Easing into Menopause

Aug. 30, 2000 -- They are just a bit over age 40, seemingly too young for "the change." But their sleep is fitful. They sometimes wake up in the middle of the night drenched with sweat. During the day, they feel irritable and depressed. And yes, the monthly cycle isn't as predictable as it once was. It's as unnerving as the hormonal changes of adolescence.

Cindy is a classic case. "I was having a period every two weeks," she tells WebMD from her home in Urbana, Ill. "It was like having PMS constantly."

When she found herself crying in a parking lot one day for no apparent reason, she knew something had to be done. "I thought, 'This is nuts.' I'm a pretty sane person, and I just didn't want to put up with this any more." Soon, Cindy began taking low-dose birth control pills, just to keep things regular -- which, finally, they did.

Like many women, she says, "I had no idea anything could be done about it," before she discussed the problem with her doctor.

She's in the midst of what doctors call perimenopause, the decade or so that is a woman's natural period of transition into menopause. As estrogen levels fluctuate dramatically, menstrual periods can become shorter, lighter, and unpredictable. Hot flashes or "flushes" -- the signature of this era -- may come and go. For some women, this transition takes place gradually over a decade. For others, it lasts just a few years. When her period has stopped for a full year, a woman knows she is in menopause.

The study of perimenopause "is a science in its embryonic phases," Cynthia Stuenkel, MD, a gynecologist at the University of California in San Diego, tells WebMD. "We really are struggling to define what's happening, how to measure it, how to get any sense of how long it might last."

"It may be that how you go through your perimenopausal years determines your health for the rest of your life," Nanette Santoro, MD, director of reproductive endocrinology at Albert Einstein College of Medicine in the Bronx, N.Y., tells WebMD. "This transition has simply not been looked at."

Santoro is principle investigator of the Study of Women Across the Nation (SWAN), a five-year, National Institutes of Health-funded study involving 3,200 women ages 42-52 from five ethnic groups (Caucausian, African-American, Japanese, Chinese, and Hispanic).

"There's just a huge gap in knowledge of what makes women stay healthy after menopause," says Santoro. "Is it their level of activity? Is it their ability to resist the weight gain that seems to plague so many women? ... Are there features of their hormone picture during these years that leads to trouble in some women? Do hormones predict symptoms, predict bleeding?"

As early as age 40, some women feel the difference, says Kirtly Parker Jones, MD, associate professor and vice-chairman for educational affairs in obstetrics/gynecology at the University of Utah in Salt Lake City. "They come to me and say 'I don't feel right,'" Jones tells WebMD "They blame it on hormones. They are tired, stressed out. They are working too much. They have kids, a job or both. Their lives are very complicated." While some of its symptoms may resemble PMS, perimenopause is a multifaceted phenomenon aggravated by life circumstances, says Jones. "There are many, many things that happen in midlife, and they aren't all related to the ovaries."

The sudden ups and downs of estrogen and other hormones can indeed add an extra edge to an already stress-filled life. You can be sure that a drop in estrogen is responsible for those hot flashes women sometimes get at night, Jones explains. Here's what happens: Low estrogen levels trigger a rise in adrenaline, setting off a rapid heart rate, increased blood flow -- and higher body temperature. Most women have hot flashes, to one degree or another, in the years surrounding menopause.

While all women understand what a classic, major hot flash is, they may not recognize the more subtle ones that occur at night, says Cindy's gynecologist, Suzanne Trupin, MD, a clinical professor at the University of Illinois-Urbana. "It could feel like an adrenaline rush. It could feel like you drank a whole lot of hot coffee on a hot day. Women say they wake up and their neck is dripping wet. Some get a lot of wetness, others don't. With a lot of women, it's never feeling the right temperature," she tells WebMD.

For most women, hot flashes are bearable but can seriously disturb sleep, says Jones. To turn down the internal thermostat and to regulate periods, many women opt for some form of hormone replacement therapy (HRT). The choices: taking a low-dose contraceptive pill; taking low-dose HRT; or consuming soy, which provides natural phytoestrogens.

