Menopause---it's way more than a hot flash, and it might happen sooner than you think!
The average age of menopause in the US is approximately the age of 51, but perimenopause for many starts in their 40's. For some, it may start even earlier. Decreasing levels of hormones can disturb your mood, vaginal health, urinary health, bone strength, weight, food cravings, desire for sex (libido) and much, much more.
This is part one of series on perimenopause and menopause. Read on to learn why you feel the way you do, what you can expect, and what you can do about it from an integrative medicine perspective. We will provide you natural and also prescription options for your transition and hopefully shed some light on this poorly addressed topic in medicine.
The transition from perimenopause into menopause may take several years or come much sooner.
For many, it’s smooth sailing, but for some, it can feel like a shipwreck at every turn. It is often hard to navigate, especially in the beginning. You may hear hormone replacement therapy is harmful, yet another doctor says it is safe. Your mom might tell you horror stories of "hormones." Your friend might tell you hormones are the best thing since sliced bread, even brought back her sex life and saved her marriage.
First of all....What is perimenopause?
The gradual transition between the reproductive years and menopause (the cessation of menstrual periods) is called perimenopause (literally meaning “around menopause”). It is generally a transition that is many years long and can be associated with shorter menstrual intervals, irregular menses, night sweats, and other symptoms. In some people, these symptoms are troublesome enough to need medical intervention.
Low levels of estrogen and progesterone will eventually stop your monthly menstrual cycle.
And What is menopause ?
Menopause is a natural decline in reproductive hormones typically starting when a person reaches their 40s or 50s. Menopause is signaled by 12 months since last menstruation.
Although the diagnosis can be made by the patient’s history, laboratory testing may be performed to confirm the diagnosis of menopause. Elevated follicle stimulating hormone (FSH) and low estrogen (estradiol) are consistent with menopause. Hormonal therapy, such as birth control pills, may skew & invalidate the FSH and estradiol tests, so it is preferable to check levels without any other hormones on board.
Can menopause happen before 40?
Menopause, whether natural or induced, is called "premature menopause " when it happens at age 40 or younger. This occurs in about 1% of people in the United States. Premature menopause that is not induced can be genetic, metabolic, autoimmune, or the result of other poorly understood conditions. Premature menopause should be evaluated thoroughly.
Surgical Menopause (caused by a medical treatment such as a hysterectomy)
Induced menopause is menopause caused by a medical treatment such as full hysterectomy (removal of both ovaries), and in some cases, even with partial hysterectomy (preservation of one or both ovaries). Certain drug and radiation therapies can damage the ovaries and cause menopause. The most common cause of surgical menopause is the surgical removal of both ovaries.
If you have a total or radical hysterectomy that removes your ovaries, you'll experience menopause immediately after your operation, regardless of your age. This is known as a surgical menopause.
If a hysterectomy leaves 1 or both of your ovaries intact, there's a chance that you'll experience menopause within 5 years of having the operation.
If a hysterectomy is performed in which the uterus is removed but the ovaries are not, the body will still produce hormones, but at a lower level. Removal of the uterus without the ovaries causes less dramatic changes in hormone levels than a full hysterectomy does, but a partial hysterectomy can still cause a hormonal imbalance.
Those who experience induced menopause do not have the typical perimenopause—the gradual transition leading up to their final menstrual period when hormones wax and wane.
Surgical menopause (removal of ovaries) occurs abruptly, on the day of surgery. Abrupt loss of ovarian hormones often causes drastic symptoms compared to natural menopause.
Induced menopause at a much earlier age than natural menopause (typically, age 51) may result in increased risk for some diseases due to the loss of protection from estrogen and other ovarian hormones---the protective effect of estrogen on bone health is lost, resulting in increased risk for osteoporosis and fracture.
Those with induced menopause may need care for menopause-related symptoms such as hot flashes and vaginal dryness more often than those who reach menopause naturally; they may need treatment longer and at higher doses to control the symptoms and to lower the risk of diseases later in life.
