III. Menopause

(From a lecture given at the yearly meeting of the Anthroposophical Medical Association, U.K. Edited for publication. Third of a 3-part series on gynecology.)

The menopause is a crucial moment of change which is called in German Wechseljahre (years of change). One should look at what it is that is actually changing. The most obvious change is bodily fertility; in German it is called Fruchtbarkeit (fruilfulness), and the genius of the language provides that this word is used both in the bodily sense and in the spiritual sense. It seems important that one think of those forces which withdraw from the bodily working but which are still to be used at another level. In all moments of transition we see forces change the level of their activity or the form of their activity. For instance, the activity of the etheric forces during the first seven year period changes and later can be used for thinking.

If you read about menopause in normal books, it is something to fear because of all the bad things that happen afterwards. So it can be seen by many individuals as something very unpleasant and one should make efforts to preserve the previous state. We see that those forces of middle years of female life - from 21 to 42 - which emphasize the differentiation between the male and the female in which the menstrual cycle occurs, now withdraw from physical work and make possible the development of more general human aspects. At this time, rhythmic forces withdraw from bodily work within the lower, metabolic part of the organism. As they are also central forces, the rhythmic forces of the genital organs have to integrate within the whole organism's central part within the rhythmic system. There are also forces which find their manifestation within the warmth organism. Then it is quite understandable that there is, in this moment of transition, something irregular in the forming of this phenomenon of warmth and that hot flashes are experienced. In the treatment of hot flashes, we could use Sepia comp., which includes Conchae and Sepia.

At this moment, all further development depends on the individual's own impulses and struggles - whether they are still "attached" to the physical part, which is in decline, or whether the woman will liberate or release her spiritual part out of this physical decline to develop and to evolve spiritually. This is concerned with the development of consciousness, the activity of consciousness.

On the other hand, we have the work of the ego during the several seven year periods, and we see that in the seven year period between 35 and 42, on the level of the soul, the ego is working to transform the physical forces. This means that we develop, in this seven year period, the Consciousness Soul. This includes the greatest tension between extremes and also the development of the possibility to withstand this tension between the most different, the most polar things, on any level. This also means that the ego is free to work on making the body similar to its own intentions, ready to act as the ego wants to act in this incarnation; to be the best instrument for this incarnation. This work really reaches the bones, the most concrete, physical part of the human organism.

In the development of physical life, starting with embryonic development, we see that the growth movement prepares for the later use of an organ or part. All etheric activity will lead in the end to making it possible for the ego to work with its instrument. That is a law which goes through the whole of life. If in the second part of life, the human organism is to serve as an adequate instrument for the ego, then the etheric body has to act in a right sense to prepare this organic instrument for the activities of the ego.

If this doesn't happen, there is illness or deviation, and the bones or other parts of the body will not serve the whole rightly. When we see, for instance, the phenomenon of osteoporosis, then we have something like a reflection of development which has not led to the proper forming of what would be the concrete, physical base for the ego activity. It leads to a state where the bones cannot any longer go on in an adequate way. On the other hand, we become less physical; but there should be an equilibrium in the tendency to be more weak and also to maintain a certain state of usefulness.

This is what really happens between the forces of Lucifer and Ahriman. If Ahriman is too strong in the organism, then he withdraws the forces of consolidation from the bones to other parts of the body, producing sclerosis and other illnesses. So consolidation should be in balance, in the bones and not in other parts of the body where it is too great. On the other hand, Lucifer pushes the ego into the astral body, so that the ego cannot act sufficiently within its physical base of the skeleton. The bones need the force of forming - bones and teeth are the most concrete things that the scientist meets in the human organism. They are in constant metabolism and change, and that has to be in the right way. So there are the forces of consolidation and the forces of formation, and both are withdrawn by Lucifer and Ahriman. Therefore in one sense one can see osteoporosis as a collaboration of both Luciferic and Ahrimanic forces.

To the conventional picture of osteoporosis, I want to add another aspect. Nowadays in Germany, and I suppose it is the same here, the fear of osteoporosis is like hysteria - first of all among the doctors and then it is transmitted to the patients themselves. You can feel the strong pressures from interested circles to establish the opinion that all women, after the age of 50, should take hormones, should take estrogens to avoid osteoporosis. But the facts are different, because osteoporosis will be really present in only a third of all women over 50. Some publications give 20%, or 25%, or 30%. It differs a little.

