeping with national park lodging regulations all rooms are non-smoking. Guests staying at the Thunderbird Lodge check in at the Bright Angel Lodge front desk.
Children 16 years old and younger stay for free. All no-shows as well as cancellations less than 4 days prior to arrival will be charged with the room charge times the number of nights reserved. There are no refunds for early departures.
A $35 administration fee will be charged for all cancellations from the time of booking to five days prior to the check-in date. All cancellations inside of four days of the check-in date will be charged for all the room nights that were reserved for you. A no show will be charged for ALL the nights reserved - no refunds. Those departing early will not be refunded for any unused nights.
|Room Type
|1 to 2
|from $283
|from $295
|from $307
|1 to 2
|from $306
|from $317
|from $329
January 1, 2018 - March 2, 2020
All taxes and fees are included in the price.


text:
So, as you may have already concluded from my three day posting frenzy, I love Thanksgiving. Who doesn't? I mean, it's a holiday about food.
Er, I mean giving thanks. For food. And farmers. And family.
This year is trickier than most, though, and it's not just because my sister lured our mom to Colorado. Being a GAPS family around the holidays requires some creativity, but it's totally doable! Just ask my family, who scarfed down two pumpkin pies, two batches of stuffing with cranberry sauce, and cauliflower mashed "potatoes" so we'd have all the recipe kinks sorted out before the big day.
Looking for more GAPS-friendly ideas?
I have some suggestions! Kristen from Food Renegade has a quick and easy pecan garlic salad dressing AND a hot bacon dressing that could make dirty socks taste good. That girl can cook.
My peasant-style gravy recipe is here, but if creaminess is your hearts desire check out this White Wine & Thyme Cashew Gravy from The Urban Poser.
I have a homestyle paleo stuffing recipe here.
And oh, there's my friends Whittney's broccoli grape slaw. So delicious!


text:
GMail Got A New Interface And You Can Try It Now !
Starting today, you'll see the "Preview" and "Preview (Dense)" themes in the Themes tab in Gmail Settings. Why two themes? Our new interface will eventually expand dynamically to accommodate different screen sizes and user preferences, but until then you can pick the information density that you prefer.
To try it now, simply go to Gmail Settings, click on the Themes tab and select "Preview" or "Preview (Dense)" as your theme to try this yourself then tell us what do you think?
[GMail Blog]


text:
Stay on Top of Enterprise Technology Trends
Get updates impacting your industry from our GigaOm Research Community
Last week, HP(s hpq) CEO Meg Whitman tapped Bill Veghte to take over the company's "disappointing" Autonomy business unit. This week, the company named Veghte as its new COO and brought in George Kadifa of Silver Lake Partners to spearhead software.
All of this is in service of fixing HP's enterprise software franchise, which was a key priority for Whitman and her ill-fated predecessor Leo Apotheker. HP bought Autonomy for $10.2 billion last year in a deal that closed in October. Six months later, it booted Autonomy's founder Mike Lynch and put Veghte in his place
According to the HP statement addressing Kadifa's hiring:
Kadifa a 30-year veteran of the IT industry, will report to Meg Whitman, president and chief executive officer, HP, and will join the HP executive council. He will lead HP's multibillion dollar IT Performance Suite software portfolio, which enables enterprise IT organizations to manage and secure IT from applications to infrastructure in the cloud and on premise across platforms.
HP is still dealing with issues that have plagued it for years. It is a hardware company struggling to get and stay relevant by moving more into enterprise software and cloud computing — the latter in an aggressive push led by Zorawar "Biri" Singh. But turmoil at the top — as evidenced by the bizarre succession of three CEOs in as many years — continues to sting the company.


