What Is Menopause?
Before we can discuss how to deal with menopause, we need to have a clear understanding of what it is. If menopause means "the time after your periods stop," why are you having hot flashes while you still have periods? What if you have had a hysterectomy-does that count as menopause? What if you never go through menopause: your doctor just puts you on hormones and you still get your periods?
STAGES OF MENOPAUSE
Some of this confusion exists because there are two different stages of the menopausal process. During perimenopause, your hormones are winding down, fluctuating, and often creating the mass of symptoms we think of, incorrectly, as "menopausal." (I'll discuss those symptoms in detail in Chapter 3.) In most cases these are self-limiting and will go away in a few years.
Then there's menopause itself-which is, strictly speaking, your last period (the permanent "pause" of your menses). In the aftermath of meno-pause, you may also experience some symptoms, but these are typically different from the symptoms of perimenopause. (Menopause itself, by the way, probably lasts for only a few days, and you can never be absolutely certain when it's occurred. Menopause is usually identified retrospectively, when it's been a year since your last period. Everything afterward is, strictly speaking, "postmenopause"-though for some reason this term has never existed as a noun.) To avoid ambiguity, in this book I'll comply with popular custom and continue to speak of menopausal women, menopausal symptoms, etc. Keep in mind that I'm referring to the time after that elusive moment when your last period ends.
The reason I'm making such a fuss about semantics is that terminology can cause a lot of needless fear. One of the reasons many women dread menopause is that they confuse the lesser, often nonexistent symptoms of menopause with the symptoms of perimenopause-and so they think that the most difficult, confusing symptoms will last the rest of their lives. In reality, the vast majority of women experience these two stages very differently.
A study done in 1965 found that, with the exception of hot flashes, the symptoms of perimenopausal women were closer to those of adolescents entering puberty than to those of postmenopausal women.1 When adolescent girls experience weight gain, bloating, and mood changes, doctors assume it's because of high estrogen levels. When women around menopause get the same symptoms, the assumption is that it's caused by low estrogen. Yet it has seemed obvious to me for quite a while that the time right before menopause is the mirror image of puberty. During puberty, this mechanism is starting up. Then, at the other end, when the process is gearing down, the same things happen again. What these two life stages have in common is big hormonal shifts.
Times of hormonal shifts and changes are times of symptoms. Remember the highs and lows of puberty? Your face broke out. You slept half the day. Your brain didn't seem to work the way it used to. You didn't know what was going on with your body. Well, with perimenopause it happens all over again. This, too, is a time of symptoms in many women-hot flashes, mood swings, fuzzy thinking, insomnia, and, most of all, unpredictability. Fortunately, just as with puberty, these symptoms do end. The hot flashes dry up, just as the acne did. Your sleep patterns return to normal; your brain becomes able to focus again. Nothing lasts forever. Overall it takes about three to six years for each transition, until your body is balanced at a new place. (God help those of you who have teenage daughters going through puberty while you are going through perimenopause!)
Acknowledging the parallels between puberty and perimenopause makes the whole process less strange and scary. You've been through puberty. It may not have been fun, but you survived it. And you did it without any of the wisdom and coping skills you now have. Most of you also experienced the enormous hormonal shifts that accompany pregnancy and childbirth, and you got through those as well. There's no reason to fear perimenopause or menopause. It's just hormones again, and we all know how to deal with them.
Biology of Perimenopause: Puberty in Reverse
What exactly is going on in your body, bringing about all this change? In order to clearly define the phases of the menopausal transition, we need to review a little biology. Okay, I know there are those of you who want to skip the technical stuff-"I don't want a biology class-just tell me what to do!" Feel free to skip the next several paragraphs and pick up again on page 16. For those of you who want to know how it works, read on.
It's amazing to realize how little we actually know about the way a woman's body works. We do know, however, that hormones work together in a wonderful and intricate dance.
At birth your two ovaries contain all the eggs you'll have throughout your lifetime (Figure 1.1). The eggs sit there comfortably for several years; then you hit puberty and the beginning of your years of menstruation. Your hormone levels begin fluctuating wildly before settling down as you reach maturity. The major hormones involved in this process of puberty are follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which come from the pituitary gland (a small gland that lives near the brain, between the eyes); and estrogen and progesterone, which come from the ovaries. In addition, the hypothalamus (part of the brain) produces gonadotrophic-releasing hormones (GnRHs). (Are you still with me? One friend who read this chapter said it was great until she saw FSH, and then her eyes glazed over. And she was a doctor!)
