Perimenopause

Preparing for the Change of Life

As our daughters blossom into teenagers and start menstruating, many of us in our mid-thirties or forties notice changes in our own bodies. These changes are the very early signs and symptoms of perimenopause-the confusing, little-understood time surrounding menopause.

Defining perimenopause

The traditional medical perspective defines perimenopause (peri means “enclosing, surrounding”) as the years surrounding a woman’s last menstrual period. During this time, the ovaries’ function declines and the body’s estrogen levels drop. Between ages 35 and 50, a woman may experience physical and emotional perimenopausal changes, although signs and symptoms of perimenopause vary in every woman. Some women experience gradual changes over several nears, while others may have symptoms that are more intense, but that last only a few months.

What is the difference between a woman who is “perimenopausal” and “menopausal?” A perimenopausal woman will still have a menstrual cycle, although her cycle may become erratic and she may skip periods as her hormone levels fluctuate. She may also notice that PMS-like symptoms either begin if she has not had them before, or become noticeably more intense. A perimenopausal woman may also experience symptoms such as hot flashes or night sweats, and stress incontinence, among others. “Menopause” is technically defined as a woman’s last menstrual period. Most physicians consider a woman to be post-menopausal when she has not menstruated for 12 months.

When Jill Maura Rabin, M.D. talks with women and their partners about changes they may experience during perimenopause, she explains the effects of estrogen’s decline. Chief of the division of uro-gynecology, and ambulatory care at Long Island Jewish Medical Center in New Hyde Park, New York, Dr. Rabin gears her practice toward helping women and their families understand perimenopausal symptoms:

Hot flashes. The exact role of estrogen decline in hot flashes is still unclear. Estrogen’s effect on blood flow and its relationship with chemicals in the body that control temperature may explain the waves of heat and sweating some women experience. The hypothalamus, the portion of the brain that stimulates release of important sex hormones, is very near the brain’s “temperature control” center. Another sex hormone, follicle stimulating hormone (FSH), rises as estrogen declines, although not at an even pace. Rising FSH dilates blood vessels, which may also explain the rush of heat women feel during a hot flash.

Sleep disturbances. Hot flashes can interrupt sleep, but the relationship between estrogen and the brain chemical serotonin, which plays an important role in sleep, may also be implicated in perimenopausal insomnia.

Vaginal dryness. The cells in the vagina are sensitive to estrogen. When estrogen levels fall, the pH of vaginal tissue increases. The tissue becomes thinner, drier, and more susceptible to infection. When estrogen is present, the pH decreases. When estrogen levels fall, vaginal dryness and thinning can make intercourse uncomfortable.

Decreased sex drive. A host of factors can influence a decrease in sexual desire during the time around menopause. Symptoms such as painful intercourse, depression, fatigue, and hot flashes may lessen sexual desire. And, the body’s reduced testosterone supply is also associated with the change in sex drive. Testosterone is an androgen, a hormone that promotes male characteristics. Women produce testosterone, although in significantly smaller amounts than men.

Changes in memory and mood. There are estrogen receptors in the parts of the brain that govern mood and emotion. Estrogen’s interaction with neurotransmitters, or brain chemicals, is also thought to influence menopausal symptoms of irritability, depression, and forgetfulness.

Stress incontinence and/or urinary urgency. Muscles around the urethra help keep urine in the bladder. Estrogen loss can weaken these muscles and cause urine to leak from the bladder-this sometimes happens when women laugh, sneeze or cough.

Potential loss of bone density. Bone loss, or osteoporosis, will cause one-third of all women over 65 to suffer a fracture, according to the National Osteoporosis Foundation. Bone loss results from a combination of factors, decline in calcium absorption, less Vitamin D in the body, and the drop in estrogen and progesterone after menopause.

Increased risk of heart disease. After menopause, blood-cholesterol levels rise. Hormone replacement therapy has been shown to have a protective effect against heart disease.

The significance of perimenopausal symptoms is often overlooked or underestimated, says Elizabeth Vliet, M.D., founder of HER Place: The Women’s Center in Tucson, Arizona. “We are not looking at women soon enough, and we are not taking their symptoms as early clues to the fact that ovarian decline is beginning.”

