THE RIDDLE OF PERIMENOPAUSE
Some women have never heard of it, yet have experienced it. It’s part of a woman’s normal progression of life, but it’s neither an event nor a disease. It’s perimenopause - the transition into menopause.
The female fertility cycle ends much as it begins way back in childhood: anovulatory (no menstrual periods). The “declaration” of menopause - when there have been no periods at all for about 12 months - occurs most commonly in one’s early 50's. The time before menopause, which lasts up to 10-15 years for some, can be, with its hormonal fluctuations, reminiscent of the turbulence of puberty. While puberty represents a hormone production that is spiraling upwards, in perimenopause the spiral moves downwards. And yet the changes brought on by this significant time are often ignored. Mothers may prepare their daughters for the pubescent changes, but rarely address those at the other end of the spectrum. Small wonder then that many women find themselves in the midst of perimenopause without the information needed to meet it head-on.
Ah, Those Pesky Hormones!
The hormones circulating throughout our bodies regulate more than just our periods. Hormones are produced in many areas of our body and, along with other factors, are involved in regulating such things as:
Mood
Appetite
Blood Pressure
Blood Sugar
Small in size, but a powerhouse of production, the walnut-sized ovaries produce estrogen, progesterone and androgen. Recent research links estrogen with protection against heart disease, osteoporosis, dry skin, wrinkling, and colon cancer. Vaginal dryness and associated painful intercourse may be related to decreased estrogen levels. The lack of ability to hold one’s urine can also be a problem associated with decreased hormonal production. Should you have these problems and decide to take supplemental estrogen, be sure you are also prescribed progesterone along with it. “Unopposed” estrogen can put you at risk for endometrial cancer.
The Signs of Perimenopause
Many women don’t anticipate dealing with menopause until their 40’s or 50’s. For this reason, the signs of perimenopause often go unrecognized or explained away as something else.
Changing Periods
You’re in your late 30's or early 40's and life is hectic: you are balancing some combination of career, kids, and parental aging. Between all the juggling you do, a missed period here or there may go unnoticed. A light period - now that’s a gift. Then along comes a heavy period just to make up for it. All in all, unless you are coping with issues of infertility, you may not pay much attention to what’s going on with your periods. You may be unaware that the missed and even the light periods may represent the occasional anovulatory cycle and that the heavier period is the shedding of the now extra-thick lining of the uterus (endometrium) which was not shed previously. Periods may be farther apart or come closer together - it is a time of fluctuation in the production of estrogen and progesterone. Progesterone may be prescribed to help even things out.
Flushes, Flashes, Sweats and Floods
A co-worker comments on your bright red cheeks.
You are the only one taking off your suit jacket during a presentation.
You wake up at night with the neck of your pajamas wet, kick off the blanket and get up to turn down the heat.
When these incidents happen sporadically, you might fail to make a connection. At this level, they may only evoke minimal disruption in your life. Dressing in layers, drinking plenty of cool water, and using light bed covers may manage these symptoms.
However, for some women, the events above can be more extreme and far more disruptive. Irregular menstrual cycles can lead to an increasingly thickened endometrium, which sloughs off at random, causing “flooding” - or gushes of blood - and the passing of large clots that can lead to panic-struck visits to the emergency room. Months of heavy bleeding can result in undiagnosed anemia, which is experienced as fatigue or episodes of dizziness. Moods swings may come in the form of depression or anxiety. Night sweats may mean waking up five times a night and crawling out of bed in the morning exhausted from insufficient sleep. Hot flashes may rattle you if you start sweating profusely in the middle of an important business presentation. Such severe symptoms can lead a woman to lose faith in her body, feeling uncertain about what happens next. How can you plan your schedule if you can’t count on your body behaving in a predictable manner?
Treatments for heavy bleeding
Progesterone may be prescribed to get heavy bleeding under control. Other recommendations include a D&C (dilation and curettage - a procedure in which the cervical opening is dilated and the endometrial lining is scraped clean with a curette, a small spoon-like instrument), or even a hysterectomy (the surgical removal of the uterus). However, rarely is a hysterectomy the only choice when the problem is excessive bleeding. Don’t forget the value of a second opinion when procedures or surgery unfamiliar to you are suggested. Just because your physician does things one way, it doesn’t mean all physicians would treat the same problem identically.
