Don’t Call It Menopause: Embracing the Change

Q

How do you contextualize perimenopause? When does it start?

A

I don’t like the word “menopause,” which means “the end of the period.” It’s much more than just the end of the period. It’s a moment in a woman’s life when there may be myriad symptoms and changes. Perimenopause means everything that happens leading up to and around that time, which I refer to as hormonal changes.

There’s no real definite age when perimenopause begins. In the US, it’s generally between forty-five and fifty. However, I have seen women who develop symptoms in their early forties. Menopause means twelve months with no period at all. The average age in the US is fifty-one.

“I don’t like the word ‘menopause,’ which means ‘the end of the period.’ It’s much more than just the end of the period.”

Perimenopause often begins with irregularities in a woman’s cycle. This can include having cycles that come too quickly—like, two periods in one month—or suddenly skipping two months, and then having your period return with constant spotting. Some women experience chronic fatigue, trouble sleeping, mood swings, or depression. Often we’re dealing with major life changes and asking ourselves questions that can cause both mental and physical fatigue.

Q

What’s happening to your hormones at that time?

A

At first, you still have some eggs in your ovaries, and you see an increase in FSH (follicle stimulating hormone), which shows that ovulation is getting a bit harder. Your body acts as if you were going to ovulate normally, causing your estrogen to elevate. Estrogen stays at a good level—even sometimes too high—during that first period of perimenopause.

Estrogen levels vary depending on where a woman is in her cycle. Normally, as women enter perimenopause, estrogen levels are around 200 to 300 picograms per milliliter. But suddenly, as menopause approaches, estrogen levels can fall to around twenty or thirty. Women can start having hot flashes at that time, and when levels go below eleven, women are typically in menopause.

Once ovulation ceases, progesterone—the hormone that comes after ovulation—decreases. During the first few years, you may have either normal estrogen and low progesterone, or too high estrogen and low progesterone. The ratio is in favor of estrogen, which is the hormone that makes you feel sexy, happy, and full of life, so these sensations may become exaggerated. But as you may simultaneously experience a decline in your levels of progesterone, the hormone responsible for making you feel calm and relaxed, you might end up feeling more nervous, agitated, or impatient. This is all called estrogen dominance.

As a result, what I call the “harmony between all the hormones” is disturbed. Changes in progesterone may also affect our thyroid hormones and cortisol levels.

For most women, this time is a period of great change, when kids are going off to college, parents are aging, and there’s a lot of stress in their lives. Cortisol is a stress hormone that our bodies make from progesterone during the night when we sleep. So if your progesterone levels are already declining and you’re under a lot of stress, you’re not going to feel great. This is why many women experience trouble sleeping. They wake in the middle of the night because their bodies are converting the feel-good hormone progesterone into the stress hormone cortisol.

Eventually, our bodies’ production of estrogen declines and finally stops, as there are fewer and fewer eggs in our ovaries. That is when women typically experience the second group of symptoms, including hot flashes and night sweats.

Q

Are there other symptoms associated with this hormonal transition?

A

There are a variety of symptoms that include changes in metabolic rates, mood, skin and hair texture, and energy levels.

One of the earliest and most common symptoms is insomnia and fatigue. While you may be able to fall asleep, suddenly at one o’clock, three o’clock, five o’clock, you wake up, and sometimes you can’t go back to sleep. That is the decrease in progesterone.

Some women become very sensitive. Many women tell me, “I am very irritable; I cry for no reason—what is wrong with me?” I remember having a similar experience. Suddenly I would hear bad news about people whom I didn’t know, and I would cry for two hours. Or I would go to a movie and cry through the whole thing. Most of my patients also tell me, “I am impatient. I am short-tempered. I am mean to my family.” I tell them, “It’s not you—it’s your hormones.” There’s a direct connection between hormones and the neurotransmitters in your brain. Young women have a good balance of estrogen and testosterone, but around perimenopause, the growing hormonal imbalance creates a chaotic atmosphere in the brain that causes shifts in mood.

