Chapter 4
Getting In Sync with the Symptoms
In This Chapter
Getting in touch with the changes before the change
Discovering the physical and emotional effects of menopause
Talking to your doctor
You’re irritable for no reason, you have trouble sleeping, you experience heart palpitations, and you’re sure somebody keeps sneaking the thermostat up when you’re not looking. Sound familiar? If so, you’re almost certainly starting down the road to menopause.
Every human body is unique — that’s no surprise. But the path to menopause reveals just how different we really are. Some women breeze through the change, experiencing very few physical discomforts or emotional upsets. Other women experience a whole menu of disturbing symptoms for a number of years. Fortunately, for most women the symptoms often pass as you move into menopause and beyond.
In this chapter, we provide an introduction to the perimenopausal and menopausal symptoms you may experience. We go into much greater detail concerning the biology of menopause and how to alleviate these symptoms in other chapters of this book (especially in Chapters 5 through 10).
The symptoms we discuss in this chapter are all symptoms of perimenopause or menopause, but they’re not unique to just perimenopause or menopause. Other medical conditions — or even normal variations — cause these symptoms as well. If you experience any symptoms that worry you, though, don’t just assume that they’re a result of perimenopause or menopause. Your doctor will help you rule out any more serious causes.
Kicking Things Off with Perimenopausal Symptoms
In this section we give you the laundry list of symptoms that have been attributed to the sudden drops of estrogen during perimenopause. Individual women experience none, a few, or quite a few of these symptoms. If you think we sound a little vague about what perimenopausal symptoms are like, we’re guilty as charged, but we have to hedge our bets because everyone’s experience with menopause is unique.
In fact, many women in the United States report experiencing no perimenopausal symptoms at all. For women who do experience symptoms, the symptoms can range in severity from being somewhat annoying to interfering with their ability to enjoy life.
Getting physical
If you do have physical symptoms as you enter and go through perimenopause and menopause, though, you may find them hard to ignore. They’re just, well, different. People often compare reaching menopause with hitting puberty, but approaching adolescence didn’t bring on hot flashes, hair loss, insomnia, or heart palpitations.
Many of the physical symptoms are the result of a string of events that are set in motion when estradiol (the active form of estrogen — the “good” stuff) levels suddenly drop — a typical occurrence during perimenopause. The drop causes a chain reaction within your body, which we describe in the “Revealing the biology behind the symptoms” sidebar later in this chapter.
The relationship between estrogen and serotonin plays a role in many of the mental symptoms, but it also has a hand in some of the physical symptoms — such as interrupted sleep. Serotonin is a compound that helps the body regulate sleep and moods. Though all the details aren’t in, estrogen plays some kind of role in the production and maintenance of serotonin. It’s amazing how all this stuff gets connected, huh?
Turning up the heat
Hot flashes (also called hot flushes) are the traditional, highly recognized symptom of menopause — 85 percent of women have them at least a time or two as they enter perimenopause, and 10 to 15 percent of women report having them often enough or severely enough to seek medical treatment. When you have a hot flash, you suddenly feel intensely warm and very flushed — especially in your face and upper body. Increased perspiration — anything from a moist upper lip to enough sweat to leave your clothes or bedsheets uncomfortably wet — usually accompanies this feeling of warmth. And sometimes, dizziness, heart palpitations, and a suffocating feeling can precede or accompany hot flashes. As many comediennes have said, it feels as though your inner child is playing with matches.
A sudden drop in estrogen levels triggers a hot flash. This drop in estrogen sends a message to your brain that something is terribly wrong, so your brain sends out a power burst of adrenaline (norepinephrine). Norepinephrine is the hormone that triggers the fight-or-flight response in humans, so your body moves into ready mode, which gets your blood pressure up and your heart pounding and also causes the blood vessels in your head, neck, and chest to dilate. All this commotion brings on that sweltering feeling.
Until 1970, doctors didn’t acknowledge hot flashes as a real physical phenomenon; they attributed the sensation to a woman’s imagination or to a psychological problem. In fact, though, the effect of hot flashes is real and measurable — ask anyone who’s ever slept next to a woman when her internal thermostat goes haywire. The temperature of your skin may go up as much as six degrees, as if you had a fever. The symptom is only temporary, though, typically lasting no more than 10 minutes or so. Hot flashes aren’t dangerous, but the first time or two that you have one, it can be mighty scary unless you’ve been warned to expect them.
Sweating your lack of sleep
Night sweats are essentially hot flashes that occur at night. The same estrogen drop that triggers hot flashes during the day triggers night sweats.
