Chapter 9

Perimenopause and Menopause

As I said earlier, at some point your ovaries will run out of follicles to turn into eggs to be released. When that happens, your monthly cycles will cease, which is called menopause. The cessation of your monthly cycle will bring some changes, which I’ll get to in a bit. But before you reach menopause, your body will undergo other changes, and this period of your life is called perimenopause. The changes at the perimenopause state have less to do with the release of eggs, but rather with a decrease in the amount of hormones that your ovaries produce, specifically, estrogen, progesterone, and androgens. On average, this decrease in hormone production will start about four years before you reach menopause, but some women begin to sense these changes much earlier, in their late thirties, whereas other women don’t become aware of any changes until a few months before they actually reach menopause. By the way, you are said to have reached menopause twelve months after your last period, so the entire year after your periods have ceased is part of perimenopause.

Why does it take so long for a woman to undergo this process? The answer might be found in looking at women who undergo instant menopause. If a woman has medical problems that require a complete hysterectomy, and her ovaries are removed, too, then she will undergo what is called surgical menopause. Instead of there being a gradual decrease in hormones, she’ll go from having a full complement of hormones before surgery to almost none after surgery. It seems that these women suffer from all of the various symptoms of perimenopause (see the following section) but to a greater degree. So, the gradual hormonal decrease that takes place in perimenopause helps you adapt to the coming changes in your body and may also protect you from having worse symptoms.

Although symptoms such as hot flashes are generally considered to be a part of menopause, in actuality they begin during perimenopause, and for many women, many of these symptoms will actually end when they are fully menopausal (although that’s not true for all women). Once you start to detect some or all of these symptoms, you will know that you are in the perimenopausal state of your life.

The Top Ten Symptoms of Perimenopause

You should report any changes to your doctor because although you may assume that what’s happening to you is simply routine, it might not be. In addition, your doctor may be able to provide you with relief from some of these symptoms. Because the symptoms can begin years before you reach menopause and can continue afterward, it’s certainly a good idea to check with your doctor to see whether you can do anything to minimize or even eliminate any negative effects.

1. Irregular bleeding is the one symptom, out of all of them, that you should most definitely report to your doctor. Irregular bleeding can include many different variations, such as irregular periods, an increased or decreased flow during your period, and spotting at other times. All of these could be a result of your changing hormones, but they could also signify something else. Only your doctor will be able to tell, and that’s why you must report these symptoms to make sure that they are part of the normal changes that occur during this time and are not being caused by anything else. Just because you’re in perimenopause doesn’t mean that you can’t develop a uterine fibroid, for example, so don’t make the mistake of assuming that any changes in your menstrual habits are simply due to the aging process.

2. Hot flashes are the symptom that everybody connects to menopause. For some women, they can be very annoying, but for most women, hot flashes aren’t that bad. Some women never get them at all, while other women experience them for only a brief time. Getting rid of hot flashes used to be the main reason that women took hormone replacement therapy (HRT). But because of the risks, the routine use of HRT has stopped. Instead, doctors prescribe HRT only when women have severe symptoms and its benefits outweigh the risks (more on HRT in a bit).

3. Breast tenderness may be something that you remember from when you were first pregnant, and here you are, so many years later, and you find yourself facing the same issue. All of these conditions have to do with changes in your hormone levels. If you’re in perimenopause, you shouldn’t be surprised to find your body undergoing a change of some sort.

Breast tenderness during perimenopause and menopause is not one of the symptoms that gets very much attention, but one possible consequence is that this tenderness means your breasts are suddenly off limits to your sex partner. This can be very frustrating to the man, for whom touching his partner’s breasts was an important part of becoming aroused, especially if this restriction comes at a time when he himself is already having some difficulties in that department. There are also women who require breast stimulation to become aroused themselves. For them, the issue of breast tenderness can be very problematic. If both partners end up getting mad at each other for this change in their sexual habits, which is beyond their control, that could be the biggest problem of all.

Increased communication with your partner is the key to preventing any harm to your sex life caused by the issue of breast tenderness and most problems in the sexual arena. Talk about what these changes to your breasts are doing to your sex life. Make sure that your partner knows this isn’t something you thought up as an excuse not to have sex but is actually a common symptom of entering menopause. Just don’t have such a conversation in the bedroom, especially if you’re trying to have sex. In coming to a solution, ideally you might find other parts of your bodies that will have a similar erotic effect (and simply looking for them will perk up your sex life in the short run). If you can share in this experience and use it to bring yourselves closer, rather than let it become a wedge that drives you apart, you can definitely mitigate the effects these changes have on your sex life. Even if you don’t find the perfect solution, hopefully you will end up with a relationship that remains sexually fulfilling nevertheless.

