Menopause: Liberation or Loss? (What Our Mothers Didn't Know To Tell Us)

When most of my patients ask me about menopause they want to know if they are "in it" or not, very few ask about the purpose of "the change." Most women feel that they just need to accept it, but acceptance is difficult when dealing with what often seems such a mystery.

The generally accepted definition of menopause is the first day of the first year of no menstruation for a woman of appropriate age (average age 51-52). This is imprecise as any woman may ovulate and menstruate remote from her "day of menopause," prompting a warning to not throw away supplies for at least 2 to 3 years. What most women call menopause is a time of transition from cycling sex hormones to very low levels of hormones due to ovarian (or gonadal) decline.

In menopause what to expect is a very tough question as each woman experiences the "change" so uniquely. Ultimately, the reason is that the ovaries are programmed to retire--a process that begins before we are born. In fact, the design is so purposeful, that it must have an evolutionary benefit. The logical emerging theory is that because our species has such a long dependency period for our young, one of the sexes must have programmed gonadal retirement so not as to reproduce with "one foot in the grave." The obvious choice of which sex has this timed end-to-fertility is the same that bears the fruit--the woman. The surprising aside is that the female brain doesn't give up on the retiring ovary, kicking out the signals even more strongly, to try and re-ignite the extinguishing gonad as it declines.

Many of the side effects of menopause can be traced to what is referred to as "estrogen withdrawal," due to the fact that as estrogen production is reduced, the brain craves more estrogen. Certain side effects (such as hot flashes) are very similar to those seen with drug withdrawal. While not all women experience hot flashes after ovarian decline, about half do, and most women have at least one symptom that relates to a withdrawal syndrome. Others have no symptoms at all. There is essentially no test to determine how long such symptoms will last, but the range of duration for hot flashes, the most common problem, is 6 months to 3 years. A very few women will have them forever.

Another dilemma is that men do not have a clear planned gonadal decline. Sperm production occurs in the testicle to some degree until death, but a woman "spends" her limited amount of eggs. Just like an hourglass turning over, the eggs decline steadily from before birth, and only a relative few are "rescued" by puberty to generate the menstrual cycle and the hormonal rhythms that ensue. In fact just 300 to 500 eggs out of an initial 10 million or so are ovulated in a lifetime. The millions of others degenerate through what is called apoptosis: programmed cell death. When the last egg is "spent," the reproductive function of the ovary is finished (remember, not dead--just "retired"), but the ovary still provides a source of hormonal vitality beyond this time, prompting what many women may experience as "post-menopausal zest."

An inconvenient truth is that most of the physical signs of beauty and attractiveness for women are related to estrogen levels. Even a young woman's curvy, low waist-to-hip ratio is enhanced by estrogen, and withdrawn to some degree by menopause. This is not to mention the estrogenic support of collagen content, scalp hair volume, skin quality, sleep quality, and verbal memory, to name a few. There is much that can be done, but the best approach is to start with understanding.

Menopause is not a disease, but it can put women out of sync with some of the estrogen-enhanced physicality, behaviors and appearances on which they have come to rely. It can also put women out of sync with the men in their lives, who may be affected by a subtle, or not so subtle change in relationship dynamic. Sexual synchronicity is not Mother Nature's prime concern. As far as She is concerned, it's all about reproduction; love is for intellectuals, which can interfere with the former. In the meantime, reproduction has risks, especially to the female. It would follow that Mother Nature may consider ovarian retirement a gift, in other words, "Congratulations, you are off-duty. Now you may rely on your true, unadulterated personae to guide your passions--go forth and be free." Not all women feel this way, but it is very liberating for those who do.

