Menopause and perimenopause

What are menopause and perimenopause?

Most women think of menopause as the time of life when their menstrual periods end. This usually occurs during middle age, when women are also experiencing other hormonal and physical changes. For this reason, menopause is sometimes called the "change of life."

A woman is said to be in menopause after she has gone for one full year without periods. While most women in the United States go through menopause around the age of 51, a small number will experience menopause as early as age 40 or as late as their late 50s. Rarely, menopause occurs after age 60. When menopause is diagnosed before age 40, it is considered to be abnormal or premature menopause.

In women, the ovaries produce the female hormones estrogen and progesterone. Estrogen and progesterone control a woman's periods and other processes in her body. As a woman approaches menopause, her ovaries gradually makes less and less of these hormones.

As hormone levels fall, a woman's pattern of menstrual bleeding usually becomes irregular. Many women experience light, skipped or late periods for several months to a year before their periods stop altogether. Some women may experience heavier-than-normal bleeding. Heavier-than-normal bleeding should be evaluated by a doctor to exclude problems in the genital tract.

It is important to realize that until menopause is complete, a woman still can become pregnant even when periods are light or missed.

For most women, menopause is a normal process of aging. If a woman has had her ovaries removed by surgery or has had damage to her ovaries for other reasons, such as radiation therapy, she may become menopausal from that process.

Perimenopause, also known as the climacteric, includes the time before menopause when hormonal and biological changes and physical symptoms begin to occur. This period lasts for an average of three to five years.

Symptoms of menopause and perimenopause

Some women don't have any symptoms during menopause or only have a few symptoms. Others develop disturbing and even severe, disabling symptoms. Studies of women around the world suggest that differences in lifestyle, diet and activity may play a role in the severity and type of symptoms women have during menopause. Symptoms can be noticed for several months to years before the last menstrual period and can continue for several years after.

Symptoms of menopause or perimenopause include:

• Hot flashes — A hot flash is a feeling described as suddenly being hot, flushed and uncomfortable, especially in the face and neck. Hot flashes come in bursts or flushes that usually last a few seconds to a few minutes. They are caused by changes in the way blood vessels relax and contract and are thought to be related to the changes in a woman's estrogen levels.
• Irregular periods — A woman can have irregular periods for several months to years before her periods finally stop. Any vaginal bleeding that develops after a year of no periods is abnormal and should be evaluated by a doctor. Heavy or prolonged bleeding during the perimenopause should also be evaluated.
• Vaginal drying — As estrogen levels fall, the vagina's natural lubricants decrease. The lining of the vagina gradually becomes thinner and less elastic (less able to stretch). These changes can cause sex to be uncomfortable or painful. They can also lead to inflammation in the vagina known as atrophic vaginitis. These changes can make a woman more likely to develop vaginal infections from yeast or bacterial overgrowth and urinary tract infections.
• Sleep disorders — Sleep often is disturbed by nighttime hot flashes. A long-term lack of sleep can lead to changes in moods and emotions.
• Depression — The chemical changes that happen during menopause do not increase the risk of depression. However, many women experience major life changes during their middle age including menopause and sleep disturbances, which can increase the risk of developing depression.
• Irritability — Some women report irritability or other mood changes. Irritability is commonly caused by poor sleep resulting from nighttime hot flashes. A number of women, however, do not feel irritable.
• Osteoporosis — This condition is a thinning of the bones that increases the risk of fracturing a bone, especially in the hips or spine. As estrogen levels drop and remain low during menopause, the risk of developing osteoporosis increases. The risk is greatest for slender, white or light-skinned women. You can help prevent osteoporosis by getting enough vitamin D through sunlight or a daily multivitamin, eating a diet rich in calcium and performing regular exercise. Women should start taking these actions well before menopause begins because women begin to lose bone mass as early as age 30.
• Cardiovascular disease — Before menopause, women have lower rates of heart attack and stroke than men. After menopause, however, the rate of heart disease in women continues to rise and equals that of men after age 65.

Diagnosing menopause and perimenopause

For most women, the diagnosis of menopause is made based on a woman's description of her symptoms and the ending of her menstrual periods. Laboratory testing is not usually needed.

Because women can still become pregnant while they are perimenopausal, doctors may do a pregnancy test when a woman's periods become irregular, infrequent or light. In some cases, a blood test for levels of follicle-stimulating hormone (FSH) may be recommended. FSH levels are normally high in menopause, so high FSH levels can help to confirm that a woman is in menopause.

At the time of menopause, doctors often recommend a bone density measurement. The test result sometimes will detect early osteoporosis. More often the result is used as a baseline to compare rate of bone loss in the future.

Another test is endometrial biopsy. An endometrial biopsy is an office procedure in which a tiny piece of endometrial tissue from inside the uterus is taken and examined under a microscope for signs of cancer. This test may be done when a woman is having irregular, frequent or heavy bleeding, but it is not routinely recommended as a test for menopause.

Expected duration of menopause and perimenopause

Perimenopause usually lasts three to five years but it can take as few as two years or as many as eight years for some women. The changes in the body that occur during menopause last for the rest of a woman's life. However hot flashes usually improve over time, becoming less frequent and less severe.

Preventing menopause and perimenopause

Menopause is a natural event and cannot be prevented. Medications, diet and exercise can prevent or eliminate some symptoms of menopause and enhance a woman's quality of life as she grows older.

