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By poring over the latest research, interviewing doctors and scientists, attending conferences, and talking ...
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By poring over the latest research, interviewing doctors and scientists, attending conferences, and talking to other women, Pat Wingert and Barbara Kantrowitz offer the everything-you-need-to-know guide to menopause. IS IT HOT IN HERE? OR IS IT ME? is accessible, comprehensive, practical, reassuring, scientific, and written in the lively, smart voice of friends helping friends.
First comes the overview: the beginnings of menopause, including why knowing if you’re actually in menopause can be so tricky; the stages of menopause and their typical duration; the role of hormones and the viability of hormone therapy; when and why to seek treatment, the risks involved, and a primer on pills, creams, patches, shots, and bioidenticals.
Then, at the heart of the book, two essential sections: “What You’re Feeling Now,” which offers the relief of solid information on the symptoms of your menopausal life—hot flashes, insomnia, mood swings, bleeding, memory loss, and those inexplicable glitches in thinking that make you feel like a kid with ADD—plus the comfort of advice on what to do. And “Staying Healthy Forever,” a jam-packed guide to caring for your changing body: It begins by trusting your knowledge of yourself, then learning the things to do to ensure a long and healthy future, one in which you look your best and feel your best.
No matter what your path through menopause, the experience is one of great change: and now for this great change, great help.
Your last period was shorter than usual. Or maybe it was longer. Somehow, the flow seemed a little different. It could be nothing— or it could be the first sign that you’ve entered perimenopause, the years before your last menstrual period. A few lucky women have regular periods to the end and then, almost overnight, no more tampons. But for most of us the transition takes four to six years. The journey may be marked by subtle changes that only the most attuned woman would notice, or it can be a bumpy ride. If it’s the latter, you may struggle with a variety of symptoms: irregular bleeding, hot flashes, sleep problems, moodiness. You may wonder if you’ll ever feel like your old self again. Understanding what’s going on with your body is the first step toward being back in control.
WHAT YOU NEED TO KNOW
Remember when you were 13 and your girlfriends shared their complaints of menstrual aches and pains with you? Around that time, you probably realized that not everyone’s periods were the same. After the initial shock of menstruating passed, some of your girlfriends hardly noticed a thing. Some got on a regular schedule pretty quickly, while others were so erratic they never knew when their “friend” would surprise them. Others were constantly popping aspirin for cramps, while a few of your pals were really troubled by premenstrual syndrome and were difficult to live with for about a week each month. Lots of other girls fell somewhere in between. In some respects, menopause is back to the future, because it often includes many of the same experiences in as wide a variation as menstruation. Just look at the chart on the facing page, and you’ll see how little difference there is between the cycles of early menstruation and those of the menopause transition.
Natural menopause starts without your intervention; that’s why it’s sometimes described as “spontaneous.” You might detect the first subtle hints of what’s coming (slight changes in menstrual duration and flow) 10 or more years before your periods stop. As you get closer to the end of your reproductive years, the timing may become more unpredictable and the level of flow may be unusually heavy or almost nothing at all. Some women experience problems like hot flashes (overwhelming waves of heat), night sweats, sleeplessness, less lubrication when sexually aroused, and moodiness as their hormone levels become increasingly erratic. All of these experiences are considered normal. You won’t know for sure that you’ve reached menopause until you go a full year without a period. This can happen at any age from 40 to 58, although the average age is 51.4 years. A few women don’t reach menopause until they’re in their 60s.
Induced menopause, which can occur at any time after puberty, describes what happens to a woman whose periods have stopped because of some outside intervention such as chemotherapy, pelvic radiation, or the removal of both ovaries (sometimes as part of a hysterectomy). With chemotherapy and radiation, the perimenopausal transition can last for months. Sometimes fertility ends immediately. The most common type of induced menopause is surgical menopause, which occurs when both ovaries are removed. As a result, your body’s main source of natural estrogen disappears immediately. This abrupt drop in hormones increases the likelihood that you’ll experience menopausal symptoms such as hot flashes and verbal memory problems.
Premature (or early) menopause refers to any type of menopause (natural or induced) that occurs before age 40. While rare, premature menopause puts women at greater risk for bone loss.
TIMING IS EVERYTHING
Q. I was surprised to learn that natural menopause typically occurs between the ages of 40 and 58. That seems like a really wide time span. What determines whether it happens early or late?