text:
Give Now
Find aDoctor
Search All Doctors and Providers Affiliated with WakeMed.
WakeMedPhysician Practices
Search For Providers Who Are Members of WakeMed Physician Practices.
Our Practices
Centers of Excellence
WakeMed PhysicianPractices Specialties
Specialty Hospitals
WakeMed PhysicianPractices Locations
Outpatient Facilities
Find a Service Location
As you prepare to welcome a new baby into your family, we'd like to welcome you into the WakeMed family. We're here to take care of you, your baby and your entire family, not only now, but for many years to come.
But let's not get ahead of ourselves. Right now it's all about you! We have many terrific programs and services to help you prepare for your new baby. We can even help you find the right pediatrician for your baby with our WakeMed Doctor Choice line. When the big day arrives, we'll be ready and waiting to assist you in welcoming your new baby to the world. The peaceful, homelike setting of the WakeMed Women's Pavilion & Birthplace, with locations in Raleigh and Cary, is the perfect place for this amazing event.
Is it time? Most women begin having "warm up" contractions during the last weeks of pregnancy. If these contractions continue, begin monitoring how often they come and how long each one lasts. If the contractions become longer, stronger and closer together, it may be a sign that the onset of labor is near.
Typically, you don't need to call your doctor or leave for the hospital until contractions are five minutes apart and are so strong that you cannot walk or talk through them. In addition, if your water leaks or breaks, or if you experience any bleeding, call your doctor immediately.
What to Bring Many expectant mothers wonder what they should bring to the hospital to be most prepared and most comfortable during their stay. Here is what we recommend:
For Mommy
For Partner
Birth PlanPrior to your baby's birth, it is important that you, your partner and your doctor understand your preferences, hopes and desires for the experience. Although there is no guarantee that things will go exactly the way you anticipate, it is still helpful to have a plan in place.
According to the American Pregnancy Association, a birth plan is defined as a simple, clear, one-page statement of your preferences for the birth of your child. For example, who do you want to be in the labor room with you? What is your choice of labor pain management? Do you want to use pain medication? Would you rather stay in bed or be mobile during your labor? What type of positions do you think will be most comfortable during labor?
About the EpiduralMany women wonder if an epidural will take away all of the pain of labor and birth. An epidural is typically administered after a woman has progressed well into labor. At this point, a laboring woman has already had fairly intense contractions and may have experienced a fair amount of pain. While an epidural eases some of the pain, a lot of women still feel a lot of pressure and discomfort after receiving the epidural. That's why staying mobile and active, listening to your body, and employing other comfort measures are so important during labor.
Most expectant women are familiar with the epidural, but there are many other choices for pain relief that can be combined with, or used in lieu of, an epidural. These include analgesics (narcotics), hydrotherapy (shower and tub), massage, positioning, alternating hot and cold therapy, and comforting from your labor partner. It's best to discuss your choice of labor pain management with your doctor in your eighth or ninth month of pregnancy.
Cesarean SectionIf your baby's birth requires a Cesarean delivery, you will start off in a Labor & Delivery room and return to this room after surgery. Your surgery will take place in an operating room (OR), and one person will be allowed in the OR with you.
You will be cared for by the same nurse before and after your surgery, and while you are recovering, only one person will be allowed in the recovery room with you. You will typically have the chance to see your baby while you are still in the OR, barring any complications, and based on your stability during recovery, your baby will be brought to you in your room.
Your incision may be painful and require medication for pain control. Please don't hesitate to ask your nurse for pain medication as needed. Keep the incision clean and dry. If you are permitted to take a shower, dry the incision carefully after showering.
Call your nurse to assist you when you are ready to get out of bed. Walking is helpful to prevent complications, to stimulate your bowels and to relieve soreness from the incision. Do not lift objects heavier than your baby or do vigorous exercise until instructed to do so by your provider. Climb steps slowly and only when necessary.
Kamm, McKenzie, Harden, Smith & Bass
Our top priority is to protect the health and wellbeing of our patients, their families and our staff who are working on the frontlines. While we recognize the important role that visits from loved ones play in the healing process, we must have visitation restrictions in order to protect lives.
Visit COVID-19 Information Page
3000 New Bern Ave.
Raleigh, NC 27610


text:
The basic Zen Cart shopping cart is simple, plan and not full of information. For a on line shopping cart, it fails to give much inspiration to buy! What it does is just lets your customers know the total amount items add up to. If you want to see shipping, theres another button to show, but doesn't add up the totals!
So.. with ZC, if you think of something, it can be done.
Modifying the shopping cart required more code edits then I first thought and I'm still thinking of simplifying it more than maybe I'll post the code. What I wanted to do, I seen on other big box stores. The cart showed the total of products, with shipping and tax based on a default zip code. Change the zip to your address and you could see what the shipping/tax for your area would be.
Sounds simple right, know before you add all your personal info and buy it all..
Zen Cart is based on the idea that customers need an account and are logged in to buy. In this day and age, for me I would leave.
I've setup my site so customers don't need an account so why not have a cart to show more!
This turned out better than what I was looking for, not only can they select a location, but the selected shipping continues into the checkout process.
The process of making a better shopping cart..
- First, I don't believe that a responsive design should require massive scripting to detect your device! With css and html I should be able to do it and yes you can. The cart is done in css and html5 only. each container is setup to stack or unstack according to screen size.
- I used Shopping Cart Price Broken Down mod to make sense out of all the attributes in my products.
- Totals block I stacked the totals on top, then the estimated shipping form below it.
- Added a info box to take up empty space below the items which hides when the screen drops to a stacked view.
I think it came out grate and the estimated shipping is based on true shipping and not estimated at all..
Interested in the code, ask!


