by Tori Hudson, N.D.
More than ever before, women are entering menopause, educating themselves, asking their doctors questions, and requesting information about options for treatment. No two women’s menopause transition is alike and women themselves, educators, and health care practitioners are experiencing the challenge of evaluating and managing each woman individually to achieve optimal results and optimal health.
Many women begin to experience an array of physical and mental emotional symptoms long before they meet the definition of menopause. These changes that occur over as much as several years usually from around age 40 to 51 are a transition period called perimenopause. Menopause is the proper term used after 12 months since the last menstrual period.
During perimenopause, several biological changes occur:
- The number of ovarian eggs (oocytes) have reached very low levels from 1-2 million at birth to only a few thousand.1-3
- The menstrual cycle begins to vary typically to a shorter cycle from one menses to the next. This is due to a shortened length of the first half of the cycle (follicular phase).4,5
- An increasing number of anovulatory cycles and subsequently a significant lowering of progesterone levels, which may explain many of the early perimenopausal symptoms even more so than the decline in estrogen levels.
- The follicle stimulating hormone (FSH) increases at a rate greater than luteinizing hormone (LH) even though the cycles are still regular. This rise in FSH is one of the first signs of reproductive aging. This observation is most easily made in the early part of the follicular phase when estradiol levels are lower. This is why doctors often measure the FSH levels to determine if the symptoms you are having are related to menopause. The problem with the test is two-fold:
- Varying patterns of FSH may occur even in the same woman;
- The FSH is often normal even though the woman really is perimenopausal because the test detects only a percentage of the over 60 FSH peptides that are really present.
Ovarian production of estradiol and progesterone and testosterone levels decreases with the onset of true menopause. Although hormone levels will eventually decrease, lower estrogen levels aren’t experienced until 6 months to 1 year before true menopause. It’s only in the last year of the perimenopause that estrogen levels begin to decrease. Near menopause, estrogen levels rise very high and then drop very rapidly. These levels may be up to twice the levels found in a normal menstrual cycle. Then the estrogen production by the follicles rapidly drops from 700 to 30 pg/mL within 2 or 3 days.
Eventually the lowered level of estrogen secretion is no longer adequate to cause a build-up of the uterine lining and there is not enough tissue to produce a menses. The average age of a last menstrual period (LMP) is age 51 in the U.S. The FSH will then rise 10-20 times and reach a maximum within 1-3 years after the LMP.The symptoms of decreased hormone levels and perimenopause symptoms are varied, unpredictable and often go unrecognized as a perimenopause symptom. Due to not recognizing a problem as a erimenopause symptom, lack of precision in FSH testing, inadequate understanding of menopause on the part of both patient and health care practitioner, many women become dissatisfied with their health care.
The signs and symptoms of perimenopause include menstrual irregularities, hot flashes, vaginal dryness and thinning, skin changes, fatigue, decreased libido, mood swings, depression, changes in memory and cognition, sleep disturbance, hair loss on head, hair growth and acne of face, palpitations, nausea, headaches, urinary tract infections, and the beginning stages of osteoporosis and heart disease.
The symptoms initially will vary from subtle and infrequent to overt and daily. Symptoms can be mild, moderate, or severe. Some women will have no significant menopausal symptoms except in the menstrual cycle and others will have symptoms that are progressive and problematic for years to come.
Perimenopause is a time of instability and unpredictability. Many things are changing other than declining estrogen and progesterone levels. Women’s hormone levels are changing not only in their total serum levels, but they are also changing in relationship to each other. Women are also aging which contributes to many of the changes like weight gain, changes in metabolic rate, and outlook on life. Factors such as age, stress, and body weight also begin to play a larger role in estrone production.
Irregular bleeding can be one of the most problematic problems of perimenopause. All bleeding patterns are seen: more frequent, less frequent, lighter, heavier, shorter in duration, longer in duration, stopping suddenly, random spotting, and every which way imaginable. The greatest concern is that of managing excessive bleeding, and ruling out endometrial hyperplasia. Routine endometrial biopsy is not recommended but ruling out endometrial hyperplasia is an important differential diagnosis to establish. The technology of pelvic ultrasounds have improved to such an extent that many women will be adequately assessed by checking the thickness of the endometrial stripe with a transvaginal ultrasound.