“Many women tell me, ‘I am very irritable; I cry for no reason—what is wrong with me?’ I tell them, ‘It’s not you—it’s your hormones.’”

Another common issue is weight gain, especially around the midsection. This can be a metabolic change that stems from hormonal imbalance and may be related to what we call insulin resistance, which interferes with the body’s ability to burn calories and thus promotes fat storage. Furthermore, the hormone cortisol often plays a role in weight gain. Women in perimenopause may experience high levels of stress, as we’ve discussed, and this increase in stress can elevate cortisol levels, which in turn encourages fat storage.

There may also be changes to your skin and hair. Very frequently, my patients come to me struggling with acne, even if they’ve never had it before. This can be due to the decrease in female hormones, which may increase the risk of developing adult acne. The skin may also be sensitive to sugar. Another big component of my practice is treating hair loss associated with hormonal changes. During perimenopause, hair follicles become very sensitive, and this sensitivity increases during menopause. When the female hormone levels decrease, there is a heightened risk for hair loss. I treat my patients with topically applied products that target DHT—a naturally occurring hormone that causes hair loss—and stem cell injections.

Q

Can supplements help?

A

Absolutely. But some over-the-counter products can be fraudulent or even dangerous. I recommend extreme caution when choosing a vitamin or a supplement. If possible, work with a health care professional who knows which brands are safe and effective.

Supplements that contain both estrogen and progesterone—which many OTC medications do—should be taken only after the onset of menopause, when both hormones are declining. During the first phase, before entering full-blown hormonal change, you may need to address only progesterone. You may not want to use anything that raises estrogen if estrogen is still being produced by the ovaries and estrogen dominance is a concern.

All that being said, one supplement I’ve found to be useful to support progesterone production, even though research on this is not conclusive, is evening primrose oil. It is best to take this at nighttime, especially during the second part of the menstrual cycle when progesterone should be produced. I also recommend vitex, or chaste tree, which can be taken in conjunction with primrose oil. Another wonderful product is called Serenol. It is made in Norway from bee pollen and I’ve found that it can help with many symptoms, from mood imbalances to hot flashes. Finally, there is a supplement called Cortisol Calm, which is made from a combination of Ayurvedic plants, such as Rhodiola rosea, magnolia (which is a calming plant), lemon balm, and other herbs. These plants can help the body adapt to stressors.

“We can also look to support the brain’s neurotransmitters since many symptoms are mood-related.”

As hormones continue to decline, other supplements can be introduced, such as black cohosh extracts, or Estrovera. Estrovera is made from a special kind of rhubarb that has been used for over twenty years to address multiple menopausal symptoms, including hot flashes, sleep disturbances, and mood imbalances. Relizen is another plant-based therapy from Sweden. It has been used by more than 1 million women in Europe. In one clinical study, 72 percent of women claimed that it improved their quality of life, reducing the symptoms of perimenopause or early menopause.

We can also look to support the brain’s neurotransmitters since many symptoms are mood-related. I recommend a supplement called L-theanine. It’s a unique amino acid derived from the biologically active component of green tea associated with relaxation. L-theanine may affect alpha brain wave activity, supporting an alert but relaxed mental state. For sleep issues, I include L-theanine in a special formula of supplements that I call my sleep cocktail.

Q

When is hormone therapy typically prescribed? What are the best options if you do hormone therapy?

A

It depends on both the levels of hormones and what the woman wants to do. I will never impose hormonal treatment if someone wants to take a natural approach. I present recent evidence-based studies and discuss case by case the benefit-risk ratio of hormone therapy for each patient. My approach to the treatment is generally conservative, and I recommend the safest dosages and formulas possible. We first discuss current symptoms, diet and lifestyle, past medical history, and family history, as well as the patient’s objectives and goals around hormonal balance and aging.