Now you've left puberty, and you're in your fertile years. Here's basically what goes on for the next three decades. Stimulated by FSH, the follicles (the eggs encased in their little sacs) produce estrogen. When estrogen rises to a certain level, the hypothalamus gets the message and secretes LH-releasing hormone, which tells the pituitary to turn off the FSH and produce a surge of LH. When the LH is at its peak, you ovulate-that is, your body releases an egg from the follicle. The follicle shifts to a new phase (the corpus luteum) and starts to produce progesterone in addition to estrogen. These hormones build up the lining of the uterus. The corpus luteum is short-lived, and its production of hormones soon begins to decline. Once the progesterone in your blood drops to a certain level, you get rid of the uterine lining by getting your period. In addition, these lower levels of estrogen and progesterone tell the hypothalamus to get some FSH going, and the cycle continues. Every month (except for those few months when you're pregnant), your body goes through this familiar dance.
It can take a while for this dance of hormones to get its choreography down (Figure 1.2). One study confirmed that earlier on, girls have longer periods. The follicles don't mature, and there may be a longer time between periods. This seems to be in part because the ovaries aren't yet really producing eggs, and egg production is necessary for a regular "loop" to be completed. Once the whole system gets coordinated, a girl's cycles become regular and her symptoms settle.
This dance, like most dances, has a few variations. In some months, you don't ovulate. Then there's no progesterone, and your period may actually come early and be lighter or later, or you may skip a period altogether. Your body also requires a certain amount of fat to ovulate; if you're very thin or anorexic, or an athlete who is very muscular with very little fat, you will often lose your period and in essence be in temporary menopause. This time it is literally a "pause," because you'll get your periods back once your fat level increases.
So far, so good. But our understanding of the process gets a little fuzzier when you come to the end of your fertile years. The standard line in the textbooks is that when you run out of eggs and you're no longer ovulating, your body stops making estrogen. This causes your FSH to go up as your pituitary tries to kick start the ovary into producing more eggs. When that doesn't work, everything just shuts down.
Yet often the symptoms of perimenopause (breast tenderness, headaches, increased vaginal lubrication) are symptoms not of low estrogen but rather of high estrogen. Some recent studies have looked more deeply into what may explain this phenomenon. A study in 1989 followed five perimenopausal women, one of whom had occasional periods every six weeks. Fortunately, the researchers were monitoring her while this was going on. They discovered that she had low estrogen in the beginning of her cycle. Her ovaries were just tired. As a result of the low estrogen, she had symptoms such as hot flashes for a couple of weeks. Meanwhile, her hypothalamus and pituitary responded to these low levels by increasing her FSH. Her ovaries woke up in a panic, as though they had been sleeping on the job, and decided to make up for their inattention by sending out lots more estrogen-two to three times the normal amount. And then she ovulated. Now her symptoms were those of high estrogen-breast tenderness, etc. Her progesterone went up after ovulation and her period came exactly two weeks late and was very heavy, because of the extra estrogen. You can see why life at this stage is so unpredictable. (While working on this book, I experienced exactly the same cycle as the woman in the study and was relieved to know exactly what was going on.)
This is often what happens in perimenopause. Sometimes your estrogen levels are high and your progesterone is low, and you might get symptoms of PMS. At other times, your estrogen levels shift and you get hot flashes. Then for several months you're back to normal. So the common explanation-that your symptoms are due to low estrogen-is wrong. Your symptoms are actually caused by fluctuations of high and low estrogen. This also explains why you can't just get a blood test, as some doctors suggest, to tell if you are in perimenopause. Because your FSH goes up with menopause (once your periods have stopped for a year), some doctors will measure your FSH level in perimenopause, hoping to determine whether or not your symptoms are related to menopause. If your FSH is low, they tell you you're not in menopause and they don't know what your symptoms are from. If your FSH is high, they say you're menopausal-even if you're still menstruating.
Are they crazy? No. They simply don't understand perimenopause. A study in 1994 confirmed that perimenopausal women show varying patterns. Some women in the study still menstruated, even with increased levels of FSH. Some had increased FSH and normal to low estrogen. Some continued having cycles and had abrupt fluctuations of both FSH and estrogen. Some had typical postmenopausal levels one month and typical premenopausal levels the next month. So testing FSH isn't a really definitive tool for determining your menopausal status.
If you've stopped menstruating for several months, the FSH test might be a little more useful for determining if you've really gone into menopause. But even then it's not 100 percent accurate. Another study found that 20 percent of women who have no period for three months start having their cycles again. I've had patients with breast cancer who were thrown into menopause by their chemotherapy treatments, missed three or four months of periods, and showed high FSH levels-and then got their periods back. There's no foolproof test to determine menopause. The only way we can really do that is the good old-fashioned way. If you haven't menstruated for a year, you're menopausal.