text: The Alta premium cowhide rug range by Art Hide combines smaller tiles and tessellations with pops of colour, in a combination that delivers on style, but saves on price. This collection breaks new ground in cowhide by challenging what's possible with eye-catching, trend-based, colourful and eclectic pieces. All Art Hide rugs are made from premium cowhide and finished with commercial grade nylon thread and a ribbon edge finish, ensuring they will last a lifetime.


text:
if you don't know who she is already then why, why, WHY? please remedy the situation asap.
AN IMPORTANT P.S. i didn't include the account: humansofny because i assume everyone knows about it and loves it as much as i do. if you don't, please please hop on over and take a peep. the owner takes photos of every day people in new york, and shares snippets about their life as told by the people themselves. the owner has also been around the world sharing other people's happy/sad/momentous stories such as in pakistan. right now he is sharing the stories of a handful of syrian refugees. the owner has impacted many people's lives enormously, through petitions, donations, and recently, president barack obama acknowledged and commented on a certain refugee's story. maybe you can help make a difference in people's lives too, through something as simple as an app on your phone.


text:
I know, I know, it's only October! Halloween is almost here so we're putting up Halloween decorations, planning our costumes and looking forward to watching a Halloween movie. See my Halloween movie bucket list here. However, I am seriously excited for Christmas and have started planning my Christmas shopping. Being massive Disney fans, I always end up buying a few items from the Disney Christmas range. I've been looking at their Christmas selection for a few weeks now, so here I list my favourites.
I have visited our local Disney Store so many times over the last few weeks, I'm sure the cast members are starting to recognise me. Just the other day I was walking around the store, taking photos of all the lovely things I am adding to my Disney wish list. I have bought a few Disney Christmas decorations to add to this collection. However, there are still lots of lovely things I'd love to buy, if only my purse would allow it!
Here are some of my favourite Disney Christmas things I spotted online at ShopDisneyUk. Hopefully I will be able to get one or two more things this year.
I love buying a new Christmas jumper every year and it's tradition for our family to each get new Christmas pyjamas on Christmas Eve. I spotted these children's pyjamas and the jumpers are for adults. They look so cosy and are ideal for a perfect Disney Christmas.
In our house we don't drink a lot of hot drinks. I don't drink any hot drinks at all and the rest of the Disney Mad Family only have an occasional hot chocolate or green tea. But these mugs are very cute and would be great for whipped cream topped hot chocolate on Christmas Eve. When I saw the Disney Christmas throw I fell in love with it! I love having a soft, warm blanket to snuggle up with when watching Christmas movies and this one is amazing. I also love the tumbler with the straw. We seem to have dozens of these types of cups in our house, but one more wouldn't hurt ; )
All the Disney Christmas Tree Ornaments are so incredible it was hard to choose favourites. In the end I chose this selection of ornaments. We already have the Up house and we bought the Chip 'n' Dale hanging ornaments in Walt Disney World. The rest of these are really lovely but unfortunately I can't buy all of them this year. I hope they keep them around for next year, so I can add to our collection a little bit at a time. If I do get to buy one more this year, I will get the Tinkerbell bauble where she is sat on a cute vase. All Disney Christmas tree ornaments are beautifully made and look amazing on our Christmas tree. If you are only going to get one item from the Disney Christmas range this year, I highly recommend getting a tree ornament.
These last few items are miscellaneous ones that I think are lovely. Advent calendars are a must to help everyone get in the festive spirit during December. This one is customisable and reusable because you can put anything you want in the drawers. We have a similar one here and I always put a mixture of things in the calendar. I put chocolates, small stationery items, hair accessories and nail polish.
The Eeyore cuddly toy is super cute. He is a special edition cuddly, but they also do another Christmas Eeyore. The little craft set is a 'Make Your Own Decoration' set. It looks like it would be great fun for kids and a really cool activity on the run up to Christmas.
Everybody in our family loves watching Christmas movies and TV programmes. I saw this Disney Christmas DVD online. I've never seen it before, so I'm not sure if it's a new collection but I think I'll buy it to watch while I'm wrapping Christmas presents this year. Does anyone else leave all their wrapping to the last minute? I tell myself every year that I'm going to be more organised but still end up doing the majority of my wrapping the night before Christmas Eve.
Last but by no means least is the really pretty Disney Christmas gift boxes. They do a variety of sizes and I think they're such a great idea. Some presents are not easy to wrap because of their shape, so gift boxes can be handy for those tricky presents and they still look festive.
Have you started your Christmas shopping yet? Do you have any of the Disney Christmas range on your wish list?
If you want to see more of our Christmas plans, please follow us and keep updated with new posts.


