Everything you wish your mother told you about menopause

Perimenopause, or the “menopausal transition,” as it is now called, is as individual as your fingerprint, meaning that no two women experience it the same way. Some women breeze through menopause quickly and uneventfully, while others suffer debilitating symptoms that can last for years. The reason for a prolonged transition is that women’s periods don’t simply stop one day.

“For most women, the ovaries gradually slow down over several years and because of that women can have years of hot flashes, years of irregular bleeding and other symptoms,” said Joshua Lupton, DO, at Cape Cod Hospital Obstetrics & Gynecology.

The earliest a women could experience normal perimenopause is her early 40s, but some women also go through the transition much later, with some even occurring in the late 50s. The average age of menopause is 51.

“There is definitely a genetic component to menopause,” Dr. Lupton said. “What is interesting is that many women don’t know their mother’s history because women just didn’t used to talk about it. Women never talked about their periods. Women never talked about hot flashes. They never talked about any other menopausal issues that they were having. They just felt like they had to keep it to themselves.”

Another complicating factor is that in previous generations, when women had a hysterectomy, surgeons often removed the ovaries from women in their 40s and 50s, along with their uterus. That put those women into an artificially-induced menopause, which means they don’t actually know when they would have experienced it naturally.

“Now we give women a choice until they are in their 60s because the ovaries are still producing a little bit of estrogen, which we know is beneficial for bone health, heart health, skin health, mental health, sleep health, and sexual health,” he said.

Heavy Bleeding

Hot flashes can be debilitating, but even if they last for years, they usually become less severe and less frequent over time, Dr. Lupton said. The other very common issue that can really affect a women’s quality of life is irregular bleeding. Women experiencing perimenopause might not have periods on a predictable schedule and some experience extremely heavy periods that can make it hard to leave the house.

In the past, women who experienced heavy bleeding only had one choice: hysterectomy. The good news for women today is there are safe and effective nonsurgical or minimally invasive procedures to alleviate excessive bleeding, he said. One solution is a Mirena or other brand of progesterone-releasing IUD that slows heavy bleeding.

“There are also several different techniques of ablation,” Dr. Lupton said. “The most commonly used one now is the radiofrequency waves and actually ablating or burning the uterine lining.

Most women actually have really great success with that.”

The ablation procedure is done with light sedation or local anesthesia. Afterwards, the patient may have a couple of weeks of cramping and some abnormal discharge, but the risks are low, and the success rate is high, so it’s a good option for many women.

A common question that Dr. Lupton gets asked by women in their 50s who have not undergone the menopausal transition is, “Can I still get pregnant?”

“It’s unlikely, but it is possible,” he said. “As long as women are still having periods, they are likely ovulating and they could absolutely get pregnant.”

Dr. Lupton recalls a labor delivery nurse he worked with in Michigan who became pregnant at age 56. For most women this would be devastating emotionally. It would also be a risky pregnancy because of her age. For that reason, a lot of OB/GYNs place IUDs in women in their 40s and 50s. They are effective for several years and can be taken out at any time.

Hormonal Options

Even though menopause is a natural process that doesn’t require any treatment, there are things women can do to alleviate bothersome symptoms, if they are interfering with their quality of life, he said. Treatment depends on what symptom you are trying to alleviate. In terms of hot flashes, there are both hormonal and non-hormonal options. There are lifestyle changes that can help like wearing multiple layers of clothing and cotton underwear. Keeping a fan next to the bed at night is also a good idea.

There are non-hormonal medications like Gabapentin, Paroxetine and Clonidine that can help some women, Dr. Lupton said. There are also natural supplements but they have mixed reviews. Some women find relief with black cohosh, but there are some reports of liver problems with chronic use, he said. Phytoestrogen from soy products also get mixed reviews.

“In terms of hormonal options, nothing is going to work as well as estrogen replacement therapy,” Dr. Lupton said. “It’s very important if women are going to take hormonal replacement therapy to know if they have their uterus or not because if they have their uterus, we don’t want them to have unopposed estrogen for several years. They have to take progesterone alongside of it.”

Hormone replacements come in many forms and there are very few contraindications to it. Different hormones carry different risks, but overall, the risks are pretty small, according to Dr. Lupton. For women taking estrogen and progesterone, there is a very small increased risk of blood clots and breast cancer. When women take estrogen alone, there is an increase in the risk for blood clots, but there is a benefit for bone loss.

“Some women are willing to take that risk and others are not,” he said. “The rule of thumb is to use the lowest dose for the shortest amount of time to get the desired effect.”

The exception to that rule is vaginal estrogen, which comes as a cream, tablet or ring. Women can start taking that in their 50s and continue for the rest of their life if they want.

“I tell patients vaginal estrogen has basically no risk,” Dr. Lupton said. “I ask all of my perimenopausal patients if they have any vaginal symptoms like vaginal dryness or discomfort with sex. If they say yes, I talk to them about vaginal estrogen. It’s wonderful and it can change people’s lives.”

Other discomforts or complaints about menopause include skin changes and mood changes like depression or anxiety. Dr. Lupton always directs women who are experiencing perimenopause or menopause to the North American Menopause Society website. There is a lot of great information and resources for women there and he even prints handouts from the website to give to patients.