Menopause & Perimenopause -- April 21, 2008 -- Dr. Larry Gurley - NewsChannel5.com | Nashville News, Weather & Sports

MEDICAL MONDAYS NEWS NOTES
Dr. Larry D. Gurley
The Menopause Center at Baptist  

Dr. Gurley's practice specializes in menopause and menstrual disorders.

TOPIC: Menopause & Perimenopause
Monday, April 21, 2008

Overview

What is menopause? What is perimenopause?

Menopause is the point in a woman's life when she has not had a menstrual period for 1 year. Menopause marks the end of the childbearing years. It is sometimes called "the change of life."

For most women, menopause happens around age 50, but every woman's body has its own timeline. Some women stop having periods in their mid-40s. Others continue well into their 50s.

Perimenopause is the process of change that leads up to menopause. It can start as early as your late 30s or as late as your early 50s. How long perimenopause lasts varies, but it usually lasts from 2 to 8 years. You may have irregular periods or other symptoms during this time.

Menopause is a natural part of growing older. You don't need treatment for it unless your symptoms bother you. But it's a good idea to learn all you can about menopause. Knowing what to expect can help you stay as healthy as possible during this new phase of your life.

What causes menopause?

Normal changes in your reproductive and hormone systems cause menopause. As your egg supply ages, your body begins to ovulate less often. This causes your hormone levels to go up and down unevenly (fluctuate), causing changes in your periods and other symptoms. In time, estrogen and progesterone levels drop enough that the menstrual cycle stops.

Some medical treatments can cause your periods to stop before age 40. Having your ovaries removed, radiation therapy, or chemotherapy can trigger early menopause.

What are the symptoms?

Common symptoms include:

• Irregular periods. Some women have light periods. Others have heavy bleeding. Your menstrual cycle may be longer or shorter, or you may skip periods.
• Hot flashes.
• Trouble sleeping (insomnia).
• Emotional changes. Some women have mood swings or feel grouchy, depressed, or worried.
• Headaches.
• Feeling that your heart is beating too fast or unevenly (palpitations).
• Problems with remembering or thinking clearly.
• Vaginal dryness.

Some women have only a few mild symptoms. Others have severe symptoms that disrupt their sleep and daily lives.

Symptoms tend to last or get worse the first year or more after menopause. Over time, hormones even out at low levels, and many symptoms improve or go away. Then you can enjoy being free from periods and birth control concerns.

Do you need tests to diagnose menopause?

You don't need to be tested to see if you have started perimenopause or reached menopause. You and your doctor will most likely be able to tell based on irregular periods and other symptoms.

If you have heavy, irregular periods, your doctor may want to do tests to rule out a serious cause of the bleeding. Heavy bleeding may be a normal sign of perimenopause. But it can also be caused by infection, disease, or a pregnancy problem.

You may not need to see your doctor about menopause symptoms. But it is important to keep up your annual physical exams. Your risks for heart disease, cancer, and bone thinning (osteoporosis) increase after menopause. At your yearly visits, your doctor can check your overall health and recommend testing as needed.

Do you need treatment?

Menopause is a natural part of growing older. You don't need treatment for it unless your symptoms bother you. But if your symptoms are upsetting or uncomfortable, you don't have to suffer through them. There are treatments that can help.

The first step is to have a healthy lifestyle. This can help reduce symptoms and also lower your risk of heart disease and other long-term problems related to aging.

• Make a special effort to eat well. Choose a heart-healthy diet that is low in saturated fat and includes plenty of fish, fruits, vegetables, beans, and high-fiber grains and breads.
• Include plenty of calcium in your diet to help your bones stay strong. Get 1,200 mg a day after age 50 (plus at least 400 IU of vitamin D to help your body use the calcium). Low- or nonfat dairy products are a great source of calcium.
• Get regular exercise. Exercise can help you manage your weight, keep your heart and bones strong, and lift your mood.
• Limit caffeine, alcohol, and stress. These things can make symptoms worse. Avoiding them may help you sleep better.
• If you smoke, stop. Quitting smoking can reduce hot flashes and long-term health risks.

If lifestyle changes are not enough to relieve your symptoms, you can try other measures, such as:

• Meditative breathing exercise (called paced respiration). Studies have shown that it can help reduce hot flashes and emotional symptoms.^{1, 2}
• Black cohosh. This herb may prevent or relieve symptoms. But experts don't know if it is safe to use for longer than 6 months, and you should not take it if there is a chance you could be pregnant. If you plan to try black cohosh, talk to your doctor about how to take it safely.
• Soy (isoflavones). Some women feel that eating lots of soy helps even out their menopause symptoms. It may also help keep your bones strong after menopause.³
• Yoga or biofeedback to help reduce stress. High stress is likely to make your symptoms worse.