text:
Part of the Saint Nicholas Owen Catholic Multi Academy Company. In Jesus we live learn and serve.
Fact Sheet.pdf
Handwriting Phrases.pdf
Linked Story Books.pdf
National Curriculum.pdf
Parents Meeting.pdf
Phonics Screening Check Year 1 Parent Information.pdf
St Joseph's Catholic Primary School
Principal: Mr A Carry
Lea Vale Road
West Midlands
For enquiries or to request paper copies of information from this website please contact the school office via:
Tel: 01384 818325
Email: email@example.com
Prospectus: Digital Online Flipbook


text:
It's been confirmed that Google has begun rolling out a new design and look for their desktop search results page. The new design has a look more akin to a mobile user interface.
The rollout might have begun yesterday, but Barry Schwartz had spotted some tests of this new design a few weeks ago.
Here's an image of the new design:
How long will this new design take to roll out to all searchers? We'll have to wait and see!


text:
Prescott Country Club first opened for play in 1969. The course was designed by Al Rayford.
The Prescott Country Club Golf Coursehas natural mounding in the fairways and trees that come into play. A creek comes into play on two holes, and the greens are tough to putt.
The Prescott Country Club Golf Course plays to a 9-hole par-36 and a maximum distance of 3,182 yards.
Latest Golf Course Reviews


