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Menopause...

and Peri-menopause

The changes of menopause begin when your ovaries, the organs that form eggs, no longer produce those eggs. Their production of female hormones decreases at this time as well. As discussed earlier hormones are chemicals secreted by endocrine glands that travel through the blood to organs, where they produce a specific effect on some bodily process. Two hormones made in the ovaries estrogen and progesterone help to regulate a woman's monthly period.

 

As a woman approaches mid-life, estrogen begins to drop to low levels. The reproductive organs gradually become less active, just as they gradually became active during puberty. Most women notice that their periods become lighter, farther apart and then eventually, they end. The menopausal transition may take from one to 10 years, and during that time hormone levels are likely to fluctuate. Some months you may have a period; other months you may not. During this time, you may still be able to get pregnant. Natural menopause typically happens gradually, over time. But the onset of menopause may occur suddenly for reasons such as the removal of ovaries, radiation or chemotherapy, or a sudden severe illness.

The first menopausal symptom that most women notice is hot flashes and mood swings. Some report mental confusion and sometimes a sense of sadness or depression. Some women also experience vaginal dryness or significant decreases in libido. Eventually, as the estrogen stays consistently at a low level, symptoms of menopause including the hot flashes, changing moods and mental confusion will disappear. This may take several years. We’ll talk more about menopause later and the specifics about how to stay healthy during this transition.

So what exactly is menopause anyway? Menopause is defined as the time when a woman's menses, or menstruation, permanently ceases. After menopause, a woman will no longer produce eggs that can be fertilized to develop into a baby. Believe it or not, the reason menopause occurs is not entirely clear. It appears to be closely tied to the depletion of follicles, tiny cellular entities found in the ovaries. Each follicle is made up of an egg surrounded by cells.

Menopause is the last stage of a gradual biological process in which the ovaries reduce their production of female sex hormones. So the primary hormones estrogen and progesterone have fallen. The process actually begins about 3 to 5 years before the final menstrual period. This transitional phase is called peri-menopause. It is during this peri-menopausal period that many women begin to experience symptoms.

Menopause is considered complete when a woman has been without a period for 1 year. On average, this occurs at about age of 50, but this varies from woman to woman. The age at which your mother underwent menopause is a good indicator as to when you might enter menopause. There are some other contributing factors that will cause a woman to reach menopause earlier, such as cigarette smoking or other stressors such as extreme mental or physical stress.

For most women their menstrual cycle ends in their early 50’s. A few women fall outside of this average on the younger and older end. Some women undergo menopause as early as 40, or as late as 60. Women who smoke undergo menopause about two years earlier than nonsmokers. Most women notice some changes in their menstrual flow such as shortening of cycle length (periods occurring closer together), skipped menstrual periods and occasional heavy periods anywhere from a few months to a few years before their cycles end completely.

More than one third of the women in the United States, about 36 million, have been through menopause. The life expectancy for women continues to increase. With a life expectancy of about 81 years, a 50 year old woman can expect to live more than one-third of her life after menopause. It is important that women understand this transition, so that they can spend this stage of their lives comfortably.

What causes menopause?

As stated above, we are not completely sure why the process occurs, but it is most likely associated with the depletion of ovarian follicles. The ovaries in women contain follicles that hold the egg cells. At birth, there are about 500,000 egg cells. By puberty, only about 75,000 eggs are left. Only about 400 to 500 eggs ever reach maturity and get released during adulthood. The rest degenerate over the years.

During the reproductive years, a gland in the brain called the pituitary gland generates follicle stimulating hormone and luteinizing hormone, hormones that cause a new egg to be released from its follicle each month. The follicle then produces the sex hormones estrogen and progesterone, an egg develops and the uterine lining thickens.

This thickened lining is prepared to receive and nourish a fertilized egg which could then develop into a baby. If fertilization does not occur, estrogen and progesterone levels drop, the lining of the uterus breaks down, this breaking down of the uterine lining and the sloughing of it is responsible for the monthly blood flow commonly referred to as menses.

