by Andrea Stein, M.D.
I have been searching everywhere - through all of my books, patient pamphlets, and the Internet, - to find a "simple" explanation for many of my patients and friends of what it means to be going through "menopause" or "perimenopause".I’ve gone through it with many of my patients, colleagues, and friends. We can’t predict when our menstrual periods will occur, whether we’ll have a hot flash or night of sleep deprivation or what our mood will be tomorrow. Ovarian "cysts" occur and hormones are highly variable and this is all NORMAL. Yet, it is hard to accept. There are no books or pamphlets where it is well described (for a physician OR a patient), there is no simple explanation and there is no single treatment choice. We don't know when to consult a healthcare professional.
The strict definition of "menopause" is a year without one’s menstrual period. Unless a woman has both of her ovaries and/or uterus taken out, this will rarely occur suddenly. "Perimenopause" only entered medical jargon in recent years and is more loosely defined. The North American Menopause Society (www.menopause.org) describes it as a time when hormonal and reproductive functions change. This is a difficult task because whatever our hormone levels are today, at this moment of "perimenopause," the levels will change the next time they’re checked. So, perimenopause is a challenge to study, define, evaluate, and treat in a research situation.
The changes of perimenopause usually manifest themselves in menstrual cycle irregularities in our late thirties and early forties. Unfortunately, this might happen to some women in their twenties or early thirties. The average age of menopause (COMPLETE cessation of bleeding) in the USA is 51 (range 40-58). This means the transition into menopause starts long before most of us anticipate it, let alone understand what is happening. During this timeframe, stresses (lack of sleep, illness, change of job, medication, travel, etc.) might disrupt the hormone pulses and change our menstrual cycle and hormone "balance" even more. It is virtually impossible to predict, let alone control. Hormone tests and ultrasounds only give a glimpse of what is happening on that particular day; they will be helpful only if the "big picture" of a constantly changing hormonal environment are kept in perspective.
Perimenopause is a time of diminished fertility and ovarian reserve. Strictly speaking, that means we cannot keep reproducing forever and our oocyte (egg) quality is poor. With fewer oocytes, we have changes in the hormones that effect the eggs and their development such as estrogens, progestins, androgens, FSH and Mullerian Inhibiting Hormone (MIH or MIS). The checks and balances of ovulation and, hence, our menstrual cycle, become disrupted. Our body continues to do all sorts of things to keep producing estrogen - make ovarian cysts, put on weight (usually in the midline), change the length of the menstrual cycle, etc. Our body still wants the estrogen of our youth into our forties and fifties to protect our bones, vagina, skin, eyes, and many other things besides reproduction. As menopause approaches, we eventually run out of eggs and the estrogen-producing cells in the ovaries. It is impossible to predict when that day will be - the day we are "in menopause". To confuse matters, every once in a while a new "cyst" might make a little estrogen after we think we are "in" menopause. We’ll get mucous or a discharge, changes in moods, fewer hot flashes, bleeding, or any number of symptoms. The only thing ?normal? about this transitional time of life is its unpredictability. It is important to stay informed and be flexible with the unpredictability of this stage of life.
Menopause will occur when the ovaries have been surgically removed or when estrogen completely stops being produced by the follicle cells of the ovaries. These hormonal changes can usually be determined by a medical professional taking a medical history. When blood tests are necessary (such as in the woman under 40 with menopause symptoms), these are usually done by FSH (follicle stimulating hormone) and estradiol levels done simultaneously. Many health-related issues change at this time, including an increase in heart disease (the number ONE cause of death in menopausal women) and diabetes, weight changes, sleep disruption, bone loss, possible changes in sleep, skin, vagina, hair, libido, weight, memory, etc. It is an important time to reassess and change major lifestyle factors such as diet, exercise, smoking and stress. Vitamin needs will change with menopause as women may need to increase their calcium and Vitamin D intake to maintain their bones. Medications may help their problems, although estrogen is still the most effective medicine for hot flashes and other vasomotor symptoms.
So, as clinicians learn more about perimenopause and menopause, it is important that consumers are presented with nonjudgmental facts and choices. Unfortunately, advertising can be very misleading, as can one's frien's’ stories, chat rooms, a popular magazine or television show, and uninformed health professionals.
Stay informed about your choices, ask questions, read legitimate sources (e.g. www.acog.com, www.menopause.org., and www.4woman.gov) and be flexible as new information emerges and your body changes.