Perimenopause, Menopause, and Other Natural Wonders of Women's Mid-Life

The cartoon read, "I'm out of estrogen and I have a gun." I laughed when I spied those words pinned on an office wall showing a frustrated middle-aged woman suffering from mid-life menopause behind her office desk. That was a few years ago. Today, at the mid-point of my life, I'm now experiencing sometimes powder-keg angry outbursts, confusing mood swings, crying jags, prolonged menstrual cycles, headaches, and night sweats that remind me of that cartoon.

So, what's going on? Why for more than 40 million female baby boomers (close to 38 percent of the U.S. population), who've reached the age of 50, is "estrogen" the buzzword of women's health? For starters, approximately 14 percent of American women over the age of 45 are now taking supplemental estrogens, as they enter first perimenopause and, subsequently, menopause.

How does estrogen perform in the body anyway? Perhaps the better question is, how doesn't it perform? All of a woman's most important body tissues contain estrogen receptors. There are 300 different tissues, ranging from the brain to skin to bone in a woman's body, that contain receptors for estrogen. That includes the breasts, skin, and blood vessels. They're all depending on estrogen to stay flexible and toned. Estrogen keeps the uterus, vagina, and base of the bladder moist. And there are many sites in the brain where estrogen receptors are found, which may explain why some women entering perimenopause and menopause experience forgetfulness, free-floating anxiety, and memory loss.

Each woman's experience as she enters perimenopause, a transitional period of declining estrogen levels marked by fluctuations in her estrogen cycle, is different. For some, the transition is quiet, unobtrusive - like a cat on a night prowl. Some unexplained exhaustion perhaps, some acne eruptions, atypical headaches, some irritability, or lapses in libido. For others, it's dramatic, startling - like a wolf howling at the moon. There's a shortening of menstrual cycle intervals, or a change in the pattern of bleeding, perhaps also so-called "hot flashes," "power surges," and night sweats. A footnote here from the experts. "Abnormally prolonged, intermittent, or heavy bleeding, could also be a signal of other pathological conditions that need to be checked out by a physician," cautions Dr. Shahla Nader, co-director, The University of Texas-Houston Medical School Office of Women's Health, and professor, obstetrics, gynecology, and reproductive sciences, and internal medicine. In fact, this period of a woman's life calls for an early baseline checkup. Blood tests, such as measuring the level of estradiol, menstrual history, and a transvaginal ultrasound are some of the options, if clinically indicated.

Perimenopause is the period of time, normally about four years, that leads into menopause. Menopause is defined as a woman's last menstrual period. This is strictly defined retrospectively as an absence of menses for one year. The woman is no longer producing estrogen and progesterone. How do you know when you've reached menopause? Normally symptoms such as hot flashes and night sweats herald the impending event. But a test to see whether a woman's serum FSH (follicle stimulating hormone) level has risen into menopause rank can be done. There is a gradual rise of FSH during perimenopause. At the menopausal point, a woman may be placed on a traditional hormone replacement therapy (HRT) regime. The goal is the least medication for the most benefit.

There is still much research being done on the different medical options for women during perimenopause and menopause. In 1995, the National Institutes of Health (NIH) launched a $628 million Women's Health Initiative to study 27,500 women, half receiving HRT, and the other half, a placebo. Results are expected out in 2005. Comments Dr. Nader, "Unlike other studies, this is a prospective, randomized trial." Also at UT-Houston Medical School, Dr. Firyal Khan, obstetrics, gynecology & reproductive sciences, has devoted 20 years to studying the reproductive cycles of female baboons. Presently she is examining the Papio baboon in a study entitled "Aging Female Baboon and Ovarian Function." Dr. Khan says that normal human ovarian tissue and samples of blood can be difficult to obtain, but the baboon's perimenopause-menopause cycles are easier to observe and are similar to a human female's cycles.

Between a woman at mid-life and her gynecologist or physician, there can occur a lot of fine tuning. In younger patients, doctors may prescribe low-doses of oral contraceptives, such as Loestrin FE 1/20, Alesse, Mircelte, or Levlite, to control some of perimenopause's problems and symptoms - menstrual irregularity and hot flashes and night sweats. This also provides contraception if needed. Birth control pills, used in this way, essentially turn off a woman's fluctuating estrogen levels and supply it to her in low regulated doses. These cycle regulators also protect against ovarian and endometrial cancer as well as lower the risk of benign or fibrocystic breast disease, by a 35-50 percent decrease.

Hormone replacement therapy (HRT) and estrogen replacement therapy (ERT) literally add estrogen to a woman's body. HRT is commonly prescribed when a woman is menopausal, that is, when she is no longer making estrogen, and when there are other obvious symptoms like hot flashes and vaginal dryness. The most common hormone replacement therapy prescription for menopause is Premarin, which also comes in a vaginal cream form for relief of local symptoms. Other options include Estrace, from a plant compound, Ogen, from a modified plant estrogen, skin patches such as Estraderm, and designer estrogen-like compounds called SERMs (Selective Estrogen Receptor Modulators), such as raloxifene, marketed as Evista. The latter has no stimulating effect on the uterus or breast but may cause hot flashes. During perimenopause, adds Dr. Nader, hormone replacement therapy options "may need some adjustment to avoid erratic menses."

What can women do? The experts, such as Dr. Nader, advise:

Relax.

Keep calcium levels up and take your vitamins. 400 IU vitamin D; 1,000-2,000 mg time-release vitamin C; 400 IU vitamin E; 10,000 vitamin A; and 200 mg time-release B6. Vitamin B6, also known as pyridoxine, may help mood swings, for both men and women. Doctors recommend on average 1000 - 1500 mg daily calcium intake. If you have reached menopause, are not on hormonal therapy, or have additional risk factors for osteoporosis, you may want to consider the DEXA (dual-energy X-ray absorbitometry) test for measuring your bone mineral density. Good sources of calcium include: milk, yogurt, cheese, oysters, sardines, canned salmon with bones, dark-green leafy vegetables such as spinach, broccoli, kale, collard and mustard greens, chard, cabbage, and watercress. Vitamin C, carotene and fiber sources include: oranges, grapefruit, carrots, winter squash, tomatoes, and cauliflower. Vitamin E sources include: apples, apricots, blackberries, yams, mangoes, papayas, asparagus, celery leaves, lamb, hazelnuts, and haddock.

Reduce your fat intake. But include complex carbohydrates, such as whole grains and breads. Control weight gain.

Drink lots of water (8 glasses a day). Eat smart. Limit caffeine and alcohol.

Exercise regularly. For bone maintenance, include weight-bearing exercises in your routine.

Be prepared ahead of time; use over-the-counter products to increase vaginal lubrication; dress to stay cool.

Don't smoke.

Develop an attitude of gratitude. Take time to pursue healthful hobbies such as gardening, painting or growing friendships. Try some breathing, meditation, and relaxation techniques that can help regulate your body.

While estrogen is not the only sex hormone produced by women, it has star quality. "Women who still have a uterus need to take an additional hormone called progestin, if they take estrogen," says Dr. Nader. Estrogen itself is linked to increased cognitive skills, sexual vigor, restoring moisture to dry skin, and luster and shine to brittle hair. Concludes Dr. Nader, "Observational studies have linked estrogen treatment with lower incidence of heart disease, and estrogen has been shown to improve cholesterol profiles." Heart disease, not breast cancer, is the biggest health threat to American women, killing 250,000 a year from heart attacks and another 90,000 deaths from strokes. Thus, the celebrity hormone of female baby boomers is also an amazingly efficient sentry to women's health.

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©2006 Texas Medical Center

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