4. Premenstrual syndrome (PMS) is a condition that affects some women more than others. Many women never experience any changes prior to the start of their menses, while others have symptoms that can be truly debilitating. The range of symptoms goes from the physical (such as backache, headache, and cramping) to the psychological (forgetfulness, irritability, and fatigue).

If you suspect that you have PMS, write down your symptoms as they occur. Keep a log for a period of several months so that you can describe to your doctor exactly what’s been happening to you. The more information your doctor has, the more likely he or she will be able to help you. This is also true if your symptoms suddenly worsen as you enter perimenopause.

5. The cause of increased fatigue can be physical or mental. If you’re feeling depressed, that will tend to drain you of much-needed energy. Believe it or not, one of the best things you can do to reduce these feelings is to exercise (assuming there is no underlying physical ailment that is making you feel tired). Exercise causes your body to release endorphins, which will elevate your mood and thus reduce fatigue. Several medications can also help with your PMS symptoms. Your doctor can help you find the best treatment for you.

6. Vaginal dryness can begin with a simple reduction of lubrication when you are sexually aroused and can progress to a point where your vagina becomes very dry and easily irritated, so that intercourse can go from being mildly uncomfortable to painful and can result in abrasion and bleeding. In addition to producing less lubrication after menopause, the tissues that make up your vagina get thinner and become less elastic (after all, your vagina no longer needs to stretch to allow a baby to get through). These changes can also make sex less comfortable and even painful.

Many young men complain that they ejaculate too quickly (what is called premature ejaculation). As a man ages, he’s likely to lose this problem and may well end up with the reverse condition, so that it takes an extralong period of intercourse for him to have an orgasm. If this change occurs at the same time that his partner is suffering from vaginal dryness, the added time taken for intercourse can make her vagina feel even sorer after intercourse.

The cure for vaginal dryness is using an artificial lubricant, but don’t assume that one application will do the trick. If you are very dry, and he is taking quite a long while, you’ll probably have to apply the lubricant one or two more times. Because your partner may be afraid that removing his penis from your vagina will cause him to lose concentration and maybe even lose his erection, this can become a cause of conflict. If you’re in that situation, don’t fight with him, but instead make sure that the lubricant is within easy reach and simply put some on your hand and apply it to his penis as it is sliding in and out of you. Not only will this save you from needless discomfort, but he may even find that the process adds to his excitement and decreases the time he needs to have an orgasm.

Although routine hormone replacement (HRT) for all women in menopause is not recommended anymore because of the potential health risks, HRT in a localized version is available and can relieve severe menopausal symptoms such as vaginal dryness, using a much lower dose of estrogen.

One reason to consider this treatment is that vaginal lubrication, in addition to facilitating sex, is also a sign of sexual arousal. Some women who stop lubricating become unsure of whether they are aroused, and the dryness also makes it more difficult for their partners to tell. If a dose of hormones applied to the vagina can solve this problem, you and your doctor might decide that it’s the right treatment for you.

7. Sleeping difficulties can sometimes stem from hot flashes that wake you up in the middle of the night and then don’t allow you to fall back to sleep, or else they can come from your having to get up several times to go to the toilet. Or maybe they simply cause havoc in your life with no rhyme or reason. It’s better to try nonmedical remedies first, such as exercise, staying away from caffeine, and not going to bed until you are just about ready to fall asleep, but if nothing works for you, ask your doctor to see what else might be available.

Whether you’re having problems sleeping because of menopause or because your partner is snoring away half of the night, if you have a spare bedroom (and many older couples whose children have left home do have an extra bedroom or two), use it. First, it will help you avoid unnecessary conflicts, because interfering with your partner’s sleep time when you could avoid doing so will not make you very popular. If you’re up because you can’t sleep but are just lying there in bed in order not to disturb your partner, that will make it even more difficult for you to go back to sleep. Maybe you need to turn on the light and read for twenty minutes or so or change the room temperature in some way. Whatever it is, if you have the luxury of added privacy in a separate room, staying up will be a little less stressful if you can do it on your own.

