Menopause can be an intimidating transition. The physical and emotional rollercoaster that hormonal changes take us on can be jarring if you’re not prepared for it (and sometimes it can be, even if you are prepared!)  Through my clinical and personal experiences with menopause, I’ve learned that addressing physical symptoms seems to be the most powerful way to address the emotional trials that come along with it.  Although sometimes we also have to address the emotional issues that come up head-on.

I wrote this blog to give you some insight into transitioning through menopause with grace. Using scientific tools that we have at our disposal, we can make menopause feel more like a peaceful hike than a rollercoaster. Let’s dive in!

 

woman travelling

What is Menopause?

As we all know, menopause is a natural biological process that marks the end of a woman’s reproductive years. It is typically defined as the complete cessation of menstruation for 12 months (1). Perimenopause, on the other hand, refers to the years of hormonal changes that lead up to menopause (2). Though we might talk about menopause and perimenopause symptoms interchangeably in our day-to-day lives, it’s important to know the difference.

We know that we stop having periods with menopause – but what else goes on? And what’s with all of the annoying symptoms? The simple explanation is “hormonal changes,” but let’s look into some of the science below.

You’ve probably heard of estrogen and progesterone, two key female hormones. The two are integral to fertility and menstruation throughout the reproductive years. But they also play a role in cognition, memory, skin, bone, and even cardiovascular health (7). The ovaries are a major site of estrogen and progesterone production in the body (we get most of our estrogen and progesterone from them) (1).

During our reproductive years, two other hormones have been working together to tell the ovaries to produce estrogen and progesterone. These hormones are called FSH (follicle stimulating hormone) and LH (luteinizing hormone) (1). Think of them as messengers. These hormones are produced in the pituitary gland in the brain.

Eventually, as we get older, our ovarian tissue atrophies and becomes less sensitive to our messenger hormones (1). Maybe the ovaries are just fed up with listening to FSH and LH after all of these years.

When our ovaries stop complying with FSH and LH’s messages, estrogen and progesterone production decreases. This reduction causes us to stop having periods and experience several other symptoms in response (3). One of the hallmarks of menopause in terms of lab work is not only lower levels of estradiol and progesterone but also high levels of FSH and LH (3).

Remember, estrogen and progesterone influence our bone health, cardiovascular systems, and brains. Pulling the plug on our organs’ estrogen and progesterone supplies can be a difficult transition for them. This manifests as pesky symptoms that can arise during perimenopause and often worsen closer to actual menopause (1,3, 17, 19).

Hot flashes and night sweats are common, but we also see other frustrating symptoms in our clinic, like joint pains, brain fog, irritability, libido fluctuations, insomnia, memory issues, and more.  Our bodies are changing with fat moving and growing in places it never did before, and it’s so much harder to lose that extra few pounds.   Our skin starts to wrinkle and sag.  Sometimes it is even hard to recognize the person in the mirror!  Menopause can be upsetting and  undesirable.

While the absence of menses for over 12 months is the clinical definition of menopause, we recognize that symptoms can significantly impact our patients’ quality of life before this point. In accordance with patients’ preferences, we often treat our patients before menopause, in the perimenopausal time frame.  There are many solutions.  Just keep reading!

 

Why Do We Go Through Menopause?

Surprisingly, most other animals don’t go through menopause; they reproduce throughout their whole lives. Whether we want to continue having babies or if we can’t wait to stop bleeding, the fun of menstruating comes to an end for all female homo sapiens usually around age 50, give or take a few years.

Scientists have become increasingly interested in understanding menopause and in overcoming it. Several biotechnology companies are working to postpone menopause and/or address the symptoms that come along with it. The scientific advancements that will come in the following decades are sure to be interesting.

Remember, postponing menopause isn’t solely about having kids later in life. It’s also about prolonging optimal health. Estrogen receptors are found in various parts of the human body, including the brain. Optimal hormone levels, including estrogen, have been linked to cognitive function, bone health, and overall well-being (16, 18, 19).

 

older woman exercising

Mental, Emotional, and Spiritual Aspects of Menopause

We’ll talk more about treating perimenopause and menopause below – but first, let’s talk a bit about the mental, emotional, and spiritual aspects of this time in our life. Ample psychology research validates women’s menopausal mental and emotional struggles; research indicates that women experience increased irritability, mood swings, decreased quality of life, and even a risk of mood disorders like depression and anxiety during perimenopause and menopause (21).

But as a woman myself, I don’t need to consult a study to know that growing older can contribute to emotional upheaval.  I’ve guided numerous patients, family members, and managed my own treatment through this process.

The spiritual aspect of menopause is different for everyone. For some women, the physical changes that signal the end of their reproductive years can be tough. In all transparency, I never birthed my own children. I focused on my career. When my hormones declined and I knew that biological children weren’t in my future, I had to really look at my life’s choices and process how I felt about them. It is not always easy to face our choices head-on, but with every health experience we have, we have the opportunity to listen to our bodies and learn about ourselves. I can tell you from my own experience that addressing the physical hormonal fluctuations I experienced granted me the bandwidth to process the bigger picture: the emotional and spiritual aspects of menopause.

