Signs precede true menopause
Sharon Pruhs was only 42 years old when she began experiencing menopausal symptoms.
“I remember exactly where I was when I experienced my first hot flash,” she recalls. “I was standing at the card catalog at the library.” The Los Angeles librarian figured, “Here we go.”
But she didn’t actually reach menopause until she was 54.
Her experience is not uncommon. Gradual hormonal and physical changes typically start years before menopause, which begins at a woman’s final menstrual period. (Menopause isn’t diagnosed, however, until a woman has gone 12 months without a period.) These changes signal the beginning of the menopausal transition, or perimenopause (meaning “around menopause”).
The average perimenopause lasts about four years and frequently starts while women are in their late 30s and early 40s. (About 1% of women actually experience menopause before age 40.)
Not all women are as unsurprised by these changes as Pruhs was. They catch many women -- particularly younger ones -- off-guard, causing confusion and worry.
Experts suspect that many of the changes occur because ovarian function begins to decline, making hormone levels go up and down erratically. These hormonal swings are thought to have far-reaching effects on a woman’s body and to cause a wide range of physical symptoms.
Irregular menstrual cycles and changes in menstrual bleeding are often the first signs that the transition into menopause has started. The intervals between periods may become longer or shorter; the menstrual flow can become heavier or lighter. Frequently, one or more periods may be skipped entirely.
Hot flashes are also extremely common. A recent study suggests that almost 60% of perimenopausal women have hot flashes and that they are actually more common before menopause than after it.
One in three perimenopausal women experience difficulty sleeping. Although nighttime hot flashes (“night sweats”) are one cause of sleep disruptions, even women who do not have them report sleep problems.
Psychological symptoms such as mood swings may be a component of perimenopause, although researchers are still unsure. Although many studies have shown no link between mood and menopausal status, a report published last year in the American Journal of Epidemiology found that perimenopausal women complained of irritability, nervousness and mood swings more frequently than women who had not yet entered the transition. But feeling “blue” was reported with equal frequency among the two groups.
It’s usually not difficult to determine what’s causing these symptoms. In healthy middle-aged women, the symptoms themselves are typically evidence enough.
However, when women complain about these symptoms, their doctors often order blood tests -- particularly tests measuring hormone levels. Many experts believe such tests are inappropriate. “In the setting of diagnosing and treating perimenopausal symptoms, the tests have no value,” says Gail Greendale, an internist and geriatrician at UCLA.
Because hormone levels fluctuate so widely during the perimenopause, the tests are often misleading. A low level of estrogen doesn’t mean that menopause has occurred or even that it will occur soon; it simply means that estrogen levels were low at the time the test was taken.
The most effective way doctors have found of controlling perimenopausal symptoms is to correct the hormonal imbalances that may be causing them. By providing a routine supply of hormones, birth control pills “even out” fluctuating hormone levels. (They also offer the added benefit of protecting against pregnancy.)
Birth control pills are generally believed to be safe for women in their late 30s and early 40s and are widely used to treat perimenopausal symptoms, particularly hot flashes. In large part, that’s because few other options exist.
But there have been few clinical trials on the use of oral contraceptives in perimenopausal women, and those that have been conducted are too small to assure their safety. Recent concerns about the potential dangers of hormone use after menopause highlight the need for more study. (Because of an increased risk of blood clots, women older than 35 who smoke should not take birth control pills.)
“A whole new research agenda on how to take care of women’s symptoms during the perimenopause is needed,” Greendale says.
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Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. She can be reached at themd@att.net. The MD appears the first Monday of the month.