From her work with perimenopausal women, Dr. Vliet found that these early perimenopausal symptoms indicate that a woman’s estrogen levels are falling-even when her periods still occur regularly. And, as her estrogen levels decline, she begins to lose estrogen’s protective effects on her heart and bones.

Estrogen and the heart

Estrogen protects the heart in premenopausal women by increasing beneficial HDL (“good”) cholesterol and decreasing levels of harmful LDL (“bad”) cholesterol. Estrogen also helps keep the smooth inner lining of coronary arteries elastic and helps prevent arteries from constricting. During perimenopause and especially after menopause, heart disease rates in women increase.

Estrogen and our bones

Estrogen helps maintain bone density in several ways. Our bones are a dynamic system, with cells that grow (remodel) new bone tissue and cells that dissolve (resorb) old bone continuously throughout our lives. Estrogen helps us absorb calcium from the intestinal tract, helps deposit calcium into bone, and helps prevent bone from being broken down in the remodeling process.

Before perimenopause, we grow more bone than we resorb, and our bone mass increases until our mid-thirties. Estrogen, progesterone, and testosterone work together in the body: estrogen slows the action of cells that cause bone breakdown, and progesterone and testosterone stimulate cells that build bone. Sometime in the thirties the process reverses. Men and women start losing bone, but in women bone loss accelerates. During perimenopause, as estrogen and progesterone levels fall, women can lose from 0.5 percent to 6 percent of their bone mass per year without realizing it.

“It’s pretty clear that you need regular ovarian function to maintain bone mass,” says Robert Lindsay, M.D., Ph.D., chief of internal medicine, Helen Hayes Hospital, and president of the National Osteoporosis Foundation.

As the ovaries’ production of estrogen declines, Dr. Lindsay explains, bone mass declines proportionally”It’s more obvious in sites of faster bone growth, such as the spine.” To prevent this loss, he says, blood levels of estradiol, the predominant estrogen produced by the ovaries, should stay between 60 picograms and 120 picograms per milliliter of blood serum. When measured in saliva, estradiol levels should be between 0.5 to 5.0 pg/ml.

Measuring bone density

Bone density can be measured using dual energy x-ray absorptiometry, (DEXA) or a urine test to detect bone loss. “A bone density test can determine how strong bones are, predict future fracture risk, and is an accurate test to assess osteoporosis risk,” says Dr. Lindsay. “You need to ask the question of a physician, ‘Am I at risk for osteoporosis, and is it worthwhile to get a bone density test?”‘ he advises.

Reasons for bone loss

Bone loss can have several possible causes, Dr. Vliet says. Women who never have built up good bone mass in young adulthood, smoking, excess dieting, drinking excess alcohol, caffeine, or soda (it is very high in phosphates), or a diet very high in animal protein (over 15 ounces of meat daily) can cause bone loss. Also, women who have built up good bone mass can lose it when estrogen levels decline.

“Medicalizing” menopause?

Living successfully with perimenopause and menopause is not only about hormones, Dr. Vliet cautions. “It’s a combination of lifestyle changes-nutrition, exercise, and relaxation training-along with hormonal balance.” Each woman and her doctor must evaluate her situation individually, based on her medical historv, symptoms, test results, and risk factors.

But studies do show that taking estrogen can reduce a postmenopausal woman’s risk for heart disease and bone fractures by 50 percent. And, while the average age of menopause has stayed almost the same, around age 50, a woman’s average life expectancy today is more than 80 years, compared to an average of 48 years a century ago.

“It’s not natural to live 30-40 years after menopause without full hormonal stability, whether it’s thyroid, ovary, adrenals, pancreas, or any other source of hormones in the body,” Dr. Vliet states. “You can get evaluated, make choices, and know the options that are right for you.”

Perimenopause is the gateway to a whole new phase of life, Dr. Vliet adds, quoting anthropologist Ashley Montagu:”‘The goal in life is to die young as late as possible’-to stay as healthy as possible for as long as possible.”

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