Vasomotor symptoms as experienced by hot flashes and nightsweats remain the most predominant perimenopause symptom of US women. Prevalence ranges from 28% to 65%, compared with 6% to 63% for premenopausal women and 58% to 93% in the first two years postmenopausal years.6 Hot flashes vary in intensity and frequency from woman to woman. There is no consistent or predictable pattern. Some women begin to have hot flashes while their menses are still very regular. Other women experience hot flashes as their menstrual cycles become irregular but occur only during the days when they do not bleed and then quickly disappear when their bleeding resumes. Yet others begin to have hot flashes later on and even several years after their menses have ceased. And of course, many women have no hot flashes at all.
Hot flashes can be aggravated by warm drinks, hot weather, stress, salt, alcohol, and spicy foods. Women who have more body fat may have less hot flashes than lean women.7
Several other medical conditions should be differentiated from menopause related hot flashes. Hyperthyroidism, anxiety, carcinoid syndrome, pheochromocytoma, and niacin flush should be ruled out.
It is often debated whether or not depression is actually more prominent in perimenopausal women than premenopausal women or whether the depressive symptoms occur as a result of hot flashes, memory, changes in cognition and alertness, loss of libido, and facing the facts of aging. It’s not surprising that menopausal women who have depressive symptoms seek health care more than menopausal women without depression so the patients we see in our practice are the ones that are having problems. This may lead to an inaccurate perception of the prevalence of depression in menopausal women. Studies have shown conflicting results; some showing no greater increase in depression in menopausal women than premenopausal women while other studies clearly show a greater incidence in peri- and post-menopausal women.
Vaginal atrophy is a result of a decreased estrogen effect on the collagen tissue in the lower genital tract. Decreased vaginal lubrication with sexual activity, vaginal dryness, itching and burning, pain with vaginal sexual activity, post-coital bleeding, vaginal infections, urinary incontinence and urinary urgency, frequency, nocturia, and dysuria are common changes that can occur. The decreased estrogen effect increases the pH, changes the bacterial environment, lessens the elasticity and thickness of the tissue and reduces the amount of vaginal secretions. Again, the clinician should rule out other causes of these symptoms including malignancies, vulvar dystrophies, infection, allergies, skin conditions and foreign bodies.
Some women need encouragement to discuss their sexual concerns and for perimenopausal women a decrease in libido or changes in their sexual response are causing stress in their intimate relationship life. Women should be reassured about the common nature of these symptoms and both practitioner and patient should realize that sexuality is affected by a complex array of factors. Anatomy, physiology, psychological factors, medications, stressors, co-existing medical problems are all potential causes or contributors to changes in sexual function.
Changes in the skin begin to occur with brown spots, dryness, easy bruising and increased wrinkling. Skin is partially composed of collagen, and with age, collagen decreases. During the first five years after the menopause, 30% of skin collagen is lost. For many women, the health and appearance of their skin is one of the motivating factors for taking estrogen replacment therapy.
The two most significant changes associated with the perimenopause and continuing into the postmenopausal years are decreases in bone mineral content and changes in lipid profiles. Perimenopausal women should be screened to determine those who are at risk for osteoporosis and those who are at risk for premature cardiovascular disease. Adequate advice about diet, exercise, nutritional supplementation should be fundamental for all women. Individual assessments and recommendations about the use of either phytoestrogens, natural hormones, and/or conventional hormone replacement therapy need to be made for each woman based on her risk factors and needs and preferences.
Natural therapies are very well suited for the peri-menopause. Increasing the soy foods in the diet can decrease hot flashes,8,9 regulate the menstrual cycle,10 stabilize bone density,11-13 and reduce cholesterol.14 The perimenopause is not only a time to relieve symptoms but a time to practice progressive prevention by screening and risk identification for osteoporosis, cardiovascular disease, breast cancer, Alzheimer’s and colon cancer.
