Menopause

Everything You Need to Know

Nicole Jaff

• Publisher: Bookstorm
• Year: 2011
• ISBN:
  9781920434724
• Edition: 1
• Topic: Medicine
• Subtopic: Sexual Health & Sexuality

Nicole has tremendous empathy for helping women understand what is happening to them during menopause and her empowering approach to wellness means women walk away knowing and believing menopause can be a positive time of vibrant health and happiness.' Frith Thomas, Woman&Home The pressure on women to remain forever young can make menopause a time you approach with dread. The thought of battling with hot flushes, uncontrollable weight gain, brittle bones, mood swings and memory loss can plunge you into depression. Is menopause really the end of life as you know it? Nicole Jaff understands the pressures and the confusion experienced by women in menopause or approaching menopause and acts as their guide through the maze of conflicting theories, the advertisements of companies offering cure-alls and the array of medical options offered by doctors. In her trademark style -- thoroughly researched, clearly written and with an essential touch of humour -- Nicole explains the theories, the claims and the myths surrounding menopause. She uses numerous case studies of the women who have come to her for counselling to illustrate women's concerns to support her central theme -- each woman is different and so the treatment of menopausal symptoms needs to be customised for her, a one-size-fits-all approach is of no benefit to women. Nicole addresses all the issues that midlife women raise in her workshops and in private consultations: Why do I get hot flushes and will they ever end? My doctor has recommended a total hysterectomy -- what does this mean? Is it safe to take hormone therapy, or does it cause cancer? Does menopause mean my sex life is over? Aren't natural hormones better than hormone therapy? Will I never be thin again? I'm so depressed, will hormone therapy cure me? If I stop hormone therapy will my bones become brittle? Nicole's mission is the empowerment of mid-life women and she hopes they will achieve this through reading Menopause: Everything you need to know -- the power to ask the right questions, to insist on being properly informed on their health options and the power to take an active part in their own health management.

1

What is menopause?

Prue is tall and slim. She is an ardent sportswoman in her early forties, matter of fact and organised in her daily life, self-contained and extremely down to earth. So it was out of character for her to be laughing hysterically and describing her anxiety and distress during the past few weeks. ‘I am so relieved this morning,’ she said, ‘I’ve just got my period. I’d missed two months, had unbelievably sore boobs and felt emotional, even slightly sick. I was absolutely sure that I was pregnant – it felt just like it. But it’s back again and really heavy.

‘The reason I was so freaked out,’ she explained, ‘apart from my age [she has two children in high school] is that my husband’s had a vasectomy and there’s no possible way I could be pregnant!’

We all laughed, but what Prue had just experienced could happen to any woman of her age. She is perimenopausal. The symptoms of perimenopause vary widely and may come out of the blue. For some women there are clear, unambiguous signs; for others, the transition from being a fertile woman in the menstrual cycle to being menopausal is so gradual that they hardly even notice.

Because there is so much research into the subject of menopause at this time and because the findings of the Women’s Health Initiative (WHI) in 2002 turned the accepted ideas about menopause on their heads, it is vital that women understand what is happening to their bodies in the years before the actual moment of menopause so that they are better able to micromanage this often tumultuous time and will be able to look back on those years as fulfilled, healthy and productive.

WHAT DOES PERIMENOPAUSE MEAN?

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The term menopause actually means the last day of your last period ever. From that point, in medical terms, you are considered menopausal. Until then, your body – as it moves from being fertile, able to produce eggs and bear children, to the moment of menopause when you no longer ovulate – is in a transition period known as the climacteric, a word meaning a critical stage in human life; a period that is especially likely to be connected with a change in health. During this time when you are moving towards menopause, the changes taking place in your body cause certain symptoms, physiological (physical) and psychological changes that are happening to you as the levels of estrogen in your body fluctuate and the levels of progesterone start to decline. We use the word peri, which comes from the Greek word meaning ‘around, round about and about’, in conjunction with the word ‘menopause’, because it is a useful way to describe all the things that are going on in your body before, during and after the actual moment of menopause.

Before I describe what happens in perimenopause, there is a very important point that you need to understand. Each woman is an individual so her menopause is unique and specific to her and her own body or biochemistry. It is pointless to compare yourself, your perimenopausal symptoms and the way you choose to manage your menopause with anyone else. As a friend of mine who is a preschool teacher points out, ‘You always have to remind parents that each child develops differently. I tell parents that just because Jenny is catching a ball at four years old doesn’t mean that Susie’s ready to do so; she will in time, but she is developing at her own pace.’ Don’t forget this when you’re sitting around discussing your perimenopause with your friends.

