what is menopause?
Definitions can be extremely confusing when we’re talking about menopause, but the bottom line is this: when a woman with ovaries has gone a full 12 months without a menstrual cycle, she is considered to be “in menopause” or “menopausal” from the date of her last period. She will be menopausal for the rest of her life, whether or not she has symptoms.
Perimenopause on the other hand, is the transition phase between the onset of those first changes or symptoms of menopause and the date that a woman is officially in menopause. It’s important to note that this phase, perimenopause, lasts about 5-7 years on average and can exist for up to 10-12 years. It’s also important to remember that perimenopausal and menopausal symptoms can differ dramatically from one woman to the next and from one stage of menopause to another.
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The Stages of Menopause
The first phase of perimenopause is called “Early Peri”. During this time, your periods might be fairly regular but they may start to get closer together. Your menstrual bleeding may be heavier than before. Chemically, what is happening in your body is that you are experiencing a decline in progesterone during the luteal phase of the cycle (the second half of your menstrual cycle, the two weeks or so prior to your period.) This progesterone drop can cause mood changes, difficulty sleeping and menstrual cycle changes.
The second phase of perimenopause is called “Late Peri”. This phase is characterized by estrogen levels that are declining, but may also be fluctuating, sometimes wildly. These estrogen swings lead to more of the classic symptoms of perimenopause: hot flashes, night sweats, weight gain, dry skin, vaginal thinning, low libido, skipped periods and brain fog.
The last phase in this transition is menopause or post-menopause. Menopause itself is actually marked by a single day, the last day of your last period. It can be frustrating that menopause can only be identified “retrospectively.” That is, you will only know, a full 12 months without a period, that the day 12 months ago, was your official date of “menopause”. Once you have identified a date of menopause, we know that since that date the ovaries no longer have been releasing eggs or producing the hormone estrogen. This is how things will remain for the rest of your life and you will now enter the phase described as being “postmenopausal”.
There are a few other types of menopause that are worth listing:
- Premature Menopause refers to menopause that occurs before the age of 45. This occurs in about 5% of women and can be caused by any number of reasons including genetic factors or illnesses.
- Induced Menopause can refer to “surgical menopause” or “medically induced menopause”. Surgical menopause occurs with the surgical removal of both ovaries prior to the average age of menopause. Medically induced menopause refers to the suppression of ovarian hormones in a premenopausal female. This is sometimes part of treatment for breast cancer or severe endometriosis.
One of the most frustrating issues for women as they enter perimenopause and menopause is that symptoms can be so varied and amorphis that they wonder if they are actually having symptoms or are just “overly sensitive” or “crazy.” But it is important to remember that these symptoms are real and are hormonally/neurologically based. They are not “just in your head.”
Here is a list of the most common ones that health practitioners see with their patients:
- Vaginal Atrophy – Many women start to experience irritation or pain in their vaginas. Your vagina is particularly sensitive to hormonal shifts, so as estrogen levels drop, many women feel this first in their vagina. It can be sudden and startling to feel like your vagina is not functioning like it has in the past, or it can be a subtle and a slow change where you wonder if you are imagining things.
- Hot Flashes – Usually this is experienced as a sudden feeling of heat in the face, neck and chest. Many people start to sweat. For some women the skin reddens, and gets blotchy. Some women feel like they are blushing. If you lose too much body heat during a hot flash, you might get chills afterward.
- Night Sweats – Night sweats are essentially extensions of hot flashes. Sometimes they are not worse but there are times that they can be experienced as drenching sweats that soak clothes and bedding. For most women, the most difficult part is that they disturb sleep. Sometimes the night sweat is followed by a cold chill.
- Brain Fog/Memory Changes – Women in perimenopause or menopause will often describe periods of slow thinking, difficulty remembering things, and poor concentration. Often women will ascribe this to “aging” but it may well be connected to dropping estrogen levels.
- Mood Swings or Depression – While this can occur at any stage in a woman’s life, women in perimenopause or menopause are particularly prone to developing anxiety or depression and again, this may be directly linked to hormonal shifts and swings.
- Sexual Dysfunction – Many women experience this time as one of sexual challenges. Their desire for sex might be dropping, their arousal might not be kicking in like it usually does and their orgasms may feel like they have gone on hiatus. Hormonal changes drive many of these challenges.
- Weight Changes – Hormonal changes make menopausal women more likely to gain weight around their abdomens (rather than around hips and thighs). There also seems to be some evidence that lower estrogen levels lead to decreased movement (which may not be noticeable because it’s gradual) and that can lead to slow and steady weight gain. Muscle mass also typically diminishes with age, while fat increases and that can slow the rate at which a body uses calories. That also might contribute to menopausal weight gain. Finally when people don’t get enough sleep, (and menopause can have a significant impact on ones’ sleep) metabolic changes can lead to weight gain.
