Many women talk about their difficulties with the change-of-life process
known as menopause. But menopause does not come on suddenly—it can
be a slow process. We also hear the term perimenopause— but how
is it related to menopause? Three Torrance Memorial Medical Center obstetricians/
gynecologists, Cheryl Sanders, MD, H. Elena Rodriguez, MD, and Ricardo
Huete, MD, give us the facts on perimenopause.
WHAT IS PERIMENOPAUSE?
“Peri” means “around” so perimenopause means “around
HOW IS PERIMENOPAUSE DIFFERENT FROM MENOPAUSE?
“During this transitional time of perimenopause, menstruation becomes
irregular,” says Dr. Sanders. “This is when menstrual periods
can occur for example one month, then not again until five months later,
then not again for another nine or 10 months. This is perimenopause.”
Dr. Rodriguez adds, “Perimenopause can occur over a four-year span
before the final menstruation and is associated with changes in the body
that can affect a woman’s quality of life.”
“Menopause means a woman has not had a menstrual period for at least
12 months. When this occurs, she is considered menopausal,” Dr.
Sanders notes. “Symptoms can vary between women. Some women have
a smoother transition than others because estrogen levels can fluctuate
during the perimenopausal period,” explains Dr. Rodriguez.
AT WHAT AGE DO WOMEN EXPERIENCE PERIMENOPAUSE?
“For some women this transition and being perimenopausal can occur
as early as 35 to 40 years of age,” says Dr. Huete. “However
from 40 to 45 years of age, most women become more symptomatic. Perimenopause
can last from approximately one to three years.”
WHAT ARE THE SYMPTOMS?
“When we think of ‘symptoms,’ we tend to think of a disease,
and perimenopause and menopause are normal and not diseases,” Dr.
Sanders says. “Perimenopause is a transition just as puberty is
a transition. In addition to menstrual irregularity, other indicators
are hot flashes, night sweats, mood changes, food cravings and sleep difficulties.”
“Many women experience heavier, longer menstrual cycles, as well
as breast tenderness, irritability, vaginal dryness, water retention (bloating)
and weight gain,” says Dr. Huerte. “Excess estrogen, or estrogen
dominance condition, and the subsequent hormonal imbalance is what causes
“Other symptoms,” according to Dr. Rodriguez, “are memory
loss, weight gain and difficulty losing weight. Menstrual irregularity
occurs as the intervals between cycles are prolonged. In the reproductive
years, cycles range from 25 to 35 days. In perimenopause there can be
two or more months between cycles. And periods may shorten from an average
of seven days in the reproductive years to three or four days during perimenopause.”
SHOULD HORMONE REPLACEMENT THERAPY BE STARTED?
Dr. Huete is a strong supporter of hormone replacement therapy (HRT), unless
a woman has a medical contraindication for using it or is opposed to using
it. “Hormones are involved in our bodies from our heads to our toes.
There has been a lot of misinformation about HRT in the last 15 years.”
Much of this he believes, stems from the Women’s Health Initiative
(WHI) study that used one particular drug combination that showed an increase
in blood clots, heart attacks and breast cancer in patients using this
formulation. “Estrogen will not cause breast cancer but it can stimulate
the growth of cancer cells in the breast that are already present and
hormone dependent. Estrogen is related to one type of cancer and that
is of the uterus, not the breast.” Dr. Huete uses bioidentical hormones
(different from the drugs used in the WHI study), which have been shown
to be safer if used in the right way. He says there is evidence that transdermal
(through the skin) delivery of estrogen may have a positive effect on
cholesterol. Dr. Sanders adds that HRT can help women get through the
transition of perimenopause and move them to the next stage, which is
menopause. “Perimenopause does not ‘have’ to be treated
because it’s not a disease. However HRT does have some benefits.
For example, women have an increased risk of heart attacks after menopause,
and studies have shown that
HRT can have a protective effect on the heart.” “If a patient
still has a uterus, progesterone must be given along with the estrogen
to protect the uterus from cancer,” Dr. Sanders continues. “Further,
if a woman has a history of liver disease, a transdermal patch to deliver
estrogen is a better route versus an oral formulation which is processed
through the liver.”
Dr. Rodriguez says HRT is a viable option depending on the severity of
symptoms. “Some women have milder symptoms and choose to wait before
initiating treatment while others have severe symptoms that reduce their
quality of life. If still in perimenopause and a non-smoker, patients
can be offered a low dose birth control pill that contains both estrogen
and progesterone. Once a patient meets criteria for menopause we then
change the dose based on risk factors, type and severity of symptoms.
If a patient has a history of heart disease, stroke, liver disease or
breast cancer that is estrogen receptor positive, they are not good candidates
for hormone replacement therapy. Ultimately, we need to weigh the risks
with the benefits. We know hormone replacement therapy resolves the hot
flashes, mood swings, vaginal dryness and may help stop the progression
of bone loss in patients with osteoporosis. It may even help increase
HDL (high density lipoprotein), which we know can be cardio protective.”
ARE THERE ANY SUPPLEMENTS OR NONHORMONAL PRESCRIPTIONS THAT CAN HELP?
“There are different treatments that are either over-the-counter
(OTC) or nonhormonal prescriptions that can help reduce symptoms,”
Dr. Sanders says. “One nonhormonal prescription treatment is a low-dose
antidepressant, known as paroxetine and goes by the brand name Brisdelle.
It acts on the nervous system to help reduce night sweats. An OTC treatment
called Relizen (from a Swedish flower) helps minimize hot flashes but
takes a few months to work. Another OTC called Estroven (with soy and
wild yam extract) calms hot flashes and night sweats.”
“I like to consider the whole picture when looking at a patient,”
Dr. Huete says. “SSRI (anti-depression) medication can be helpful.
I encourage patients to talk to their doctors if they’re experiencing
unpleasant symptoms related to perimenopause and menopause. Some doctors
may be uncomfortable prescribing hormones, so it’s important to
find a doctor who will work with you. Many women are living well into
their 80s, and HRT can help women feel energetic and attractive and maintain
a good quality of life.”
In addition to OTC products, “bioidentical” topical hormones
and synthetic oral hormones, there is a laser treatment called Mona Lisa
that can help with painful intercourse, vaginal dryness and atrophy. “This
is a good option for women who have a contraindication to hormone replacement
therapy or are uncomfortable taking medications and experiencing only
vaginal symptoms,” says Dr. Rodriguez. “The laser helps rejuvenate
the vaginal wall and promote collagen and elastin formation. Other ways
to help alleviate symptoms of aging and menopause are to get regular weight-bearing
exercise. I encourage my patients to stay active, take classes to help
stimulate their minds and not to go down without a fight. Menopause can
be the best years of your life.”