Perimenopausal symptoms

Much of the confusion arising from menopause is caused by the fact that for decades women were lumped together as a species and treated as if they were all the same, with no understanding that what was great for one woman might be disastrous for another. The old adage (slightly altered from a feminist perspective) holds good here: ‘One woman’s meat is another woman’s poison.’ It is vital to remember that the time leading up to menopause is different for every woman, just as the symptoms listed below are different for every woman.

The changes of perimenopause usually begin in the most subtle way, two to 14 years before the actual onset of menopause, depending on your own body chemistry, unless you have undergone a surgical or chemical menopause. The diagram of the perimenopause shows how these symptoms build up over a period of time and then slowly decline after the actual moment of menopause. For some women the good news is that they will hardly experience any symptoms, or only some of them for a very short time, while other unfortunate women will experience the full range of symptoms. These symptoms may continue for several years after the moment of menopause. So, as you read through the list and recognise some or all of these symptoms, remember that there are millions and millions of women out there going through a similar experience; you are not alone and what is happening to you is part of your life process as a woman. This stage will resolve itself, as did all the other stages in your life.

Some of the main symptoms of perimenopause

• Hot flushes (you may see books written in America describing them as hot ‘flashes’)
• Night sweats
• Forgetfulness
• Undefined anxiety
• Inability to concentrate
• Mood swings
• Weight gain
• Sleep pattern changes
• Loss of libido (sexual desire)
• Change in the type of PMS
• Headaches or migraines
• Irregular periods – either too often or with months in between
• Changes in the type of menstrual periods
• Symptoms that mimic pregnancy: sore breasts, ravenous hunger, tearfulness, fatigue

Symptoms that may persist after the other symptoms have abated

• Vaginal dryness
• Persistent loss of libido
• Urinary problems

The list of perimenopausal symptoms is long, varied and often specific to you alone, so although I have only listed the most common symptoms in this chapter, at the end of the book (here) you will find a list of almost every possible symptom that women complain about during perimenopause, which may reassure you that you are not going mad or suffering from some obscure and life-threatening disease.

The symptoms of perimenopause may mostly be blamed on your changing hormone levels. Your levels of estrogen are fluctuating and you don’t have adequate progesterone to balance the estrogen. In fact, when the levels of estrogen stop fluctuating, many of the symptoms that have plagued you throughout the perimenopause will stop. Estrogen is an extremely potent hormone and in Chapter 2, I will explain the physiology of estrogen and why it has such a powerful effect on you.

YOUR MENSTRUAL CYCLE

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Once you understand the process of your menstrual cycle and the roles that estrogen and progesterone play in it, it is much easier to understand what is happening to your body during perimenopause. Look at the diagram of the womb below so you have a picture of what your reproductive system looks like.

Simple diagram of the womb

You are born with two ovaries containing eggs. Each egg is surrounded by a sac-like structure called a primordial follicle (this means that the follicle is in a primitive state). The egg and follicle are often called the egg unit and are in a resting state. When you start puberty your ovaries contain about 500 000 eggs, but by the time you reach menopause only about 3 000 eggs remain. The diagram of the reproductive cycle will help you understand how the ideal 28-day menstrual cycle works. This is also a good place to remind you that only about 12 per cent of women have a 28-day cycle, so your cycle may normally be between 24 days and 35 days, or you may be one of those women who has always had irregular periods.

The menstrual cycle

The build-up to ovulation

Your menstrual cycle begins on the first day of your period (the first day of a full bleed). The pituitary gland in your brain produces a hormone called follicle stimulating hormone (FSH). This is one of the important hormones to note when understanding what is happening to your body, because when women become perimenopausal or go to their doctors complaining about some of the symptoms I have listed above, they often have blood tests which show that their FSH levels are raised.

The FSH causes the egg units to produce estrogen and this increased production level of estrogen causes the lining of the womb (endometrium) to thicken. During this time up to 1 000 egg units begin to mature. By day nine, one of these egg units starts to grow much more quickly than the others and becomes the dominant (leader of the pack) follicle. The other egg units, having done their work in supporting the dominant follicle, start to degenerate.

As this follicle matures its estrogen production increases and on about day 13 it reaches a level which tells the hypothalamus, the part of the brain involved with your endocrine system and thus your menstrual cycle, to send a message to the pituitary gland to reduce the FSH production and to secrete luteinising hormone (LH).