In the meantime, lifestyle strategies can help redirect "the change" to meet the individual needs of any woman. Even the least symptomatic woman needs to know that her bone density may decline, as does her body's collagen, and that her metabolism will slow, especially carbohydrate metabolism. Increasing exercise, keeping dietary plant protein high (a good source of phyto, or plant estrogens), 1500mg of calcium a day in divided doses (through food or supplements), adequate vitamin D (at least 1000 IU a day), and a good intake of Omega 3 fatty acids.*

Some women choose hormone replacement therapy, and others try over the counter herbal supplements or non-hormonal medications for symptom relief. Some women may need help with changes in libido, or painful intercourse. Some battle depression and may need therapy or specific medication. Meditative practices can be extremely helpful for those that seek guidance from an expert.

The bottom line is that menopause is normal, as is puberty. And as with puberty, the "change" can be famously unsettling...or beautifully smooth. This is a time to stay informed, and stay healthy. Your doctor can help, but it should not be "add-on" to your annual exam. Make a special appointment to meet with him or her, and be prepared to follow up. There are many choices, and the key is to understand--menopause and your options.

* For more information on supplements click here

Comments

[JCPriorMD]

I appreciate Dr Booth’s attempt to decrease the “mystery” of “the change”, but am appalled and angered by her cover-up of perimenopause. Mid life women’s life cycles include two different distinct phases; 1) perimenopause and 2) menopause (or post menopause). Perimenopause is the long and tough time (for 20% of us) when estrogen levels increase and swing erratically. I call it “Estrogen Storm Season” (CeMCOR publishers 2006)

I guess it is progress to hear a gynecologist say menopause is “not a disease”. But it is no help if she recommends estrogen “replacement” when perimenopausal levels are already too high. That’s a sure fire recipe for heavy flow and eventual surgery.

Instead, treatment with progesterone, estrogen’s forgotten hormonal partner, (“The Estrogen Errors-why progesterone is better for women’s health”-Praeger/ABC Clio 2009), makes sense because perimenopausal levels are already low. Progesterone’s job is to counterbalance estrogen. Bonus effects of 300mg oral micronized progesterone (Prometrium®) at bedtime are improved sleep, decreased hot flushes and control of heavy flow. Visit www.cemcor.ubc.ca to learn accurate and empowering information.

Dr. Jerilynn C. Prior
Professor of Endocrinology, University of British Columbia
Scientific Director Centre for Menstrual Cycle and Ovulation Research

[greendream]

I went through chemo induced menopause. Had a few hot flashes but nothing serious. Recently had a total hysterectomy and my outlook on life has never been better. I'm looking forward to new experiences and this particular stage of my life. I do have some weight to loose but I'm not stressing over it.

But then I never had problems with PMS or mood swings back when I was having a normal cycle.

[MicheleCA]

all the posts regarding hormone replacement... there is a correlation between cancer & hormones.

[4cats4]

This is a great discussion. I'm 66, and until very recently was on low dose of estriol (bioidentical). Then I got thickening of the endometrium and bleeding, and my gyn recommended I go off the hormone. So I did, about three months ago. Sex is a little more difficult, but I use a product that is like hand cream for your vagina, inserted twice a week. I'm still very interested in sex, but maybe that will change. I'm one of those women who will have hot flashes forever (I had my first one in 1988!), and they are a bit worse since I stopped the estriol, but it's not that big a deal.
The main thing I wanted to say is that I LOVE LOVE LOVE menopause because of no periods. Mine were always horribly painful and profuse. I could never plan anything. For the last fifteen years, I've been enjoying life far more than I did as a young woman. I don't enjoy the dry, wrinkly skin, but I'd rather have that than cramps.

[minapod]

Those same men will find themselves sooner than they think in Andropause, and if they are lucky, they will have a kind and loving woman to be there for them while they get moody, cranky, chubby, and depessed, and wonder where their youth and sex drive went.

[MsCuda]

I had a hysterectomy (not a total one) in my 30's and supposedly didn't need hormone replacement then (they lie--I lost my sex drive, gained a 'stash, lost my waistline, etc), so later I didn't know that I'd started going into menopause. Eventually it got so bad that--for one example--I was not able to sleep more then 4 hours max. This went on for way over 3 years--more like 5+. I went through absolute he77 until the doctor FINALLY gave me hrt.