- Sleeping Difficulties – Hormonal fluctuations can cause sleep disturbances, with many hormonal women describing either difficulty falling asleep or wakefulness in the middle of the night. Night sweats can contribute to additional problems with regular sleep.
Not to worry. Nearly every one of these symptoms can be addressed with the appropriate treatment.
How Do You Diagnose Menopause?
We know that most women will experience menopause at some point in their 40’s or 50’s. Unfortunately, there is no lab test that can definitively diagnose menopause, or tell us exactly when it will occur for an individual woman. FSH (Follicle stimulating hormone) is a test that can sometimes help us understand symptoms of menopause, however it does not, on its own, lead to a diagnosis of menopause. AMH (Anti-mullerian hormone) is another test that is sometimes looked at to understand ovarian reserve, and to give a clearer picture of fertility. There is some data to suggest that it can help predict the timing of menopause, however the science is just not there yet to support its use diagnostically in the clinical setting.
Let's Talk About Treatment
The gold standard of treatment for menopause will include a high level of expertise working with all the available medical resources, medications, herbal supplements, hormones, lasers and exercise. It will also include some element of psychological support.
Women in this stage are going through so many changes in their lives, in their careers, family situations, relationships and in their bodies. Those changes can be difficult to navigate alone and can result in stress and tension that shows up in all kinds of unexpected ways. Additionally, the frustration of medical concerns that have you running from provider to provider and being continually told that it “must be in your head” can be overwhelming, demoralizing and depressing. We have found it to be invaluable to work with someone to process and discuss these things and find more healthy solutions.
At Maze, our Certified Menopause Practitioners approach every patient with a combination of treatments:
- We complete a full evaluation with both a medical provider and a therapist. We want to make sure we have a full history of both your medications, prior treatments, symptoms and concerns.
- We want to see a full panel of blood work to make sure we are aware of any additional underlying conditions that might be effecting your experience of menopause.
- Our therapist will work with you to assess how these issues might be affecting the way you perceive yourself and your body, how they are presenting in your relationships, in your mood, sleep and stress level.
- We will work with you to tailor the right treatment for you which may include:
- HRT – estrogen replacement therapy
- TRT – testosterone replacement therapy
- Local estrogen/testosterone treatment for your vulva and vagina
- Topical treatments for your vulva and vagina.
- Medication adjustments
- Bioidentical hormones
- Herbal medications
- Laser therapies (MonaLisa Touch)
- Breathing and relaxation exercises
- Lifestyle advising and modification
- Short term counseling
When you consider treatment for menopausal symptoms, you need to first decide if you want to approach the entire underlying cause or if you want to treat each individual symptom. There is no right answer. Each woman needs to decide which treatment makes the most sense for her.
Hormone Replacement Therapy (TRT)
The most common overall approach to treating menopause is HRT or Hormone Replacement Therapy. When medical practitioners talk about prescribing HRT, they are referring specifically to the replacement of estrogen. It is most often prescribed to (and indicated for) women with moderate to severe symptoms of menopause. It will also often be recommended to women who experience premature or early menopause (when periods stop before age 45) and those at significant risk for bone loss or osteoporosis. Estrogen can be prescribed by your provider systemically, to reach and affect your whole body, or as “local treatment” to target one specific area or concern. We discuss that more below.
Other hormones may also be prescribed to menopausal women, including progesterone, DHEA, testosterone, or oxytocin to name a few, but just be aware that these are generally not referred to as “HRT”.
Systemic vs. local hormones:
First of all, as you consider treatment, you need to be clear about the distinction between “systemic” hormones, hormones that are meant to support your entire body, and “local” hormones, that are meant only to affect the part of the body to which they are applied. Please make sure you take the time to understand this point because it will have a significant impact on the treatment you decide to pursue.
Systemic estrogen is given in a high enough strength that it will impact your whole body, with the idea that the estrogen will then go to where it is most needed. There are any number of ways to prescribe systemic estrogen. It can be prescribed via patch, pill, capsule inserted into the vagina or ointment. However it is delivered, these treatments are developed in dosages and strengths that are intended to circulate throughout your body and help get that estrogen everywhere necessary to you.That may be your vulva, vagina, bones, skin, hair or brain.
On the other hand, there are “local” estrogen therapies that are meant to affect only the vulva and vagina and are not intended to circulate throughout the rest of your body. These too can come in various forms, such as creams, gels, pellets and rings. That’s an important distinction and one that women often overlook. So when you are prescribed an estrogen, you may want to ask if it is local or systemic.
What is a “bioidentical hormone?”
What bioidentical does not mean:
- “Bioidentical hormones” does not mean that the hormones are “organic.”
