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Hormone
Changes During Perimenopause
Symptoms of Perimenopause
Dealing Actively With Your Midlife Changes
The term
“menopause” comes from two Greek words that mean “month” and “to
end.” It translates as “the end of the monthlies.” The medical
definition of menopause is the absence of menstruation for 12
months. In American women, the average age for menopause is 51.
However, it can occur between a woman’s late thirties and her
late 50s. Menopause also occurs when a woman’s uterus and
ovaries are surgically removed.
Perimenopause
is the two to fifteen year span before menopause during which a
woman experiences changes due to declining levels of estrogen
and progesterone. For some women, the perimenopausal time can be
more troubling than actual menopause.
Hormone
Changes During Perimenopause
A woman’s
menstrual cycle is governed by the endocrine system. The central
glands, located deep in the brain are the hypothalamus and the
pituitary. These structures regulate the sex hormones produced
by the ovaries. Other glands and structures are also involved,
but these are the main players. When a woman is having regular
menstrual cycles, the hypothalamus releases Gonadotropin-Releasing
Hormone (GnRH.) This induces the pituitary to release increased
amounts of Follicular Stimulating Hormone (FSH) during the first
two weeks of the menstrual cycle. The FSH stimulates growth in
some of the eggs in the ovary. The ripening egg (follicle)
produces estrogen, which causes the lining of the uterus to
thicken. At about day 14 in the cycle, the pituitary produces an
increased amount of luteinizing hormone (LH.) This causes the
release of the follicle from the ovary. The area around the
released follicle becomes the corpus luteum. The corpus luteum
secretes a lower amount of estrogen and an increasing amount of
progesterone. If the egg is not fertilized in the critical
period after ovulation, the corpus luteum produces declining
amounts of estrogen and progesterone. When the estrogen and
progesterone reach a low point, the hypothalamus begins to start
the next cycle, and menstruation begins.
A woman may
notice changes in her menstrual cycle several years before true
menopause. The ovary has a finite number of eggs, and these
begin to run out. The hypothalamus stimulates the pituitary to
make more FSH in an attempt to cause the remaining eggs to
mature. FSH and LH levels rise. Estrogen levels may vary. FSH
levels can help determine whether a woman is entering menopause.
During
perimenopause, ovulation occurs intermittently. If there is no
ovulation, the progesterone does not increase and the estrogen
production may continue. This may cause the uterus to build up a
thicker lining. The menstrual period may occur irregularly and
may be quite heavy. Other cycles may produce a light menstrual
period. As perimenopause moves into menopause, the ovaries
produce much less estrogen and progesterone and the menses
cease.
Symptoms of Perimenopause
During true
menopause, estrogen and progesterone levels are low and fairly
constant. However, during perimenopause, their levels may
fluctuate in an irregular pattern. Some perimenopausal women
have an exacerbation of their premenstrual symptoms.
Fortunately, when menopause occurs, the PMS symptoms cease.
Hot flashes
are experienced by up to two-thirds of perimenopausal women.
They usually occur one to five years before the end of
menstruation. These symptoms are more severe in women who have
had their ovaries surgically removed. It is thought that low
levels of estrogen cause the brain to release a surge of
Gonadotropin-releasing hormone. This may be the cause of the hot
flash. A woman suddenly feels hot and may perspire profusely.
She may then have a cold chill. They are more common at night
but can occur at any time of day. They last from a few seconds
up to an hour.
Changes in
menstrual cycles: Menses
may be heavier, or lighter. There may be increased or decreased
cramping. Eventually, menses lighten, become less frequent and
then stop.
Increased
PMS symptoms
Mood changes
and irritability: This
may be more common in women who have had difficulty with PMS.
There is some suggestion that estrogen levels influence the
production of serotonin.
Difficulty
with memory and attention span:
Some women report difficulty with concentrating or remembering
specific words. A woman with attention deficit disorder may
first come for treatment at this age because declining estrogen
level has exacerbated her ability to concentrate.
Insomnia
is a common complaint of women in perimenopause or menopause
itself. Night sweats may disrupt sleep. Irritability and
depression can impair sleep. Reduced sleep can lead to tiredness
and irritability during the day.