8. Frequent urination is another symptom caused by a diminishing of your hormones. One of estrogen’s many duties is to maintain your bladder and urethra in a healthy condition. When your levels of estrogen begin to drop in perimenopause and menopause, one result is a weakening in these parts of the body. As a result, you may find that you have to go to the toilet more often or that you leak urine at certain times, such as when you cough or sneeze.

The main thing that you can do for yourself is practice Kegel exercises. To perform these, you tighten and loosen your puboccygeus muscles. You say you don’t know which muscles those are? Of course, you do, you probably have just never heard the name. They’re the muscles you use when you stop your flow of urine. Once you’ve identified them, you’ll see that it’s easy to tighten them at other times. You can start these exercises by doing a few sets of three repetitions and build up to a point when you can do three sets of ten or more. As these muscles tighten, you’ll gain more control over your need to urinate.

By practicing Kegel exercises, you’ll also be able to tighten your vagina around your partner’s penis, which may cause sensations that he will enjoy. You can do Kegels everywhere, because no one can see what you’re doing. I sometimes suggest to women that they do them while they’re driving and have stopped at a red light.

9. Mood swings can also occur in this time of life. They might arise as a result of other symptoms; for example, if you’re extra tired because you’re not sleeping well, that will make you grouchy. Or else the mood swings may be caused entirely by the changes in your hormones. It’s important to try to judge what exactly is happening to you. If you feel sad because of an actual symptom, it may be easier to overcome that on your own than it is if you feel depressed because of a drop in hormone levels, which you can’t control.

10. Changes in your sex drive can also be a consequence of menopause. There are women who assume that when they enter menopause, their sex lives are over, and with such thinking, you can almost guarantee that it will come true. On the other hand, some women discover that without the risk of pregnancy and with no interruptions because of “that time of the month,” their sex lives blossom. It may also help if their children are gone, and the couple has added privacy.

There’s that phrase, “Use it or lose it,” and although it’s not always true, what is true is if you stop having sex at this time of your life, your sex life will come to an end. But if you do whatever is necessary to keep your sex life in good health, then there’s no reason for it to end. In other words, it’s up to you.

In my opinion, many of the women who give up on sex when they hit menopause do so because they never got sexual satisfaction before this stage in their lives. If they weren’t really enjoying good sex lives with their partners, then menopause became the excuse they were long hoping for. A woman who has had regular orgasms for her entire life, however, is not going to give up on sex without a fight. She’ll find a way to compensate for any difficulties thrown her way by menopause, such as vaginal dryness, and will continue to have sex and have orgasms for decades to come.

Is Hormone Replacement Therapy for You?

Why can’t the medical community decide whether hormone replacement therapy is good or bad? It’s true that there was a revolution in thinking on HRT by the medical community, but it didn’t arise out of bad faith. Patients were coming to their doctors with the list of complaints I’ve described previously, and doctors wanted to help alleviate these symptoms. HRT seemed to be able to do that, while at the same time diminishing the risks of developing breast cancer and heart disease. Or, at least, that’s the way it seemed, according to the studies available at the time. Yet then some long-term studies showed that HRT actually increased the risk of breast cancer and cardiovascular problems, so the medical community put the brakes on.

From Dr. Amos’s Office: Hormone Replacement Therapy

Hormone replacement therapy (HRT) consists of one or more of the following hormones: estrogens, progesterone, and sometimes testosterone. It can be given via tablets, patches, creams, vaginal rings, gels, or injection.

Today, HRT in menopausal women should mainly be given only for short-term relief (less than two years) from menopausal symptoms such as severe hot flashes or irregular bleeding. Patients need to make an informed choice and know about all of the benefits and the risks. Normal menopausal women with symptoms should take HRT treatment only at the lowest feasible therapeutic dose and for no longer than necessary. Other medications can be taken as an alternative to HRT; they include SSRIs (selective serotonin reuptake inhibitors) and neurontin.

Certain menopausal health problems, such as osteoporosis, can now be treated without HRT, and additional efforts may include exercise, diet improvements, and other lifestyle changes.

Younger women who have undergone surgical menopause or those with premature ovarian failure can safely use HRT for longer time periods.

