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Strange as it may seem, feelings of lethargy are often associated with a lack of strenuous physical activity. Lack of exercise, especially exercise that takes you beyond your home, can make you feel rather depressed too. A program of regular moderate physical activity is one of the first things to consider when feeling out of sorts. In general, it is best to set a manageable target, .beginning slowly and increasing the level of activity progressively. Inertia is one of the most difficult states to overcome. Setting too high a target can be counterproductive and may send you backwards.

Sticking to an exercise plan for a couple of weeks does wonders for morale and, instead of inventing excuses to avoid exercise, you will find it becomes something to look forward to with pleasure. In working out an exercise plan, there are some important factors to consider.

- The aim is to make regular physical activity part of your life, so choose something you enjoy — something that is convenient, interesting, can be done independently and is realistically achievable.

- If you are over forty or have high blood pressure, diabetes or a known heart problem, check with your doctor before you start your plan. A preliminary health check is sometimes advisable anyway, especially if you intend working up to strenuous forms of activity.

- Always warm up for at least five minutes before exercising, and cool down after it. Include some stretching exercises in the warm-up to reduce the risk of muscle strains.

- Never exercise if you are not feeling well. If illness interrupts your plan, resume at a lower level than before and slowly build up again.

- Tell your doctor about any symptoms you experience during exercise, particularly chest discomfort or undue dizziness.

Any woman at midlife who smokes should consider giving it away. If you are a typical twenty-cigarettes-a-day smoker who quits, you will experience changes something like these:

- Between twelve and twenty-four hours after stopping, you will start to feel less short of breath when you exert yourself.

- Within a couple of days you will begin to feel and smell fresher. Your taste buds will come alive and your sense of smell will return.

- Within three weeks your lungs will be working better and physical activity will be easier.

- Within two months, blood flow to your limbs will improve and you will have more energy.

If you have tried quitting repeatedly without success it may be time to consider a Quit group, which will provide a sound educational approach and ongoing support.

Finally, help for lethargy and depressed moods may be obtained from plants that contain oestrogen-like substances, called phyto-oestrogens. They seem to have less powerful effects than the oestrogens used in HRT, but are worth trying. Plants with a considerable amount of oestrogen-like content include alfalfa, aniseed, basil, caraway, chervil, the common beans, fennel, fenugreek, hops, licorice (which should be avoided by people with blood pressure problems), parsley, red clover, sage and soya bean sprouts.

Foods containing smaller amounts of oestrogen include fresh corn, corn oil, green peas, cabbage, wheat bran and wheat germ, rice bran and milk. The list is so long that you should have no difficulty finding something you can add to salad, vegetable or other dishes each day.

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There is as yet only a limited amount of research evidence about short-term use of oestrogen patches, implants, vaginal creams and pessaries. No one knows yet whether the body handles oestrogen from these sources differently from oestrogen taken by mouth, or whether oestrogen in these forms offers protection against the development of heart and blood vessel disease. Preliminary data suggests that oestrogen administered in these ways produces beneficial changes to blood fat levels, and long-term findings are eagerly awaited from several studies capable of providing answers.

It is still unclear to what extent cardiovascular disease and osteoporosis are due to oestrogen deficiency and to what extent they can be remedied by HRT.

There is good evidence that heart disease risk factors for men, on whom most research has been done, cannot be applied holus-bolus to women. Since the risk of heart disease is figuring more and more among the reasons why doctors prescribe HRT, this raises questions about the basis on which such decisions are made.

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Another HRT option (oestrogen with or without testosterone – which may be suggested for boosting your libido) is insertion under the skin of pellets containing one or more hormones. The pellet is usually placed in the fat of the lower abdomen, buttock or upper thigh, and a replacement is inserted every three to twelve months, depending on the dose required. This small and simple surgical procedure is performed in the doctor’s rooms or at a menopause clinic.

The amount of hormone absorbed from the implant varies according to how long it has been there, its position (for example, more hormone is absorbed if the implant is in the upper arm of a swimmer than if it is placed in a buttock), its depth under the skin (the deeper the implant, the greater the absorption), physical activity levels (exercise increases blood flow) and the presence of inflammation or scar tissue around the implant.

Women who find implants useful include those who for one reason or another cannot tolerate oestrogen in pill or patch form, and those needing large doses of oestrogen. These advantages may offset a common problem with implants, which is that the dose of hormone entering the body is initially high and reduces with time.

For example Natalie, a young woman who had an artificial menopause following cancer treatment, required relatively large amounts of oestrogen to alleviate recurring bouts of severe hot flushes. She found the implant both more convenient and more effective than pills, although she experienced sore breasts for some weeks after the implant was inserted (a higher than average hormone dose was entering her body), and a return of flushes as the time for a replacement implant approached (the hormone dose released by the implant had dropped significantly).

Many doctors believe that oestrogen implants should not be used as first-line HRT in women who have a uterus. This is because implants deliver substantially higher levels of oestrogen than other HRT formulations (at least part of the time) and, while helping women to feel wonderful, these levels can greatly increase the risk of severe, uncontrollable bleeding and possible hysterectomy. According to Dr John Eden from the University of New South Wales, some women on oestrogen implants feel a euphoria similar to that experienced by men on anabolic steroids. ‘But women pay a price if they have a uterus; they run the risk of heavy, uncontrollable periods.’ In the case of Margo, a patient with fibroids who had an implant inserted, the bleeding was so heavy that hysterectomy was the only option. ‘You rarely see this with other therapies, because the oestrogen levels are relatively low’, Dr Eden says. ‘Women with fibroids may get irregular bleeds, but you don’t see the activation and growth that you may get with an implant.’

It is extremely important that any woman with an intact uterus who is using an oestrogen implant realises the necessity of teaming progestogen with it for one to three years after the last implant is inserted. Implants continue to release small amounts of oestrogen for a very long time after their ‘use by’ date. It is unwise to discontinue the progestogen until two to three months after withdrawal bleeds have stopped.

An advantage of implants is their convenience, with no need to remember a daily pill or twice-weekly patch.

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How food intolerance might create this underlying instability is not known. One study suggests that migraine patients, although not apparently atopic, have a mild IgE/mast-cell reaction to the food when it comes into contact with the lining of the gut. This may set up inflammation locally, make the gut wall more leaky, and thus allow more food molecules through. These might then provoke an immune response in the blood, although it is not clear how this could make the person susceptible to migraines.

Another possibility is that certain naturally-occurring chemicals in the foods, which require detoxification by enzymes, are to blame. If the patient has a deficit in certain detoxification enzymes, this could be made much worse by overloading them with particular foodstuffs. There might then be less spare enzyme capacity to deal with ‘triggers’ such as tyramine. At present this is just speculation, and much more research is needed in this area.

Although elimination diets do seem to be useful for many people with migraine, they are probably not worth trying for those who only get migraines occasionally – once a month or less. In such circumstances, it would be difficult to tell if excluding foods had had any effect, unless there were other symptoms as well. Testing might also be rather inconclusive. But for anyone who has migraines at particular times – during the monthly period for example -then it might be worth carrying out an elimination diet, timed to coincide with the moment when migraines usually occur.

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