Menopause symptoms related to induced menopause can be similar to those from natural menopause, including hot flashes, sleep disturbances, and vaginal dryness.
How Do I know if I am going into natural menopause?
There is no simple test to tell you that your menopausal transition begins or end. After your periods have stopped completely for a year, you are considered to be postmenopausal. Before that point, your periods will likely become highly irregular. Menopausal symptoms usually do not stop after a person reaches this point but, for many, they will slowly subside as estrogen stays consistently at a low level. Often we will check follicle stimulating hormone (FSH), progesterone, and estrogen when assessing for possible perimenopausal symptoms. Sometimes we will also check testosterone.
Many women experience symptoms such as hot flashes, mood swings, sleep difficulties, low libido, weight gain, increased urinary problems, painful sex and vaginal dryness during perimenopause and menopause.
How do my hormones play a role?
Perimenopause and menopause are defined as natural decline in hormones. The primary hormones that decrease are estrogen and progesterone. Testosterone also typically decreases. At different times in your life, you may have any of three forms of estrogen circulating in your blood. Estradiol is naturally present in perimenopause, estrone is dominant in menopause and estriol is the weakest of all three.
Testosterone is often thought of as 'the male hormone', but it is also an important sex hormone in women and it too declines with age (and with induced menopause).
Testosterone is one of a group of hormones known as androgens, which in larger quantities produces male traits and reproductive characteristics. Women also produce testosterone, along with the sex hormones estrogen and progesterone, and it is vital.
Since menopause is due to the depletion of ovarian follicles/oocytes and severely reduced functioning of the ovaries, it is associated with lower levels of reproductive hormones, especially estrogen.
Low estrogen and fluctuating can result in vasomotor instability (such as hot flashes and night sweats), psychological changes (such as mood swings, depression, and difficulty concentrating), insomnia, genital tract atrophy (such as vaginal dryness, painful intercourse, and urinary incontinence), and skin changes (such as thinning and decreased elasticity).
Lowered testosterone can contribute to the loss of sex drive.
Any abnormal vaginal bleeding should be reported immediately to your provider, since this may represent a precancerous or cancerous condition of the uterus or endometrial lining.
Medical Problems of Prolonged Low Estrogen
Low levels of estrogen are associated with menopause and increase the risk of osteoporosis, bone fractures, and cardiovascular disease (such as myocardial infarction and stroke).
Estrogen is believed to have a positive effect on the inner layer of artery wall, helping to keep blood vessels flexible. Low estrogen can increase your inflammatory response to cholesterol deposits in your blood vessels. This inflammation can constrict blood flow even further and increase the risk for blockages to the heart. Low estrogen may also cause your heart and blood vessels to become stiffer and less elastic. This can increase your blood pressure, which can damage your blood vessels and increase your risk for stroke, heart disease, and heart failure.
Estrogen acts on the liver to help reduce bad cholesterol and increase good cholesterol in your blood. Therefore, low estrogen levels can lead to high cholesterol.
Another common symptom due to low estrogen levels are heart palpitations. Lower estrogen levels can overstimulate the heart and cause arrhythmias.
Low estrogen levels have been linked to increased insulin resistance. Insulin resistance is a risk factor for developing diabetes. Diabetes is another risk factor for heart disease and stroke.
Additionally, estrogen affects how your body distributes fat. Declining estrogen often leads to weight gain in unwanted areas like the waistline.
Estrogen’s known effects on the cardiovascular system include a mix of positive and negative. Estrogen does the following:
Increases HDL cholesterol (the good kind)
Decreases LDL cholesterol (the bad kind)
Promotes blood clot formation, and also causes some changes that have the opposite effect
Relaxes, smooths and dilates blood vessels so blood flow increases
Soaks up free radicals, naturally occurring particles in the blood that can damage the arteries and other tissues.
Why do we need testosterone?
