MENOPAUSE AND PERIMENOPAUSE

Menopause is the time at "mid-life" when a woman has her last period. It happens when the ovaries stop releasing eggs — usually a gradual process. Sometimes it happens all at once. It can be a stop-start process that may take months or years. "Climacteric" is another word for the time when a woman passes from the reproductive to the non-reproductive years of her life.

The ovaries' production of estrogen slows down during perimenopause. Hormone levels fluctuate, causing changes just as they did during adolescence. The changes leading to menopause may seem much more intense than those during puberty. The intensity may be affected by a woman's feelings about aging, including her reactions to social judgments about aging. Induced menopause occurs if the ovaries are removed or damaged as in hysterectomy, chemotherapy, or radiation therapy. In this case, menopause begins immediately, with no perimenopause. The time after menopause is called postmenopause.

PERIMENOPAUSE AND MENOPAUSE

Perimenopause is the time of change leading up to actual menopause-the normal biological event that marks the end of a woman's reproductive years. It usually occurs between the ages of 45 and 55, lasts about 4 to 5 years, and is commonly associated with a shift from regular to irregular menstrual cycles prior to stopping completely.

Symptoms associated with menopause may also occur during this transitional period. Menopause is one of the major turning points in a woman's life. Approaching menopause involves a process of change — and every woman experiences this transition in unique and individual ways. Many women discover that menopause gives them a new lease on life — physically, emotionally, sexually, and spiritually. They are enthusiastic about becoming free of their concerns about pregnancy and menstruation.

WHAT GOES WRONG?

In the years leading up to menopause (perimenopause) menstrual cycles that may once have been like clockwork start to become erratic. Bleeding may be heavier or lighter than usual—although women are not officially in menopause until they have had 12 consecutive months without a period. Erratic cycles are a sign of erratic ovulation leading to highs and lows in estrogen and progesterone, an effect many women describe as an emotional roller coaster.

Forgetfulness and foggy thinking, mental confusion and mood swings are hallmark symptoms for many women; as are hot flashes and night sweats, tearfulness, unwanted weight gain, thyroid problems and declining interest in sex, no matter how much we love our partner. Of course not all women experience all these symptoms—as individuals we each have our very own biochemistry—but it is common to experience some degree of discomfort during the menopausal years. And the degree to which we experience discomfort is likely to be associated with the degree to which our hormones are out of balance.

Perimenopause may begin as early as 35. It usually starts about two years earlier for women who smoke than for women who don't. Women reach menopause at different times. The timing is not related to race, class, pregnancy, breastfeeding, fertility patterns, the birth control pill, height, age of menarche (first period), or age at last pregnancy. The average age for menopause is 51. If menopause is reached naturally or surgically before the age of 40, it is called early or premature menopause.

Estrogen levels drop very abruptly after induced menopause — when both ovaries are removed surgically or through radiation or chemotherapy. This often intensifies the conditions associated with menopause and may lead to major physical and emotional changes, including depression. Most women who have "natural" menopause experience a more gradual decrease in hormone levels.

It is somewhat reassuring to remember that perimenopause is a temporary phase. And most symptoms are temporary, such as mood changes and hot flashes. For most women perimenopause will last two or three years, though for some it lasts as long as 10 or 12 years.

A few symptoms — vaginal dryness and changes in sexual desire - may persist or worsen after menopause unless they are treated.

Women in perimenopause have reduced fertility but they are not infertile. Although menstruation may be sporadic, pregnancy can happen. That's why women need to consider birth control during perimenopause. All women should discuss their contraceptive options with a clinician — whether or not they are menstruating.

HORMONAL CHANGES THAT OCCUR WITH MENOPAUSE

As women age, the number of viable ovarian follicles decreases. It becomes more difficult to stimulate the remaining follicles to release an egg. Still, the body struggles to stimulate ovulation by increasing FSH and LH production. Occasionally, FSH and LH succeed in developing a follicle to maturity and ovulation occurs. However, as menopause nears, these attempts are increasingly ineffective and the menstrual cycle begins to sputter. Menstrual periods become irregular as a result of repeated failures to ovulate. Missed ovulation leads to an excess of estrogen over progesterone, because the follicle did not rupture, no corpus luteum exists to produce progesterone.

Consequently, symptoms of estrogen excess, like headache, fluid retention and irritability can occur. Declining estrogen and progesterone levels can change the frequency, length and intensity of menstrual periods. (Note: irregular periods and heavy bleeding can be signs of a more serious condition. Please contact your physician if you experience these symptoms.) The changes in hormone balance can result in a variety of symptoms. In the end, the few remaining follicles are too worn out to respond, and menstruation ceases entirely. The change has begun!

RISK FACTORS

Certain surgical or medical treatments can bring on earlier than expected. These include:

• Hysterectomy
• Chemotherapy and radiation therapy
• Premature ovarian failure

These surgical or medical conditions often intensify the conditions associated with menopause and may lead to major physical and emotional changes, including depression. Most women who have "natural" menopause experience a more gradual decrease in hormone levels.

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