Menopause is a natural phase of a woman's life that marks the end of her reproductive years. While it is a normal and inevitable process, it can bring about significant physical and emotional changes that can affect a woman's overall well-being. Understanding the intricacies of menopause and being aware of the various challenges and opportunities it presents is crucial for women to effectively manage this transition.
The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines.
In this installment, three AMA members took time to discuss what patients need to know about menopause. They are:
- Madelyn E. Butler, MD, an ob-gyn in Tampa, Florida.
- Laura Katz, MD, an ob-gyn who is in private practice at Laura A. Katz, MD, PC, in Monroe, Michigan, and a member of Professional Medical Corp.
- Lanny F. Wilson, MD, an ob-gyn in Hinsdale, Illinois.
Professional Medical Corp. is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
It starts with perimenopause
“Perimenopause is a transitional period that can be anywhere from 35 to 55 years old, and sometimes can last that long when the hormones are just starting to change,” said Dr. Katz, noting that some people can go through perimenopause in a shorter time frame while others it can take longer.
“So, it’s that transition period where you’re wondering what is going on. You become not yourself and you’re having hot flashes, but those ovaries are occasionally functioning just enough to make you feel normal for a second,” she said.
“What's happening during perimenopause is it's a transition phase from your fertile years to your unfertile years. And it's not something that just kind of happens instantaneously,” Dr. Butler said during a video interview with the AMA about menopause. “It happens gradually and it's a period of transition that can last three to eight years. And it's characterized by a decrease in estrogen.”
“When you have a decrease in estrogen, you can have hot flashes, you can have night sweats, you can have anxiety … insomnia, changes in your sex drive, and just a whole host of symptoms,” she explained. “And it's very individual to the patient. So, it's a time of transition and it can last a lot longer than we think.”
Perimenopause is a transitional time that ends in menopause. Menopause means your periods have ended. During perimenopause, levels of estrogen start to decrease. You may begin having menopause-like symptoms, such as hot flashes or irregular periods. Perimenopause can last for years.
Symptoms gradually occur over time
It starts with perimenopause, which is a transitional time that ends in menopause. While some people will experience menopause-like symptoms during perimenopause, “normal menopause is a gradual transition that takes place over a three-to-eight-year time frame. Usually in perimenopause, periods start becoming a bit more irregular,” Dr. Wilson said. “Sometimes hot flashes begin in this perimenopausal time frame and some of the other symptoms of full menopause occur, which include night sweats, vaginal dryness, and problems with sleep—for example, insomnia and waking up during the night with hot flashes or cold sweats.
“The vagina contains receptor sites stimulated by estrogen. Without the estrogen stimulating those receptor sites, the vagina begins to dry,” he added. “Rarely, women experience weight gain as well. Since this can be controlled, it shouldn’t be blamed on menopause. It is more likely related to changes in diet and activity than the hormonal changes of menopause.”
“A more subtle kind of change is happening in the bones where the bones begin thinning and become weaker. Early thinning of the bones is called osteopenia,” Dr. Wilson said. “As it gets worse, it becomes osteoporosis. Women with osteoporosis are at increased risk for fractures of their bones.”
There are lesser-known symptoms
In addition to traditional symptoms, Dr. Katz noted that there are other “unsuspected things that are actually menopause related.”
“There is also anxiety, mood swings, irritability, depression and a loss of sexual interest,” she said. Others include facial hair growth and pain during sexual intercourse.
Then there are “panic attacks, weird dreams, urinary tract infections, vaginal itching, lower back pain, bloating, farting too much, indigestion, osteoporosis,” Dr. Katz continued, noting that the increased flatulence is “because of a natural result of hormonal changes and shifts in digestion.”
Postmenopause doesn’t mean symptoms are over
“There’s a thought that once menopause is ‘done,’ you don’t have these symptoms anymore,” said Dr. Katz. But “it means that the last period was at least 12 months ago. It doesn’t mean you can never have symptoms again.”