Vaginal
dryness: Before and after
menopause, lowered estrogen levels cause the lining of the
vagina to become drier and thinner. This may lead to painful
intercourse and decreased interest in sexual relations.
Urinary
leakage: Some urinary
symptoms may be related to pelvic floor changes that occurred
years ago during labor and delivery. As the estrogen level
drops, further changes can occur. Low estrogen levels may weaken
the urethral sphincter that helps hold in urine. If the woman
has gained weight, it may put more strain on the bladder.
Skin and
hair changes
There are many
choices in dealing with symptoms associated with approaching
menopause. These include healthy lifestyle changes, hormone
replacement therapy, other medications, social support and
therapy.
Healthy
Lifestyle Changes:
Regular exercise may decrease depression and irritability. Good
muscle tone can also improve energy level and decrease aches and
pains. Some forms of exercise may help decrease bone loss. Yoga
or Tai Chi decrease stress and may reverse the decreased
flexibility often associated with aging. Regular Tai Chi has
been shown to decrease the incidence of hip fractures in older
individuals. A diet high in complex carbohydrates, including
multiple small meals may reduce irritability and improve one’s
feeling of well-being.
Social
support: Many women
experience menopause as a time of increased freedom and new
possibilities. As their own children grow up, they may have more
time and flexibility. However, some women experience the empty
nest as the loss of their central role in life. Loss of a spouse
through death or divorce can increase isolation. The physical
changes associated with hormonal fluctuations can be confusing.
Menopause may cause some women to start to think about the
finite nature of life. Supportive friends and family can help a
woman understand and cope with life changes. Reading about
menopause or talking to one’s doctor can help make the changes
less mystifying. A return to spirituality can spur growth at
this phase of life.
Hormone
Replacement Therapy (HRT)
Taking estrogen and progesterone can
help some of the symptoms associated with approaching menopause.
The decision to take hormones is an individual one. A woman
considering HRT needs to consider the severity of her symptoms,
her health history and her family history. She may also have
personal preferences about taking medications. Estrogen is the
hormone that seems to relieve many of the symptoms of
approaching menopause. If a woman has already had her uterus
removed, she may take estrogen by itself. However, if a woman
with an intact uterus takes estrogen without progesterone, the
lining of the uterus may build up, and the woman may be at
increased risk of uterine cancer. Thus HRT often requires a
combination of estrogen and progesterone. The doses of estrogen
and progesterone used for HRT are generally lower than the doses
used for birth control pills. Often, women only need HRT for a
limited number of years after menopause. There can be benefits
and drawbacks to the use of HRT. Estrogen can relieve hot
flashes, vaginal dryness, urinary problems, and sometimes
insomnia. It can also promote a feeling of well-being. Some
women feel that it improves memory and concentration. HRT can
reduce the chance of osteoporosis. Estrogen may help prevent
heart disease, but recent data has suggested that this effect
may not be as dramatic as previously thought. For some women
there may be drawbacks to HRT. Some studies have suggested a
link between HRT and an increased incidence of breast cancer.
Estrogen may elevate blood sugar, cause headaches, weight gain,
or other side effects. The Women's Health Initiative (WHI)
a longitudinal study of women on hormone replacement therapy,
concluded that overall, the treatments did not provide
protection from cardiovascular problems or cognitive decline.
There were some differences between the estrogen-only and the
estrogen-progestin group. Women should discuss this with their
care provider. A good review of the WHI results can be found in
the November 2004 issue of Geriatrics.
Psychological support:
For some women, social support, healthy lifestyle changes and
hormone replacement therapy are not enough. The death of loss of
a spouse, heath changes and other stresses may cause stress.
Depression and mood swings are more common during peri-menopause
than after menopause is well established. However, a woman with
a history of anxiety or major depression may have a reoccurrence
during either of these periods. Counseling may help some women
deal with losses. Counseling may also help a woman review her
life and make decisions about new directions and interests. If a
woman has a persistent depression or experiences sleep, appetite
and energy changes, or has suicidal thoughts, she may want to
consider a psychiatric consultation and antidepressant
medication.
Passage through
this life transition may leave one with a larger view of the
rhythm and flow of life.
Revised 2004
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