Understanding the Symptoms of Perimenopause
with Patricia Dolhun, M.D., obstetrician/gynecologist at Columbia St. Mary's
Menopause can be defined as one day in a woman's life when she has not had her period for 12 consecutive months. That may sound pretty straightforward, but before reaching that momentous day, many women experience a variety of physical and emotional changes. This pre-menopause period, known as perimenopause, can last up to six years or more.
According to Patricia Dolhun, M.D., obstetrician/gynecologist at Columbia St. Mary's, the ages of 45 to 55 could be considered as perimenopause for most women. But before the outward signs begin, estrogen levels are already changing. This change can begin as early as a woman's mid-30s.
"We know ovarian functions start changing at the average age of 38," said Dr. Dolhun. "But early on, few women will have hot flashes or other symptoms. Outward signs may not manifest themselves until closer to age 45. In my mind, the whole decade of the 40s could be considered perimenopause," she added.
What can a woman expect?
Some women breeze through perimenopause with just a few irregular periods. Others may have intense hot flashes and night sweats that take their toll in the form of sleepless nights and resulting irritability. If each woman's experience with menopause is unique, how can she know what to expect as she nears menopause?
One of the first noticeable signs that a woman is entering perimenopause is the fluctuation of menstrual cycles. As many as 90% of perimenpausal women have changes in their menstrual cycles, noted Dr. Dolhun. The average age that women begin menopausal transition, when menstrual cycles start to change, is 47-1/2.
Seventy-five to 85% experience hot flashes and 30% to 50% of women will notice changes in their sleep patterns, Some perimenopausal women note changes in their sexual function: statistically, 30% will see a decline in sexual function.
While stress doesn't cause a woman to go into menopause, it may impact how she reacts to symptoms. Because stress effects the efficiency of the adrenal gland which also produces hormones, a woman under a lot of stress may not have reserves she needs to help her hormonal balance. In addition, a woman under stress may not be taking care of herself. Unhealthy choices in diet, exercise and even how much water a person drinks may impact how she feels during this transitional period.
When to see a doctor
Studies show that only 25% to 30% of women seek medical attention for menopause-related symptoms. It's possible that some women feel their symptoms aren't serious enough to warrant a doctor visit. Others may think they just have to go it alone.
Dr. Dolhun advocates women over 40 having annual gynecological exams. The exam may be done by a gynecologist, a nurse practitioner, family practitioner or internist.
By seeing their practitioner early in the perimenopausal stage, women have the chance to discuss specific changes they may experience, said Dr. Dolhun. "It's a great opportunity for women in their 40s to set themselves up for a smoother transition."
Some women may not be sure what questions to ask. They may not even realize that some things they are experiencing are hormonal-related. Their physician can help them understand what to anticipate. Because this is a time when their entire metabolism is changing, it is also be a good time to look at cholesterol levels, suggested Dr. Dolhun.
Occasionally, irregular menstrual cycles may indicate more serious health concerns such as thyroid disease, uterine fibroids, a thickening of the endometrium or ovarian cysts. "If a patient is having flows outside of the realm of what we would consider normal, they would need to have a work up to eliminate the possibility of such conditions," said Dr. Dolhun.
It used to be common to try to "normalize" menstrual cycles for women during perimenopause, but that is not necessarily the case anymore, says Dr. Dolhun. "Now we understand that menstrual cycles are going to be variable and that may be just as normal. Still, some women may not like the irregularity and opt for hormonal intervention and that's not unreasonable either."
There are many choices for women during this time, said Dr. Dolhun. "There is so much support women can get and so much that can be done for women beyond giving them a prescription. I would hate for women to stay away from their physicians because they think their doctors will immediately want to prescribe hormone therapy. There is a lot that can be done in terms of lifestyle changes, vitamins, herbal supplements or options with low doses of natural hormones."
When is menopause?
Natural menopause, that is, menopause not caused by medical interventions, is usually experienced by women between the ages of 40 and 58. The average age of menopause in the Western world is 51-1/2. Some women experience natural menopause as early as in their 30s and a small number do not reach it until they are in their 60s.
One of the few predictors of when a woman can expect to experience menopause is family history: sisters, mothers and daughters often reach menopause around the same age. Other possible factors that may correlate to early onset of menopause are health issues such as type 1 diabetes, suppressed immune systems and coronary heart disease. But the most common factor proven to affect the age of menopause is cigarette smoking: smokers may be one to two years younger than nonsmokers when they reach menopause.
When a woman had her first period has no bearing on when she will begin perimenopause, but there is some indication that women who have never had a child and those who had short, regular menstrual cycles may go through menopause at a younger age. However, "the difference is not that significant," said Dr. Dolhun.
"The good news for the 22 million women between the ages of 40 and 49 is that we now have a better understanding of the physiology behind menopause," she added. "Even if you have different symptoms than your friend or colleague, it can be reassuring to have your symptoms validated by what we know. Isn't it great if women can discover that there are common physical symptoms that many of us face, and that ultimately, we're all OK?"
Induced and early onset menopause
When a woman has surgical removal of both ovaries or has a treatment that damages ovarian tissue, such as radiation to ovaries or chemotherapy treatments, immediate menopause may occur. This is known as induced menopause. Because these women are experiencing menopause at a younger age than they would have naturally, there are some psychological components to their experience.
For women who are still contemplating childbearing, induced menopause can be very traumatic. There are some steps that may be taken in some of these cases to assist these women, said Dr. Dolhun. "If a woman knows she will be undergoing surgery or a treatment that will damage her ovaries she may wish to visit a reproductive endicrinologist to harvest some of her eggs and save them for the future. There is also the option of lateralizing surgery to push the ovaries to one side to keep them from being damaged in a procedure."