Testosterone contributes to libido, sexual arousal and orgasm. But it is also involved in metabolic functions related to muscle and bone strength, mood and cognitive ability.
In women, androgens are produced in the ovaries, adrenal glands and fat cells and women produce about a tenth of the amount of testosterone that men's bodies produce. While estrogen and progesterone decrease significantly at menopause, testosterone levels gradually decrease with age. Some women will not notice any symptoms as levels fall. Others though may be more sensitive to the changes and experience lack of sexual desire, low mood, low energy and impaired focus and concentration.
In addition to aging, a major cause of testosterone deficiency in women is surgical removal of the ovaries. This can cause an abrupt drop in testosterone and the onset of symptoms.
The changes of menopause begin when there is a marked decrease in estrogen and progesterone, often accompanied by a drop in testosterone.
What are the benefits of HRT?
Hormone replacement therapy (HRT) is a treatment program in which a woman takes estrogen with or without progestin (a synthetic form of progesterone). To decrease the risk of uterine cancer in women who have a uterus, progestin is usually prescribed with estrogen.
Benefits of hormone replacement therapy for post-menopausal folx, include:
Increased elasticity of the blood vessels, allowing them to dilate (widen) and let the blood flow more freely throughout the body
Improved short-term symptoms of menopause such as hot flashes and mood swings, as well as vaginal dryness, dry skin, sleeplessness and irritable bladder symptoms
Decreased risk of osteoporosis and fractures (broken bones)
Decreased incidence of colon cancer
Possible decreased incidence of Alzheimer’s disease
Possible improvement of glucose levels
Is HRT safe?
Short-term hormone replacement therapy is safe for most menopausal women who take HRT for symptom control. However, before HRT is prescribed, make sure you review your medical history with your health care provider. Together, you and your health care provider can decide if you have conditions or inherited health risks that would make HRT unsafe for you. HRT is not recommended for women who have:
History of prior heart attack or stroke and/or increased risk for vascular disease
Unexplained vaginal bleeding
Active or past breast cancer
Active liver disease
Endometrial cancer
Gall bladder disease
High risk for blood clots or a history of blood clots
What are the risks of HRT?
The health risks of HRT include:
Increased risk of endometrial cancer (only when estrogen is taken without progestin) For women who have had a hysterectomy (removal of the uterus), this is not a problem
Increased risk of breast cancer with long-term use
Increased risk of cardiovascular disease (including heart attack)
Increase in inflammatory markers (such as C-reactive protein)
Increased risk of blood clots and stroke, especially during the first year of use in susceptible women
All women taking hormone replacement therapy should have regular gynecological exams (including a PAP smear). The American Cancer Society also recommends that women over age 50 should:
Perform breast self-examination once a month
Have a breast physical examination by her health care provider once a year
Have a mammogram once a year
What are the side effects of HRT?
About 5 to 10 percent of women treated with HRT have side effects which may include breast tenderness, fluid retention and mood swings. In most cases, these side effects are mild and do not require the woman to stop HRT therapy.
If you have bothersome side effects from HRT, talk to your doctor. He or she can often reduce these side effects by changing the type and dosage of estrogen and/or progestin.
If you have a uterus and take progestin, monthly vaginal bleeding is likely to occur. If it will bother you to have your monthly menstrual cycle, discuss this with your health care provider.
For a more in depth look at side effects and safety please read our blog here: https://www.hearthsidemedicine.com/post/estrogen-progesterone-testosterone-side-effects-safety
What symptoms can I expect in perimenopause or menopause?
Each woman’s menopause experience is different. Many women who undergo natural menopause report no physical changes at all during the perimenopausal years except irregular menstrual periods that eventually stop when they reach menopause. As mentioned above, other changes may include hot flashes, difficulty sleeping, memory problems, mood disturbances, vaginal dryness, and weight gain. Not all these changes are hormone-related, and some, such as hot flashes and memory problems, tend to resolve after menopause.
Studies suggest that hormones may play a role in headaches.