Medicinal plants that contain estrogen-like compounds, called phytoestrogens, such as black cohosh, dong quai, licorice and ginseng can reduce hot flashes,15,16 decrease vaginal dryness, 17 increase energy, and improve moods. Additional natural therapies such as vitamin E, can decrease the risk of heart disease,18 and decrease hot flashes,19,20 St. John’s wort can treat mild to moderate depression,21,22 and ginkgo can improve memory.23
Natural progesterone cream can also be used very effectively in the perimenopause. Problems that can be addressed include regulating the menstrual cycle, hot flashes, nightsweats, low libido, mood swings, premenstrual symptoms, vaginal dryness, and headaches.
Most women in the perimenopause transition years will not need to take HRT. It is this majority of women that will be able to ease their perimenopause symptoms with natural therapies both successfully and safely. In the menopause and postmenopausal years, choices about nutritional supplements and herbal therapies and natural hormones versus conventional HRT can be made on an individual basis. A health care practitioner who is educated about all the options can assess your individual needs and individual risks and determine which therapy or combination of therapies is appropriate.
- Block E. Quantitiative morphological investigations of the follicular system in women. Acta Anat (Basel) 1952; 14:108.
- Baker T. A quantitative and cytological study of germ cells in human ovaries. Proc r Soc Lond (Biol) 1963; 158:417.
- Richardson S, Senikas V, Nelson J. Follicular depletion during the menopause transition: Evidence for accelerated loss and ultimate exhaustion. J Clin Endocrinol Metab 1987; 65: 1231.
- Treolar A, Bounton R, Behn B, Brown B. Variation of the human menstrual cycle through reproductive life. Int J Infertil 1967; 12:77.
- Vollman R. The Menstrual Cycle. Major Problems in Obstetrics and Gynaecology. Philadelphia, PA: Saunders; 1977:138.
- Kronenberg F. Hot flashes. In: Lobo RA, ed. Treatment of the Postmenopausal Woman. New York, NY: Raven Press; 1994-97.
- Erlik Y, Meldrum D. Judd H. Estrogen levels in postmenopausal women with hot flashes. Obstet Gynecol 1982, 59:403.
- Albertazzi P, Pansini F, Bonaccorsi G, et al. The effect of dietary soy supplementation on hot flashes. Ob/Gyn 1998; 91: 6-11.
- Brzenzinski, A, et al. J No. Amer Meno Soc 1997; 4(2):89-94.
- Cassidy A, et al. Am J Clin Nutr 1994; 60:333-340.
- Arjimandi B, Alekel L, Hollis B, Amin D, Staceqicz-Sapuntzakis M, Guo P, Kukreja S. Dietary soybean protein prevents bone loss in an ovariectomized rat model of osteoporosis. J Nutr. 1996; 126: 161-167.
- Blair H, Jordan S, Peterson T, Barnes S. Variable effects of tyrosine kinase inhibitors on avian osteoclastic activity and reduction of bone loss in ovariectomized rats. J Cell Biochem. 1996; 61: 629-637.
- Anderson J, Ambrose W, Garner S. Orally dosed genistein from soy and prevention of canccellous bone loss in two ovariectomized rat models. J Nutr. 1995; 125:799S.
- Anderson J, et al. NEJM 1995; 333(5):276-282.
- Stolze H. An Alternative to Treat Menopausal Complaints. Gyne 1982;3:14-16.
- Hudson T, et al. J Nat Med 1997; 7(1):73-77.
- Stoll W. Phytopharmacon Influences Atrophic Vaginal Epithelium. Double-Blind Study: Cimicifuga vs. Estrogenic Substances. Therapeuticum 1987;1:23-31.
- Hodis H, et al. Serial coronary angiographic evidence that antioxidant vitamin intake reduces progression of coronary artery atherosclerosis. JAMA 1995;273:1849-1854.
- Christy C. Vitamin E in menopause. Am J Ob Gyn 1945;50:84-87.
- McLaren H. Vitamin E in the menopause. Br Med J 1949;ii:1378-1381.
- Schlich D, Brauckmann F, Schenk N. Treatment of depressive conditions with hypericum. Psychol 1987;13:440-444.
- Harrer G, Sommer H. Treatment of mild/moderate depressions with Hypericum. Phytomed 1994;1:3-8.
- DeFeudis F. Ginkgo biloba Extract. Pharmacological Activities and Clinical Applications. Elsevier, Paris, 1991.