I went on the hrt and my quality of life dramatically improved. The anxiety attacks that I was plagued with for years went away (returned when I stopped briefly), I began to sleep through the night, my interest in life returned in many and varied ways. I had other physical improvements as well.

Losing my capacity to have children wasn't an issue; neither was aging. I looked forward to not having to worry about hormones. I looked at being older as a liberating experience.

The bottom line for me was that for whatever reason, I was one of those unlucky people who had a horrific experience that simply didn't seem to want to end.

Yes, menopause isn't a disease, but it has the capability of making *some* people so miserable it may as well be.

[mlm2005]

Amazing the medical field is not trained to provided us assistance. I learned of being menopausal @ 43 wow. After years of suffering mood swings, sweats all of it etc. Once I knew it seemed to mellow.. But still it just irks me that the medical field knows nothing about menopause.

[RMankovitz]

Many women, with the assistance of their doctors, are experimenting with bio-identical hormone replacement therapy (BHRT), where prescription plant derived hormones identical in structure to their human counterpart are used orally or topically.

Those patients and doctors who care to wait for the usual peer-reviewed evidence-based studies may choose not to try BHRT. In my opinion, it is unlikely there will be many formal studies on natural hormone replacement therapy because there is no money in it - the replacements are not patentable.

As with any hormone replacement protocol, the trick is to get the dose and timing correct.

From my research, a trial of natural progesterone along with a natural estrogen product that is a combination of estriol (80%), estradiol (10%), and estrone (10%) seems to most closely match natural ratios. One prescription version of such an estrogen combination product is known as TriEst. Another prescription combination product is BiEst, which does not include estrone. In any event, estriol (E3) is the dominant form of estrogen in these formulas. Natural testosterone can be added to the mix if hormone testing shows a deficiency. There is rarely a one-dose-fits-all solution in this field, so a trial and error method with testing is usually employed to adjust doses.

A good reference on this subject for patients and their docs is the book "The Miracle of Natural Hormones" by David Brownstein, MD, which includes references, protocols, and case histories.

Roy Mankovitz, Director
http://www.MontecitoWellness.com

[cecebo]

I really don't understand this. Can you explain to me why tricking your body into thinking that it is NOT time to hang up the old reproduction factory is a good thing? Aren't bio-identical hormones and pharma hormones both doing the same thing: delaying the inevitable? Please explain why this is good. I am in menopause and have decided not to take any hormones, for now.

[RMankovitz]

You raise a very good point. I do not believe one should postpone menopause using BHRT. I do favor BHRT over synthetic for those who want to reduce uncomfortable symptoms caused by hormone imbalances during this period.

In "The Wellness Project", I discuss the possibility that following a lifestyle which is in alignment with one's genetic heritage might eliminate the negative symptoms of menopause. In some indigenous societies, these symptoms appear to be unknown.

[amanda8]

This article really didn't say anything profound or informative. I'm use to HuffPo running progressive, meaty articles. Like Dr. Hyman. Please do an article on how empowering bioidentical hormans are. I'm sick of hearing menopause is" not a disease" so we don't need hormone replacement. No one would think of saying arthritis is "not a disease" so you can't have hip replacement.

[futuregirl]

I found it very informative as I am approaching that age and I am already noticing changes in metabolism and skin tone that I want to do something about now! Interestingly, this doctor also wrote about bioidentical hormones not long ago. She is definitely not saying we don't need hormone replacement - but every woman has individual reactions/­indication­s and needs. Some apparently find menopause liberating - which I think was the point of this. We just need to be more informed and determine what we each need to individually do about it for our own lives.