It is important that you do not know in advance which person will develop it in such a way that it really leads afterwards to fractures and other skeletal damage. Because you cannot know who will be touched by it, there is this opinion that we have to give hormone replacement treatment to every woman over 50. Then all those who would have got it are within the group being treated. But you also have to consider that you do not know in advance what the development will be - if the osteoporosis will be slight and stay stable for the rest of life or if it will develop to a severe extent and weaken the structure so that bone mass is reduced considerably in comparison with bone volume. This is one consideration. Another consideration is that the structure of this spongiosa is changed from what would normally be like a net to form that is more linear. In this way the strength of the bone to resist pressure of weight, etc. weakens.

Because the first effects are not predictable in how far the osteoporosis will proceed, you are obliged, if you want to know about the actual condition, to examine very closely. Years ago there was no real possibility to examine closely because, when you worked from X-ray pictures, then only when about 30% of the bone mass had gone, would it be visible in the X-ray. So it had reached a very late stage before recognition was possible. Then there was developed the possibility of densiometry and with very little application of X-rays you could have a measurement. But when they developed this possibility of measuring, they had no references. They only had measurements. To start with, they measured all the employees of the companies who developed the densitometers in order to have a basic measurement reference table. Later on they found that in every country, each population had its own standard - the English standard was quite different from the German, and the German quite different from the Japanese, and the Japanese quite different from the North American standard. One can say that normal reference tables that are correct for the northern United States are far from being reliable for another country, for Germany, for instance.

One could think for years about what this means. I am only reporting what has been found. In the last two or three years, there was a campaign in Germany to go around the country with an osteomobile. They invited people on the streets to be measured, to establish a German reference table. I imagine in other countries it would be the same.

What is done at present is to have one measurement and to derive from this the information for the patient: "You have a very marked degree of osteoporosis." This is really a nonsense - firstly because until now there are no reliable tables of measurement and secondly, because one simple measurement will not show the dynamic development. If you want to have a true picture of what is going on in the development of osteoporosis, then you must have at least two or three measurements within three to six months, or something similar. Then you may see if there is rapid loss, if there is a steady state, or if there is a slow loss of bone mass. However, it is only in the rapid loss you can see something that is not good taking place.

You also have indirect possibilities of gaining an impression of what is going on with the bones. If you examine the pelvic area, for instance if there are very weak areas of connective tissue - a tendency to prolapse, to varicose veins, than all this would show something of a weak general state. So you are able to derive from the general status what would also be the situation with the bones.

You can never really predict what will happen in the future. This is another reason why the wide application of estrogen is not quite justified. Nowadays you can read that some people are a little doubtful about this widespread use of medication.

We know that estrogen treatment is no real cure but can only stop the development in the bones, that means the loss of bone mass. It can only stop it so long as it is being taken. When you stop the treatment, then the development will go on as it would have done if you had not given estrogen. Therefore, some colleagues recommend giving estrogen until death because only by this means can you provide a steady state of bone density. When you stop it - say after ten years or five years - then the development of bone loss will continue. In these publications, they always refer to the fact that in the last hundred years the life expectancy has doubled, so that nowadays many more older people live to experience osteoporosis, whereas, until the last century, they had only a slight chance of living to be old. While that may be right, of course, we live at a time when those problems of inner and outer development, of not wanting to change, of wanting to have a long life, are more acute now than in former times. I think that we should not misunderstand the meaning of these facts.

So hormonal treatment only works for the time that you give it. In the development of osteoporosis, it is not at all a cure. It is very important to know that and to have that in mind.

Let us look at the places of manifestation of osteoporosis. The site where a very intensive but otherwise inadequate use of skeleton takes place is the spine. There, the vertebral bodies will lose their mass and have the tendency to collapse. Later it spreads to other parts - to the femur and the lower parts of the arms. So the first manifestation is in the deformation of the spine and only at a later stage will there also be the possibility of fractures in the long bones. There were calculations of the costs within one country - the costs of treating those who have fractures and the cost of giving hormone replacement treatment - which found that the spending on HRT was less than treating people with fractures.

The ego works into the bones, and the spinal column is one of its physical reflections. Standing erect, it is attacked first. The picture you have then is the loss of the possibility of facing the world in a straight way. There is something like a weight that pulls you down, forces you to bend. It could be the inner possibility that is attacked. Later on you have the upper part of the femur affected. You see the individual who has a fractured neck or femur or fracture of her legs cannot go on, cannot make further steps in life, as she would like to. So the continuation of taking steps in life, going on life's way, is put in question on the physical level, but I would say that it is also a reflection.

When you think of the origin of the hand there is the possibility to handle, (in German: handeln is to act), the possibility of life activity. A fractured radius or ulna interferes with the processes of life, interferes with active participation.