Treating menopause and perimenopause

Lifestyle changes

Diet, exercise and lifestyle changes can reduce the symptoms and complications of menopause. The following recommendations are appropriate for all women who are approaching menopause or who are in menopause.

• Refrain from smoking. Smoking increases the risk of osteoporosis and hip fractures. Smoking also increases the risk of heart attack and stroke.
• Limit caffeine. High caffeine intake, more than three cups per day, can aggravate hot flashes and may contribute to osteoporosis.
• Wear layers of clothing. Since you can have hot flashes any time, wearing layers can help you to cool off quickly during a hot flash and warm up if you get chilled after a flush. Keep bed blankets light and use layers at night for the same reason.
• Exercise. Exercise can:
  • reduce blood pressure and the risk of heart attack and stroke
  • relieve hot flashes in some women
  • reduce osteoporosis and fractures.

Exercise to prevent weak or thin bones must be weight-bearing exercise such as walking, low-impact aerobics, dancing, lifting weights, or playing a racquet sport such as tennis or paddle ball. Exercise does not need to be vigorous to help. Walking a few miles per day helps to maintain bone mass.

• Get sunlight and vitamin D. Vitamin D helps your body absorb enough calcium from food. You can get enough vitamin D with only a few minutes of sun exposure each day. But that may not be possible and few foods contain natural vitamin D. That's why many doctors recommend a daily 1,000 IU vitamin D3 supplement.
• Treat vaginal dryness. Lubricants such as Astroglide or K-Y Lubricant can help with dryness during sex. Vaginal moisturizers such as Replens or K-Y Vaginal Moisturizer can help to treat irritation due to dryness. Doctors can also prescribe a hormonal cream if over the counter treatments do not work.
• Consume calcium. Women should get between 800 to 1,500 milligrams of calcium every day. Good sources of calcium include:
  • dark green vegetables (except spinach, which contains another ingredient that reduces the amount of calcium that can be absorbed from the food) — One cup of turnip greens supplies 197 milligrams of calcium, and 1 cup of broccoli provides 94 milligrams.
  • dairy products — One cup of milk provides approximately 300 milligrams of calcium, and 1 cup of yogurt supplies 372 milligrams. Cheese is another good source. One ounce of Swiss cheese has 272 milligrams of calcium.
  • sardines and salmon — Four ounces of sardines provide 429 milligrams of calcium, and 4 ounces of salmon have 239 milligrams of calcium.
  • legumes — One cup of navy beans supplies 127 milligrams of calcium.

Medication therapy

A number of medications are used to treat the symptoms of menopause. The type of medication needed is a complicated decision and each woman should discuss the issue with her doctor. The treatment will depend on what symptoms are most bothersome and how bothersome they are.

Estrogen taken as a pill or applied to the skin as a patch can reduce hot flashes, sleep disturbances, mood changes and vaginal dryness. Estrogen can be prescribed alone when a woman no longer has her uterus. A combination of estrogen and progesterone is used when a woman still has her uterus. Progesterone is necessary to balance estrogen's effect on the uterus and prevent changes that can lead to uterine cancer.

However, evidence has shown that there are some risks associated with the use of these medicines. Estrogen therapy can increase the risk of heart disease, stroke, breast cancer and blood clots in a small number of women. On the other hand, it prevents fractures and can decrease the risk of colon cancer. Therefore, the decision to use hormone replacement therapy to treat symptoms of menopause is an individual decision. A woman should talk to her doctor about the risks and benefits of hormone replacement therapy for her.

There are several other medications that can be used to treat hot flashes:

• Antidepressants — Medications such as venlafaxine (Effexor) and paroxetine (Paxil) are often the first choice for women with hot flashes who are not on hormone replacement therapy. They relieve the symptoms of hot flashes in 60% of women.
• Gabapentin (Neurontin) — This medicine is moderately effective in treating hot flashes. Gabapentin's main side effect is drowsiness. Taking it at bedtime may help improve sleep while decreasing hot flashes.
• Clonidine — This is a blood pressure medication that can relieve hot flashes in some women.
• Fezolinetant (VEOZAH) — This is the first FDA approved drug in a new class of non-hormonal medicines known as neurokinin 3 receptor (NK3R) antagonists. These drugs have been shown to decrease the frequency and severity of hot flashes.

Several alternative treatments have been proposed to treat the symptoms of menopause. Many of these treatments have not been studied in large clinical trials. Although black cohosh has been previously promoted as a treatment for hot flashes, well-done medical studies conclude the root is no more effective than a placebo.

Some women have found St. John's wort to be effective in treating mood disorders related to menopause.

The use of soy products in the diet such as tofu is controversial. While it may improve symptoms for some women, the phytoestrogens (plant estrogens) that may help relieve hot flashes may also increase the risk of breast cancer.

Scientific studies have found no benefit to the use of vitamin E or primrose oil. No evidence has been found to support the use of acupuncture or homeopathy, but few studies of these therapies have been done.

When to call a professional

You should see your doctor if you have any of the following:

• periods that come closer together than every 21 days
• periods that last longer than seven days
• periods that are very heavy
• bleeding between periods
• vaginal bleeding that starts after menopause (after one year without a period).

Prognosis

Although menopause can cause some uncomfortable symptoms, both lifestyle practices and medication can help to ease these symptoms and complications.

Additional info

American College of Obstetricians and Gynecologists
https://www.acog.org/

American Federation for Aging Research (AFAR)
https://www.afar.org

National Guideline Clearinghouse (NGC)
https://www.guideline.gov/