[PatricefromNH]

I agree ! Amazing how articles are quick to brag that cancer went down when women stopped using HRT but no one mentions that the statistics on suicide have dramatically gone UP for menopausal aged women during the same peroid. Many, many women who, with plenty of estrogen and a full night's sleep, can keep PTSD, depression, ADHD, etc in check are thrown for a loop when menopause hits. The loss of estrogen negatively affects the length and quality of sleep, memory, thinking etc which in turn can worsen any psychological weakenesses or predispositions. Instead of arthritis, a better analogy is diabetes. Estrogen is just as important for many of us to maintain physical and mental homeostatis as insulin is to the diabetic.

[BlackYowe]

As some one who has passed through the very thick of it I can tell you it really is the "change" of life. Some days I feel empowered and fierce as a lioness other days I am a weeping wreck and feel like a confused child. It messes with your mind and gnaws ruthlessly at your self esteem. All this new testosterone makes me impatient and loosing sleep at night to night sweats and hot flashes does not help to elevate one's mood but I am making it through. It is normal and I don't want to do any kind of replacement therapy. I am just trying to eat right and keep my sense of humor. If women for thousands of years made it why can't I? I don't want to mess with my metabolism so I am riding the wave.

[secret38b]

I couldn't have written a better comment. This is truly my sentiment, exactly. I'm 45, and I had a total hysterectomy last year. I have to admit, the memory issues get me down at times, but I constantly tell myself to just take mt and think about what I want to say. Luckily, for me, everyone that knows me knows the deal, so they are quite patient, and when I'm having a conversation with folks who don't know me, I quickly explain that I'm in Menopause, and they are patient with me as well. Words are truly hard to come by at times......:o) Anyway, there is truly a great bright side to this, the plumming works again......

[LaurieAnn]

I just joke that I have "menopause memory." Most everyone understands right away.

[Jenifer Fox - Huffpost Blogger]

I am having a reverse life. I went through menopause at age 45. I am 48 now. Mine lasted about a year and I gained 30 pounds,which now I have lost. My life began after menopause. My mind is more active, more creative and more energetic than ever. I have a greater sex drive than I ever did in my life pre-menopause. I am more optimistic about my future than ever. I've had my share of defeats and let-downs..and have always been resilient. My hair was too thick to begin with, so its thinning is a blessing. I have never in my life taken hormones--no birth control pills and no replacement. I do take vitamin D and calcium. I do not eat junk food, or drink sodas except on a rare occasion. I exercise moderately. I feel better than ever. Not sure what the secret is here. I figure I have about 30 more years of feeling this good...

[GraniteSkyline]

Thanks! Now I don't feel so alone!

When I tell people that my period tapered off and eventually stopped a year and a half ago with no major symptoms they think I'm lying! My hair has thinned out a bit and my eyelashes are a bit skimpier. My hair started going gray in my early thirties--so no big change there.

Sex is very spontaneous when you know your not going to get pregnant. And, like you, my mind is clearer. I used to suffer from quite a bit of anxiety but that is gone. I wish I had gone through menopause years ago! (I just turned 49)

[futuregirl]

What made you gain the 30 pounds and what did you do to lose it? I'm 47 and still cycling away but can tell I am not burning calories like I once did and the old diet tricks of the 20s and 30s no longer work. I know it will only continue to be challenging as estrogen declines - it seems to be a great carbo burner. Please share more about how you turned it around.

[Surreal2me]

I went through natural menopause at 39 (Premature Ovarian Failure) and because of a history of blood clots I was refused HRT. I'm 44 now and I have gained 35 pounds, sex is painful, depression/anxiety is commonplace, exhaustion and not to mention sever hot flashes.. I don't feel empowered. I felt cheated that I'm aging too early and that there is nothing but diet and exercise..
Just ticked I got the short stick!

[coastalcarla]

I have several friends that are either going through menopause or had it forced on them by surgery. I've still got a few years to go, I think. But I have one question: Is it true that women that had really bad PMS while in their reproductive years are doomed to really bad hormonal swings during menopause? Is there a connection at all? Because I really have never had any PMS, and my friends keep telling me that menopause is going to be a breeze for me, since I'm not predisposed to massive hormonal swings now.

Personally, I don't believe them. My mother was completely mental during the change.