Abnormal bleeding may be the result of hormonal fluctuations. There are a number of other conditions, however, that can lead to abnormal bleeding, all of which a doctor will want to explore in order to arrive at a diagnosis. The presence of uterine polyps (growths on the uterine lining, usually benign) or fibroids (benign smooth muscle growths) can result in abnormal bleeding. Both fibroids and polyps can be removed in procedures that leave the uterus intact. Abnormal bleeding can also be a sign of endometrial cancer. In order to rule out cancer, an endometrial biopsy (retrieval of cells from the endometrial lining for study) may be suggested. An ultrasound, which is a painless procedure that results in a picture of the uterus, can be used to help identify the problem.
Another technique for women with abnormal bleeding who have completed childbearing is uterine ablation. In this procedure, the endometrial lining is altered with a type of heated “balloon”. As with any surgery, be sure your surgeon has a great deal of experience with the exact procedure you will undergo.
Regaining Control Through Knowledge
In this, as in all areas of your life, knowledge is power: power to regain control over your body and regain control over your life. This knowledge comes from being an informed consumer: reading, talking to others, going online, etc., to learn as much as possible about your changing body. Until recently, the information needed may have been difficult to find. Perimenopause was rarely identified as such, with the emphasis always placed being on menopause - and the changes occurring afterwards. Two current and informative books that cover this topic are Dr. Judith Reichman’s I’m Too Young To Get Old and Dr. Susan Love’s Hormone Book. Love’s book emphasizes lifestyle approaches - alternative therapies such as acupuncture and herbal remedies - as well as medications and surgery. For another perspective on this transitional time, Debra Waterhouse’s Outsmarting the Midlife Fat Cell is both humorous and informative. Furthermore, many community hospitals offer educational lectures that can be another resource for compiling your arsenal of knowledge, as well as a way of meeting other women concerned with the same issues. Below is some basic information that will help you tackle this challenging time.
What You Can Do to Get Through: Lifestyle Changes
The following are some suggestions for how you can tackle perimenopause.
Lifestyle Changes
If only this part were easier! Not surprisingly, many of the symptoms of perimenopause can be alleviated, or at least kept under control, by following simple and basic rules of good health. Dietary changes, exercise and stress-reduction techniques are the key things to think about. If you are a woman who is good shape, who has a good handle on her moods, and is under a minimal amount of stress, you will be less affected by the symptoms of perimenopause. Your body will be higher functioning and physical discomfort will be reduced.
Soy
Research on this age-old bean is growing rapidly: benefits of adding soy to your diet include cholesterol reduction, maintenance of bone density, and lower incidence of breast and prostate cancers. Soy can also be very useful to perimenopausal women, as it is a phytoestrogen, or plant-based estrogen. This means that it has certain ‘estrogenic’, or estrogen-like qualities. These estrogenic qualities can provide a measure of relief to women struggling with symptoms resulting from dwindling estrogen production.
If the last time you tried it was some 30 years ago during a phase of adolescent vegetarianism, it’s time to take another look. Soy milk can replace cow’s milk in cereal, cream soups, pancakes, oatmeal, and baked goods. Soy “milk” comes in a box in the refrigerated section of the grocery store, and in a powdered form. Soy “burgers”, such as “Boca” can be placed on a hamburger bun with all the fixings, and you will be surprised by how great it tastes. There are many new soy cookbooks coming out, but for starters, try replacing half of the regular milk in a recipe with soy milk. In this manner you can substantially increase your intake of soy and start reaping the benefits. Don’t worry about counting how much soy you are getting. Just try to add it whenever and wherever you can.
Exercise
Stress creates muscle tension. Exercise helps to relax these muscles. It also precipitates the release of bodily chemicals called endorphins, which are the body’s natural morphine-like chemicals that decrease pain and improve mood. Exercise can also increase your flexibility and increase bone density if you are engaged in weight-bearing exercises.
