Peri-menopause is defined as the period of time that hormonal changes occur up until menopause. These changes are due to the decline in progesterone and wide variations in estrogen levels. It can start as early as your 30’s and last into your 50’s. During this time, menstrual cycles begin to change and can be heavier or lighter and more irregular. You might also have night sweats, hot flashes, weight gain, brain fog, anxiety, or insomnia. While fertility is declining, you still can become pregnant during this time. As you approach menopause, periods will become lighter and less frequent.

Menopause is defined as 1 year without a menstrual cycle. During menopause, the fluctuations in hormones eventually even out and most women have low or unmeasurable amounts of estrogen and progesterone. While some women may be celebrating their freedom from a monthly cycle, others experience mild to severe menopausal symptoms that affect quality of life. Many women will have symptoms such as hot flashes, night sweats, weight gain, anxiety or depression, reduced libido, and vaginal dryness. Some lucky women have almost no symptoms whatsoever. However, even without symptoms there are some health concerns that you should be aware of.

The major areas of concern in estrogen loss during menopause include:

1. Loss of bone mass: Estrogens are vital for maintaining bone mineral density. The estrogen levels decline in women undergoing menopause, leading to a decreased bone density (osteopenia and osteoporosis) and increased risk of fractures.
2. Cardiovascular disease: women in menopause are far more likely to have heart disease and less able to recover from cardiac events.
3. GI: estrogen protects against a variety of gastrointestinal diseases and as we age and our estrogen decreases, we are at greater risk for gastric cancer, ulcers, liver cancer, and reflux disease (GERD).
4. UTI: estrogen is protective against urinary tract infection and women in menopause are far more likely to get UTI.
5. Dementia: estrogen is protective against neurodegenerative diseases like dementia.
6. Melanoma: estrogen is protective against melanoma.

Reading all of this, you might be tempted to believe that all women need to start taking estrogen. This is not the case. It is important that hormone therapy be given at the right time to the right person. Given too late in life, it can lead to a greater RISK of dementia and cardiovascular disease. It’s also important to work with providers who understand your personal ideal hormone levels and the appropriate ways to monitor your blood work, bone density (DEXA) and mammograms.

What about hormone replacement?

Hormone replacement involves replacing the declining hormones to relieve the physical symptoms as well as provide you with reduced risk of diseases associated with low estrogen. For women in peri-menopause whose main symptoms are night sweats, irregular cycles, insomnia and anxiety, we typically prescribe oral progesterone. Some patients prefer the topical progesterone but we find that the oral is better for insomnia and anxiety. Once a woman is fully in menopause, we prescribe a combination of topical estrogen along with oral progesterone. We almost always give the progesterone to balance the estrogen effects and to help with symptoms. There are other methods of hormone delivery which you can discuss with your healthcare provider.
At Robinson MD we prescribe a special kind of hormone called a bio-identical hormone (also know as BHRT) which are compounds of the same chemical and molecular structure as hormones that we produce naturally in our bodies. We are also monitoring our patients regularly to make sure they are getting the correct dosages for their bodies.

Non hormonal interventions

Some women are not good candidates for BHRT or decide that they would prefer not to use this strategy. If this is you, there are some helpful non-hormonal strategies that you can employ:

• Vaginal creams or suppositories can be helpful for vaginal dryness and low libido. There are hormonal and non-hormonal formulations available.
• Supplements
  • Swedish Flower Pollen can be helpful for sweats and hot flashes. Most people do well on 300 mg once or twice per day.
  • Black Cohosh herb can also be helpful for flashing and sweats. Dosages range but 80-160 mg is good place to start.
• Diet/Lifestyle
  • Eat more soy. According to research, Soy isoflavones may help reduce hot flashes and night sweats that many women have during menopause. In clinical studies, postmenopausal women who eat high amounts of dietary soy protein (20 to 60 g per day) generally have fewer and less intense hot flashes and night sweats than those who eat less soy. And despite previous concerns about soy and breast cancer, recent studies support that soy may be protective against breast, prostate and other cancer. Sources of soy: organic tofu, miso, edamame and soy beans.
  • Ground flaxseed – 2-5 tablespoons per day can be helpful for hot flashes. It is also great for your GI and cardiovascular system. Keep open bags of ground flaxseed cold or frozen.
  • Stop smoking
  • Reduce alcohol consumption to less than 3 drinks per week
  • Yoga, meditation and tai chi all help us to manage stress which can have a profound effect on hormones and well-being in general

The bottom line is that, while menopause is inevitable, you do not have to suffer. There are many strategies that can help make this life transition easier.

Role of estrogen receptors in health and disease: frontiersin.org | nature.com

Endocrine Society Bioidentical hormones: position statement. 2006.

mountsinai.org

Chen M, Rao Y, Zheng Y, et al. Association between soy isoflavone intake and breast cancer risk for pre- and post-menopausal women: a meta-analysis of epidemiological studies. PLoS One. 2014;9(2):e89288