Losing your snoozing time
With all the weird symptoms going on during the day, getting a good night’s sleep so you can wake up feeling rested doesn’t seem like a lot to ask for, but lack of sleep during this period can be a real problem. Hot flashes in the middle of the night often result in interrupted sleep. You wake up, often perspiring (and sometimes cursing), with damp bedsheets and skin that may end up being itchy as you cool off and all that sweat dries, and have a hard time going back to sleep. If your sleep is often interrupted this way, you can build up quite a sleep deficit, which in turn leads to irritability, anxiety, and mood swings.
A rapid drop in estrogen also affects your serotonin levels. Serotonin helps regulate mood and sleep patterns. (Drugs such as Prozac and Zoloft work on the principle that serotonin regulation is key to relieving mood swings, irritability, and so on.) Estrogen makes serotonin more available by prolonging its action. When estrogen drops, it affects your serotonin levels, which contributes to interrupted sleep.
Getting to the heart of the palpitation issue
Butterflies in your stomach often accompany rapid heartbeats, or palpitations. The sudden drops in estrogen that are so common during perimenopause cause reactions all over your body (see the “Revealing the biology behind the symptoms” sidebar later in this chapter), including heart flutters. The drop in estrogen causes your body’s natural painkillers and mood regulators (endorphins ) to drop. Your body interprets this state of affairs as trouble, so a command is issued to send out a burst of adrenaline (norepinephrine, the fight-or-flight hormone). Your body is responding as though you had just encountered a big grizzly bear. The only trouble is you don’t see the grizzly bear, and you’re left wondering why your body suddenly decided to get ready to flee from it just when you sat down to a nice candle-lit dinner.
Expecting menstrual irregularities
The approach to menopause can be blamed for a number of menstrual changes. But remember that you can’t blame all irregularities on perimenopause. Consult your healthcare provider about the following irregularities and all other symptoms before simply writing them off to perimenopause:
Irregular periods are quite common in perimenopausal women because fluctuating hormone levels can interrupt the ovulation cycle. Some months you ovulate; some months you don’t. If you don’t ovulate, you don’t produce enough progesterone to have a period, so the lining of your uterus builds up.
Heavy bleeding during perimenopause is usually caused by an “eggless” cycle. You make estrogen during the first part of your cycle, but for some reason (often unknown), you just don’t ovulate. Therefore, you don’t produce progesterone, and you develop an unusually thick uterine lining, which you shed during your period. This process translates into abnormally heavy bleeding.
Bad timing has probably struck every woman at one point or another. We just don’t want you to think that perimenopause is going to make dealing with your periods easier. As long as you still have periods, they’re liable to show up at inconvenient times (which can help make getting rid of them not sound like a bad thing at all).
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Revealing the biology behind the symptoms
As you may have suspected, the symptoms of menopause are all tied to plunging hormone levels. You may feel these symptoms more frequently during perimenopause than menopause itself because your hormone levels fluctuate more during perimenopause. Sometimes they rise to fairly normal levels, and then they come crashing down. The fluctuation is the trigger for a lot of the symptoms. In menopause, hormone levels are consistently lower than they are during your reproductive years, so they don’t pop up and drop down so frequently, though symptoms can still occur.
Here’s a step-by-step guide of what happens to your body when your estradiol (the active form of estrogen) levels drop:
1. Your ovaries produce lower levels of estradiol, which causes a drop in the amount of estradiol reaching the brain.
2. Less estradiol in the brain causes a decrease in your endorphin levels. Endorphins are your body’s natural painkillers and mood regulators. (If you’re a runner, you’re probably familiar with the effects of endorphins — they cause the “runner’s high.”)
3. Lower levels of endorphins in your brain cause it to think that something is terribly wrong, so it sends out a burst of adrenaline, namely norepinephrine (the hormone that triggers the fight-or-flight response).
4. The burst of norepinephrine causes your body to kick into ready-for-anything mode by increasing your heart rate (which causes those palpitations and flutters), raising your blood pressure, and dilating your blood vessels. Dilating blood vessels cause the hot flashes and sweating. If you’re asleep, you may wake up suddenly. You may also experience diarrhea or get a feeling of anxiety and butterflies in your stomach.
Handling the headaches
For women who experience migraine headaches immediately before or during the first few days of their periods, we have some bad news — you may have more headaches during perimenopause. Headaches during the first few days of your period mean that you’re sensitive to low estrogen levels, which are typical at that time. When estrogen levels drop quickly, which happens during perimenopause, the drop may trigger another one of those headaches. Just as your estrogen level has become unpredictable, so might your headaches. Just as you’re congratulating yourself for being headache-free in June, July might bring on a doozy.