text:
I havent written about much for a long time so I though I would enlighten you with my brief review of the iPad.
When it was first announced I laughed at the idea that it would be useful for anything. I teased a few people who were considering buying one, arguing that it was just a giant smart phone. Almost a year later, I purchased one for myself.
The 3G model is basically a giant iPhone. There is no camera (iPad 2 is rumored to have one) or any phone function. The screen is obviously much bigger, but other than these few differences, the iPad is essentially the same as the iPhone.
That said, I would never buy an iPhone. There is just too much freedom that you get with Android, I couldn't live with all the restrictions. Back on topic:
So, why did I buy the iPad? Well, there was the 'Cool' factor that came into play, but the reason I gave my wife was: To use it in class. In all honesty, I was expecting to have it replace my grades / attendance book. Pretty expensive replacement right? Anyhoo, other than playing around with downloading apps and messing with jailbreaking, the primary use for my iPad has been in the classroom.
I use an app called TeacherPal, which I highly recommend, to take attendance and grade students performance in class. The app itself is a little confusing at first, and exporting your data is only possible via email / iTunes (No dropbox support) but it does the job pretty well.
It's also great for showing students pictures, videos and presentations in class. While dragging a laptop to each class is a pain, the iPad is light and small enough to make things easier.
The iPad is a unique device in that, it doesn't make your day to day life easier unless you actively try to find uses for it. While I was always expecting to use it in class, I initially couldn't think of any other uses for it. This is where the iPad's size and battery life become an advantage. I deliberately brought it everywhere I went. Slowly, I found more and more uses for it. Taking notes, drawing pictures, computer administration. The apps available make the iPad such a versatile device and paired with the large screen basically make it a super portable laptop.
Which is the entire point of the iPad, portability. I find that with a laptop, I need a purpose to carry it with me – a presentation, work etc. With the iPad, its different. I have it with me all the time. This makes it so much more useful than a laptop.
Some might argue the functionality of a smart phone makes the iPad less useful. This is true to a certain extent, sending sms messages and checking friends status updates are all pretty easy to do on a smartphone however, having the larger screen makes it a less frustrating experience. The other great thing is it is perfect for sharing. Almost every time I have had to show someone something on my phone, they scrunch up their eyes and complain about being unable to see anything.
The iPad can be as useful as you want it to be.
The negative:
Coming from an Android environment, I was quite used to trying out apps before paying for them via ad supported demos. Some apps follow this trend in the Apple app store, but most don't. The biggest annoyance for me is that the app store does not allow for refunds (in this sense). On Android you have a 15 minute window (Used to be 24 hours) to download an app, try it out – and see if it is what you wanted. If not, you can get a refund, simple as that.
On the app store however, no such luck. I was looking for a timetable app to manage my class schedule and I came across something that looked like what I wanted, and after paying for it – found that it was pretty useless. No refund for me – money down the drain.
But that's not an iPad issue, it's an Apple issue. My image of Apple is a pompous, greedy, self centered and stuck up company. They do whatever the hell they like and will keep doing it until the users start complaining en masse. This wont happen as the average iPhone user isn't the same kind of person the average smart phone user used to be.
They don't care if they can't tether their phones via wifi/bluetooth, or that Skype doesn't work over their 3g connections. They only care that they have the latest and 'greatest' phone that looks good. These people buy Apple for the image, not for the device. Apple is well aware that this demographic makes up most of their users, and as such they can do whatever they like.
For those of us who like to have control over our own devices, thankfully the iPad is also jailbreakable.
Love the iPad for what it is. Hate Apple for who they are. Don't ask me why I hate Apple, I just feel it. I have nothing against their hardware. I think Apple hardware is some of the best out there. I also have nothing against OSX. I just don't like Apple the company.
Ill leave you with an interesting note that may or may not be a good indicator of this attitude toward Apple:
Search google for:
"Hate Apple" – 9,690,000
"Hate Microsoft" – 6,750,000
"Apple Sucks" – 1,400,000
"Microsoft Sucks" – 273,000
Take the results as you will.


text:
Windows 10 is a personal computer operating system developed and released by Microsoft as part of the Windows NT family of operating systems. It was released on July 29, 2015. It is the first version of Windows that receives ongoing feature updates. Devices in enterprise environments can receive these updates at a slower pace, or use long-term support milestones that only receive critical updates, such as security patches, over their ten-year lifespan of extended support.
Windows 10 introduces what Microsoft described as "universal apps"; expanding on Metro-style apps, these apps can be designed to run across multiple Microsoft product families with nearly identical code?-including PCs, tablets, smartphones, embedded systems, Xbox One, Surface Hub and Mixed Reality. The Windows user interface was revised to handle transitions between a mouse-oriented interface and a touchscreen-optimized interface based on available input devices?-particularly on 2-in-1 PCs; both interfaces include an updated Start menu which incorporates elements of Windows 7's traditional Start menu with the tiles of Windows 8. The first release of Windows 10 also introduces a virtual desktop system, a window and desktop management feature called Task View, the Microsoft Edge web browser, support for fingerprint and face recognition login, new security features for enterprise environments, and DirectX 12 and WDDM 2.0 to improve the operating system's graphics capabilities for games.
Windows 10 is a product developed by Microsoft. This site is not directly affiliated with Microsoft. All trademarks, registered trademarks, product names and company names or logos mentioned herein are the property of their respective owners.
All programs not hosted on our site. When visitor click "Download" button files will downloading directly from official sources(owners sites).
- Why should I download the latest version of Windows 10 for Windows 10?
- What's the difference between 64 bit and 32 bit version of Windows 10?
- Will this Windows 10 download work on Windows 10?
We recommend to download the latest version of Windows 10 because it has the most recent updates, which improves the quality of program.
The Windows 10 64 bit version was specifically designed for 64 bit Windows Operating Systems and performs much better on those.
Yes! The free Windows 10 download for PC works on Windows 10 64 and 32 bits operating systems.
How do I uninstall Windows 10 in Windows 10 / Windows 7 / Windows 8?
- Click "Start"
- Click on "Control Panel"
- Under Programs click the Uninstall a Program link.
- Select "Windows 10" and right click, then select Uninstall/Change.
- Click "Yes" to confirm the uninstallation.
How do I uninstall Windows 10 in Windows 10?
- Click "Start"
- Click on "Control Panel"
- Click the Add or Remove Programs icon.
- Click on "Windows 10", then click "Remove/Uninstall."
- Click "Yes" to confirm the uninstallation.
How do I uninstall Windows 10 in Windows 95, 98, Me, NT, 2000?
- Click "Start"
- Click on "Control Panel"
- Double-click the "Add/Remove Programs" icon.
- Select "Windows 10" and right click, then select Uninstall/Change.
- Click "Yes" to confirm the uninstallation.