Ovulation

On day 14, which is called mid-cycle in our ideal 28-day cycle, the ripening follicle develops a weak spot caused by a surge of LH and the contents of the follicle are slowly pushed out through this weakened area. This process creates a chemical change around the ovary, which attracts the finger-like extensions at the end of the fallopian tube. These behave very much like the waving fronds of a sea anemone and create a current that draws the egg and the fluid that was in the follicle into the fallopian tube, which leads into your womb. This process is known as ovulation. It may pass unnoticed or it may be painful and many women say they know when they have ovulated because of the physical sensation or pain on one side, which may come from the rupturing follicle.

Sometimes the small amount of fluid or blood spilled when the follicle releases its contents may irritate the pelvic lining, which may cause tenderness. Often women can tell when they have ovulated because they experience some of the symptoms that are caused by rising progesterone which is released during this time. These may be a sudden very bad headache or migraine, a craving for chocolate, tender or very sensitive breasts, or an outbreak of acne or one huge pimple that always seems to appear in the same place.

The ruptured follicle is now known as the corpus luteum (Latin for yellow body) and begins to produce small amounts of estrogen and increasing amounts of progesterone, which stabilises the thickened lining of your womb or uterus, so that if the egg is fertilised the lining will be lush and ready to receive the fertilised egg. If you do not become pregnant the corpus luteum begins to degenerate and the levels of progesterone and estrogen it produces begin to drop. Since the lining of the womb needs progesterone to sustain it, when the levels of progesterone and estrogen have dropped far enough the lining begins to crumble and within a couple of days it separates from the wall of your womb and you start to menstruate approximately 14 days after ovulation. This menstrual cycle generally continues in more or less the same way during your fertile years unless you are pregnant, or until you begin to get older, which is when things start to change.

WHAT HAPPENS TO YOUR MENSTRUAL CYCLE AS YOU BECOME PERIMENOPAUSAL?

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As I have discussed above, the ovary is a hormone-producing organ that becomes less effective as you age, but it doesn’t just shut down and stop producing hormones. This is where so many doctors were so mistaken in their determination to explain to women how they had ‘run out’ of estrogen and why they needed hormone replacement therapy (HRT). During your fertile years, the main hormones produced by your ovaries are two types of estrogen (estradiol (E2), which is very potent, and estrone), progesterone and small amounts of androgen (see Chapter 2). As you approach menopause your changing ovaries produce estrogen in lower amounts and increased amounts of androgen. (Testosterone, the main male hormone, is an androgen.) At the same time the balance of the types of estrogen being produced changes and you begin to produce larger amounts of estrone and smaller amounts of estradiol. Your ovaries are still functioning, but less efficiently.

From your late thirties onwards an ageing process takes place. This varies widely among women. Each of us has a biological clock and the rate at which it ticks depends on the different biochemistry of each woman. This means that it may tick faster for some women, so their egg units become less efficient earlier, or more slowly for others, in whom the symptoms and signs of perimenopause appear later. The process may happen in your mid-thirties or in your late forties and may take from two to 14 years.

As you age your remaining egg units become progressively less efficient, regardless of the rate of your biological clock. Because the egg unit is becoming inefficient, which means that it is less responsive and less functional, the hypothalamus and pituitary gland respond accordingly. The pituitary has been doing its job month in and month out for many years, producing FSH, which means that there is a consistent level of hormones rising and falling during your most fertile years. When the pituitary ‘recognises’ that the remaining follicles are not responding to FSH as they used to, it increases the FSH production to try to force the follicles to respond, a process that may be slow and subtle in some women, and precipitous in others. This is the reason why so many doctors tell women they believe to be perimenopausal to have a blood test to see if their levels of FSH are rising.

WHY DO HORMONES FLUCTUATE DURING PERIMENOPAUSE?

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So, why do levels of estrogen rise and fall so erratically during the perimenopausal years? It’s quite simple really. The follicles in your ovaries are starting to show their age and are less effective, so their response at the beginning of your 28-day cycle is poorer. The pituitary, responding to the fact that the follicles aren’t doing their job, pumps out higher levels of FSH in a desperate effort to stimulate them and some follicles respond by pushing out large amounts of estrogen, sometimes much higher than average. If this happens you may ovulate and experience exaggerated symptoms of ovulation like sore breasts, heightened emotional responses and sugar cravings. If you have ovulated, your levels of progesterone rise and fall and you get a period, whic...