A. How many follicles (egg sacs) you were born with and the rate at which they deteriorate play a role. So does your lifestyle. Heavy smokers, longtime smokers, and current smokers reach menopause approximately a year and a half earlier than average. The same is true for women who have been treated for depression, epilepsy, or childhood cancer (specifically with pelvic radiation and certain anticancer drugs called alkylating agents) or who have been exposed to certain viruses or toxic chemicals. According to a few studies, heavier women and women with higher childhood cognitive test scores may reach menopause later than the average age. Women who have used supplemental estrogen (in oral contraceptives, for example) in the previous five years also tend to reach menopause later. The length of your menstrual cycles may give you a hint of what’s coming. Women between the ages of 20 and 25 whose cycles are completed in 26 days or less tend to have an earlier menopause than those whose cycles last 33 days or more. If you’ve been pregnant more than once, you may have a slightly later menopause. If you’ve never been pregnant, you may have an earlier menopause. Here are some things that don’t appear to affect the timing of your last period: the age when you started menstruating, race, marital status, and socioeconomic status.
Q. Are premature menopause and premature ovarian failure the same thing?
A. Premature ovarian failure refers to the cessation of periods over several months or years, well before the typical age of menopause. It may be temporary if it’s caused by drastic weight loss, an eating disorder, excessive exercise, or stress; once the aggravating cause is eliminated or reduced, menstrual periods may resume. It can be a permanent condition if it’s related to genetic abnormalities or certain autoimmune diseases. In the latter case, it’s synonymous with premature menopause.
AGE AND MENOPAUSE
Q. I know that the average age of puberty is lower in girls today. Does menopause come earlier, too?
A. Even though women are living longer than ever, the average age of menopause hasn’t budged. As far as scientists can tell, it has always occurred around age 51. It’s likely, however, that you’ll live more of your life after menopause than your great-grandmother did.
Natural menopause is not a disease or a hormone deficiency disorder, although historically it has been treated as both. These days, many women want to “de-medicalize” this life transition and embrace it as normal. It’s probably safe to say that most get through it with little difficulty and have no need for any medication. You could well be part of that group.
But there’s a reason that menopause has a bad rep and is a regular butt of jokes. A significant minority of women have a rough time. A few have a very rough time. Doctors think these women may be extra sensitive to hormonal changes or may have more rambunctious hormones. It’s not always easy to figure out what to blame on menopause and what to blame on midlife, when you’re more likely to have high blood pressure, obesity, diabetes, and thyroid problems. Some symptoms appear to be related to fluctuating estrogen: hot flashes, night sweats, heavy bleeding, vaginal dryness, decreasing bone density, breast tenderness, and headaches. Others appear to be indirectly related: sleeplessness, moodiness, and urinary tract and vaginal infections, as well as verbal memory and reading problems. Some are related to a drop in estrogen or an imbalance of estrogen and androgens: dry eyes, a low libido, abdominal weight gain, hair loss (or too much in the wrong places), wrinkles, and hearing loss. Health habits (such as sun exposure and smoking) affect the pace of many of these changes.
Before this list sends you screaming into the street, keep in mind that it’s highly unlikely that any one woman will get hit with everything. You may experience a few of these problems over a period of months or years, or only intermittently. Some will be barely noticeable. Others will qualify as annoying, and still others may interfere with your ability to function. But you can learn to deal with all of them until that time when things actually improve. For example, some women’s sex lives get better during the transition. (Yes, you read that right.) And no matter what else happens, by the end of this process you won’t have to worry about unplanned pregnancies or contraception for the first time in decades. You’re going to be just as smart as you ever were—and no doubt wiser. And you can use the rest of these changes to motivate yourself to start doing all the things that your doctor has been telling you to do for years but that you’ve been putting off until tomorrow. Tomorrow is here. If you play it smart, you could be looking and feeling better when you reach postmenopause than you do right now. (See Appendix I for recommended screenings.)
But we digress. What exactly is happening to your body as you set out on this menopause journey?
It all started while you were still in the womb. Your body was set up differently from a boy’s because of genes and hormones. When you hit puberty, you began to ovulate, and except when you were on hormonal contraceptives or pregnant, you’ve probably been doing this every month.
Just before you get your period, your body’s levels of two hormones—estrogen and progesterone—take a nosedive. When they near bottom, the hypothalamus and pituitary gland in your brain receive the signal that it’s time to get cracking. The hypothalamus sends pulsating doses of gonadotropin-releasing hormone (GnRH) to the pituitary gland, causing it to release the folliclestimulating hormone (FSH). This signal is enough to get about a dozen eggs to start maturing and producing estrogen, prompting the lining of your uterus (the endometrium) to start thickening in preparation for a possible pregnancy. Just before you’ve reached the middle of your cycle, the uterine lining has tripled in size, one follicle has matured to the point that it’s ready to release an egg, and your testosterone levels have risen, boosting your libido along with it. By now, so much estrogen is circulating that your body issues a jolt of luteinizing hormone that causes the follicle to release the egg, which moves through the adjacent fallopian tube and into the uterus. This process is called ovulation. The remains of the follicle, called the corpus luteum, secrete progesterone to further enrich the uterine lining. If the egg is not fertilized over the course of the next few days, the whole operation shuts down. Estrogen and progesterone start to nose-dive again, the corpus luteum shrivels up, the uterus starts to shed its lining, and menstruation takes place.