- “Bioidentical hormones” does not mean that the hormones are “natural.”
- “Bioidentical hormones” does not mean that the hormones are “not really hormones.”
Bioidentical hormones are products in which the chemical makeup of the hormones exactly matches the chemical makeup of the same hormones in your body.
It’s important to understand that these products are usually man-made and created in a laboratory, but the molecular components are exactly the same as (identical to) the hormones in your body. If you test blood for estrogen or testosterone, the bioidentical versions that were compounded in a laboratory should not be discernible from the same compounds created in your body. Whether you are prescribed pills, topical creams or pellets, we always strongly encourage patients to use products that are “bioidentical”.
You may wonder why any pharmaceutical company would make hormones for you that don’t exactly match what your body creates. And the answer is really simple: Products that match your biology can’t be patented. Think about it: bioidentical hormones cannot be patented, the same way you can’t patent water, unless you add some flavoring to it. You can’t patent estrogen unless there is something different about your estrogen. So, drug companies are incentivized to alter the chemical compound because then they can patent the product. As a result, drug companies sometimes suggest that the difference in their hormonal compound is an improvement. We haven’t found that to be the case.
In recent years, that trend has changed. Since bioidentical hormones are often preferred, either because women feel safer with them or because they are likely to have fewer side effects, drug companies have looked for new ways to patent and market bioidentical hormones. The way that they have done this is by developing better or unique “delivery” systems. That is, since they can’t patent the product itself, they try to come up with an easier or more effective way for the hormone to be delivered. That can be by developing a specific cream or spray, patch or pellet, which contains the hormone. You, the patient, have been the beneficiary because now, the most commonly used hormones are all available, by prescription, in FDA-approved bioidentical formulations!
Here’s another common misconception. Often people assume that anything which is made in a “compounding” pharmacy is bioidentical. But that is not true. Compounding pharmacies are simply pharmacies that make medications on the premises. They often make drugs to-order for specific problems or specific doctors. Compounding pharmacies can make bioidentical or non-bioidentical hormones. It’s all in what the doctor orders.
Sometimes patients gravitate towards compounding pharmacies because they assume that if the medicine (or hormone) is being mixed specifically for them it must be safer or “better for them.” That is not necessarily the case. Products bought from FDA-approved companies have rigorous safety standards and are made by machines, and not as subject to human error. For that reason, where possible, we try to use bioidentical products that are prepackaged for commercial use and not compounded by a compounding pharmacy. However, compounding pharmacies can often be a good resource for us. When we are using a medication that is not available in a pre-prepared product, or if we want a combination of products that currently don’t exist as a combo, we will have them compounded by a compounding pharmacy. And that can be extremely helpful. Also, sometimes compounding pharmacies can make products less expensive than the product on the market.
Why Have I Heard That HRT is Bad For You?
In 2002, a massive study known as the Women’s Health Initiative (WHI) rolled out the results of their research on HRT. The results suggested that HRT usage led to an increased risk of breast cancer, heart disease and blood clots. Unfortunately, the group of women that were included in this study were already in a high risk category in terms of age and health and many were more than a decade past menopause. So the results were severely skewed.
When the results of the WHI were further analyzed, it was noted that a significant group of the WHI subjects saw improved health outcomes on HRT. Unfortunately, the media uproar that followed the initial release of the study led the majority of women and their doctors to abandon and even vilify HRT – and those stigmas still persist in women’s health to this day.
Today, the North American Menopause Society (NAMS) considers HRT to be safe and effective for most women in perimenopause through menopause, especially when started prior to age 60 or within 10 years of the final menstrual period.
HRT: Pros and Cons
- Hot flashes and vaginal dryness: Systemic estrogen therapy is extremely effective at reducing hot flashes and night sweats. Women who still have a uterus need to take a progestogen (progesterone or a similar product) along with the estrogen to prevent cancer of the uterus. Women who have had their uterus removed can take estrogen alone.
- Vaginal dryness or discomfort with intercourse: the preferred treatment is a low dose of local vaginal estrogen or laser treatment, such as MonaLisa Touch, which typically have successful outcomes.
- Osteoporosis: Estrogen therapy is indicated to prevent bone loss and maintain bone health. (However, it is not indicated for the treatment of osteoporosis.)
- Alzheimers: If HRT is started at or around the time of the final menstrual period, the available evidence shows a reduction in risk for Alzheimer’s disease and dementia.