So I want to emphasize that addressing the physical manifestations of menopause really provides the foundation for managing the mental and emotional aspects of menopause. Something as simple as getting a good night’s sleep is absolutely key for emotional health!  That being said, some women might really struggle with the loss of fertility and for some the loss of a dream of motherhood or being a mother again.  Besides menarche, when you started menstruating, this is a tremendous transition and it needs to be honored rather than resisted.  Be sure to seek out appropriate counseling and support if you find yourself struggling.  It is perfectly understandable to feel grief and sadness over this transition.  But I promise, there is beauty and many benefits on the other side as well!

However, if hormonal changes are causing insomnia or mood issues, for example, addressing the emotional side of menopause may not be as seamless as it could be! If you and  your family are wondering what happened to you, asking why are you so angry or weepy all the time, mom?  then it may be time to consider some treatment for your menopause.

 

How We Approach Menopause

Addressing the hormonal imbalances that occur during perimenopause and menopause is essential for managing the symptoms effectively. To do that, we take a personalized approach by examining each woman’s case. Let’s break down our approach.

First, we inventory the patient’s symptoms, personal health, and family history, as well as their goals and expectations.  And we need to find out at what stage of this transition the patient is in, whether it be perimenopause, menopause, or something else. We do this through laboratory work, by checking hormone levels (5 – 9).

We always look at the ovary messenger hormones (FSH and LH), estradiol (a type of estrogen), and progesterone. Additionally, we also look at estrone levels, a non-favorable estrogen, which can provide us with more context clues about the patient’s estrogen metabolism. Testosterone (free and total) levels are also evaluated, especially if there are concerns regarding libido.

We may also look at other hormones such as prolactin, pregnenolone, DHEA-s, and cortisol to evaluate adrenal function (keyword: stress!) and their overall hormonal balance. We leave no stone unturned when it comes to testing hormones. And this includes also checking thyroid hormones!

Timing of the testing is also important, depending on whether or not women are still cycling (5 – 9).   If the cycles have stopped completely, we can check levels at any time.  However, if women are still cycling occasionally, then we may want to check levels on specific days of the cycle. For example, day 12 and day 21 of a 28-day cycle correspond to the peak of estradiol and the peak of progesterone respectively. We know the reference ranges of those days in the cycle. We can then compare the patient’s levels with reference values to have an idea of what is going on. Sometimes practitioners will check on random days of the cycle, but this has very little value in a menstruating woman!

For patients who have concerns about hormone-related cancers or other specific conditions, we’ll bring out the big guns: a DUTCH test. A DUTCH (Dried Urine Test for Comprehensive Hormones) test looks at hormone metabolites in urine over time (6). This type of testing paints a thorough picture of a patient’s hormonal profile and helps me to develop a tailored treatment plan for them.

No treatment plan would be complete without looking at the patient’s symptoms in addition to their lab tests. I want to hear which symptoms bother the patient the most. From there, we set goals to improve their quality of life as soon as possible. If their insomnia is driving them crazy, we’ll make sure to address it in the early stages of treatment. I make sure to address all their issues!  If a healthy love life is important, and vaginal dryness is a concern, then personalized ways to address this concern become part of the plan.

 

woman outside thinking about menopause

Creating a Treatment Plan

We have quite a few routes to take when it comes to treating perimenopause or menopause symptoms. To pick the right plan for the patient at hand, we’ll need to consider their lifestyle, needs, and preferences.

Each treatment option relies either on “balancing” their hormones or “replacing” their hormones. There’s quite a difference. When we “balance” their hormones, we work to bring their hormones to a healthy, symptom-free place through supplements and lifestyle changes. When we “replace” their hormones with HRT (hormone replacement therapy), we look to augment their body’s hormone production by supplying the body with hormones exogenously.

So let’s take a look at what some of the treatment options entail. In our next blog, “All About Menopause Part 2,” we’ll go into detail about the pros and cons of each.

First up, we can go “au naturel” and focus on lifestyle changes (10). Surprisingly, simple lifestyle adjustments are powerful enough to significantly impact menopause symptoms. This can include diet changes, adapting their exercise routine in accordance with cortisol levels, reducing stress with meditation or yoga, improving sleep hygiene, and removing endocrine disruptors from their environment (such as toxic chemicals like Bis-phenol A and phthalates from plastics) . My amazing nutritionist Sarah, my medical team at the Spring Center, and I are here to help with these choices.

If relying on lifestyle practices isn’t adequate or desired, we can incorporate herbal supplements, which are more powerful than you might think. Research shows they can provide relief for hot flashes, mood swings, and sleep disturbances (12, 13). We often use a class of herbal supplements called adaptogens for regulating adrenal function and addressing stress.

Beyond that, we can prescribe HRT (hormone replacement therapy). This would require taking a pill, using a compounded prescription cream, or wearing a patch that supplies the body with exogenous hormones. Oftentimes it’s estradiol and progesterone. The HRT world can be a bit of a Wild West, so it’s important to do it appropriately with an experienced doctor like myself.