Recent studies have shown that HRT taken soon after menopause may help protect against dementia, and HRT may actually prevent the development of heart disease and reduce the incidence of heart attacks in women between fifty and fifty-nine but not for older women. There is still an increased risk of breast cancer, although one recent study showed that the increased breast cancer risk applies only to women who take certain progesterone preparations but not to those taking progesterone itself.

Women who have taken HRT and then stopped want to know whether they’ve increased their risks forever or only for a short time. Regarding the increased risk of breast cancer, it seems that there is a two-year window after a woman stops taking HRT when an elevated risk remains, but then it disappears. For cardiovascular issues, as soon as a woman stops taking HRT, the risk fades away.

Aging Gracefully

In the early 1960s, hormone replacement therapy was touted as being a fountain of youth for menopausal women. Doctors prescribed it almost indiscriminately, and the high doses of estrogen did create an illusion of youth in older women. Their skin became moister, firmer, and plumper and problems with vaginal dryness lessened. Yet this came with a price, as was revealed by long-term medical studies that began to warn of the risks of HRT. Nowadays, even though modern women still have the normal amount of female vanity, most of them don’t want to take a chance on using HRT simply to look younger.

In any discussion of why a woman’s sex drive might diminish as she hits menopause, let’s not forget an important component: body image. We are all bombarded with images of young women on TV, in movies, and in magazines, and rarely do we see older women. For the most part, if you do see an older woman in the media, any signs of aging are airbrushed away. The truth, of course, is that as both men and women age, their bodies change. And when you’re ready for sex, that is, when you’re naked, those changes stand out even more.

The mistake that many women make is to go into hiding. Where they once proudly showed off their bodies to their partners, suddenly they’re always under some sort of wrap. The problem is that when a woman reaches an age where she doesn’t find her body as appealing when she looks in the mirror, her male partner is also changing. He now needs more stimulation to become aroused, rather than less, and remember, visual stimulation is very important to a man.

While there may be no ideal solution, the best is a compromise. If you feel that you want to cover up your body, and he prefers that you do not, make a point of covering up with something sexy, rather than with an old flannel nightgown. If there are parts of your body that you still like, show them off. And the parts you want to cover will look better under see-through lace than if you wear a ratty old T-shirt.

Why is it that so many older men run off with younger women? While this book is supposed to cover the knowledge base of a gynecologist, here I have to diverge a bit and go into the male realm, although I promise that this also has to do with you. A woman’s hot flashes are visible, so they’re a common-enough subject, but the early changes that a man goes through, before he may have any actual erectile difficulties, are invisible. Young men have what are called psychogenic erections, which means if they see or think about something that they feel is sexy, their penises will become erect. At a certain age—which, depending on the man, could begin in his forties, fifties, or sixties—a man loses the ability to have psychogenic erections. Instead, he requires physical stimulation to become erect. But if he doesn’t know this, and neither does his female partner, that can cause problems. As I’ve just discussed regarding body image, a woman who was used to seeing her husband’s penis pop up when she walked around naked will feel badly about herself when this stops happening. She’ll either blame herself or maybe jump to the conclusion that he’s having an affair, and as a consequence, she’ll withdraw from him sexually. He may also believe that because his wife doesn’t look the way she did when she was twenty, his penis no longer gets hard when he sees her naked. So, what’s his solution? To find a younger woman.

Once you know the cause of this, you can predict what will happen. True, if he’s in a new relationship with a younger woman, his penis will probably react in a positive manner. He will most likely find himself having those psychogenic erections once again. The question is, for how long? The underlying physical changes won’t have diminished, so there will soon come a day when this new love of his life will no longer be able to produce the same psychogenic erections that she once could. And he may well have thrown out a very good marriage, damaged his relationship with his children, and saddled himself with paying divorce lawyers and settlements, all in a cause that was ultimately hopeless. So, the more that older couples understand about what is happening to them, the better choices they will make.

Osteoporosis and How to Prevent It

Osteoporosis is a condition in which a person’s bones thin out and become less dense. Although it can and does happen to both sexes, women usually suffer from it earlier than men, and it is often triggered by menopause, so it is a disease that is more commonly associated with women. In fact, one out of five women older than age fifty has osteoporosis, which means at some point in their lives 50 percent of them will suffer from a bone fracture.