- Heart Disease: HRT is not indicated for the primary prevention of heart disease in postmenopausal women. The data on heart disease, menopause and hormone replacement therapy is mixed. Estrogen itself does relax and dilate the smooth muscle that lines blood vessels, improving blood flow. And we do know that when estrogen levels decline, levels of LDL cholesterol (the harmful kind) increase, and levels of HDL cholesterol (the positive kind) decrease. This is a setup for the buildup of cholesterol in the arteries that contributes to heart attack and stroke. However, estrogen replacement (especially when taken orally) can promote blood clot formation. For that reason, long-term use is discouraged because the risk for heart attack and stroke do increase the longer that HRT is used in the years beyond menopause. We have yet to fully understand the way that estrogen interacts with the cardiovascular system – more research in this area is needed.
- Breast Cancer: Data from the WHI showed that women who used estrogen + progesterone did see a slightly increased risk of breast cancer. However, women who were able to use estrogen alone have a slightly reduced incidence. Observational studies done since the WHI suggest that the risk of breast cancer may be less with the use of oral micronized progesterone compared with the synthetic progestogens that were originally studied. More research is needed in this area to fully understand the absolute and relative risks of breast cancer using bioidentical hormones vs synthetic ones.
- Endometrial Cancer: HRT can increase risk of endometrial cancer (this only occurs when you still have your uterus but are not using a medication or treatment to protect the uterus adequately).
- Blood clots and stroke: HRT can increase risk of blood clots and stroke (this applies almost exclusively to the use of oral estrogen, since it is processed in the liver. This risk does not apply to transdermal estrogen).
- Dementia: Increased risk of dementia if started after the age of 60 (if HRT is started at or around the time of the final menstrual period, then the risk of Alzheimer’s disease and dementia are reduced)
What If I Don't Want To Use Hormones?
There are non-hormonal FDA approved medications that can help with vaginal dryness and hot flashes; these include Osphena (ospemiphene) for vaginal dryness and Brisdelle (paroxetine) for hot flashes.
Vaginal moisturizers and lubricants are available over the counter that can help with vaginal dryness as well. See our full list of lubricant options and find one that’s right for you.
The newest treatment method which is loved and recommended by patients and physicians alike, is a laser treatment called MonaLisa Touch. It’s fast, painless and does not involve the use of hormones.
Lifestyle changes can offer some relief from hot flashes and other menopausal symptoms, especially for those symptoms that are mild to moderately bothersome. For example, wearing light layers of clothing to avoid becoming too warm, engaging in physical activity to help reduce stress, and dietary changes including limiting spicy foods, alcohol and caffeine.
Are There Herbal Supplements That Can Help?
There are some supplements that may help as they act like estrogens. However research on these products is limited and we don’t know much about either efficacy or safety. You should proceed with a healthy amount of caution when using supplements since they are not regulated by any government agency and can contain more, less or even different, substances than the ones listed on the labels. And even though they are “herbal supplements,” they may have side effects. However, here are three that may be worth exploring:
- Black Cohosh (Actaea racemosa, Cimicifuga racemosa) – Women have reported that it has helped them but studies of its effectiveness in reducing hot flashes have produced mixed results.Black Cohosh has had a good safety record over a number of years but it has been reported to contribute to liver problems. This connection continues to be studied. Recent research suggests that it does not act like estrogen, as once thought, and this reduces concerns about its effect on breast or uterine cancer.
- Soy Isoflavones/phytoestrogens – These are supplements isolated from soybeans and contain phytoestrogen isoflavones (essentially naturally occurring estrogens).We don’t understand why but soy isoflavones mimic estrogen action and affect estrogen receptors and are thus able to regulate hormone balance, hot flashes and may reduce the risks of breast cancer, heart disease, and osteoporosis.
- ERr 731 (Rheum rhaponticum) – This is a pill containing rhubarb extract. There have been studies which showed reduced frequency and severity of hot flashes, decreased anxiety and improved general well-being in perimenopausal women.
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In A Patients Own Words:
It has been three months since my initial visit and I no longer experience painful intercourse. I have my sex life back!
I was experiencing painful intercourse for about a year and with proper treatment I got my sex life back in a short period of time.
My husband is a patient of Dr. Werner’s. I went with him to an appointment one day and I saw a pamphlet in the waiting room explaining how many women experience painful intercourse post menopause. After reading the pamphlet I immediately decided to make an appointment.
My first appointment was a very pleasant experience. I had a consultation with Tara Ford and Bat Sheva Marcus and they both made me feel very comfortable. I was able to speak freely about my sex life and what I was experiencing with painful intercourse. The next thing was the physical examination. Tara described each part of the exam to me prior to it being done. I was relaxed during the exam as I knew what to expect. My reaction did not change, but just reinforced my decision to seek treatment.
My treatment included medication first and then dilation. I began to see results within the first month and my condition kept getting better with every week that went by.
Women should know that they are not alone. There are many women experiencing the same problem. If you are experiencing post-menopausal painful intercourse like I was, don’t wait to seek treatment. Make an appointment right away. You too can get your sex life back.
– MC, Age 51 –