Menopause

The medical definition of menopause is “No uterine bleeding for 12 months”. Normally this occurs between the ages of 40 and 60, a fairly large age range. This is a somewhat arbitrary definition, but what it means is that if you are within the normal menopause age range , if you go a year without bleeding, statistically you are very unlikely to bleed again. But it’s not that uncommon to bleed at 13 months, 16 months, or even 2 years, especially if you are still near the early end of the age range. There is never an age at which the uterus loses it’s capacity to bleed, although the older you are, the more it could be a sign of a serious problem, not just hormones effects. At least 5-10 years before menopause, the ovaries start to go through some significant changes. Their production of hormones starts to become more variable causing your cycles to become more irregular and unpredictable. Bleeding can be heavier and/or longer, or less than you have been used to. Due to the erratic nature of hormone levels during this time, many women start to experience symptoms such as hot flashes, night sweats, insomnia or interrupted sleep patterns with or without the sweating, and  mood changes such as more  irritability, anxiety, or episodes of depression. There is a wide spectrum of symptoms that women can notice. Some women have essentially no noticeable changes; some women have severe bothersome symptoms, and most women end up somewhere in between. Even if you don’t have any symptoms during the early years of the “change”, almost everyone eventually has issues with vaginal dryness, and may experience pain with intercourse.

On top of these hormone changes, this can typically be a very difficult time in a woman’s life due to social or economic stresses. The kids are “grown up” but still often quite needy, and now there are the parents who are in decline and need help from their kids,too. Plus there are demands from work or other responsibilities, money and retirement concerns, and it’s sometimes just TOO MUCH.

All women who live to middle age go through this hormonal transition. Once you are truly menopausal (NO detectable ovarian hormone production), you are forever in menopause, which might mean 1/3 to ½ of your adult life. This is a natural phenomenon, not a disease or condition that necessarily needs treatment.  On the other hand, there may be situations where intervention should be considered. During the transition years if there is excessive bleeding, you may run out of iron stores and become significantly anemic (not enough red blood cells to carry oxygen around). This can have adverse effects on your body . This situation should be treated with  iron supplementation, other medications, and/or a procedure to slow the bleeding down. ( See my page on Bleeding Problems).

The other problems may also warrant intervention if they are severely impacting your quality of life. The hot flashes and night sweats might be managed adequately by just wearing and/or sleeping in layers. Insomnia or anxiety might be improved with regular exercise, practicing yoga and meditation, or learning other psychological techniques to help you calm yourself down or bring your mood up.

If symptoms are still too bothersome though, you can try some OTC (over the counter) supplements such as those with black cohosh, or soy. Some women find these quite helpful, but if you don’t notice much improvement in a month or 2, it’s not worth spending a lot more time or money expecting results. The bottom line is that there is very little science proving that these supplements are effective, and there is no FDA regulation attesting to the quality of the products. My impression is that they are likely pretty safe, but there is no data to really confirm that either. There are studies to suggest Melatonin can be helpful for sleep issues with out significant risk, starting at a 5mg dose and increasing a bit if needed. OTC sleep aids , such as Tylenol PM, are safe as well, although probably it’s best not to use nightly.

If the above measures are not helpful enough, there are prescription treatments which are safe and effective. For the sleeping and mood issues, low doses of mood stabilizing meds such as Effexor, Paxil, or Prozac are often helpful. Another option, which in general is even more effective, is Hormone Therapy (HT).  The primary hormone given is Estrogen, usually in bioidentical form. If you have not had a hysterectomy or endometrial ablation, you will be advised to also take progesterone. This latter hormone is given to prevent bleeding problems, although some women thinks it seems to help with their symptoms as well. These hormones are generally given in pill,patch, or cream form, and through the entire body, providing benefit to multiple areas.

If the symptoms are primarily vaginal dryness and discomfort though, they can usually be relieved with regular use of OTC lubricants or moisturizers, or a prescription vaginal preparation (cream, suppository, or tablet) with Estrogen.

In general HT is very safe for the vast majority of otherwise healthy women. The concerns about causing breast cancer or blood clots in the early menopause group are greatly over exaggerated. There are also numerous studies indicating it’s benefit on bones (decreasing risk for osteoporosis and fractures), and also decreased risk for cardiovascular events , such as MI’s (heart attacks).

The most bothersome symptoms may start before obvious bleeding changes, during the phase of irregular menses, or even after the bleeding is done. It is very variable how long they last. It could be just a few months, a few years or even quite a bit longer. I don’t know that there’s any age at which you might not still have a hot flash, but they are almost always a lot better by the late 60’s or 70’s than they were when you were younger. There is no good way, such as menstrual history or blood tests, to predict how long you will be bothered. Family history, mothers, sisters,etc. may give some insight, but is far from perfect in predicting how you will fare in menopause. It could be a lot easier than those women, or possibly worse.

If you do decide to take HT, you are not committed to staying on it for any specific amount of time. And there is no absolute end date either. As long as it appears to be helping your symptoms, and there are no new risk factors that develop along the way, women can safely take them for years. In general, it makes sense to try and lower the dose as the years progress, since it appears that as women age, they do not seem to need as much estrogen to treat their menopause symptoms.

In summary, there is rarely a reason to really suffer due to the menopause changes. Treatments are safe if you are willing to consider them.

Dr.Heidtke