“People have this misconception that once you’re done with menopause, you’re good, but I have 90-year-old women who still have hot flashes,” she said. “Some people won’t have symptoms anymore, but then there are some who are off one day to the next and you don’t know when your symptoms will appear or disappear. You can’t really tell who is going to be who, but postmenopause doesn’t mean you’re in the clear.”
Menopause usually happens between 45 and 55
“The normal age of menopause occurs around age 51 in the U.S. So, anywhere from about 45 to 55 would be a normal time frame to go into menopause,” Dr. Wilson said, noting “menopause is the time in a woman’s life when menstrual periods have stopped. The diagnosis is made when a woman has not had a period for one year.
“Menopause occurs because the ovaries have stopped producing estrogen, and the egg follicles have stopped producing other hormones as well, including progesterone” he added. “Ovulation and hormone production have ceased. So, the ovaries have gone quiet.”
There are four causes of menopause
“Natural menopause occurs because as a woman grows older, her ovaries have gradually released the eggs with which she was born,” Dr. Wilson explained. “And so, as the follicles have gradually diminished, along with the eggs that were within them, natural menopause takes place.”
“We start off with millions of eggs in our ovaries when we’re still in the womb and then by the time we’re born, we’re down to 600,000—which sounds like a ton, but that’s a huge decrease just by being born,” Dr. Katz said. “So, those eggs are slowly breaking down every day, every minute, every hour, naturally.”
“Surgical menopause occurs when a woman has surgical removal of her ovaries. Oftentimes it occurs during a hysterectomy, but occasionally the ovaries can be removed just by themselves if someone is concerned about ovarian cancer,” he said. “Chemotherapy or radiation-induced menopause can occur when cancer therapies are directed at the ovaries.”
“Premature menopause occurs because of a fairly rare condition called primary ovarian insufficiency, or premature ovarian failure. In these instances, a young woman stops having menstrual periods early in life before the age of 40,” Dr. Wilson said.
Many are not prepared
Patients are “very unprepared in many ways because coalescing with that time of transition, many of them are taking care of elderly, ill parents,” or they may have children leaving home for the first time or are going through career transitions, Dr. Butler said, noting that patients are going through different changes at different points in their lives.
“In the middle of all these transitions and all these life challenges, they're experiencing hot flashes, the inability to sleep, the emotional changes that occur,” such as anxiety, stress or depression, she said. “So, they are unprepared because they don't know that the symptoms can last quite a long time.
“Is it stress? Is it the things that I'm going through—just in my life in general?,” Dr. Butler added. “And sometimes patients overlook their need for help, and they don't know how to differentiate what are symptoms of perimenopause [or menopause] and what are symptoms of the stresses that” they may be facing in their daily life.
They know that their periods “are going to stop, but they don't know what to expect leading up to that,” she said adding that “many times they think that it's just going to happen overnight, and they don't understand that some of the symptoms can last for years.”
Each transition is different
“We, as physicians, have to take the time to listen to patients and see what symptoms they're experiencing, because every transition is unique to every patient,” Dr. Butler said, noting that “perimenopause and menopause can vary so much from woman to woman” with most experiencing minimal to moderate symptoms.
But some people will have “symptoms that require treatment. And it can run the whole gamut from emotional symptoms to vasomotor symptoms—which are the hot flashes, the migraine headaches, the insomnia, all of those things,” she added. “So, most of us, thankfully, don’t have significant amounts of suffering.”
“The key here is how the symptoms affect your quality of life,” Dr. Butler emphasized. “If the symptoms are affecting your quality of life, your ability to carry on your day-to-day routine, that’s when we really need to discuss treatment.”
Menopause before 40 is rare
“It’s a rare instance to go into menopause before the age of 40—that’s called primary ovarian insufficiency or premature ovarian failure,” Dr. Wilson said. “To go into menopause before the age of 40 is not good, especially if a person waited until later in life to start their family” because it impacts fertility.
Primary ovarian insufficiency typically affects about 1% of women between 15 and 44 years old. It can affect both those who have had children and those who have not. Meanwhile, it is more common in people who are older than 30.