We know its benefits, but what can we do about getting more of it? Most of us don’t get enough exercise. Some of us may need the structure of a class. Others may put in a video at home when the twins have finally fallen asleep simultaneously. Walking the dog is exercise. So is raking the leaves and gardening. Perhaps you can walk to the post office instead of taking the car, or use the steps instead of the elevator. Many malls open their doors early so walkers can use their facilities before stores open. This is particularly helpful in bad weather. Exercise “buddies” can make the process more enjoyable. Finding something you like is key to any long-term commitment. If it’s a chore it will soon be relegated to the “to do” list once the novelty has worn off. And it’s OK to have fun - a country line-dancing class or a belly dancing class both fit the bill. On a more sedate tone, t’ai chi or yoga are good for overall health without any jarring movements.
Stress Reduction
While not all illness is caused by stress, stress has been recognized as a major contributing factor in most illnesses. Living and stress go hand-in-hand. The amount of control we perceive ourselves having over our lives is a key component in the degree of stress we are under. Current research in this area helps to confirm what age-old practices such as meditation, yoga or t’ai chi have long taught: that there is an intricate dance between the mind and the body, with the mind exerting a powerful force over the body.
How does stress affect the body?
When confronted with a stressor, whether real or imagined, negative or positive, our body kicks into action. The output of hormones such as cortisol and epinephrine (adrenaline) is increased, resulting in increased heart rate, blood pressure, and breathing rate. Blood is diverted from the skin towards large muscles such as those in the thigh. Digestion slows down, and blood becomes thicker and stickier (reducing blood loss should we get cut). All these forces work together to prepare the individual for what Hans Seyle referred to as “fight or flight”. While this mechanism is effective in handling a short-term situation - as such as fleeing an attacker or a burning building - the body exhausts itself in the process. If the event is short-lived, the body recuperates and will be prepared the next time danger is encountered. The problem with chronic stress (job, relationships, finances, long-term illness or pain) is that the body is not able to regain its equilibrium. With ongoing stress the immune system is negatively affected and illness (or worsening of symptoms) follows. If any of the following are all too familiar, looking at the stressors in your life may be a good next step. A great tool to use is The Relaxation and Stress Reduction Workbook, by M. Davis, PhD, E.R. Eshelman, MSW, and M. McKay, PhD.
Physical signs of stress include:
Insomnia - difficulty falling asleep, as well as nighttime awakening with trouble falling back to sleep again.
Aches and pains - especially stomach, head, back and neck.
Teeth grinding.
Frequent illness, or exacerbation of existing symptoms.
Shortness of breath or hyperventilation.
Heart palpitations.
Fatigue.
Psychological signs of stress include:
Difficulty concentrating.
Inattention to detail.
Memory lapses.
Fighting with family members, friends or co-workers.
Irritability and impatience.
Being a Partner
Every woman’s perimenopausal experience is unique. This is an especially important time to work with a doctor you trust and in whom you can confide. The two of you must become partners in caring for your health, both viewing perimenopause not a disease, but as a transition from one phase of life into another. Should you explore complementary therapies, it is important to inform your physician. In a recent survey of family practitioners and their patients, only about half (53%) of the patients told their doctors that they were investigating alternative treatment. The common reason given was fear of disapproval from the physician. If this is a path you choose, make sure your doctor is on board with you.
Medical Treatment Choices
The lifestyle changes discussed above may be enough to deal with hot flashes, night sweats and irregular bleeding, but you might also need more than that. Adaptations in lifestyle do not replace physicals, mammograms, or any other medical screenings such as those for colon cancer, diabetes, high blood pressure or elevated cholesterol. Be wary of over-the-counter treatments that will “balance” your hormones. While they may be quite helpful, they should be monitored, as they can create an imbalance on their own. Also, should you require surgery, their interactions with anesthesia medications may not be well known.
Summary
Women today are challenging the silence of our mothers’ generation. Perimenopause and menopause are not events, but significant time periods in our lives. We seek information to broaden our choices and hopefully what we learn will enable us to better prepare our daughters for all the changes to come in their own lives.