Your skeleton is obviously key to your well-being. A woman who has osteoporosis will experience added pain, most often lower back pain, due to spinal discs that break or fracture and lead to eventual deformities, such as curvature of the spine, which could be moderate to quite severe. Osteoporosis also increases the risk of having other bones break, such as the hip bone, either as a result of a fall or simply on their own. If a woman with osteoporosis does fall, she is much more likely to break a bone. Osteoporosis is one of the leading causes of people being admitted to nursing homes.

Your bones are made from calcium and phosphate, and if you haven’t been getting enough of these essential building ingredients, then over time your bones will suffer. That is why it is so important that younger women make sure they get enough calcium in their diets. The recommended amount of calcium is 1,200 milligrams a day and another 800 to 1,000 international units of vitamin D3. You can get this dosage from eating the right foods, which includes drinking low-fat milk and eating other dairy products, such as cheese and yogurt; eating green leafy vegetables, such as spinach and kale; and eating fish, such as salmon and sardines (with the bones).

Most women who are diagnosed with osteoporosis don’t know it until they end up breaking a bone. It is therefore vital that you see your doctor so that you can be tested for osteoporosis before you suffer any damage. A bone-density test is an important tool in diagnosing osteoporosis and protecting women from its effects.

If you already have osteoporosis, you must take extra precautions against sustaining a fall. Make sure that the place where you live isn’t cluttered with objects that you could trip over. Remember that bathrooms can be dangerous, so have safety bars installed in your tub or shower. Don’t be too proud to use a cane when walking outside on streets that could have a lot of cracks. Always wear comfortable shoes that promote good balance, as opposed to high heels. And if the weather conditions are such that the risks of falling are high, either stay indoors or if you must go out, do so only when accompanied by someone else.

One of the reasons given for taking HRT was as a supposed protection against osteoporosis. Yet it seems that this protection lasted for only about six or seven years. On the other hand, many women who took HRT for hot flashes and other symptoms found that once they stopped taking HRT, those symptoms didn’t return (although they might have disappeared in any case). Today, possible HRT risks outweigh the potential osteoporosis risk, and HRT should not be given to prevent osteoporosis.

Whether the risks posed by HRT outweigh the benefits is something that you will have to discuss with your doctor.

The question of HRT is a very complicated one, and many factors must be considered. For women with a family history of osteoporosis, the risks posed by HRT must be weighed seriously against the protection that it offers.

From Dr. Amos’s Office: Osteoporosis

You’ve undoubtedly seen the many commercials for various drugs to combat osteoporosis. Although these drugs offer some protection, the FDA has told drug manufacturers that they are exaggerating the benefits of their products. That’s not to say that you shouldn’t take any of these drugs, but because there are also possible side effects, you should first discuss this with your doctor.

On the other hand, certain forms of exercise, such as weight lifting, stair climbing, and running, do work, and they have only positive side effects. These activities are proven bone builders, plus they protect you against other diseases. They also make you feel better about yourself, because they improve your appearance and help you maintain your weight. By the way, for women younger than seventy-five, osteoporosis is a bigger problem than for men, but by age seventy-five it becomes equally problematic for both sexes, so you should encourage any older men you know who are leading sedentary lifestyles to join you in your exercise program.

One possible alternative to HRT is to take low-dosage birth control pills. They seem capable of alleviating some of the most uncomfortable symptoms, such as hot flashes, without posing the same risks as HRT, unless you are a smoker. Then there are the supposedly natural products made from soy or other ingredients that have been touted by an assortment of celebrities. The problem with these is that they really are untested. Because they’re not drugs, the FDA doesn’t get involved, so nobody really knows what the long-term side effects might be. Women have been going through menopause since time immemorial (at least, those who survived long enough to reach that stage of life), and they have done so without any drugs, so certainly one option is simply to try to cope the best you can so that you’re not taking any unnecessary risks. Many women report that by increasing the amount of exercise they do and by losing weight, they’ve been able to reduce their menopausal symptoms. Whether or not this will help you in terms of alleviating your symptoms, it certainly is a positive lifestyle change worth trying.

If you’re a twin, a study discovered that your odds of having a premature menopause, as early as forty years of age, are significantly greater. Oddly, only one of the two in a set of twins will experience premature menopause, while the other will have menopause at a more normal age. Scientists don’t know for sure why this is, but perhaps as they work at discovering the cause, they’ll also make a breakthrough in the treatment for menopause.

Are those of you who haven’t gone through menopause still dreading it? I hope not, because as I’ve tried to show here, a lot of good comes with this new chapter in your life.