“And if they go into premature ovarian failure, it’s very unlikely that they’ll be able to get pregnant,” he said. “Plus, when you go into premature ovarian failure, that means the estrogen has decreased and so you’re at increased risk for menopausal symptoms as well.”
Herbal remedies might help
When it comes to menopause treatments, “it requires a lot of time drilling down to what the patient’s most troublesome symptoms are and what sorts of things you can offer her for help,” Dr. Butler said. “There are a lot of proprietary herbal remedies that don’t totally take care of all the symptoms, but they can help with quite a few of the most troublesome symptoms like hot flashes.
“And as long as the patients are informed that it’s going to take the edge off, but it’s not going to totally treat the symptoms, having knowledge of what to expect is very important,” she added.
Hormone therapy is very individualized
“In menopause, the ovaries have stopped producing estrogen, progesterone and another less commonly known hormone in women called testosterone,” Dr. Wilson said, noting “all of these work together to help prevent the menopausal phenomenon.”
When it comes to hormonal therapy, it “is very individualized depending on the patient's personal history, her risk factors, her family history for cancer” and other factors, Dr. Butler explained. “It starts with the different kinds of menopause.”
“Systemic estrogens are a little bit more controversial because they have been associated with an increased risk of breast cancer. And certainly, if a person has a predisposition to uterine cancer, estrogens can stimulate the lining of the uterus and can cause uterine cancer as well,” Dr. Wilson said. “If a person still has a uterus, they must combine estrogen and progesterone to decrease the risk of developing uterine cancer.”
“If a person has had a hysterectomy, she can use estrogen only. The North American Menopause Society recommends that we use the lowest dose of estrogen and/or progesterone to achieve our goal, which is helping prevent hot flashes and helping decrease vaginal dryness,” he said. “So, you want to take the lowest dose amount to achieve your goal and then use it for the shortest amount of time needed to control those bothersome symptoms.”
But remember, “if hormone replacement is required, the recommended treatment is tailored to the individual patient and her medical history,” Dr. Butler emphasized.
Avoid triggers with hot flashes
“Education about menopause, as we are doing here, and speaking with health care professionals will help women navigate the transition through menopause,” said Dr. Wilson. “When counselling is not enough, there are various things that people can do to help.”
“First of all, women should be aware that there are triggers for hot flashes,” he said. “Triggers include such things as caffeine, smoking, warm or tight-fitting clothes, alcohol, spicy foods, hot weather, stressful situations, and even stressful relationships.”
Maintain a healthy lifestyle
“There’s nothing like good, healthy habits. They work to help prevent cancers. They help prevent diabetes. They also help transition through menopause,” Dr. Wilson said. “There are just so many good things that come from a healthy lifestyle.”
So, drink “plenty of water, rest, exercise and maintain a healthy diet—that means a nice balance of proteins, vegetables and fruits,” he said.
Try lubricants for vaginal dryness
“There are certainly other things that we can do to treat symptoms that really affect her quality of life, like vaginal dryness,” Dr. Butler said. “If you have a patient who’s dealing with cancer, she's had chemo and now she can't have intercourse with her partner, that is something that really affects relationships and quality of life and just satisfaction with life in general.”
With sexual intercourse, “the partners should use extra lubrication—as part of their foreplay—in order to help prevent trauma during intercourse. Embrace the lubricant!” Dr. Wilson said. “However, if they still find that they have too much vaginal dryness, estrogens can be applied locally. A small amount can be applied in the form of a cream to help prevent vaginal dryness.”
“Hyaluronic acid—a clear gel or suppository—can also be used if vaginal lubricants haven’t sufficiently helped dryness especially in patients who can’t use estrogen due to cancer history,” Dr. Butler said.
Do not be ashamed
“It is important for women going through perimenopause or menopause to not be ashamed,” Dr. Wilson said, noting that “as women transition from the childbearing years through menopause, they’re joining an even larger group of women, since more and more women are living longer into post menopause.”
“You've got to communicate,” said Dr. Katz. “You’ve got to get familiar with your body. You have to advocate yourself.
“That is so important,” she added. “You’re not alone in this.”