For most women, this cycle takes 27 or 28 days, but its length can vary widely. Usually, it’s in the range of 21 to 38 days. But after monitoring women’s menstrual cycles for 26 years, the TREMIN Research Program on Women’s Health found that they can range in length from 11 days to more than 100 days. If you have cycles like those on the extremes, you should mention it to your doctor.
The Shift Begins
About 10 to 15 years before you reach menopause, your body starts giving you the first tiny hints that changes are coming. If you’re self-aware, you might notice subtle differences in your periods. When you were in your early 20s, your cycle probably lasted about 32 days; by the time you reached your mid-30s, it had probably shortened to about 28 days. Even if it didn’t happen exactly like this, your periods were coming more quickly. This would occur because your maturing follicles (specifically, the corpus luteum) were producing less progesterone during each cycle, shortening the period of time when the uterine lining thickened in preparation for a fertilized egg. As time goes on and perimenopause begins, the number and quality of follicles diminish to the point where not enough estrogen is produced to prompt ovulation and your periods become erratic. It’s the mirror image of what happened when you started menstruating. As you approach the end of your reproductive years, these changes in duration and flow may become more obvious.
Other, quieter changes may also be under way. If you happen to have lab work done in the middle of a menstrual period, your doctor will notice that your FSH level is elevated. This happens because your ovaries are producing less estrogen and your brain tries to jumpstart the process by sending more FSH into your bloodstream. The higher level of FSH prompts your ovaries to recruit more than the typical dozen follicles to produce estrogen for the next cycle. As a result, there may be times when your estrogen levels are unusually high and other times when they’re unusually low. Both extremes can cause you to experience a variety of symptoms while you’re still having regular menstrual cycles. The perimenopause stage begins when your follicles’ response to FSH becomes wimpy and erratic. This in turn makes your periods more irregular. During some of these cycles, your body will not release an egg. Other times, it may release more than one, which may explain why older moms have more twins.
Technically, you’re in the early stage of perimenopause when the length of your cycle shifts by seven or more days from its normal track. As time goes on, you’ll probably miss two or more cycles in a row. This signals that you’re in the late stage of perimenopause. The length of time between cycles can get longer and longer over several years.
Although there is tremendous variation in how women progress through the menopause transition, a typical pattern emerges. Before perimenopause, the average menstrual cycle lasts about 27 or 28 days. During the early part of the transition, the cycle may shrink to every 21 to 23 days. After a while, the intervals between periods begin to lengthen, and eventually menstruation stops altogether. But many women have a more unpredictable pattern. Some seem to speed through the stages; others dally for years. Some might get a couple of periods in a row and then experience a long hiatus before they get another one. It’s fairly common to go six or nine months between periods toward the end. No one knows how to tell in advance what will happen to any one woman.
OUT OF EGGS?
Q. What makes the menopause transition begin? Is it because we’re out of eggs?
A. No one knows exactly why menopause occurs when it does, but it could happen because of the significant reduction in the number of follicles in the ovaries. You were born with between one and two million of these follicles, but fewer than 500 of them will be used up as a result of ovulation. Many, many others will degenerate over time and die as part of a natural process called atresia, or cell death. (About 100,000 follicles are present at puberty; this number is reduced to somewhere between a few hundred and a few thousand at the approach of menopause.) It appears that the rate of atresia is steady until about age 37 and then accelerates. (However, there’s a lot of variation from woman to woman.) It’s possible that the follicles that remain in the ovaries after menopause will occasionally produce a little estrogen, but not enough to prompt ovulation.
For a long time, scientists assumed that women were born with all the follicles they would ever have. But recent studies at Harvard indicate that female mice produce new follicles during their reproductive years; this finding has generated speculation that the same thing might happen in humans. Scientists are also intrigued by indications that the material used to create these new follicles comes from bone marrow. This process may eventually explain the connection between stem cells, bone marrow, and human eggs.
SHOULD I SEE A DOCTOR?
Q. I’m 50 years old, and for the first time in my life I’ve gone three months without a period. I’m assuming this means I’ve moved on to the second stage of perimenopause. If I’m not having any problems (hot flashes, sleeplessness, etc.), do I need to see a doctor about this? Or can I wait for my next regular checkup with my ob-gyn to mention it?
A. If you’ve gone several months without a period and there’s any chance that you might be pregnant, you should call your doctor immediately. If there’s no chance of pregnancy and you’re having no problems, you can wait until your next regular visit.
WHY 12 MONTHS?
Q. Why is menopause declared after 12 months without a period? What’s so special about a year?
A. Frankly, nothing. It’s just the time frame that a panel of experts agreed upon. They could have picked 10 months or 14 months or 24 months, but they compromised on 12 because the vast majority of women never get another period after they’ve gone a year without menstruating. But remember this: Twenty percent of women resume menstruation after going three months without a period.