Progesterone, specifically works during the second half of the menstrual cycle to create the thickened lining in the uterus. If a period is missed, it generally means that the body is not making enough progesterone to break down the uterine lining. In contrast, the estrogen levels may remain high even though one is not menstruating.

The hormone production in the ovaries begins to decline in the mid-thirties. In the late forties, the process accelerates and hormones fluctuate more, causing irregular menstrual cycles and unpredictable episodes of heavy bleeding for some women. By the early fifties, periods finally end altogether. But even though periods have stopped, estrogen production does not completely stop. The ovaries decrease their output significantly, but still may produce a small amount. Also, some estrogen is produced in fat cells with help from the adrenal glands.

At menopause, hormone levels don't always decline evenly. They often rise and fall. These fluctuating levels of hormones levels affect the other glands of the endocrine system. Ovarian hormones also affect all other tissues, including the breasts, vagina, bones, blood vessels, gastrointestinal tract, urinary tract, and skin. So the entire body is affected when the reproductive hormones change.

Types of Menopause

Until recently menopause has been looked at as being the same for all women. So many people think that all women have the same menopause experience. What an inaccurate assumption! Not only does the menopause experience vary from woman to woman, but the actual cause of menopause can vary as well. Let’s look at the various types of menopause.

Surgical Menopause

This is a menopause induced artificially. After hysterectomy, or surgery in which both ovaries are removed, some women will immediately experience an abrupt menopause. Women who experience surgical menopause may be hit harder by menopausal symptoms than those who experience it naturally. In natural menopause the decline in the hormone levels is gradual. This gradual change in levels affords the body the opportunity to adjust. Women who undergo surgical menopause may experience hot flashes that may be more severe, more frequent, and last longer. They may also have a greater risk of heart disease and osteoporosis, and may be more likely to become depressed.

When only one ovary is removed, menopause usually occurs as it naturally would. When the uterus is removed (hysterectomy) and the ovaries remain, menstrual periods stop but other menopausal symptoms (if any) usually occur at the same age that they would naturally.

However, some women who have a hysterectomy without the removal of their ovaries still experience menopausal symptoms. They usually experience these symptoms immediately following surgery. This sudden onset of symptoms is possibly due to a decreased blood supply to the ovaries as a result of surgery.

Natural Menopause

This is menopause that occurs slowly and progressively after a natural decline in the female hormones. Usually a woman begins experiencing peri-menopausal symptoms in her late forties. As she approaches fifty the periods get light and less frequent. Many women will skip periods intermittently during this time.

Symptoms of Menopause

Menopause affects people differently. Some women notice little or no difference in their bodies or moods, while others find menopausal symptoms to be extremely bothersome and disruptive. Estrogen and progesterone affect virtually all tissues in the body, but everyone is influenced by them differently. The patient described below is a composite of the many menopausal women I treat in my practice.

"Fifty-one year, Helen is having irregular periods. Her periods come close together or she misses them altogether for sometimes several months. When they do come they can be extremely heavy, with large clots and cramping.

Several times a day she has hot flashes that last for two to three minutes, drenching her in sweat, followed by a tingling sensation. Sometimes she is so hot she feels claustrophobic or anxious during these episodes. Worse than the hot flashes she experiences during the day are the night sweats. When she gets hot at night she throws the covers offs and often has to strip off her nightgown. As soon as she falls back asleep she awakens chilled, causing her to scramble for the nightgown that she flung into the night just minutes earlier. Shortly after she gets good and asleep again, the madness starts all over again. The cycle repeats itself two or three times in the course of a night, and she sometimes wakes up at three in the morning, and doesn’t fall asleep again until it is time to get up and start her day.

