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Understanding the Perimenopausal Transition

Reproductive “aging” is a long process ending in menopause.  For most women, this process begins in the mid-30’s with changes in hormones well before any changes are seen in the menstrual cycle.  This process is a continuum. 

Perimenopause and Menopause

Changes may occur with the menstrual cycle, usually shortening of the cycle, but also irregularity or lengthening.  This process usually starts 2-9 years before menopause.  Perimenopause has also been described as the period of greater irregularity and missed periods, with > 60 days of no cycles.  However, some women do not fit into anything as above and are regular and stop their periods without any changes.  Approximately, 20% of perimeopausal women are symptom-free.  Unfortunately, about 30% of women can be significantly affected by symptoms.  The most common symptom is hot flashes which occur mostly in the late perimenopause.  Breast enlargement often can occur in early-mid-perimenopausal period. 

Menopause is defined as one year after the final menstrual period.  Some experts will extend menopause as to two years with no cycle.  The average American woman is menopausal around age 51, but for some women it may be “normal” for that individual as early as age 40.  There is no way to predict when menopause will occur in any woman.  Sometimes the best predictor of the menopausal transition is self-assessment of hot flashes, night sweats, vaginal dryness, high FSH and low inhibin levels.  Studies suggest that 50% of the individual variability can be attributed to family genes.  Cigarettes can cause a person to become menopausal from 1-3 years earlier. 

Cycles are frequently unpredictable in perimenopause, so symptoms change.  It is not unusual to have intense symptoms interspersed with normal cycles.  It can be hard to tell if a certain therapy is truly working.  Women who are troubled by irregular and frequent cycles can be regulated by low-dose birth control pills.  Cyclic progesterone can help with bleeding.  Flow can also be decreased with a progesterone-containing intrauterine device. 

Controlling weight, exercise, smoking cessation can be helpful.  Psychological support is important.  Hormone therapy can be considered in the menopausal patient.  Menopause is a complex transition; it can affect almost every system in your body.  Recent studies suggest concerns with hormone usage.  It is clear that hormones do not prevent heart disease or cancer. 

Q : Are hormones appropriate for treating hot flashes and night sweats?

Definitely, however, these symptoms usually disappear in 3-5 years.  For women who have a hard time getting  restful sleep, hormone therapy is probably the most effective treatment of night sweats and of course hot flashes.  Most of the time, women find relief with very low dosages.  Some women, who don’t want hormones, can find alternatives in low dose antidepressants antihypertensive medication or herbal remedies like black cohosh.

Q:  Can exercise or changing my diet help with menopausal or perimenopausal symptoms?

Yes.  Regular exercise, avoiding spicy food, caffeine, red wine, and relaxation techniques of meditation, yoga, or simply deep breathing can help.

Q:  I am having problems with vaginal dryness and painful sexual intercourse.  Can hormones help?

Vaginal dryness occurs because the lack of estrogen results in thinning of the vaginal tissue and decreased lubrication.  Local application of estrogen to the vagina in a cream or vaginal ring results in less overall systemic absorption.  Over -the counter vaginal lubricants and moisturizers can help ease the discomfort. 

Q:  My sex drive has decreased since menopause.  What can I do?

Sexual desire is a complex process that can be affected by your psychological and physical state.  Medical studies have not shown that hormones directly increase libido; it does help with vaginal dryness, hot sweats, and sleep deprivation.  Decrease libido may also be a sign of depression.

Q:  I noticed that I have troublesome mood swings and feel depressed at times.  Will hormones help?

Depression is a serious problem that needs to be addressed.  Other diseases may mimic depression.  You may have to get your thyroid tested.  If you are diagnosed with depression, selective serotonin uptake inhibitors called SSRIs will also help with hot flashes.

Exercise and stress management can help significantly with mood swings.  Some studies have found that estrogen can be helpful for depression with perimenopausal women and may help increase the effectiveness of antidepressants. 

Q:   Can I use alternative therapies for my menopausal symptoms?

There needs to be more research on the safety and effectiveness of alternative therapies.  Some of the more common ones are black cohosh, soy, supplements, wild yam extract, phytoestrogen (plant-based estrogens).  Remember to tell your doctor.  These supplements can also have side effects and drug interactions. 

Q:  How long should I take the hormone therapy?

Most women will complete menopause in 5 years.  At this time, the lowest-dose to relieve your symptoms for a short duration, 2-5 years is recommended.  But each patient must discuss with their doctor to individualize treatment.  By educating yourself on menopause and its effect on your body, you empower yourself and help enable a good working relationship with your health care provider.