A conversation about menopause can bring up a variety of shared experiences, unique challenges and differing emotions, from extreme dread to great relief. It’s a lengthy process that includes three stages: perimenopause, menopause and postmenopause.
“Perimenopause includes the few years prior to the last menstrual cycle, when symptoms such as hot flashes and irregular cycles begin,” says Pamela Miles, M.D., an obstetrician-gynecologist with OU Health in Oklahoma City. “There will be a final or last menstrual cycle that begins menopause, but the definition of menopause is retrospective once there is a year without a period.”
The average age of menopause is 52, but if symptoms occur before the age of 40, Miles recommends being evaluated for premature ovarian insufficiency.
“Once we have a year without a spontaneous cycle, we are menopausal and everything from then on is postmenopause,” she says. “This all occurs because the ovaries have stopped producing estrogen.”
Common Symptoms and Treatments
One of the most reported symptoms and complaints of menopause is vasomotor symptoms, such as hot flashes and night sweats.
“About 70% of these night sweats will awaken women and thus disturb sleep,” says Miles. “This is the most common reason women look for treatment … hormonal treatment with estrogen is FDA approved for hot flashes and is the most successful treatment.”
If a woman has not had a hysterectomy, then progesterone is added to protect the endometrial lining of the uterus.
“Estrogen is used in many different regimens to treat symptoms, that includes pills, patches, topical gel/cream and a vaginal ring,” she says. “Progesterone is added separately, or there are pills and patches with both ingredients already combined. Into the early 50s, we may even use a low dose oral contraceptive pill.”
It’s important to talk with your doctor about the variety of treatments available for an individualized plan.
Miles says a key factor to the best benefit to risk ratio for hormone replacement therapy (HRT) is to start early in the menopausal years.
“The longer time from last menses to initiation of HRT decreases benefits and after about 10 years isn’t recommended as risks then increase,” she says. “Transdermal formulations of estrogen have some safety benefits compared to oral medication—and bio-identical estrogen and progesterone are available generically too.”
However, she says not everyone is a candidate for HRT.
“Risks can include venous blood clots, strokes, gallbladder disease and a very small increased risk of breast cancer,” she says. “There are many FDA-approved regimens, and that includes bio-identical options. Checking blood levels is not needed when using an FDA-approved formulation as dose adjustments are based on symptoms. There is not an FDA-approved testosterone for women and levels do decrease by the time we are 40 years old.”
The assignment Miles gives patients is to research the topic at menopause.org, where providers from different areas of medicine evaluate the best and safest treatment for women in midlife.
“This is a time to think of wellness and to decrease risk for future problems, so we can enjoy the third of our life we spend after menopause,” she says.