Like many people who are sleep deprived, Helen is grumpy, fatigued and anxious. She has difficulty concentrating, and often starts tasks that she is unable to finish. She finds herself struggling to stay awake during the day; she is worried that she has some underlying illness that has not yet been detected. Her ongoing fatigue is really starting to affect her quality of life. She is fatigued from the lack of sleep, and from the constant worrying that she does when she is not able to sleep.

Sound familiar? There are millions of women just like Helen, who experience the same scenario or some version of it on a daily basis. If you are a Helen, don’t despair, there is help available.

Symptoms of Menopause

  • Hot flashes
  • Night sweats, often leading to sleep disturbance
  • Nervousness
  • Dizziness
  • Depression
  • Mood swings
  • Osteopenia or thinning of the bones
  • Weight gain
  • An irregular or rapid heart beat
  • Difficulty holding urine
  • Vaginal dryness, itching or other discomfort which results in painful sexual intercourse
  • Decreased libido
  • Skin changes such as dryness and increased moles
  • Osteoporosis or brittle bones, leading to frequent fractures that may be slow to heal
  • Varicose veins
  • Joint Pain
  • Constipation
  • Irregular bleeding

Physical Changes that occur with Menopause

In addition to the symptoms listed above, the body undergoes a number of physical changes. These changes are outlined below:

  • Some shrinking of the vagina, cervix uterus, and ovaries
  • Shortening of the vagina, with loss of muscle tone and thinning of the lining
  • Changes in labia majora including possible thinning, and loss of elasticity
  • Loss of muscle tone of supporting ligaments of the uterus
  • Reduction in vaginal and cervical secretions resulting in dryness
  • Changes in breast size, firmness, and shape
  • Thinning of scalp hair in most women; possible increase of facial hair
  • Wrinkling and loss of skin tone
  • Loss of bone mass
  • Slowing of metabolic rate

Some of the symptoms are so common, and so significant that they warrant more discussion.

Hot Flashes

Hot flashes, or flushes, are the most common symptom of menopause, affecting more than 60 percent of menopausal women. It is the symptom that brings most women in to my office to be evaluated for menopause.

A hot flash is a sudden wave of heat that can start in the waist or chest and work its way up to the neck and face, and sometimes spread to the rest of the body. The face and neck may become flushed. This is often followed by profuse sweating and then cold shivering as the body temperature readjusts. They are more common in the evening and during hot weather. They can hit as often as every 90 minutes, or more frequently in some. Each one can last from 15 seconds to 30 minutes - 5 minutes is average. Seventy-five to eighty percent of American women going through menopause experience hot flashes. Hot flashes bother some women more than others. Sometimes heart palpitations accompany the flashes.

Hot flashes occur sporadically and often start several years before other signs of menopause. They gradually decline in frequency and intensity with age. Eighty percent of all women with hot flashes have them for 2 years or less, while a small percentage have them for more than 5 years.

Hot flashes can happen at any time. They can be as mild as a light blush, or severe enough to wake you from a deep sleep. Some women only develop insomnia. Others have experienced that caffeine, alcohol, hot drinks, spicy foods, and stressful or frightening events can sometimes trigger a hot flash. However, avoiding these triggers will not necessarily prevent all episodes.

They appear to be a direct result of decreasing estrogen levels. If there is no estrogen, your glands release other hormones that dilate blood vessels and destabilize body temperature. Hormone therapy relieves the discomfort of hot flashes in most cases. Vitamin E and some other supplements are effective for some women as well. See the treatment section for specifics.

Irregular periods

This varies and can include:

  • Periods that get shorter and lighter for 2 or more years
  • Periods that stop for a few months and then start up again and are more widely spaced
  • Periods that bring heavy bleeding and/or the passage of many or large blood clots

Vaginal/Urinary Tract Changes

With advancing age, the walls of the vagina become thinner, dryer, less elastic and more vulnerable to infection. These changes can make sexual intercourse uncomfortable or painful. To help relieve the discomfort women can lubricate the vagina with water-soluble lubricants, oil based lubricants like petroleum jelly are not advised. Tissues in the urinary tract also change with age, sometimes leaving women more susceptible to involuntary loss of urine (incontinence), particularly if certain chronic illnesses or urinary infections are also present. Scheduled bladder emptying is a simple and effective treatment for most cases of incontinence and is less expensive and safer than medication or surgery.

