Approaching Menopause


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Approaching Menopause
Glenn Brynes, M.D.
Carol Watkins, M.D.
Baltimore, Maryland


Hormone Changes During Perimenopause

Symptoms of Perimenopause

Dealing Actively With Your Midlife Changes 

  • Healthy Lifestyle Changes

  • Social Support

  • Hormone Replacement Therapy

  • Social Support

  • Psychological Support

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 

Dealing Actively With Your Midlife 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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Please use telephone for appointments or medical questions.

Carol Watkins, M.D.
Glenn Brynes, Ph.D., M.D.
Rita Preller, LCSW-C

Copyright © 2004  Northern County Psychiatric Associates
Last modified: February 07, 2005 bot="TimeStamp" endspan i-checksum="41417"