Karen Knapp, MD Commonwealth Ob/Gyn Specialists |
Laura (not her real name) visits
every year for her annual gynecologic exam. We have known each other for many
years, but today, she is not herself. Laura’s periods have become less regular,
and she has hot flashes some nights that disrupt her sleep. Some months she
feels like her old self with regular periods, but other months, her periods are
accompanied by severe cramps and breast tenderness. Laura is understandably
distressed and wants to know what is happening.
Laura is experiencing the
typical symptoms of perimenopause. This is when her periods become less
predictable before eventually stopping at full menopause. This lack of
predictability is from her brain’s response to the aging of the remaining eggs
in her ovaries. To have a period and ovulate (pass an egg), a woman’s brain
must send stimulating hormones to her ovaries. With ovulation, the ovary makes
estrogen and progesterone, but as the ovaries age, the brain has to issue
increasingly higher levels of its stimulating hormones, with the ovary not
always responding. All of Laura’s symptoms are explained by this “waxing and
waning” of her ovarian function. How do we help with her symptoms?
She needs
to understand that it’s all normal, but understanding what may not be normal is
just as important. Periods every 21-35 days during perimenopause are normal,
while bleeding at intervals less than 21 days or bleeding more than eight days
at a time is not normal, and indicates a need for further evaluation by a
gynecologist.
Laura must
also remember she is still at risk for pregnancy during perimenopause. Low-dose
birth control pills or a progesterone intrauterine device are good choices for
contraception as they also help regulate bleeding. If contraception is
unnecessary, bioidentical progesterone can be used to regulate periods while soy
and black cohash can help alleviate hot flashes. Laura decided she would just
ride it out and see what happens.
Laura came
back 8 months later having had no periods. Hot flashes, sleep disturbances,
mood changes, and irritability had really begun to interfere with the quality
of her life. Information from the internet and bookstores just confused her
more. What does Laura do now?
Menopause
can be divided into “early” menopause (no period for six months) and “late”
menopause (no period for one year). Laura is between, having had no periods for
eight months. We know her stimulating hormones are elevated as her brain tries
to get her ovaries to work, but they no longer produce eggs and only make low
levels of estrogen. This combination affects the body’s “thermostat” and causes
the hot flashes, leading to sleep disruption, fatigue, irritability, and mood
changes. Low estrogen can also cause mood changes and increase susceptibility
to anxiety and depression, with accompanying physical changes. Vaginal dryness,
pain with intercourse, decreased libido, joint pain, and decreased elasticity
of the skin can also be experienced. Fortunately, there are a variety of
options to help alleviate Laura’s symptoms.
Hormone
replacement therapy was once the most commonly prescribed treatment, but we now
know it can increase the risk of heart attack, blood clots, stroke, and breast
cancer, regardless of the type of therapy used or its route of administration.
Furthermore, contrary to popular belief, both bioidentical and non-bioidentical
preparations carry these risks. Despite this, hormone replacement therapy is
still the most effective way to alleviate menopausal symptoms, but it must be
used with caution and with the understanding that the symptoms will return when
the hormone replacement is stopped.
In 2013,
the Food and Drug Administration (FDA) approved paroxetine (Brisdelle), a
serotonin reuptake inhibitor anti-depressant, for the treatment of hot flashes.
Neurotonin or gabapentin, long used for the treatment of chronic pain, can be
helpful as well, but may be overly sedating at undesirable times. With mood
changes, again, paroxetine may help, both as an anti-depressant and in
promoting restful sleep. There’s a good chance that a full night’s sleep will
help Laura’s mood improve.
Vaginal
dryness, pain with intercourse, and decreased libido are also common during
perimenopause. Bioidentical estrogen preparations for the vagina and vulva
dramatically relieve the dryness and decrease libido by keeping estrogen levels
in balance, and Osphema, an oral medication for vaginal dryness, has recently
also been approved by the FDA.
Non-pharmacologically,
numerous other treatments for the symptoms of menopause have been widely
studied, but with varying results. These include vigorous aerobic exercise,
yoga, hypnosis, paced breathing, mindfulness meditation, and acupuncture. As
mentioned earlier, herbal supplements such as soy and black cohash may help,
but dong quai, ginseng, kava, and evening primrose have not been found effective
and can instead have serious side effects.
Laura
decided to try a local estrogen supplement for her vaginal dryness and an
anti-depressant for her hot flashes, and she increased her exercise. Six weeks
later, her symptoms were not entirely gone, but she was managing them well and
was much happier.
Over the
past 20 years, a better understanding of the physiologic changes of aging in
women has led to vast improvements in menopausal medicine and the treatment of
disruptive symptoms. To find the latest information on menopause and to locate
a certified menopause practitioner, visit the North American Menopause Society
website at www.menopause.org.
For further inquiries about menopause management or
general gynecology, contact Karen Knapp, MD, of Commonwealth Ob/Gyn Specialists
at 804.285.8806, or visit their website at commonwealth-obgyn.com.
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