If you have severe symptoms, you may want to ask your doctor about prescription medicines. Choices include:

• Low-dose birth control pills before menopause.
• Low-dose hormone replacement therapy (HRT) after menopause.
• Antidepressants.
• A medicine called clonidine (Catapres) that is usually used to treat high blood pressure.

All medicines for menopause symptoms have possible risks or side effects. A very small number of women develop serious health problems when taking hormone therapy. Be sure to talk to your doctor about your possible health risks before you start a treatment for menopause symptoms.

Remember, it is still possible to become pregnant until you reach menopause. To prevent an unwanted pregnancy, keep using birth control until you have not had a period for 1 full year.

Menopause and Perimenopause - Cause

Natural and expected hormone changes cause perimenopause, menopause, and postmenopause.

Perimenopause

As you age, your body begins the natural sequence of changes that eventually bring an end to your menstrual cycle (menopause). The number and quality of your eggs decline, hormone levels fluctuate, and your menstrual cycle becomes less predictable. This time of unpredictable change is called perimenopause.

Menopause and postmenopause

After a few years of fluctuating hormones, your estrogen and progesterone levels begin to decline. When your estrogen drops past a certain point, your menstrual cycle and your ability to become pregnant end. After 1 year with no menstrual bleeding, you reach menopause and begin postmenopause.

A year or more into postmenopause, estrogen levels typically even out at a low level. Since estrogen also plays a role in other functions of your body, its decline has far-reaching effects, including faster bone loss and drying and thinning of the skin and the vaginal and urinary tracts.

Menopause can be caused suddenly and prematurely by surgical removal of the ovaries (oophorectomy), by chemotherapy, or by radiation therapy to the abdomen or pelvis.

Causes of early menopause

Your body has its own timeline for when menopause will start and how long it will last. In fact, it's likely that your timeline will be much like your mother's was. However, certain lifestyle choices and medical treatments can cause or are linked to an earlier menopause, including:

• Smoking. On average, women who smoke reach menopause 1.5 years earlier than those who don't. The longer you have smoked and the more you smoke, the stronger this effect is likely to be.⁴
• Radiation therapy to or removal of the pituitary gland.
• Chemotherapy.
• Radiation therapy or other treatment to the abdomen or pelvis that damages the ovaries so that they no longer function.
• Genetic and autoimmune diseases.
• Removal of both ovaries (oophorectomy), which causes sudden menopause.
• Living at high altitudes.⁴
• A vegetarian diet.⁴
• Low body fat (body mass index of 25 or less).

Symptoms

Although some women have few or no menopause symptoms, most women do. Similarly, while some women have mild symptoms, others find that their sleep, daily life, and sense of well-being are severely affected. Menopause symptoms eventually subside when hormone levels even out. Postmenopause changes are normal signs of low estrogen and typically continue over time.

Signs and symptoms of perimenopause

Signs that you are in perimenopause include:

• Irregular menstrual periods.
• Less frequent, light menstrual periods.
• Heavier menstrual periods than you are used to having.

Symptoms of menopause

Symptoms related to menopause are caused by changing or dropping hormone levels and usually end 1 or 2 years after menopause. Some women continue to have symptoms for 5 or more years afterward. Menopause symptoms include:

• Hot flashes.
• Sleep disturbances (insomnia).
• Emotional changes, such as mood swings or irritability.
• A change in sexual interest or response.
• Problems with concentration and memory that are linked to sleep loss and fluctuating hormones (not a permanent sign of aging).⁵
• Headaches.
• Rapid, irregular heartbeats (heart palpitations).
• Generalized itching.

Menopause caused by surgery, chemotherapy, or radiation therapy can cause more severe symptoms than usual.⁶ Preexisting conditions such as depression, anxiety, sleep problems, or irritability can get worse during the perimenopausal transition.

Signs of postmenopause

Signs that you have reached menopause and are in postmenopause include:

• No menstrual periods (and no need for birth control measures).
• Drying and thinning of the skin, hair, and nails caused by lower collagen production.
• Vaginal and urinary tract changes, such as:

• o Vaginal dryness, irritation, and itching.
• o An increased risk of vaginal and urinary tract infections (UTIs).
• o Pain during sexual intercourse (dyspareunia).

Other conditions can cause changes in the menstrual cycle or symptoms resembling perimenopause and postmenopause. Examples include pregnancy, a significant change in weight, depression, anxiety, disease, or uterine, thyroid, or pituitary problems.

