Menopause is an eventuality that all reproductive women will reach; her final menstrual period. It is, however, a somewhat useless term as we define the menopause only 12 months after the fact. This means that during the time a woman is likely to be most symptomatic she may not realize that her symptoms are associated with changes in hormones and her impending menopause.
A more useful framework to describe reproductive aging is the concept of the menopause transition and the various stages from early peri-menopause to late post-menopause. This framework is based on the clinical history, including bleeding pattern and symptoms. However, testing hormone levels may help to confirm the stage.
As periods become more irregular, estrogen levels begin to decline and trigger further symptoms such as the hallmark hot flashes and night sweats.
Early in the transition, women often begin to experience disruptive symptoms such as sleeplessness and mood disturbance even while periods are still happening with a regular cycle. The higher estrogen state that can accompany the early peri-menopause may mean that she has swollen, tender breasts, heavy bleeding and increased pre-menstrual symptoms (i.e. PMS). During this phase she may not be offered much from conventional physicians as menopause hormone therapy is only indicated to control symptoms after menopause is reached. But there are several evidenced based interventions that may help buffer some early symptoms.
A healthy lifestyle is important to mitigate both symptoms and risks that arise at this time. Maintaining a healthy body weight, minimizing use of alcohol and caffeine and partaking in regular exercise are all important lifestyle interventions. Non-hormonal and herbal therapies such as researched derivatives of black cohosh, rhubarb, soy and red clover may be helpful and can be combined with progesterone therapy usually given in the second half of the cycle. While there are no commercially available forms, vaginal progesterone therapy is most effective with direct effects on the uterus and can be custom compounded to treat the individual woman's needs.
As periods become more irregular, estrogen levels begin to decline and trigger further symptoms such as the hallmark hot flashes and night sweats. While anti-depressants and anti-seizure medications can be used off-label to control hot flashes, nothing is more effective than estrogen. Estrogen, given in combination with progesterone offers not only symptom control but for the newly menopausal and otherwise well woman, important preventative benefits toward the bone, brain and heart. Hormone therapy has been shown to meaningfully reduce the risk of osteoporosis and bone fractures, memory problems, and heart disease.
There are many options available when it comes to hormone therapy. Bioidentical hormones are available by prescription in both pharmaceutical and custom compounded formats. Estrogen therapy has been shown to be both safer and more effective when delivered through the skin in a "transdermal" cream or patch. Vaginal estrogen therapy as the added benefit of protecting the vagina and lower urinary tract from the degenerative changes that occur in low estrogen states. While pharmaceutical estrogen patches are available, a vaginal cream containing both estradiol (ovarian estrogen) and estriol (a weak protective estrogen) may be preferred. Progesterone taken orally or vaginally when combined with estrogen has been shown to reduce the risk of clots, stroke and breast cancer. Thus, progesterone is markedly different than the progesterone-like synthetic analogues like Provera that have been shown to increase these risks.
From diet to herbs to hormones, there is much that can be done to successfully navigate the menopause transition.
By the later stages after menopause, hormonal needs tend to change. Typically, there systemic hormone therapy as described above would be discontinued possibly with a transition to lower dosed local vaginal estrogen therapy. Because vaginal dryness is the one certain and progressive symptom of the late post-menopause, vaginal estrogen therapy is critical to maintain the health of the vagina and lower urinary tract as well as for sexual health. This treatment is considered safe; even for many women with a history of breast cancer. Vaginal estrogen therapy can reduce dryness, pain, risk of infection and improve urinary dynamics and bladder control.
While there are no hard fast rules as to how long hormones can be prescribed, some guidelines recommend initiating therapy within five years of menopause and continuing for up to 10 years of therapy or the age of 60 years. However, hormone therapy requires a highly individualized assessment that considers each woman's unique set of symptoms, risks, goals and preferences. When prescribed in the right form, dose and route by a well qualified medical expert, hormone therapy can be an integral part of navigating midlife aging successfully.
From diet to herbs to hormones, there is much that can be done to successfully navigate the menopause transition. For many women, starting this proactive approach in the mid-forties can manage early peri-menopausal symptoms and simultaneously reduce emerging health risks. For all women, the discussion of hormone therapy is important and should be conducted with a health professional who is qualified to discuss the goals, benefits and risks and monitor the safety of recommended treatments.
Dr. Pearlman is a physician focused on Women's health, hormones, and beauty. She is staff physician at the Menopause Clinic at Mount Sinai Hospital and Medical Director of PearlMD Rejuvenation, a state-of-the-art Women's health and wellness facility.
Dr. Jennifer Pearlman
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