What is menopause?

A persistent decline in ovarian (hormone making organ in your body) function that causes a decrease in the level of the hormone estrogen. The diagnosis is clinically made after 12 consecutive months with no menstrual cycle. Menopause most often occurs between 45-55 years of age and marks the end of the reproductive years.

What is perimenopause?

The time between regular menses and menopause. It often starts in the 30’s and 40’s and is classified by fluctuations in the ovarian production of estrogen. Clinically, it can cause cycles to become shorter or longer, you may experience changes in your flow (more or less) and you may start to skip periods.

What are symptoms of menopause and perimenopause?

Hot flashes (Vasomotor)
Night sweats (Vasomotor)
Vaginal irritation (Genitourinary)
Vaginal dryness (Genitourinary)
Pain with intercourse (Genitourinary)
Urinary issues (Genitourinary)
Changes in sexual function (Genitourinary)
Depression (Mood)
Anxiety (Mood)
Rage & anger (Mood)
Fatigue, but inability to sleep (hormonal)
Brain fog (hormonal)
Hair thinning, dry skin, nail changes (hormonal)
Sleep disturbance (Mood, Vasomotor)
Changes in weight distribution (Metabolic)
Joint pain (hormonal)
Itching (hormonal)

How long will perimenopause last?

It can last anywhere from 4-8 years, but this is highly variable from person to person (some report it can last up to 14 years), and not everyone will feel all the symptoms listed above.

How long do menopausal symptoms last?

4-5 years, though again, this is a highly variable experience, and I’ve had some patients report 5-10 years of symptoms.

What are other health consequences of menopause?

The drop in estrogen has both physical symptoms (like the ones listed above) as well as implications for other aspects of your health.

Bone loss (if it is severe enough, it can cause Osteoporosis)
*Increased risk for stroke
*Increased risk for heart attack

*The increased risk of heart attack and stroke is secondary to the loss of the protective effect of estrogen, coupled with the age-related risk factors of high blood pressure, high cholesterol and physical inactivity that are also seen around the time of menopausal transition.

What can I do about my symptoms?

When it comes to managing menopausal symptoms, there are plenty of options. It is best to talk to your doctor to come up with the best plan, based on your personal medical history, your goals for treatment and a thorough understanding of the risks and benefits of each option.

I’ve summarized a few treatment options that you can discuss with your doctor. For simplicities sake, I have grouped the symptoms into 4 major categories including vasomotor, genitourinary, mood and metabolic- the last category may not cause symptoms, but it is important to discuss none the less.

What medications can help with my vasomotor (hot flashes and night sweats) symptoms?

Symptom	Treatment option	Benefits	Risks
Vasomotor symptoms (hot flashes) Non-hormonal	Antidepressants (SSRI and SNRI)	Can also help with concomitant mood issues Cost effective	Side effects of nausea, dizziness, dry mouth
	Veozah	Effectively reduces hot flashes	Monthly prescription is over $500 without insurance coverage
	Gabapentin (anticonvulsant)	Cost effective, can help with insomnia	Dizziness, fatigue, weight gain
	Clonidine (centrally acting medication)	Cost effective	Low blood pressure, nausea, fatigue, headache
	Lyrica (anticonvulsant)	May help with insomnia or concomitant nerve pain	Dizziness, dry mouth weight gain
	Oxybutynin (antispasmodic)	Can help with concomitant urinary issues	Dry mouth, dizziness, blurred vision

Vasomotor symptom treatment with hormone replacement therapy:

Hormone therapy with estrogen is an effective strategy for the management of moderate to severe hot flashes in patients who are younger than 60 years, do not have any medical contraindications to treatment, desire hormone replacement, and are within 10 years of symptom onset.

The use of estrogen alone in patients with a uterus, increases the risk of endometrial cell proliferation (which can lead to endometrial cancer), and as such a combination of estrogen and progesterone should be given. However, the use of combined estrogen and progesterone may increase the risk of breast cancer, though not of breast cancer mortality. Interestingly, estrogen alone does not increase the risk of breast cancer, and may, in fact, decrease it.

Both pills and patch formulations are approved for the treatment of vasomotor symptoms.

If you are concerned about changes in libido, it is best to stick to a patch formulation, this will avoid an increase in sex hormone binding globulin (SHBG) which can bind testosterone and decrease level of effective circulating hormone in your blood.