I test each patient’s hormone levels before prescribing anything. Does she still produce enough estrogen? Is it only her progesterone level that is down, or have estrogen levels also declined? How is her testosterone level? The approach and treatment are different in each case.

Commonly, at the early stages of hormonal changes, a small dose of progesterone during the luteal part of the cycle (just after ovulation) and for fourteen days of the month will be sufficient to regulate the menstrual cycles. If prescribed appropriately, it will address and relieve most of the symptoms of that stage, especially sleep issues. I’ve seen many patients who were miserable as a result of symptoms such as severe insomnia, anxiety, mood imbalances, and irritability, who suddenly began sleeping like a baby again with a small dose of progesterone at bedtime. Many felt that their energy was back and their life was normal again.

If the laboratory tests show a decline in estrogen and symptoms of low estrogen are present—such as dry skin, hair loss, mini hot flashes, night sweats, and memory issues—then we are coming closer to full menopause, and the use of estrogens may be warranted. We start with a low dose and adjust to the patient’s needs over time. I call this period the moving-target period, when hormones are not fully stable—levels are going up and down and symptoms are fluctuating. I educate my patients to recognize the various signs of either too high or too low estrogen levels and work with them to adjust their dosage accordingly.

I never prescribe synthetic progestins. I prescribe only the natural form of bioidentical progesterone, either by mouth to treat mood and sleep, or through a cream in milder cases.

“I try to help women, as we age, to accept the changes our bodies go through as normal and healthy and embrace them as part of a full life.”

I do not give my patients estrogen in oral form, except in rare cases when patients report that the percutaneous form did not work. I prefer the transdermal application of the bioidentical estrogen creams, gels, or patches. Several studies seem to show a lesser risk of clotting when estrogens are applied through the skin and then bypass the liver, not interfering with the clotting process. Again, the dosage will vary depending upon the symptoms and the needs of each patient.

When prescribing hormones, I work with a few pharmacies that I trust: It is essential to work in close collaboration with reputable state-licensed compounded pharmacists that respect all the standards of the profession and comply with the requirements of compounding products.

For those who prefer a natural approach or don’t want to start hormones, I usually look to herbal supplements and amino acid support.

Q

Have you seen a connection between perimenopause and frozen shoulder?

A

Yes. This month alone, three women came to my office with frozen shoulders at the moment of hormonal change. Frozen shoulder is a condition that mostly affects women in their fifties and sixties and is a period in which one begins to experience pain and stiffness in their shoulder joint. This can come on suddenly, with no previous trauma, and often interferes with one’s day-to-day life. I’ve hypothesized that there could be a correlation between the decrease in hormones—specifically progesterone, which appears to have some anti-inflammatory activity—and frozen shoulder. Sometimes I use progesterone cream for people who develop acne and it calms the inflammation of the acne. Declining hormones can also impact your joints and contribute to joint pains in your hands or wrists, such as carpal tunnel.

Q

Is there anything you wish more people understood about menopause?

A

The ideas that we have about menopause, as a culture, can impact our experience of this transition. I have traveled to other cultures, such as Senegal, where there is no stigma attached to the process of menopause. In the West, menopause has negative connotations. I think we can change that. We can view menopause not as the end of something but as a beginning. I try to help women, as we age, to accept the changes our bodies go through as normal and healthy and embrace them as part of a full life.

Dominique Fradin-Read, MD, MPH, is board-certified in preventive medicine. After receiving her medical degree from Université Libre de Bruxelles she completed various fellowships in Europe and moved to the US in 1999. Fradin-Read completed an internship in internal medicine through UC San Francisco and a residency in preventive medicine at Loma Linda University, where she also earned her master of public health degree. She previously worked closely as a physician with dermatologist Dr. Howard Murad at his medical group. She opened her own practice, VitaLife-MD, in Los Angeles, specializing in wellness and anti-aging programs for women.