So on all levels, in the realization of individual aims, there is restraint. One could say - this osteoporosis shows us how it can be, in a certain sense, when you give up the possibility of inner development and of following the aims of the ego development that could be realized in the physical world. Then it comes to a point when the physical body shows you - here is something to do, something to overcome. It is not a punishment but it is a picture that comes from the outside as a reflection of what is really inside.

When, for whatever reason, you lose the possibility to act physically, then the real and corresponding force to overcome this problem is to be found within yourself. It will not be something that you can take from outside as a substitute. Treatment from outside in no case will help the Will forward, but will only cause other problems. Only with the real necessity of healing should we give outside treatment, but it is important to develop consciousness of the problems which we face. Something which is very important in this sense is curative eurythmy because it directs the ego forces to the etheric body, and it is just this combination which is lacking in this instance.

Family history is also important because there can be familial factors, but there is also the question of physical activity. Physical activity can be on the one hand the exaggerated activity of sportsmen and sportswomen. When young girls have to train excessively, they can get amenorrhea and in consequence can also lose bone mass. On the other hand, if you have no physical activity or training, as is shown in an extreme situation in astronauts, then you also have loss of bone mass. So the right amount and type of training and movement are very important factors in maintaining the right amount of bone configuration. Always it means to treat in an equilibrated way with the force of gravity.

Also, well balanced nutrition is important. It will help in having the right basis of human bone mass and for the whole human organism.

We have not yet mentioned any remedies, and I will mention only one as being very important - Agaricus comp. If you think back to the beginning of bone development, there is the tendency of "concretization" by chalk which leads to the precipitation. What you see in osteoporosis in a certain sense is an exaggeration of density and a tendency to brittleness, so it would not be helpful in most cases to base your therapy on chalk. Phosphorus will be a basic medicament in the treatment for recovery to the former physical state. Agaricus/Phosphorus comp. is an example of this. It contains Argentum, which makes the link to the processes of reproduction and renovation.

The Agaricus, a mushroom, is almost a relic of a former time when there was in the atmosphere no carbon dioxide, but only carbon and nitrogen. This carbon and nitrogen, cyanide, means more activity of the astral forces in places where the earth is awake in summer and here grow the mushrooms. There is also Aspidium Filix mass, the male fern, and the ferns have their activity not in the air but in an atmosphere of wetness, again a relic of former times. There is also the oyster shell - D7. This combination of substances includes phosphor, which helps the ego organization to act in the body. That is why you should make sure that it is Agaricus/Phosphorus comp.

In modern medicine you put together with estrogen also calcium supplement because they consider the calcium is lacking, but that is only a small part of the problem, and it is not the most important thing. There is also a new medication, a chelating agent, Diatinate.

Spiritual development could also be thought to help in strengthening the bones, done in the right way, but it is not the only thing. When you are really accompanying the normal processes of aging, you treat so that you are up to date with the inner consciousness. Then you will have the right amount of movement because you are active in the widest sense. You will not hold back in depression. It is obvious that there are interactions between the many aspects of this problem. However, if one makes the effort to have this inner development, perhaps if you see some indication of deterioration of the bone, something like that, you can treat it with remedies, but you can combine the remedies also with therapies - on the one hand, curative eurythmy and, on the other hand, painting, especially veil painting.

Depression can be an element of menopause. It can be treated with Ignatia comp., Hypericum in low or middle potency, Sambucus or Hypericum Arurm culto. The treatment generally would be for six to nine months; it should be very individual, but always see that it is given in a rhythmical way.

Even with a strong indication of osteoporosis, generally I will try to avoid treatment with conventional medicines, but there can be some women who really want that treatment. If you cannot have a conversation and stimulate something else in them, you cannot avoid treating them with estrogen. Whenever you can reach them with the help of a conversation and can stimulate something, I would rather try to avoid such treatment.

There is also treatment with lead. There was a time when lead was still within the organism. Then there were no bones. Then the lead was sent outside the organism, then bones formed. This means that the forces overcoming lead are the forces which help maintain the bones. You would use a high potency of lead in combination, for instance, with Silicea - for example. Plumbum Silicicum D20. This is a suggestion from Rudolf Steiner for treating bones.

It would also be important to apply Aurum. I started with this picture of the rhythmic forces at the menopause which have to reintegrate into the whole organism. Aurum would help in this effort; in a comparable way to Cardiodoron Aurum would be used in a middle potency - D6 or D10. When you feel a lack of light in the patient, you could apply Hypericum Aurum culto (low or middle potency).

