it’s been described as the “change” and a “second spring.” How a woman thinks of this inevitable phase of life depends on how it unfolds for her. Some breeze through, others have a few troubling but not alarming issues, while still others struggle with debilitating symptoms that can be both confusing and frustrating.
Covering in a single article a topic that many books have been written about is impossible. When I was given this assignment, I simply set out to write the article I wish I’d read myself before menopause.
What’s Happening When?
Some stages may overlap, which adds to the confusion of a clear definition:
Pre-menopause: Time before menopause (may include months or years) that may include changes in menstrual cycle. Menopausal symptoms may begin.
Peri-menopause: Time around menopause as a woman’s body moves toward the cessation of the menstrual cycle. Also referred to as “menopausal transition.” Estrogen levels rise and fall. Irregularities in menstrual cycle occur. Menopausal symptoms continue. Typically starts in the mid-40s, but some changes may occur as early as the mid-30s. (Peri-menopause includes both pre-menopause and early menopause.)
Menopause: Peri-menopause ends and permanent infertility occurs. You’ve officially reached menopause after going 12 consecutive months without a menstrual cycle. Menopausal symptoms may continue into the late 50s and early 60s—or longer, for some women.
It’s All About Change
The average age of menopause is 51.6—although it can occur much earlier for some women and later for others. Despite the exact time that menopause takes place, the physical changes are universal and include:
Complete cessation of monthly periods
Reduction and almost complete cessation of the manufacturing of estrogen and progesterone
Changes in the genitals and bladder
“The changes are physical, while the symptoms are what you feel. For example, upon examination, I might notice thinning of the skin on the vulva or a pale color to the vaginal mucosa, which are physical changes, while the patient may be experiencing discomfort with intercourse, which is a symptom,” explains Owen Montgomery, M.D., FACOG, NCMP, chairman of the Department of Obstetrics and Gynecology at Drexel University College of Medicine in Philadelphia.
Among the most common symptoms are hot flashes, night sweats and vaginal dryness. The majority of symptoms for most women occur in their 50s, decline in their 60s, and are, for the most part, done by their 70s. Some women experience multiple symptoms, while others make it through “the change” with few symptoms.
All of the following have been linked to menopause:
Vulnerability to urinary and/or vaginal infections
Changes in odor
Bone loss/brittle bones
menopause isn’t a disease but rather a normal part of every woman’s life as she ages, it makes sense to consider a natural approach to handling symptoms. For some women, this may be enough to ease them through the years when symptoms are most annoying.
Lifestyle changes are one of the most straightforward ways to combat symptoms and should be a first step. These include: 4Eating a balanced diet
Avoiding alcohol and caffeine
Staying well hydrated
Sleeping seven to eight hours per night
Taking vitamins B, C, D and E
You’ve heard about the importance of diet your whole life, and it’s especially helpful at this stage. Incorporating foods that promote natural estrogen levels in the body (think soy, alfalfa, apples, cherries, potatoes, yams and rice) can help, sometimes significantly. You also want to be sure you’re getting enough calcium and vitamin D to protect your bones.
Herbal supplements are one of the most common ways women manage menopausal symptoms. These supplements fall into two basic categories: phytoestrogenic and hormone-regulating.
Phytoestrogenic supplements contain plant-produced components with estrogen-like actions. These can include such herbs as black cohosh, red clover, soy, dandelion, dong quay and others.
Hormone-regulating supplements contain no estrogen but nourish the pituitary and endocrine glands to stimulate the body’s own production of natural hormones.
Alternative medicine, including acupuncture, Chinese herbal medicine and massage, is increasing in popularity as a treatment for relief of menopausal symptoms. Personally, I’m a fan of acupuncture and Chinese herbal medicine and have had success with both. I like the holistic approach that treats the entire person—physical, mental, emotional—not just her symptoms.
A multi-pronged approach may bring about the most satisfying results. For some women, however, symptoms aren’t alleviated with these measures, and, for them, hormone replacement therapy (HRT) may be useful.
What About Hormone Therapy?
“The most effective treatment for hot flashes, night sweats and urogenital changes is estrogen therapy,” notes Montgomery, who is certified as a specialist in menopausal practice. “This is a medical fact, but it doesn’t mean every woman needs or wants to use hormone therapy.”
A few decades ago, the vast majority of menopausal women were prescribed hormone replacement therapy (HRT). Then, in the early 1990s, the Women’s Health Initiative (WHI) was launched to address the pros and cons of HRT. After the study results were published in 2002 in The Journal of the American Medical Association, many women understandably shied away from hormone therapy for fear of increased risk of some cancers, heart disease and blood clots.
Montgomery finds there is still a great deal of fear and misinformation about HRT. Education is required in order for each woman to find what’s best for her.
A 2013 update to the WHI study carries some hopeful news for women struggling with menopausal symptoms but who are fearful of HRT. It concluded that the risk level depends on the individual and includes her age, overall health history and years since menopause began. This update reveals that younger women (those under age 60) are at low risk with estrogen therapy and that short-term hormone therapy is still considered beneficial for those with troubling hot flashes.