Facing the fibroid factoids
Fibroids are simply balls of uterine muscle tissue. Nearly one-third of women have fibroids by the time they’re 50. Fibroids tend to get bigger as you approach menopause, but they usually don’t continue to grow in size after menopause.
You really don’t need to do anything about fibroids unless they cause symptoms such as pain, pressure, or increased bleeding. As with other symptoms, talk with your doctor if you’re having any problems you feel may be related to fibroids.
Playing head games
The mental/emotional symptoms associated with perimenopause can be very frustrating given that many women don’t associate their recent irritability or depression with perimenopause.
The symptoms we list generally pass when your hormones settle into their new, lower levels after menopause. However, these symptoms severely inconvenience or otherwise bother many women during perimenopause. If this description mirrors your situation, there’s no need to sit there suffering in silence.
Be sure to inform your medical professional about these mental and emotional symptoms. They may be more closely related to hormonal imbalances than to psychological issues. But, either way, your healthcare professional can ensure that you get the proper treatment to alleviate your symptoms. (For more detailed information on the mental and emotional issues associated with perimenopause, check out Chapter 10.)
Sitting on the mood swings
Mood swings are common among perimenopausal women. But remember that mood swings are also common before your period (part of premenstrual syndrome) and after pregnancy. Although medical researchers don’t know all the details, low levels of estrogen are associated with lower levels of serotonin, which can lead to mood swings, in addition to irritability, anxiety, pain sensitivity, and insomnia.
Worrying about anxiety
Anxiety is another common symptom perimenopausal women face. As with mood swings, anxiety seems to be tied to low levels of estrogen. The lower levels of endorphins and serotonin associated with low estrogen levels may trigger anxiety. Another theory is that low levels of estrogen, serotonin, and endorphins leave you more vulnerable to the emotional stressors in your world. According to this theory, lower estrogen, serotonin, and endorphin levels don’t trigger anxiety; they simply limit your ability to deal successfully with stressful situations.
Touching on irritability
The same hormonal shifts that cause mood swings and anxiety (see the previous “Sitting on the mood swings” and “Worrying about anxiety” sections) cause irritability. As with these other symptoms, marked irritability is a temporary condition that seems to blow over after you’re officially menopausal (if you can put up with yourself for that long).
Recalling memory malfunctions
Memory problems during perimenopause sneak up on you. You forget your friend’s name one day; you leave your keys somewhere in the grocery store another day. Pretty soon you start remembering how many times you couldn’t remember something. We’re not talking about dementia or Alzheimer’s disease here; we’re talking about forgetfulness and a lack of focus. This category covers relatively minor memory glitches: You forget where you’re going with a thought in mid-sentence, or you get to the store and forget what you need to buy. Thank goodness for sticky notes and grocery lists.
Estrogen seems to facilitate communication among neurons (nerve cells) in the brain. Much of memory is a matter of the brain sending information from one memory storage center to another. Because estrogen helps maintain connections and grow new ones, shifting estrogen levels can stymie communication between memory storage areas. Memory problems seem to be a short- term issue; some women seem to lose the memory lapses after menopause.
Indications from later stages of the Women’s Health Initiative seem to be that for women 65 and older only, hormone therapy is associated with an increase in the risk for dementia and overall cognitive functioning. Because this is the opposite of what researchers in this large, 15-year study predicted they’d find, follow-up studies of the relationship between hormone therapy and a decline in cognitive functioning are continuing. There’s no official word yet on the effects of hormone therapy in younger women on dementia, cognitive functioning, or memory.
Even though the Women’s Health Initiative Study reported a statistically significant increase in the risk of dementia among women between 65 and 79 who were using either combination (estrogen plus progestin) hormone therapy, the overall risk of Alzheimer’s in the United States is still extremely low.
Thinking through a haze
Fuzzy thinking is common when you’re deprived of sleep or your hormones are in flux. When we say fuzzy thinking, we mean the feeling that you’re just not with it today — as though you’re walking through a fog or you just can’t concentrate on what you’re doing. Fuzzy thinking can be the result of interrupted sleep (which is extremely common during perimenopause).
Fluctuating hormone levels also cause fuzzy thinking (as you may have experienced during pregnancy or at certain points in your menstrual cycle). Fuzzy thinking is a temporary thing. It generally clears up when your hormones settle down and your sleep patterns chill out during menopause. Experiencing little brain farts now and then doesn’t mean that you’re on the slippery slope to premature senility — this will pass.