There can also be a fear which arises when the media tells patients about treatments for fractures, treatments which immobilize them. It depends on the inner attitude how much a patient can do. For a particular patient it can be an ego step to say: "I accept the risk of a fracture to allow for development."

The forces of personality may, in a certain way, not form themselves on the spiritual level but go down to the astral level. They exert themselves on this level, and that is what we see in this time of mid-life crisis. On the one hand, many people tend to preserve habits of ten, twenty, thirty years before. There is a sort of mummification on the level of soul development. On the other hand, there is a tendency to live life to the full, with the fear that everything will come to a sudden end. Living life so very intensively, we can see that there is an aberration of the astral body in this sense. All thought, all ego intentions, all ego forces, are only to this aim. So we have two tendencies which detract from the proper way of development of the individual. The aim at this time - in every time but in this time of change more so perhaps than at others - should be to maintain the thoughts of personal development, not for oneself only, but for the world also, in a non-egoistic way.

So with the question of the preservation of the former state, which is nowadays more or less the only aim that is considered, I will repeat once more what I believe is very important - all etheric activity which provides for the ego its proper development leads to further development and maintains health; all etheric activity which does not lead to this purpose will lead to illness. If we act with the aim of preserving something which is no longer part of the normal way of development, then because of this it must lead to some form of illness.

Now I would like to look for a moment at the problem of hormone replacement therapy (HRT). We have seen that the menstrual cycle is something like a basic rhythmic phenomenon and that some influences can modify this essentially rhythmic manifestation. Within certain limits it can be modified, and the human being feels that there is a sort of freedom in it. It shows or reflects what is really happening and is not obliged to come always on the exact day. It is the difference between being a rhythm on the one hand or a mechanical beat on the other. When you give hormones, there is no more possibility of variation - three weeks on the hormones, then one week off. Inevitably bleeding will come, and afterwards you start again with three weeks hormones, etc. So that is the goal - to maintain a certain, not very varied, concentration of hormones within the body. There is no longer the possibility of showing any modification because of what is going on or what is happening on the emotional level. In many talks with patients I heard of this feeling - like being in a prison or being enclosed. With some women this is after a short time, but sometimes only after years, they start to feel some sensation of imprisonment, that they cannot breathe emotionally, that all is not as it should be. Unconsciously in some women, in others very consciously, this is the reason why many women stop taking HRT sometimes years, sometimes months after starting.

It is good to understand this because there is a mutual influence between the physiological processes and what happens within the soul. In the normal state, what goes on within the soul will have the possibility to reflect itself in the physiological processes. But if these physiological processes are fixed, are covered with an artificial "tape," the soul cannot live as it should. There is this feeling of imprisonment, or restraining, and this throws back an effect onto the soul itself. On the astral level also, there is a deformation, but if we know about these facts, and I think I can say they are facts, then there is also the possibility that the imprisonment is not absolute. It can be as a tendency, and there is also the possibility to make efforts to overcome the restraint.

In conversation with some women where there is confusion in the determined epoch of life, where taking HRT seemed to be less worse than the complaints, then one can make efforts to establish something like a counterforce to work against this restraint. One should, however, be very awake not to introduce to these women delusions about the personal possibilities. For instance, if patients try consciously to improve their possibilities of sensitivity in normal life, to be conscious about personal relationships and what is going on, then from the center of consciousness this special effort can help to develop those capacities which are otherwise "taped" by taking hormones.

So it is really not a simple question, and I am not of the opinion that there is only a yes or no answer. One has to work with this problem. I think that there is a basic problem (applying hormone therapy), and we can easily translate this point of view to the use of hormones at the menopause. Taking estrogens as recommended, or in combination with progesterones, we cause the same effect on the soul and ego development, and perhaps it is worse because it is taken with the aim of preserving a state which the individual fears will go. There is a more intense desire to have this preservation which was not a fact before the woman was taking the hormones. So in a more intense sense, there is a danger of losing the struggle for personal development, and when you see these patients who very intensively want to take HRT, you see that they are those who have the weakest imagination of what inner development could be. I don't want to sentence someone, but this is an impression which you can experience. This is both an answer to the question of taking HRT or not and a picture of what this time of life should be.

I am convinced that in anthroposophical medicine we cannot offer to the patients the short way, the easy way, but we have to offer them the most complicated way - which is most truly close to the character of life - and stimulate the comprehension of the necessity for this.

Christoph Zerm, MD
Gemein. Gemeinschaftskrankenhaus
Beckweg 4
D-58313 Herdecke
Germany