“If you’re between the ages of 50 and 60, it’s perfectly reasonable to be taking HRT, but if you are, you should have this discussion with your health care provider every year. At age 70, you’d have to make a very strong case for being on HRT. By that time, the symptoms are usually gone and the risks are greater,” says Montgomery.
For women whose primary symptom is vaginal dryness and discomfort with intercourse, low-dose estrogen therapy in the form of a vaginal ring, topical cream or tablet inserted vaginally may be the answer. This type of therapy is typically considered lower risk than systemic HRT because only a minimal amount of estrogen is absorbed into the bloodstream.
“Quality of life is important. Even some women who’ve had breast cancer are now being allowed to use low-dose estrogen vaginal preparations for vaginal menopausal changes,” observes Montgomery.
“There’s a lot of new research recently, which is exciting, and there are some new therapies for menopause,” he adds.
These include the non-hormonal medications ospemifene (brand name Osphena®) to treat painful sex due to menopause; paroxetine (brand name Brisdelle®), which is FDA-approved to treat hot flashes; and the combination of conjugated estrogens and bazedoxifene (brand name Duavee®) to treat hot flashes and prevent menopausal bone loss.
With any type of HRT, the general concept is to use the lowest dose that meets your personal health goals as discussed with your health care provider, including a realistic assessment of risks and benefits.
Montgomery points out that if you start taking medicine to relieve symptoms, once those symptoms are better, or gone, you should talk with your health care provider about stopping the medication or going to a lower dose to have the same quality of life. He emphasizes the importance of having an annual well woman visit and addressing the continued use (or not) of any HRT you’re currently using.
“Fear—particularly of breast cancer—is a potent factor driving women in their health care choices, so you need to discuss HRT with your health care provider,” says Montgomery.
“What I suggest is that patients try herbal therapies first. They don’t have a lot of scientific evidence supporting broad usage, but if they help, that’s all that matters. If they don’t work, then we can try hormones, but this should always be done on an individual basis.”
It’s a Desert Down There
Doctors recommend staying sexually active through menopause, as this increases blood flow to the genitals and can help maintain vaginal health. But when sex becomes painful, it’s hard to psyche yourself up for it.
Vaginal dryness is a common symptom of menopause. Thanks to the dramatic drop in estrogen that occurs around menopause, many women experience a decline in their natural secretions. In addition, menopause can also change the acidity of the vagina, leading to dry, thin skin that is easily irritated and less elastic.
If you always took for granted that your body would respond when it was time for sex, this single symptom can be one of the most discouraging. In fact, discomfort during sex is one of the primary symptoms mentioned in advertisements of medications used to treat menopause.
Some women struggle with vaginal atrophy, a condition in which the vagina narrows and the tissue deteriorates, in addition to a lack of lubrication. Thinner tissue can put them at risk for bladder infection, not to mention painful sex.
As when treating other menopause symptoms, what works to relieve vaginal dryness for one woman might not work as well for another. This is another area where personally trying potential solutions is necessary.
Regular use of a water-based moisturizer can be incredibly helpful to restore and nourish mucous membranes in the vagina. Lubricants are definitely recommended for more comfortable sex, but all lubricants are not created equal, so it’s crucial to read labels.
Common ingredients in many lubricants include propylene glycol (Do you really want to put something that is contained in anti-freeze in your most intimate area?), parabens (which mimic estrogen and shouldn’t be used if you’re avoiding HRT or have had breast cancer), and glycerin, which can irritate mucous membranes and have a drying effect.
Two organic lubricants free of such harmful ingredients are Yes (yesyesyes.org) and Good Clean Love (goodcleanlove.com). From personal experience, I give a hearty thumbs up to Yes lubricants, which has both water- and oil-based options.
Vitamin E (in suppository form intended for vaginal use) has been shown to help moisturize and protect membranes.
Diet can also help increase your natural lubrication. Drink plenty of water to stay well hydrated. Some experts believe a low-fat diet can make vaginal dryness worse, so make sure you’re eating healthy, unsaturated fats (wild salmon, nuts, avocado, seeds, coconut oil, olive oil, flaxseed, etc.). Avoid caffeine, alcohol and the use of antihistamines, as these are drying to mucous membranes. Phytoestrogenic herbal supplements may also help.
Don’t Lose Heart
It’seasy to get frustrated when you’re searching for answers to ease your transition into menopause. The good news is that the subject is no longer taboo, and there’s more information available today on this subject than ever before.
“Just a generation ago, communication on this topic was not as open or as available. There was a time when people in ‘polite’ society didn’t discuss symptoms. Now we have TV stars going on talk shows and talking about leaking urine when they sneeze,” says Montgomery. “Every woman deserves the opportunity to talk about her personal health with her health care provider when she has concerns or questions. If that person is not answering your questions or doesn’t meet your needs, you might need to seek out another provider with more expertise.”
Montgomery encourages women to do their homework and come to their appointment with a list of questions.
“You can get lots of information just by searching reputable sources online, and this can help people feel more empowered,” he says. “There’s a huge amount of unnecessary fear, which I think prevents some women from getting the best care. Don’t be afraid. Talk to your health care provider and get the right answers for you.”