Jones tells WebMD that "most women take perimenopause in stride. Eighty percent of women in this country get through it just fine without any treatment. They don't need estrogen; they have lots of estrogen. When estrogens are higher; women have breast tenderness, breast cysts. The next month, estrogens drop, and they're having hot flushes. The unpredictability, that's what can make it difficult."

Still, estrogen replacement can decrease hot flashes, which makes sleeping easier. It also helps decrease the rate of bone loss associated with aging. And while vaginal lubricants can temporarily ease dryness, "nothing works like estrogen," Jones tells WebMD.

For some women, the pill is a good solution for the symptoms of perimenopause. "Women who are busy, leading pretty rewarding lives, and who stay active and eat well, usually do fine," Jones says. "Their bodies are making estrogen; they just are not ovulating regularly. For them, birth-control pills are great. Then they can choose when they want to have their period."

For others, perimenopause is not an easy time, Jones says. "Women who clearly suffer are those who already have very heavy periods, fibroid tumors. Some 35% of American women have a hysterectomy because they don't like the bleeding and cramping" caused by fibroids. Heavy bleeding can lead to anemia, and persistent spotting over several weeks may indicate something abnormal inside the uterus.

For women whose routine Pap tests and gynecological exams have been in the hands of a primary-care physician, perimenopause might signal a need for a new practitioner, advises Bruce Ettinger, MD, a senior investigator in the division of research for the Kaiser-Permanente Medical Care program.

"It takes almost an act of courage for a family practitioner to bring up the whole issue of HRT," he tells WebMD. "It's complicated, it takes time, and even if the knowledge is there, the setting has to be appropriate for presenting the material and discussing it. And unfortunately, many primary-care doctors just don't have that kind of time. Ob/gyns are more enthusiastic about hormone support."

Health educators, nurse practitioners, and physician assistants can also provide counseling, he says. "And the other person coming into the picture is the pharmacist. Pharmacists are taking a bigger role in advising women about risk and benefits of medications and how to use them, what their choices are, including estrogen-replacement therapy."

But the big issue, Ettinger says, is whether drug therapy is really needed. He agrees that for relief of major symptoms, "nothing works better than estrogen, absolutely nothing." But not everyone wants to take a drug at this time in their lives.

For women with less-than-serious symptoms, studies have shown that "soy protein can reduce hot flashes at least 15% better than placebo," Ettinger says. "Increasing soy protein up to 25 grams a day can also lower cholesterol. ... We're talking about eating a diet similar to what Japanese women eat."

While soy in capsule form may boost estrogen levels too high and increase the risk of certain cancers, such as breast cancer, that's not true of edible soy, he says: "You couldn't eat yourself into trouble."

  • Taking a multivitamin
  • Eating a well-balanced, vegetable-based diet with a little meat protein
  • Getting regular exercise to reduce stress (it also helps with hot flashes)
  • Getting support from friends
  • Doing something that involves rhythmic breathing, like singing or meditation
  • Getting a deep-muscle massage, perhaps going to a spa

"Chronic stress is toxic," Jones says. "It makes you fat, it makes you have a tendency to diabetes, it makes you forgetful. It causes hypertension. More and more, the hard science is showing that hormones from the brain and the adrenal glands associated with chronic stress are not good."

Struenkel advises women to see a doctor about fatigue, because it could mean thyroid or cardiovascular problems, or another hormonal imbalance such as diabetes. "Ask to have thyroid stimulating hormone (TSH) levels tested. Women's thyroids are very sensitive, especially after they have had a baby. [Fluctuations] in hormones can affect thyroid function. Some researchers think there's an increase in autoimmune thyroid disorders in perimenopause or in menopause."

Also, tests of follicle stimulating hormone (FSH) -- the hormone that triggers ovulation -- can tell doctors whether you are truly in menopause. For women who have had a hysterectomy, and therefore don't have a period, this can be the only clue.

Finding a good gynecologist to advise you on perimenopause is getting easier, Stuenkel tells WebMD. "The demographics are driving it. By virtue of necessity, doctors are learning more about this. ... But we don't have enough data to have clear-cut rules for treating women in perimenopause."

For lists of physicians, she refers people to the North American Menopause Society web site, "Of course, it won't tell you who is a good doctor or who isn't. You have to rely on word of mouth and your local medical society," says Stuenkel.