Symptom	Treatment option	Benefits	Risks
Genitourinary	Vaginal lubes (prior to intercourse)	Hormone free, relatively cost efficient, effective	May not be as effective as hormone replacement
	Vaginal moisturizers (every 2-3 days)	Hormone free, relatively cost efficient, effective	May not be as effective as hormone replacement
	Osphena (selective estrogen receptor modulator)	Reduces vaginal dryness and improves symptoms of pain with intercourse	May be expensive
	Intrarosa  (DHEA)	Reduces vaginal dryness and improves symptoms of pain with intercourse	May be expensive

Genitourinary symptom treatment with hormone replacement therapy:

The treatment options for the genitourinary symptoms of menopause (vaginal dryness, vaginal irritation/itching, urinary burning, urinary frequency, urgency and recurrent UTI) include creams, tablets and ring inserts.  Vaginal lubes and moisturizers are excellent first choice options. However, for those that do not respond, topical vaginal estrogen preparations are a reasonable next step. The use of vaginal estrogen may also improve symptoms of urinary urge/incontinence as well as prevent recurrent UTI.

Typically, progesterone is not needed for uterine protection when using low-dose vaginal estrogen.

Estrogen therapy alone does not improve sexual interest or arousal related to menopause.

Who should NOT be on hormone replacement therapy?

• Patients with unexplained vaginal bleeding
• History of a stroke
• Active estrogen sensitive cancer- breast or endometrial
• History of estrogen sensitive cancer- breast or endometrial
• History of blood clot
• Personal or family history of blood clotting disorders
• History of coronary artery disease
• Active liver disease

Hypoactive sexual desire:

Hormone replacement therapy with estrogen alone has not proven to be an effective treatment for decreased sexual interest/ arousal related to menopause. Androgen therapy including topical testosterone (patch), and vaginally administered DHEA are both options for menopause associated libido changes.

Androgen therapy should not be used in patients with heart disease, liver disease, endometrial disease/cancer, breast cancer and patients with risk factors for these conditions. Side effects of androgen therapy include excess hair growth (facial), acne, and with excessive dosing, voice changes.

It is important to note that testosterone is converted to estrogen- therefore use of androgens also pose the same risks as estrogen therapy.

Flibanserin, marketed as Addyi is generally reserved for low libido in premenopausal females, but is used off label in postmenopausal females for the same indication. It does have significant drug interactions and side effects are exacerbated when used in combination with alcohol.

Bupropion may be an effective treatment for hypoactive sexual desire disorder (HSDD), with a similar mechanism of action to Addyi, and a better side effect profile. Research on its role in the treatment of HSDD is ongoing.

Mood changes:

There are several theories behind why women experience mood fluctuations in menopause, the most widely accepted reason is the decrease in estrogen. However, the timing of perimenopause or menopause may also be a contributing factor. Earlier we mentioned that women tend to go through this change in their 40’s and 50’s. This is typically a time when they are at the peak of their careers, managing households, caring for young children, or watching older children go off to high school and college. These major life events coupled with fluctuating hormones and the end of the fertile period of one’s life can all add up to significant emotional turmoil.

Many of the treatments for vasomotor symptoms also treat symptoms of anxiety, depression, brain fog and agitation. These are the same medications that are used to treat PMDD (premenstrual dysphoric disorder) and the fluctuation in hormones seen in perimenopause and menopause often cause women to experience PMDD type symptoms. Both SSRI’s (selective serotonin reuptake inhibitors) and SNRI’s (serotonin norepinephrine reuptake inhibitor) are indicated for the treatment of hot flashes and anxiety.

Metabolic changes:

One of the most common and earliest signs of hormonal fluctuation that women tend to notice is a change in body composition, specifically they notice that their clothes may be tighter around their midsection, plus or minus a change in the scale.

They have not made any significant changes in their diet, and yet, they are gaining weight or their pants fit tighter. This change, like many other menopause related symptoms, is also due to a drop in estrogen. Women tend to start losing muscle mass in their mid to late 30’s, this process is accelerated by a drop in estrogen. This is significant for 2 reasons:

1. Our muscle mass is what determines the amount of food we need to eat daily to survive and carry out basic bodily functions (aka our Basal Metabolic Rate)- so less muscle mass means we need less food.
2. As our muscle mass decreases, we also experience a change in body composition- if you are not actively gaining muscle mass (or working to maintain it), you will inevitably start to lose it. As muscle is lost, if dietary changes are not made, fat mass is gained- and we all know that a pound of muscle on the body does not look the same as a pound of fat.