Visiting the Menopausal Symptoms
All the symptoms we describe as perimenopausal have long been attributed to menopause. But after you’re menopausal (without a menstrual period for a year), things begin to settle down a bit. Hot flashes subside and your moods stabilize. Your body and psyche seem to get used to some aspects of lower estrogen production. A small percentage of women may continue to experience menopausal symptoms for years after their periods end.
The symptoms experienced after menopause may even be a bit more uncomfortable physically. If this describes you, don’t just suffer — work with your physician to help you find a hormonal or non-hormonal treatment to keep you comfortable.
Long periods of low levels of estrogen encourage conditions such as osteoporosis, cardiovascular disease, heart attack, stroke, colon cancer, and other diseases discussed in Chapters 5 and 6 of this book.
To avoid wordiness, we use the term menopause in this chapter (and most others) to refer to the time period that incorporates both menopause and postmenopause.
Figuring out the physical facts
After you officially reach menopause (after 12 full months without a menstrual period), you produce lower levels of estrogen without the sudden spikes and drops typical of perimenopause. Your hormones calm down — way down. As time goes by, these long periods of low estrogen levels result in some physical changes.
In this section, we discuss what these conditions feel like. We go into greater detail about the biology behind these conditions and how to alleviate the symptoms in other chapters of this book. (Chapter 7 deals with vaginal and urinary issues; Chapter 8 covers your skin and hair during menopause.)
Some of the symptoms are the result of lower levels of estrogen, pure and simple. We call these primary symptoms. Some of these primary symptoms can actually cause further unpleasantness, which we call secondary symptoms.
Looking first at the primary symptoms
The primary symptoms include
Vaginal dryness: The medical establishment refers to this condition as vaginal atrophy. Because estrogen keeps vaginal tissues moisturized and pliant, continuous periods of low estrogen can result in the drying out and shrinking of vaginal tissue. Between 20 and 45 percent of women in the United States experience vaginal dryness. They often notice it when intercourse becomes painful due to a lack of lubrication.
Vulvar discomfort: Itching, burning, and dryness of the vulva isn’t uncommon among menopausal women. But remember that many conditions and diseases that affect the vulva have nothing to do with estrogen, so have your doctor check out any vulvar changes.
Urinary incontinence: This condition is much more prevalent in women during perimenopause and menopause than it is during their earlier reproductive years. The tissues of your urinary tract become drier and thinner, and the muscles lose their tone as estrogen levels diminish. You know you’re experiencing urinary incontinence if you have a hard time holding it when you laugh, exercise, or sneeze. Your urinary tract, especially your urethra, depends on estrogen to maintain its form and muscle tone. The urethra has a hard time sealing off the flow of urine after years of diminished estrogen levels.
Urinary frequency: Similar to incontinence, urinary frequency results from sustained, low levels of estrogen that define menopause. Urinary frequency simply means that you have to urinate frequently. You may leave the bathroom and quickly feel as though you have to go again. This condition can be very frustrating during the day — and even more frustrating at night. Urinary frequency can also cause interrupted sleep, which understandably, turns into irritability.
Headaches: Women who experience their first migraine during perimenopause often find that the migraines go away after menopause.
Skin changes: Lower estrogen levels cause your skin to lose firmness and elasticity. Estrogen doesn’t literally prevent sagging or wrinkles. But estrogen does keep your skin supple and help your skin retain fluid, so it remains “filled out” rather than becoming loose and droopy.
Hair changes: Your hair becomes thinner and more brittle with menopause, though some women report that their hair feels as soft and fluffy as cotton several years into menopause. Estrogen seems to promote your body’s natural moisturizers, so with lower levels of the stuff flowing through your body, your hair takes a hit and becomes more brittle and wiry. You also have a tougher time keeping a perm permanent. Some women, though, also note that their hair has more body than it used to, and find that they no longer need to shampoo every day to keep their now somewhat drier hair looking good.
Weight changes: Your weight shifts to the center of your body — around your waist. Instead of the lovely hourglass shape you once had, you take on more of an apple-shaped appearance due to shifting hormone levels. Although you may gain a bit of weight, you probably can’t directly blame that on hormonal changes. Your body simply becomes less forgiving about nutritional imbalances and poor eating, drinking, and exercise habits.