Treatment Overview

Menopause is a natural change that doesn't require treatment. However, symptoms of hormonal change can be difficult. If you have insomnia, mood swings, hot flashes, cloudy thinking, heavy menstrual periods, or other menopause symptoms, treatment can help you manage this transition more comfortably. As you review your options, consider the following:

• Healthy lifestyle habits will help you reduce menopause symptoms. These habits include eating a balanced diet; reducing stress; getting regular exercise; and avoiding smoking, heavy caffeine, and heavy alcohol use. An unhealthy lifestyle can make symptoms worse.
• Low-dose hormone therapy (HT) or low-dose birth control pills may be an option if you are still having periods and have multiple or severe symptoms. Birth control pills aren't used after menopause because they contain higher levels of hormones than women need.
• After menopause, hormone therapy can be used as a short-term treatment for severe symptoms when taken in as low a dose as possible.
• You may only need a specific treatment for certain symptoms, such as hot flashes or vaginal dryness.
• Meditative breathing, as well as supplements such as black cohosh or soy, may help relieve symptoms.

Recent studies have led to a big change in how health professionals use hormone therapy after menopause. For a long time, estrogen-progestin, or hormone replacement therapy (HRT), was thought to protect against heart disease or dementia. But studies now show that HRT use can cause serious health problems in a small number of women. These health problems include dangerous blood clots, stroke, heart disease, breast cancer, ovarian cancer, and dementia.^{8, 9, 10} The heart disease risk does not seem to affect women during their first 10 years after menopause.¹¹

Average HRT- and ERT-related risks are low among the general population of women. However, your personal risk that hormone therapy may stimulate breast cancer, ovarian cancer, cardiovascular problems, blood clots, or neurological changes may be lower or higher, depending on your risk factors for those health problems.

Treatment options for menopause symptoms

Hot flashes. Meditative breathing exercises (paced respiration) have been shown to reduce hot flashes.¹ Medications that can improve hot flashes include short-term, low-dose hormone therapy, selective serotonin reuptake inhibitor (SSRI) antidepressants such as fluoxetine and paroxetine (for example, Paxil and Prozac), the high blood pressure medication clonidine, and the antiseizure medication gabapentin (Neurontin).^{12, 13}

Heavy periods. The hormone progestin can help relieve heavy menstrual bleeding caused by low progesterone levels (after you have an exam to rule out other possible causes). Other options include nonsteroidal anti-inflammatory drugs (NSAIDs), the levonorgestrel (LNg) IUD, or birth control pills. For severe blood loss, some women choose permanent surgical treatment. These options include removing the uterus (hysterectomy) or using heat energy to damage and scar the wall of the uterus (endometrial ablation). For more information, see the topic Dysfunctional Uterine Bleeding.

Vaginal dryness and irritation. A vaginal lubricant can help with dryness. Estrogen creams, rings, or tablets can help thin skin, dryness, and irritation. Less estrogen is absorbed into your system with vaginal use, so the risks associated with ERT are less likely.

Multiple or severe symptoms. Hormone therapy can relieve multiple or difficult menopause symptoms. For symptom relief before menopause, low-dose estrogen-progestin birth control pills or low-dose HRT (estrogen-progestin) can reduce heavy menstrual bleeding and other symptoms. After menopause, low-dose HRT is an option. Also, for severe symptoms that don't improve with estrogen-progestin, there is an estrogen-testosterone therapy. But testosterone is not FDA-approved for women, because it is not yet well studied. Talk to your health professional about short-term HRT along with checkups every 6 months.

Bioidentical hormone replacement therapy (BHRT) is an alternative to HRT. But it has not been well studied. The hormones are made in a laboratory from wild yams or soy. BHRT is thought to be more similar to human-produced hormones than synthetic HRT is. (Well-designed studies have yet to prove this theory.¹⁴) However, bioidentical HRT may carry the same heart, stroke, blood clot, breast cancer, ovarian cancer, and dementia risks that are linked to traditional HRT. Any form of hormone therapy, including BHRT, is best taken for as short a period as possible after menopause.

Should I use hormone replacement therapy (HRT)?

Testosterone is sometimes used to increase sexual desire in postmenopausal women who have low testosterone. The U.S. Food and Drug Administration (FDA) has not approved testosterone treatment for this purpose. Studies of testosterone in women have not lasted longer than 6 months.¹⁵ FDA experts want to know more about long-term risks before they approve testosterone for female use.

If you have a problem with low sexual desire, consider that most sexual problems in women relate to such things as relationship troubles, depression, or medicine side effects. For more information, see the topic Sexual Problems in Women.

Other treatment options

Because of concern about HRT health risks, many women have turned to alternative medicine for menopause symptom relief.

• Black cohosh (Remifemin) is a plant-based alternative to hormone therapy for hot flashes, mood problems, and other symptoms. It is not clear how black cohosh works in the body.¹⁶ It is also not known whether black cohosh increases the risk for breast or uterine cancer.
• Dietary soy is thought to ease symptoms, although there is little evidence to support this. Dietary soy may also reduce heart disease risk and improve bone health, but these benefits also are not yet well proven by research.¹