This is another reason that “weight” and “BMI” are not great indicators of health, this is especially true for postmenopausal females who experience changes in their body composition. The bright side- the accelerated muscle loss from dipping estrogen does taper off around 2 years after menopause has set in.  That being said- building muscle is still imperative to maintaining a healthy basal metabolic rate and it does wonders for bone health, which brings me to my next point- osteoporosis.

Osteoporosis, or severe bone loss, is another sequela of dipping estrogen levels. Not all women will have it, but the risk does go up- I will discuss this further in another post- but for now, the best thing you can do to support bone health is engage in weight bearing exercise and take your calcium and vitamin D supplements.

The last set of metabolic changes you may notice in menopause- the increased risk for stroke and heart attack. Estrogen is cardioprotective, meaning it helps to keep our cholesterol, blood sugar and blood pressure in check (at least to some extent). We lose this protective effect once menopause sets in. Additionally, the timing of menopause is also when many women are the most stressed in their lives (see the mood section above for more details) leaving very little time for exercise. The lack of exercise, drop in estrogen and change in body composition all increase your risk of high blood pressure, high cholesterol, diabetes, stroke and heart disease.

At this point, you may be wondering- why don’t we just take estrogen and avoid all of this?! Well, for one, we already discussed the contraindications to estrogen use above, additionally, while the findings of the WHI study were clarified with the KEEPS and ELITE trials; estrogen is still not a universal recommendation and the decision to take estrogen should be individualized with an appropriate discussion of risks and benefits.

For those of you interested in lifestyle changes you can make to help combat changes in body composition and how to optimize bone health, stay tuned for follow up articles on those specific topics. For now, lift heavy things, move as much as possible, focus on protein & fiber rich meals and be sure to get your recommended daily intake of calcium and vitamin D.

Going the natural route:

We can’t have a conversation about managing the symptoms of menopause without addressing all the natural options on the market. I know I say this often- but it’s important, and I can’t stress it enough- the supplement market is largely unregulated, and anyone can make unsubstantiated claims of benefit, not to mention you could be getting a contaminated product. Finally, natural does not always equal safe. Natural products/ supplements can cause harm, and usage should be discussed with your physician so they can help to monitor for potential side effects.   

Data is conflicting about the efficacy of many all natural and herbal treatments; however, these are certainly options that can be discussed and may be beneficial in the right patient.  Especially when hormonal replacement therapy and pharmaceuticals are not acceptable options, or you simply prefer to avoid them.

Symptom	Treatment	Benefit	Risk
Vasomotor symptoms (hot flashes) and genitourinary symptoms	Black Cohosh (herbal supplement) 40 to 120mg daily	All-natural supplement, may help multiple different aspects of menopause	Production is unregulated, GI upset, rash, hepatitis (liver inflammation)
Mood	Wild Yam 12mg daily	May help with mood changes of menopause	Production unregulated
Mood, vasomotor (only in combination with others, unclear benefit alone)	Dong Quai	May work for vasomotor symptoms, however it is unclear if this benefit is only seen with a combination of herbs	Causes photosensitization, blood thinning, potential carcinogen (needs more research)
Female hormone balance	Maca	Claims to relieve multiple symptoms of menopause	Need more safety data, limited research
Mood and vasomotor	Pollen Extract	Claims to help with mood and vasomotor symptoms	Unclear benefits, need more safety data
Bone and vasomotor	Evening Primrose oil	Omega-6, may help with hot flashes and bone health when used in combination with calcium- no real data	Unclear benefit, need more safety data
Vasomotor	Vitamin E	May reduce frequency/ severity of hot flashes	Unclear benefit, fat soluble vitamin, intake should be regulated
Vasomotor symptoms	Phytoestrogens (Plant based chemical that acts on an estrogen pathway)	claims to relieve hot flashes, no real evidence	Need more safety data, inconclusive studies

Honestly, not much data to support the efficacy of natural supplementation for menopausal symptoms, but this chart gives you a clear picture of which options may be beneficial and which ones you should steer clear of based on your personal medical history.

I hope this post provided some guidance and clarification around what’s going on in your body during perimenopause and menopause- understanding the “why” is half the battle.

Now take a moment to embrace this time in your life, wear the white pants with reckless abandon and celebrate knowing that with a little bit of effort, and the right support system, these will be your best years yet!

Sincerely,
Corsano MD- Your friendly neighborhood PCP

References:
Menopause | ACOG
Managing Menopausal Symptoms: Common Questions and Answers | AAFP
Complementary and Alternative Medicine for Menopause – PMC (nih.gov)
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