[Rebecca Booth, MD - Huffpost Blogger]

Thanks coastalcarla:
PMS (or PMDD) occurs because of a cyclic drop in hormonal support, which triggers the period. In menopause there is a gradual decline to a more steady (albeit low) state of hormones. PMS usually worsens in perimenopause as the “in-between” hormonal support is weak, but that does not necessarily predict severe menopausal symptoms once cycling stops. Once again, each woman has her own unique experience.

[SpiralUp]

Well, I had really bad PMS/PMDD in my 20's and 30's, got a little wierd in my early 40's when the changes started [frequent periods, mostly]. Now I"m almost 49, had 3 periods in 2008 and have had 1 so far this year. I get uncomfortably warm [no power sweats] and I feel sooooooooooooo much less crazy. I'm loving it, personally.

Not being ruled by sexual urges is a very nice change, too.

[ColumbiaPatricia]

On a well known free dating site - there are tons of men who are blaming their failed marriages on menopause and basically all their dating woes on women experiencing menopause. Women are being called crazy (well, when did we ever get called sane?) for experiencing menopause.

I liken this lack of information to the era when doctors told you that cramps were just in your head.

We MUST inform the public that this phase of life is just that, a normal, biological retirement of the fertility of a woman, perfectly normal and not something to support failed relationships.

[minapod]

Those same men will find themselves going through Andopause sooner than later, and will be fortunate if they have a loving and understanding woman by their side when they get cranky, moody, chubby and wonder where their youth and sex drive went.

[toetweet]

I meant vaginal stenosis and not senosis.

[LaurieAnn]

I began my experience of surgical menopause three months ago at age 48 after losing my uterus and ovaries to cancer. For me the experience has so far been a mixture of fear, loss, relief and "what now?" At this point my gynecologist is allowing me a slow descent into menopause by prescribing me bioidentical estrogen though I'm not sure how long she will allow me stay on this due to possible increase risk of breast cancer.

This article reminds me that I have to get myself in gear and seriously begin to increase my daily excise, take the proper supplements, maintain good communication with my husband about our sexuality and let the second half of life begin.

[Rebecca Booth, MD - Huffpost Blogger]

LaurieAnn:
Check out the largest prospective study to date on estrogen alone therapy (the famed WHI). There does not appear to be an increase risk in breast cancer with estrogen alone. There are other risks (namely stroke, and blood clot risks were increased), but the increase in breast cancer was with combination hormone therapy in women who had not had their uterus removed. Copy this link:

http://www.nhlbi.nih.gov/new/press/06-04-11a.htm

Good luck to you!

[LaurieAnn]

Fantastic! I'm taking this to my gynecologist. While it was my intention to grow into menopause without hormone supplements, the all at once surgical menopause changed my focus. Now I'm allowing the estradiol to help me with my menopause symptoms so that I can spend more time recovering from the cancer and regaining my health. Knowing that my breast cancer risk (have a strong family link there) is not elevated allows me to focus on overall health-something I truly need.

Thank you doctor. Fanned and Faved!

[MicheleCA]

Dr. how do you explain all the estrogen positive tumors?

[toetweet]

Menapause totally changed my life. I began to menstruate when I was 10. Thus menapause began around age 43 and was over (no period at all) by 44. I was not allowed to take hormone replacement, because I am very high risk for breast cancer.

The only positives were no more cramps and loss of most of my pubic hair. I grew a mustache. Have hair loss all over, which is not funny when it comes to the thinning hair on my head. I am almost 67, but I still sweat terribly, both day and night. I have far worse migraines and the worst is vaginal senosis (Look it up if you don't know what it means.) which is a rotten side effect to say the least.

I used to have a great body and was long wasted. Now my breasts practicly meet my stomach and my waist is barely noticeable.

I suppose I could have taken hormones, but my life was more important than risking death by breast cancer. I might add that everyone that I know personally who has had breast cancer, also took hormone replacement therapy!