 

The Takeaway: Address Physical Symptoms to Improve Emotional Symptoms

We all know that menopause can be complex. I love being a guiding light for women as they make their way through it. The take-home message here is that addressing the physical manifestations of menopause is crucial not only for symptom relief but also for alleviating the mental and emotional difficulties associated with this transition.  And if the mental and emotional symptoms feel overwhelming, I would still suggest we address the physical symptoms and then see what additional emotional symptoms persist and tackle those as well.

By understanding a patient’s hormonal profile through testing and symptom evaluation, I can create a plan that gets you feeling better as soon as possible. Treatment options range from lifestyle changes and supplementation to hormone replacement therapy (HRT). In our next blog, we’ll look at the pros and potential pitfalls of each option. Meet us there to feel enlightened and inspired about the possibility of feeling better!

 

References

  1. Harvard Medical School. (2019). Dealing with the symptoms of menopause. Harvard Health Publishing. https://www.health.harvard.edu/womens-health/dealing-with-the-symptoms-of-menopause
  2. Mayo Clinic. (2020). Perimenopause. https://www.mayoclinic.org/diseases-conditions/perimenopause/symptoms-causes/syc-20354666
  3. NIH. Menopause: Overview. https://www.ncbi.nlm.nih.gov/books/NBK279311/
  4. Prior, J. C. (2014). Progesterone for symptomatic perimenopause treatment – progesterone politics, physiology, and potential for perimenopause. Facts, Views & Vision in ObGyn, 6(1), 25-35.
  5. Baber, R. J., Panay, N., Fenton, A., & IMS Writing Group. (2016). 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric, 19(2), 109-150.
  6. Ruoppolo, M., Orrù, M., & Mongioì, L. M. (2020). Hormonal Metabolites Assessment by Dried Urine Spot Analysis: A Narrative Review. Journal of Personalized Medicine, 10(4), 218.
  7. Nansel, T. R., & Austin, P. (2020). Measurement of cortisol and cortisone metabolites in urine. Annals of Clinical and Laboratory Science, 50(2), 203-208.
  8. Santoro, N., Epperson, C. N., & Mathews, S. B. (2015). Menopausal Symptoms and Their Management. Endocrinology and Metabolism Clinics, 44(3), 497-515.
  9. National Institute on Aging. (2020). Menopause symptoms and relief. Retrieved from https://www.nia.nih.gov/health/men
  10. The North American Menopause Society. (2020). Nonhormonal management of menopause-associated vasomotor symptoms. Menopause, 27(6), 607-622.
  11. Faubion, S. S., Sood, R., Kapoor, E., & Genitourinary Syndrome of Menopause Panel of the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice. (2020). Genitourinary syndrome of menopause: Management strategies for the clinician. Mayo Clinic Proceedings, 95(11), 2299-2318.
  12. Shakeri, A., & Sahebkar, A. (2021). Herbal medicine for hot flashes: A systematic review and meta-analysis of randomized controlled trials. Phytotherapy Research, 35(1), 124-138.
  13. NAMS. (2017). The role of complementary therapies in managing menopause. Menopause, 24(7), 728-739.
  14. Dodin, S., Blanchet, C., Marc, I., Ernst, E., & Wu, T. (2013). Acupuncture for menopausal hot flushes. Cochrane Database of Systematic Reviews, (7), CD007410.
  15. Borud, E. K., Alraek, T., White, A., Grimsgaard, S., & Fonnebo, V. (2009). The acupuncture on hot flushes among menopausal women study: Observational follow-up results at 6 and 12 months.
  16. Santoro, N., & Randolph, J. F. (2011). Reproductive hormones and the menopause transition. Obstetrics and Gynecology Clinics, 38(3), 455-466. doi: 10.1016/j.ogc.2011.05.004
  17. Prior, J. C. (2014). Progesterone for symptomatic perimenopause treatment – progesterone politics, physiology, and potential for perimenopause. Facts, Views & Vision in ObGyn, 6(1), 25-35.
  18. Muka, T., Oliver-Williams, C., Kunutsor, S., Laven, J. S., Fauser, B. C., & Chowdhury, R. (2016). Association of age at onset of menopause and time since onset of menopause with cardiovascular outcomes, intermediate vascular traits, and all-cause mortality: A systematic review and meta-analysis. JAMA Cardiology, 1(7), 767-776. doi: 10.1001/jamacardio.2016.2415
  19. Sherwin, B. B. (2012). Estrogen and cognitive functioning in women: Lessons we have learned. Behavioral Neuroscience, 126(1), 123-127. doi: 10.1037/a0025539
  20. Thornton, M. J. (2013). Estrogens and aging skin. Dermato-Endocrinology, 5(2), 264-270. doi: 10.4161/derm.23872
  21. Sagsoz et al, N. (2001). Anxiety and depression before and after the menopause. https://pubmed.ncbi.nlm.nih.gov/11205708/