Women at increased risk for hormonal headaches during perimenopause are those who have already had headaches influenced by hormones, such as those with a history of headaches around their menstrual periods (so-called menstrual migraines) or when taking oral contraceptives.
Hormonal headaches typically stop when menopause is reached and hormone levels are consistently low. Most hormone headaches do not require treatment or can be treated with non-prescription pain medications. Some headaches, however, can be serious. More serious headaches, including migraines, may require prescription drugs; If a headache is unusually painful or different from those you have had before, seek medical help promptly.
Most women make the transition into menopause without experiencing depression, but many women report symptoms of moodiness, depressed mood, anxiety, stress, and a decreased sense of well-being during perimenopause. Women with a history of clinical depression or a history of premenstrual syndrome (PMS) or postpartum depression seem to be particularly vulnerable to recurrent depression during perimenopause, as are women who report significant stress, sexual dysfunction, physical inactivity, or hot flashes. The idea of growing older may be difficult or depressing for some women.
Vaginal dryness is extremely common during menopause. It’s just one of a collection of symptoms known as the genitourinary syndrome of menopause (GSM) that involves changes to the vulvovaginal area, as well as to the urethra and bladder. These changes can lead to vaginal dryness, pain with intercourse, urinary urgency, and sometimes more frequent bladder infections. These body changes and symptoms are commonly associated with decreased estrogen.
However, decreased estrogen is not the only cause of vaginal dryness. It is important to stop using soap and powder on the vulva, stop using fabric softeners and anticling products on your underwear, and avoid wearing panty liners and pads. Vaginal moisturizers and lubricants may help.
Persistent vaginal dryness and painful intercourse should be evaluated by your healthcare provider. If it is determined to be a symptom of menopause, vaginal dryness can be treated with low-dose vaginal estrogen, or the oral selective estrogen-receptor modulator ospemifene can be used. Regular sexual activity can help preserve vaginal function by increasing blood flow to the genital region and helping maintain the size of the vagina. Without sexual activity and estrogen, the vagina can become smaller as well as dryer.
Sexual desire decreases with age in both sexes, and low desire is common in women in their 40s and 50s, but not universal. Some women have increased interest, while others notice no change at all. There is no major drop in testosterone at menopause. If lack of interest is related to discomfort with intercourse, estrogen may help. What’s important to remember is that there is a full range of psychological, cultural, personal, interpersonal and biological factors that can contribute to declining sexual interest, so if the decline in desire is bothering you, tell your healthcare provider. A clinical evaluation can identify any underlying medical or psychological causes of low sexual desire, which then can be treated as appropriate.
Aging skin undergoes loss of structural proteins (collagen) and elasticity, which creates sags and wrinkles. It also becomes less able to retain moisture, leading to increased dryness. Hormones play an important role in skin health. In particular, for women diminished levels of estrogen at menopause contribute to a decline in skin collagen and thickness. Beyond hormone changes, a number of other factors can increase the visible signs of aging skin. In smokers, the effects of aging are more pronounced, and long-time smokers have more skin damage. Maintaining skin health is one of several good reasons not to smoke or to quit smoking.
How can I treat my symptoms?
There are many different treatment options in managing perimenopausal and menopausal symptoms. Some modalities include patches, gels, creams, vaginal rings, oral medication, tablets that dissolve in your mouth (troche), and bioidentical hormones (BHT). BHT are made in the laboratory and are based on compounds found in plants. Examples may include soybeans or wild yams. BHT are prescribed to increase or stabilize a woman’s hormone levels. This is generally done during perimenopause, when hormone levels change unpredictably, and after menopause, as the hormone levels begin to drop.
For those interested in options beyond hormones, check out our blog https://www.hearthsidemedicine.com/post/navigating-menopause-with-integrative-medicine
How can BHT /HT help me?
Hormone therapy (HT) is a good way for women to relieve many of these symptoms but, as with all medical treatments has some risks. The safety of HT depends largely on the age of the patient and any underlying medical conditions they may have (smoking, breast cancer, history of blood clots, etc).