Within 4 or 5 years after the final menstrual period, there is an increased chance of vaginal and urinary tract infections. Infections are easily treated with antibiotics, but often tend to recur. To help prevent these infections, urinate before and after intercourse, be sure your bladder is not full for long periods, drink plenty of fluids, and keep your genital area clean. Douching is not thought to be effective in preventing infection.

Menopause and Mental Health

Some people refer to the changes that some women experience during menopause as myth or psychological. Feeding the thought by some that the symptoms are all “in a woman’s head”. Although not every woman experiences these symptoms some women do experience unpredictable mood swings, depression, or stress. Studies showed that women already taking hormones who are experiencing mood or behavioral problems sometimes respond well to a change in dosage or type of estrogen.

Studies show that overall menopausal women are no more depressed than the general population; about 10 percent are occasionally depressed and 5 percent are persistently depressed. The exception is women who undergo surgical menopause. Their depression rate is reportedly double that of women who experience natural menopause.

This is one composite patient’s story of depression during menopause. The patient does not reflect any patient in particular but a combination of patients with similar symptoms:

Lisa a 55 year old entrepreneur comes to my office in tears. She has been having dreams about injuring herself for the past several weeks. She comes to my office because she is at her wits end. After a thorough exam and extensive discussion of her symptoms it was determined that she was actually having a number of symptoms. The patient was having both hot flashes and night sweats, her libido was completely gone, and she was suffering from severe vaginal dryness. She had not been able to sleep in months, but had not connected the inability to sleep with her other symptoms.

Lisa reported that she had been experiencing more and more depression, and said that even her friends were starting to inquire about her frequent crying spells. The patient suffered the loss of a close sibling several months before, and thought her crying spells were secondary to extended grief. She had seen a grief counselor but was unable to control her emotions.

After reviewing all of her symptoms, the decision was made to check the patient for underlying metabolic pathology, including hormone levels. The test revealed that the patient was indeed menopausal. She was placed on a combination of transdermal and oral hormone replacement therapy, in conjunction with continued grief counseling. After two days of therapy the patient started to feel better. In fact after the first night of therapy, she called our office and reported happily that she “slept like a grizzly bear”. After a month the patient was functioning near baseline and had her life back. Many women experience an exacerbation of their menopausal symptoms after sustaining an emotional trauma. In these situations it is very difficult to determine whether it is a true clinical depression that they are experiencing or a menopause induced depression. Often the patient has to be treated for both menopause and depression in order to regain their former functionality. Below are a few of the emotional changes that one can experience during menopause.

Emotional changes associated with menopause:

  • Irritability
  • Mood changes
  • Lack of concentration
  • Memory changes
  • Tension, anxiety, depression
  • Insomnia, which may result from hot flashes that interrupt sleep

Sexual Changes during menopause

For some women menopause brings about a decrease in sexual activity. Reduced hormone levels cause subtle changes in the genital tissues. Lower estrogen levels decrease the blood supply to the vagina and the nerves and glands surrounding it. This makes delicate tissues thinner, drier, and less able to produce secretions to comfortably lubricate before and during intercourse. So, some women show a lack of interest in sex, because it is painful. Estrogen vaginal creams and transdermal estrogen can restore secretions and tissue elasticity. Water-soluble lubricants can also be helpful. “Hormone Harmony” discussed the signs and symptoms of menopause as well as possible treatments.

GET IN TOUCH

Dr. Jill Waggoner
Charlton Medical Group
3450 West Wheatland Road
Physician Offices II, Suite 340
Dallas, Texas  75237

T 972.217.3007

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PO Box 2118

Desoto, Tx 75213

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