text:
Tom Harrington, Park volunteer and naturalist, has recently updated his Wildflower Report on the Great Smoky Mountain Association website.
His most recent report is from a hike on the Big Creek Trail in the northeastern corner of the Smokies. Mr. Harrington is reporting sightings for the following flowers: Heal All, Yellow Touch-me-nots (Pale Jewel Weed), Purple Flowering Raspberry, Common Milkweed, Wild Golden Glow, Crimson Bee Balm, Whitewood Aster, Black Eyed Susan, Pokeweed, Mountain Mint, Wood Nettle, Love Vine, Asiatic Dayflower, and Naked-Flowered Tick Trefoil.
Last week he hiked the Chestnut Top Trail just outside of Townsend and reported the following flowers: Coreopsis, Turk Cap Lily, Reclining Saint Andrew's Cross, Whorled Wood Aster, Pokeweed, Yellow Touch-me-nots, Basil Bee Balm, and Naked-Flowered Tick Trefoil.
However, what caught my eye was his "First Fall Foliage Report." In the middle of a typical summer heat wave, Mr. Harrington stated that he saw some "nice red Sourwood leaves."
To see all of his most recent reports, please click here.


text:
Combine vinegar, wine, rosemary, oil, salt, pepper in bowl. Add meat. Cover; refrigerate overnight.
Cook potatoes in boiling water 8 to 10 minutes. Add zucchini for last 4 to 6 minutes or until half-cooked. Drain potatoes and zucchini.
Slice zucchini 1 inch thick. Add with onion, sweet pepper, tomatoes to meat; marinate 10 minutes.
Skewer meat, onion, potato, zucchini, pepper and tomatoes on 6 metal 10-inch skewers.
Broil kabobs 4 to 6 inches from heat for 4 minutes on each side or until the meat is cooked through.


text:
Horses and Rabbits? Optimal Dynamic Capital Structure from Shareholder and Manager Perspectives
This paper examines optimal capital structure choice using a dynamic capital structure model that is calibrated to reflect actual firm characteristics. The model uses contingent-claim methods to value interest tax shields, allows for reorganization in bankruptcy, and maintains a long-run target debt/equity ratio by refinancing maturing debt. Using this model we calculate optimal capital structures in a realistic representation of the traditional tradeoff' model. In contrast to previous research, the resulting optimal capital structures do not imply that firms tend to use too little leverage in practice. We also estimate the costs borne by a firm whose capital structure deviates from its optimal, target' debt/equity ratio. The costs of moderate deviations are relatively small, suggesting that a policy of adjusting leverage only when it deviates substantially from a target debt/equity ratio is likely to be reasonable for most firms.
Published Versions
Ju, Nengjiu, Robert Parrino, and Allen Poteshman and Michael Steen Weisbach. "Horses and Rabbits? Optimal Dynamic Capital Structure from Shareholders' and Managers' Perspectives." Journal of Financial and Quantitative Analysis 40 (June 2005): 259-281.


text:
Zeev Binman is a Managing General Partner and the Chief Financial Officer of Pitango.
Prior to joining Pitango, Zeev served as Vice President of Finance and Organization at PazGas, the leading Israeli energy company. He also held a similar position at Fibronics International, USA, a leading fiber-optic communication company.
Early in his career, he served as referent for the defense industries in the Budget Department of the Israel Ministry of Finance.
放课后的秘密画室Zeev served on the board of Optonol, acquired by Alcon (NYSE: ACL), superDimension , acquired by Covidien (NYSE: COV) and fring , acquired by Genband. He currently serves on the Board of Directors of a number of companies, including Magenta Medical and Surf Communication Solutions.
He holds a B.A. in Economics and an M.B.A., specializing in Finance, from Tel Aviv University.