For most women, the risks are few and the potential benefits are many.
BHT and /or hormone replacement therapy can benefit you in many aspects of your life. It can help improve sleep, increase energy levels,decrease urinary problems, make sex less painful, and in some cases, help alleviate depression and/or anxiety.
Other benefits include regulating menstrual cycles, assisting in weight loss while increasing libido. Some research even suggests a decline in production of hormones can increase your vulnerability to cardiovascular disease and osteoporosis.
When are hormones unsafe?
Typically, the older a woman is, the greater the overall risk. The data is becoming clearer that women over age 60 should be aware of the increased risk of starting hormones because their risk of stroke starts to increase. Younger women who start BHT within five years of menopause may have more benefits with less risk. One prominent study by the World Health Initiative (WHI), revealed that women from age 50-59 taking estrogen were no more likely to have a heart attack or die of heart disease than those taking a placebo. Researchers even suggested that the risk for heart disease in this group might have been slightly reduced. Some risks associated with hormones include blood clots, stroke, and breast cancer. These complexities make it important for a woman to consult with her physician and tailor each treatment to the individual risks and benefits. There are many resources available to you in the next journey of womanhood, to make navigating the waters a little easier. One important thing to remember is you do not have to “just live with” the symptoms of aging!!!
For women who are unable or unwilling to use estrogen therapy, many non-hormonal medications, including selective serotonin reuptake inhibitors, complementary and alternative medicine and supplements, are available that may effectively relieve symptoms or prevent or treat disease.
Check out our blog on navigating menopause naturally here: https://www.hearthsidemedicine.com/post/navigating-menopause-with-integrative-medicine
About the author
Havilah Brodhead is a board-certified family nurse practitioner and chief medical officer of Hearthside Medicine Family Care in Bend, Oregon, an integrative medical practice. Havilah loves incorporating natural, plant-based medicine and alternative medicine into her conventional medicine training. She and her fellow NP provider Marie Mency love to care for the whole family and share a special interest in Women's Health. Havilah loves to mountain bike, practice yoga, and spend time with her husband and two young daughters exploring Oregon.
Havilah Brodhead, FNP and Marie Mency, FNP/Women's Health are accepting new patients of all ages and take most insurances.
www.hearthsidemedicine.com
We offer in-person and telehealth consults for Oregon residents, and Marie is also able to offer telehealth consults to residents of California in addition to Oregon.
www.hearthside.com
541-316-5693
Reference:
British Menopause Society
http://thebms.org.uk/wprs/wp-content/uploads/2016/04/HRT-guide-160516.pdf.
Grady D, Herrington D, Bittner V, et al. for the HERS Research Group. HERS II (Heart and Estrogen/progestin Replacement Study) Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/Progestin Replacement Study follow-up (HERS II). JAMA 2002; 288:49-57
Mayo Clinic Online. Hormone therapy: Is it right for you?http://mayoclinic.com/health/hormones ART-20046372
North American Menopause Society. Recommendations for estrogen and progestin use in peri- and postmenopausal women: March 2007 position statement. Menopause 2007; 14:1-17.
Women’s Health Initiative Web Site. Findings: Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women. www.whi.org/findings/ht/eplusp.php
Women’s Health Initiative (WHI) Participant Web Site. About WHI. www.whi.org/about/
Umland EM. Treatment strategies for reducing the burden of menopause-associated vasomotor symptoms. Journal of Managed Care Pharmacy April 2018; 14(3)(suppl S):S14-S19.
Menopause: diagnosis and management
NICE guideline [NG23]Published: 12 November 2015 Last updated: 05 December 2019
Climacteric 2019 Oct;22(5):429-434. doi: 10.1080/13697137.2019.1637079. Epub 2019 Sep 2.
Global Consensus Position Statement on the Use of Testosterone Therapy for Women
https://pubmed.ncbi.nlm.nih.gov/31474158/