Laura (not her real name) visits every year for her annual gynecologic exam. We have known each other for many years, but today, she is not herself. Laura’s periods have become less regular, and she has hot flashes some nights that disrupt her sleep. Some months she feels like her old self with regular periods, but other months, her periods are accompanied by severe cramps and breast tenderness. Laura is understandably distressed and wants to know what is happening.
Laura is experiencing the typical symptoms of perimenopause. This is when her periods become less predictable before eventually stopping at full menopause. This lack of predictability is from her brain’s response to the aging of the remaining eggs in her ovaries. To have a period and ovulate (pass an egg), a woman’s brain must send stimulating hormones to her ovaries. With ovulation, the ovary makes estrogen and progesterone, but as the ovaries age, the brain has to issue increasingly higher levels of its stimulating hormones, with the ovary not always responding. All of Laura’s symptoms are explained by this “waxing and waning” of her ovarian function. How do we help with her symptoms?
She needs to understand that it’s all normal, but understanding what may not be normal is just as important. Periods every 21-35 days during perimenopause are normal, while bleeding at intervals less than 21 days or bleeding more than eight days at a time is not normal, and indicates a need for further evaluation by a gynecologist.
Laura must also remember she is still at risk for pregnancy during perimenopause. Low-dose birth control pills or a progesterone intrauterine device are good choices for contraception as they also help regulate bleeding. If contraception is unnecessary, bioidentical progesterone can be used to regulate periods while soy and black cohash can help alleviate hot flashes. Laura decided she would just ride it out and see what happens.
Laura came back 8 months later having had no periods. Hot flashes, sleep disturbances, mood changes, and irritability had really begun to interfere with the quality of her life. Information from the internet and bookstores just confused her more. What does Laura do now?
Stages of Menopause
Menopause can be divided into “early” menopause (no period for six months) and “late” menopause (no period for one year). Laura is between, having had no periods for eight months. We know her stimulating hormones are elevated as her brain tries to get her ovaries to work, but they no longer produce eggs and only make low levels of estrogen. This combination affects the body’s “thermostat” and causes the hot flashes, leading to sleep disruption, fatigue, irritability, and mood changes. Low estrogen can also cause mood changes and increase susceptibility to anxiety and depression, with accompanying physical changes. Vaginal dryness, pain with intercourse, decreased libido, joint pain, and decreased elasticity of the skin can also be experienced. Fortunately, there are a variety of options to help alleviate Laura’s symptoms.
Hormone Replacement Therapy
Hormone replacement therapy was once the most commonly prescribed treatment, but we now know it can increase the risk of heart attack, blood clots, stroke, and breast cancer, regardless of the type of therapy used or its route of administration. Furthermore, contrary to popular belief, both bioidentical and non-bioidentical preparations carry these risks. Despite this, hormone replacement therapy is still the most effective way to alleviate menopausal symptoms, but it must be used with caution and with the understanding that the symptoms will return when the hormone replacement is stopped.
In 2013, the Food and Drug Administration (FDA) approved paroxetine (Brisdelle), a serotonin reuptake inhibitor anti-depressant, for the treatment of hot flashes. Neurotonin or gabapentin, long used for the treatment of chronic pain, can be helpful as well, but may be overly sedating at undesirable times. With mood changes, again, paroxetine may help, both as an anti-depressant and in promoting restful sleep. There’s a good chance that a full night’s sleep will help Laura’s mood improve.
Vaginal dryness, pain with intercourse, and decreased libido are also common during perimenopause. Bioidentical estrogen preparations for the vagina and vulva dramatically relieve the dryness and decrease libido by keeping estrogen levels in balance, and Osphena, an oral medication for vaginal dryness, has recently also been approved by the FDA.
Non-Drug Treatments for Menopause
Non-pharmacologically, numerous other treatments for the symptoms of menopause have been widely studied, but with varying results. These include vigorous aerobic exercise, yoga, hypnosis, paced breathing, mindfulness meditation, and acupuncture. As mentioned earlier, herbal supplements such as soy and black cohash may help, but dong quai, ginseng, kava, and evening primrose have not been found effective and can instead have serious side effects.
Laura decided to try a local estrogen supplement for her vaginal dryness and an anti-depressant for her hot flashes, and she increased her exercise. Six weeks later, her symptoms were not entirely gone, but she was managing them well and was much happier.
Over the past 20 years, a better understanding of the physiologic changes of aging in women has led to vast improvements in menopausal medicine and the treatment of disruptive symptoms. To find the latest information on menopause and to locate a certified menopause practitioner, visit the North American Menopause Society website at menopause.org. Karen Knapp, MD, FACOG, is Richmond’s only female NAMS-certified practitioner. She is specially trained to help you through all the challenges of perimenopause and beyond.
For further inquiries about menopause management or general gynecology, contact Karen Knapp, MD, FACOG, of Commonwealth Ob/Gyn Specialists at 804-285-8806, or visit their website at commonwealth-obgyn.com.