Try this experiment: Repeat the word “menopause” three times slowly, letting the words roll around in your brain. Then do the same for “perimenopause” and “postmenopause.” It may seem funny, but in doing this, you have probably spent more time than the average person thinks about menopause at all, even if you are a woman going through it.
Fortunately, that’s changing. Right now, about 30 million American women in their 40s and 50s are experiencing menopause. Many of these women have found out about its difficulties the hard way. It is not usually a topic of positive (or really any) discussion among many women. Sometimes it is framed as a burden or an unspeakable manifestation of getting old, and many women don’t know what to expect, which is strange considering roughly half of the world’s population goes through it.
Menopause occurs when you have had 12 consecutive months without a menstrual period. A woman’s ovaries stop producing estrogen and progesterone, the hormones that wax and wane to release and support eggs and the uterine lining for pregnancy.
The typical age of menopause in America is 51, with perimenopause—the hormone fluctuations leading up to menopause—often starting in the mid-40s. Postmenopause occurs after menstruation stops for good, although some women report symptoms like hot flashes and fatigue for the rest of their lives.
Perimenopause is often when symptoms can be most unpredictable and need the most management. Symptoms typically continue through menopause and even to the end of life, with varying degrees of severity. They include hot flashes, sleep disturbances, anxiety, depression, rage and other intense emotions, skin and hair changes, weight changes and vaginal dryness and/or pain during sex.
Some may experience highly irregular periods during perimenopause, with intense bleeding and clotting. It’s important to get checked at this time to rule out fibroids, endometriosis or cancer. Waning estrogen and progesterone, as well as serotonin, endorphins and dopamine also can cause a “brain fog” that usually clears up once hormones settle.
This can be quite a lot to deal with at a busy stage of life. Menopause is sometimes called “the second puberty” for this reason. In middle age, many women are sandwiched between their own household needs and those of aging parents, so sleep, general health and functionality are critical.
Fortunately, women now have some resources, certainly more than previous generations. Here in Rochester, the Mayo Clinic Center for Women’s Health is probably the highest-profile site of menopause study and treatment in the U.S., if not the world. Stephanie S. Faubion, M.D., is director of the Center and is also the medical director of the North American Menopause Society (NAMS).
The Center’s approach to menopause is multidisciplinary and comprehensive. Team expertise is used to evaluate women not just for hot flashes and other obvious vasomotor symptoms, but for sexual health, mental health concerns and the “cognitive blunting” of estrogen loss.
“At the end of the day, it’s about quality of life,” says Carol Kuhle, M.D., a practitioner:: health & wellnessRWMagazine.com:: 17 at Mayo’s Center. “Women are functioning at a high level, and we want to keep them there.”
Catherine Mascari, a certified nurse midwife and advanced practice registered nurse at the menopause Center of Minnesota and the River Valley Birth Center of St. Peter, echoes this approach. “It becomes a question of how we make sure our patients have as many ‘good years’ as possible.”
Not your mother’s hormone (replacement) therapy
The hormonal transition of menopause will eventually increase the risks of heart disease, stroke, dementia and bone loss. Some women are prescribed either birth control pills or hormone replacement therapy, now known as hormone therapy, or HT, to control their menopause symptoms and to retain the benefits of estrogen for longer-term bone and cardiovascular health.
HT was first prescribed in the U.S. in 1942, as a panacea for those women who, apparently, were losing their sex appeal and youth without these magic fertility molecules, never mind the actual medical concerns around waning estrogen. Synthetic estrogens and progesterones were the default prescriptions at the time.
Fast-forward to the years 1993 to 2002 and the Women’s Health Initiative (WHI) study of HT, which indicated risks of cardiovascular and cancer complications. For a time, women were left without a clear path for menopause symptom management and a window of just a few years for treatment using hormones.
Fortunately, the WHI studies have been ongoing and now indicate that women ages 50 to 59 can safely use newer, FDA approved forms of HT for symptom management. Some women find greater relief in cream or patch forms of estrogen and progesterone, which absorb more easily than oral medications. “There are estrogen receptors everywhere because it’s such an important hormone, and these types of prescriptions are very effective,” says Mascari.
Clinicians also now have a variety of antidepressants that have proven effective against the depression and anxiety of menopause. Treatment emphasis is shifting to more patient choice, quality of life and day-to-day functionality versus highly medicalized notions of “hormone deficiency” and atrophied sex organs and sexuality.
“We’ve learned a lot since that WHI study came out, and we’ve now been able to follow these women for 20 years,” says Kuhle. “Women in perimenopause or menopause before age 50, whether naturally, surgically or because of cancer treatment, absolutely should be evaluated and treated. They can be most at risk of long term cardiovascular, bone and cognitive issues without HT. An annual check-up then determines the treatment course. We’ve found that hormone therapy is important in preventing bone weakening (osteopenia) and osteoporosis. Many women are surprised at the bone loss they experience during menopause.”
Vaginal and sexual health are other important areas for support during menopause. “This is a big change in your life, and we find that cross-culturally, loss of libido and sexual health problems are universal,” says Kuhle. “Topical estrogen can help with the vaginal wall thinning that leads to frequent urinary tract infections and diminished sexual function.”
For some women, symptoms can persist into their 60s and 70s; Kuhle says in her practice, the number is as high as 18%. Mayo’s Center has counselors to talk women through these concerns and normalize them, and to determine the optimal window for HT or other treatments.
Complementary medicine and self-care
Both Kuhle and Mascari acknowledge products and techniques such as herbal supplements, acupuncture and other non-Western treatment modalities for menopause—these are readily available online, in pharmacies and at health markets in what’s known as the rapidly growing “femtech” universe. However, they point out that most are unstudied and, therefore, not prescribed. However, Mascari’s patients have had great success with acupuncture for hot flash control and pain management.
General self-care often goes to the wayside for busy women in this stage of life. Yet adequate sleep, nutrition, exercise, weight maintenance and intake of calcium, magnesium and vitamin D3 are key to good menopause management. A diet rich in soy and phytoestrogens can’t hurt, either.
The Menopause Center of Minnesota recommends regular Kegel exercises to improve pelvic floor function for sexual health and to prevent incontinence and urinary tract infections, which can become more common with age and low estrogen levels. Smoking, vaping and excessive alcohol consumption are not recommended for any woman. Mindfulness and yoga techniques are good for relaxation, blood pressure control and hot flash prevention. It’s no surprise that the more you invest in your health and fitness, the better your menopause experience will be.
Always consult your medical care team before making changes to your health care.
Part 2 of this article, Burning Woman, Part 2: Stepping into Our Power is in the works. If you want to tell your menopause stories and how you have “stepped into your power,” DM Anastasia on Instagram, Facebook or Twitter, or email firstname.lastname@example.org.