Menopause & Beyond!
Perimenopause and menopause are like an onion. Every time I pull back a layer, I learn something new. And the more layers I peel back, the more tools I possess to support my health during this stage of my life.
In my quest for information, I recently spoke with Dr. Julia Johnson, MD, OBGYN and Clinical Professor at University of Vermont Medical (UVM) Center. Dr. Johnson is an expert on menopause and menopause irregularities and shared some valuable insights on these topics.
We touch on everything from irregular periods to HRT to the top health concerns for women in midlife. I know you will enjoy the conversation as much as I did.
Dr. Johnson on Perimenopause
Did you know every woman’s experience with perimenopause will be unique? A multicenter study, SWAN—Study of Women’s Health Across the Nation, led to an understanding what it is like to go through perimenopause. It concluded everyone is different and it is hard to make generalities. Therefore, it is not surprising your colleague’s, sister’s or mother’s experience may be very different from yours. Therefore, the more you know, the better able you are to problem-solve your unique set of symptoms.
Dr. Johnson on Your Irregular Period
It is impossible to predict when you will hit menopause. It can occur in your early 40s or in your late 50s and be normal. There is however a genetic component, and you might get some guidance from when your mother or older sister went through menopause.
As a rule of thumb, once you start going 3, 5, 6 months or more between periods, you will on average have another 2 years before your last period. In the later stages of perimenopause your ovaries become less responsive to hormone stimulation from the pituitary gland. When your ovaries don’t respond, the hormone you don’t make is progesterone which is needed for shedding of the uterine wall. As a result, it is very common for your periods to become irregular.
When your periods become irregular the lining of the uterus can get quite thick resulting in heavy bleeding when you do get your period. This abnormally heavy bleeding is called Perimenopausal Menorrhagia. The good news is near the end of your transition to menopause your periods will get lighter again because estrogen, your other female hormone, is now low.
Fortunately, there are a couple of strategies available to address heavy bleeding. One is to take progesterone for 12 days and then stop, which will bring on a period. If you don’t get your period after a week or so you can take it again for a few months, then stop again and see if you get your period.
Another option is to use a birth control pill, which will both lighten your period and ensure you predictably have a period every month. If you use this method, once a year or so, you can stop taking your pill (as long as you are not using it as a contraceptive) and see if you still have a period.
In Europe it is very popular to use an IUD containing a form of progesterone. This keeps bleeding lighter for the reasons mentioned above and it stays in until you hit menopause. This strategy does not make your period more predictable, just lighter.
Dr. Johnson on Dealing with Hot Flushes
Dr. Johnson says to ask yourself, “How much are the symptoms disrupting your life?” “Are you having hot flushes at night which prevent you from sleeping?” “Is a lack of sleep or disrupted sleep impacting your performance the following day?” “Are stressful situations during the day bringing on hot flushes which interfere with your work or life?”
Hot Flushes 101
One of the most common symptoms of perimenopause and menopause are hot flushes. It is estimated roughly 35-50% of women will experience hot flushes before their last period. They can, on average, temporarily raise your temperature to as much as 103 degrees Fahrenheit!
Hot flushes are caused by low estrogen levels. They come and go as estrogen levels fluctuate. For most women they seem to be most severe at night and stress, what you eat, and alcohol can make them worse.
Hot flushes usually begin to get better several years after menopause, although everyone is different. And a third of women experience them into their 60s and ten percent into their 70s.
Strategies to Alleviate Hot Flushes
Using a little bit of estrogen, about a quarter of the amount in a birth control pill, can often get hot flushes under control. Hormone Replacement Therapy (HRT) got a bad rap many years ago from the Women’s Health Initiative study, which has subsequently been questioned. To learn more, check out this paper by Roger Lobo which concludes, “In younger healthy women (aged 50-60 years), the risk-benefit balance is positive for using HRT, with risks considered rare.”
Black Cohosh, a natural remedy, has been shown by some German studies to be effective at reducing hot flushes, although larger studies showed no significant effect. Black Cohosh has few side effects unlike other natural remedies like St. John’s Wart which can be more dangerous. Soy unfortunately has not been shown to work effectively. If you try something herbal, give it 3 months. If it continues to work, stick with it. But if its efficacy starts to decline then the initial success was probably due to the placebo effect rather than the herb.
Anti-depressants used to treat anxiety and depression can also reduce hot flushes. However, they are only about 60% effective in reducing hot flushes, compared with estrogen’s 90% effective rate and a placebo rate of 40%. Given these have negative side effects such as lowering libido, Dr. Johnson does not commonly recommend them solely for treating hot flushes.
Dr. Johnson on How Long to Take Estrogen
If you are taking estrogen you can expect to be on it for at least a few years after menopause. Then you gradually start to reduce the dose every couple of months until you stop altogether. Some patients reduce dosage and others move to every other day or every third day to let their hypothalamus adjust.
According to studies, it appears safe to take estrogen for at least 5 years after your last period. Then there is a small increase in the risk for breast cancer. Taking it for 10 years after your last period has been shown to lower your risk for heart disease.
However, Dr. Johnson recommends getting off estrogen by the end of 5 years if it doesn’t negatively impact your life. If you can’t, she says to make sure you are getting yearly mammograms and continue to take progesterone as long as you take estrogen. Regarding heart disease, there are other lifestyle strategies you can follow to lower your risk without the negative side effects of continued estrogen.
Dr. Johnson on Estrogen and Your Vagina
Many women post-menopause find they need estrogen for long-term vaginal health. It is not uncommon after menopause to experience dryness and discomfort due to thinning of the vaginal tissue, especially during sex or gynecological exams.
Vaginal tissue and the external vulvar tissue are very estrogen sensitive. Supplemental estrogen works to rebuild thickness in vaginal tissue which helps with the production of mucinous material. After you stop taking oral estrogen, you can start putting a little estrogen in your vagina, as a ring, cream, or tablet, to address dryness and discomfort.
Estrogen used in the vagina isn’t absorbed into your blood stream, so it shouldn’t affect breast tissue. And often women who can’t take HRT can still use estrogen vaginally.
Dr. Johnson on Midlife Health Issues
Women in midlife have an increased risk for heart disease, hypertension, diabetes, and breast cancer. It is critical to get in front of these common health disorders in midlife. Unfortunately, in midlife, women are busy with children, career, and aging parents. They often don’t make time for themselves or pay attention to their own health.
Dr. Johnson says it is important during these years to have a physician who follows you and your health. You should get your blood pressure checked regularly, review the risks for heart disease, get annual blood work (including hemoglobin A1C for diabetes), and get a mammogram at least every 2 years. As Dr. Johnson says, “the better you control your health now around these issues, the longer you get to live.”
Parting Thought
For more information on perimenopause and menopause, Dr. Johnson recommends the North American Menopause Society (NAMS) and the American Society for Reproductive Medicine. The NAMS website has a helpful FAQ on HRT.
If you take away only one thing from this conversation, take the time now to invest in yourself. Find a doctor you like, trust, and see them regularly!
See you next week…