Leading to the secondary conditions
It’s not over yet. One or more of the primary symptoms can trigger even more unpleasantness. Here you go:
Painful intercourse: Vaginal dryness and changes in the shape of the vagina can lead to discomfort or pain during intercourse. As low levels of estrogen cause your urovaginal tissues (tissues of the vagina and urinary tract) to become thinner and the supporting muscle to lose its tone, your organs naturally shift position a bit.
Interrupted sleep: Hot flashes, urinary frequency, anxiety, and a variety of other menopausal symptoms can cause interrupted sleep during the night. You wake up tired and feel fatigued throughout the day because your body isn’t able to enter the deep stages of sleep at night that make you feel resilient and energetic.
Fatigue: If you consistently don’t get a good restful night’s sleep or you experience insomnia, you may become fatigued. But fatigue can also be the result of low testosterone levels.
Discovering that it’s more than skin deep
The mental/emotional aspects of menopause are more of a mixed bag. Some symptoms experienced during menopause usually decrease or go away completely; others are a bit more difficult to deal with.
Anxiety: The anxiety common during perimenopause is often caused by the rapid drop in estrogen, which initiates a chain reaction (see the “Revealing the biology behind the symptoms” sidebar earlier in this chapter). After menopause, unexplained anxiety often dies down, and you return to your normal self.
Depression: Women who have had hysterectomies are more likely to experience menopause-related depression than are women who go through a natural menopause. Researchers don’t yet understand why this is the case, but it’s likely that physical, mental, and cultural factors all play a part.
Also, women who have been on estrogen and suddenly quit taking it, rather than going through a weaning process, also have more problems with depression. Estrogen assists in the production of serotonin (a substance which helps regulate moods), so lower levels of estrogen can mean lower levels of serotonin.
Lower libido: Decreased sex drive is a problem for many menopausal women, but the good news is that 70 percent of women remain sexually active during their perimenopausal and menopausal years. Lower libido can be traced to hormonal imbalances and may be the result of testosterone levels being too low. (For more information on menopause and your libido, take a look at Chapter 9.)
Memory lapses and fuzzy thinking: Though memory lapses and fuzzy thinking are common during perimenopause, most women notice their concentration and memory return to normal after menopause. Aging can cause mental impairment later in life, but you can’t blame everything on menopause! Remember, though, that recent research has found an association between continued use of hormone therapy after age 65 and a heightened (but still small) risk of dementia. If you are still using hormone therapy at this point, talk with your doctor about whether the reasons you continued hormone use to this point are still valid.
Understanding That It’s Not Your Imagination
Many people associate the word symptom with disease, but the definition we use throughout this book is much closer to the dictionary definition — a condition or event that accompanies something. If you’re like many women, you may feel that weird things keep happening to your body or your emotions.
Maybe you feel a flutter in your chest, and you become convinced that you’re on the verge of a heart attack. If you go to a cardiologist to check out heart palpitations, she probably won’t even think to check your hormones because she’s looking for something in your heart to answer the riddle.
Or maybe the “weird things” going on with you aren’t physical at all. Maybe they’re emotional — such as becoming easily frustrated at work or chewing your kids out 50 times a day for the last two weeks. Many women may think twice about these symptoms, but they don’t bring them up with their doctor. If you do mention them to your doctor, she may say something such as, “It’s nothing.” Nothing? We know what you’re thinking, “Try telling that to my co-workers and my kids.”
Even gynecologists sometimes overlook a hormonal imbalance as the source of symptoms. Women may suspect that their problem is “chemical” or hormonal only to have doctors say that they’re too young for menopause or that they’re still having periods, so they aren’t menopausal.
Some gynecologists go so far as to give a blood test to check your FSH (follicle-stimulating hormone) level to rule out menopause. High levels of FSH are indicative of menopause. But during perimenopause, your hormone levels go up and down. One month your FSH may be perfectly normal; another month it may be high. Without getting tested month after month, determining whether you’re perimenopausal is difficult.
But women’s estrogen and testosterone levels can (and usually do) get out of whack even before they officially become menopausal, and the imbalance triggers the annoying symptoms often associated with menopause. Sometimes you can become even more frustrated after seeking medical advice because the experts tell you, “It’s nothing,” or they alarm you with the number and types of tests they want you to take.
The reality is that the symptoms you experience are often more intense before menopause, during perimenopause, than they are after you make the change. After you get a hot flash or two, you may figure out that these “weird things” aren’t part of your imagination and that you’re getting close to menopause. If you figure out the connection, consider yourself lucky. Few women realize that the heart palpitations and the irritability can be part of the same condition — perimenopause. Having read this book, you can be the local expert — it’s up to you to coach other women through this!