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MENOPAUSE: A STAGE IN LIFE, NOT A DISEASE
Yvette Smith, M.D., MPH, F.A.C.O.G.
There is little about our lives that is static. The only constant for many of us is the inevitability of change. That it extends to our reproductive lives should not come as a surprise, but many women are startled when faced with this prospect. Our cramps worsen or lighten, our periods last for longer or shorter number of days, and our flow is heavier or lighter. This is a normal phenomenon for most women. When the changes are extreme it is worthwhile to verify that there is no physical problem to explain the change, but frequently the answer is simply that we all change.
One of the most dramatic changes we all experienced was that of puberty. Take a moment to think back to those days. Do you remember being taller than many of the boys? Feeling awkward with the changes going on in your body? Developing slower or faster than your friends? Being mortified when your period started at school or a friend's house? Were you prepared to see hair growth in new and unexpected places?
On average, the changes that occur with puberty occur over a 4-½ year time span. They include accelerated growth, breast budding, adult pattern body hair and menses. Ovulation and the capacity to conceive and bear children is a relatively late finding in puberty. What dramatic changes our bodies experienced during that phase of our lives! I would have to work hard to convince you that puberty is not a disease process. Puberty is viewed as simply a stage in life, a necessary part of our evolution into adults. We not only survived this transition, we prospered.
In a similar fashion our bodies are undergoing dramatic changes during menopause and the surrounding transitional years. Acute symptoms from these changes may be present for a variable amount of time. Once we understand this process it is easier to accept that menopause and the surrounding years should be viewed as another stage in life. And once again not only will we survive, but also we will prosper.
Menopause can present as a nagging question for many women. Frequently, women present to their physicians with complaints that they are unable to explain. It can be perplexing to experience hot flashes but still have regular periods. How are you to interpret worsening premenstrual syndrome or the new onset of mood swings? We now realize that the transition into menopause may present in many different ways for different women.
Menopause, or the "change of life," has not been a subject of much interest in the past. We know that sometime after age forty, and we really don't know when exactly, a woman will change. Our mothers went through it, but it wasn't talked about. As a result, we are left with little or no knowledge about this natural occurrence. Our memories of this time for our mother may be that she did not change at all. Some of us remember that our mothers became depressed, withdrawn, more irritable or had mood swings. We were vaguely aware that it was related to hormones and menstruation, but really nothing more as known.
Menopause is the cessation of ovarian function. We no longer produce eggs or estrogen. On average, menopause occurs at age 51 in the United States. However, the "change of life" takes place in a woman's body over a span of about 5 to 7 years. At this time we begin to see a decline in estrogen levels.
When we get into our forties women often notice changes and begin to wonder if this might be menopause. What we are experiencing are subtle changes due to declining estrogen levels.
Reaching the age of forty brings with it certain anxieties and fears, so much so that some of us stay thirty-nine forever. We suddenly become more aware of our health and may experience different feelings, especially some fear of "falling apart," "I'm losing my mind,"" I ache all over," "I've lost interest in sex," "I can't control my weight" or "I'm out of control" are not uncommon. As we pass into our forties we wonder what will happen to us physically, psychologically, and sexually. Lack of knowledge about this process only intensifies our fears.
During the reproductive years our hormones are constantly changing in a predictable, orderly rhythm, the ebb and flow of the hormones are like a well-orchestrated symphony. Each musical instrument plays at timely intervals. During the transitional years, hormones are no longer synchronized. Let us imagine the orchestra warming up, with each instrument playing independently of each other, each instrument playing its own tune and the cacophony that can ensue. That is the transition into menopause. We no longer have a predictable interplay of hormones or predictable hormone levels. Hormones are up and down from day to day, sometimes in a haphazard manner and the dissonance can be expressed as numerous symptoms. The symptoms are a direct effect of our individual response to the variation in hormone levels.
Menstrual cycles may become more frequent, every 21 days is not uncommon. Or the menstrual cycles may become less frequent. Some women experience no change in cycle length but find that the flow pattern is lighter or heavier. Perhaps the number of days have increased or decreased. Premenstrual spotting might occur. It's also possible to have a combination of different patterns. Menses may be regular for several months and then become very irregular. The point I'm trying to illustrate is that there are no fixed patterns to the transitional years. One month they have a period and the next month they have none, this is the beginning and end of their symptoms of menopause.
A female is born with all the eggs that she will ever have, about 500,000. Each month, starting in the teenage years, hormones from a small gland in the brain cause hundreds of these eggs to ripen. Only one grows to maturity and then is released from the ovary through the process of ovulation. The rest of the eggs die, but in the process estrogen and progesterone are released. This process repeats itself monthly during the reproductive years.
During the transitional years, the number of eggs remaining in the ovary decline. The reduction in the number of eggs means a woman will not continue to produce large amounts of estrogen. As a result, estrogen levels will fluctuate and begin to decline. Ovulation may or may not occur every month. Progesterone, which is produced at the time of ovulation may be absent if ovulation does not occur. Progesterone has a central role in the regulation of periods; in its absence the menstrual cycles may be irregular. You can see that the ovary's inability to produce eggs consistently results in fluctuating hormone production. Even though we haven't reached menopause and are still producing estrogen, we experience the symptoms of menopause because of these hormone fluctuations.
Hot flashes, night sweats, sleep disorders, mood swings, and depression and loss of sexual interest can be symptoms of menopause. They may be present as transient symptoms when hormone levels are low. We may experience these symptoms for a few weeks and then be without symptoms for months. All of this is explained by the variable ability of the ovary to produce eggs and hormones. It also depends on your body's response to this variation. Symptoms come and go, depending upon the ups and downs of our hormones.
The loss of reproductive ability is viewed differently by different women. Some women experience true grief regardless of their real desire to have more children. They grieve the loss of the possibility of childbearing. Other women feel great relief. No longer do they have to worry about contraception. Many women rejoice as they look forward to years without sanitary products of premenstrual symptoms. Some women are surprised at their emotional reaction to this event, not realizing how strongly they had identified with their role as child bearer. These emotional aspects certainly contribute in some fashion to our perception of the entire transition.
There are many other approaches to deal with during this time in our lives. This is an excellent time to reassess our health status and habits. Maximizing other aspects of our lives may help ameliorate many bothersome symptoms in the transition. And of course, the positive influence of good nutrition and regular exercise cannot be overstated.
I saw a woman in my office one day who was distraught. She spent most of our visit wiping the tears from her eyes and apologizing. The refrain she repeated time after time was, "This just isn't me." Her symptoms were not severe or incapacitating by her own report, but they left her feeling bewildered and ill at ease. She complained of feeling weepy and irritable and missed her old cheerful personality. We discussed hormonal and non-hormonal methods of treatment. We talked about the role of regular exercise and good nutrition in controlling some of these symptoms. We covered topics that included biofeedback techniques, meditation, massage and counseling as different avenues that have been useful for different women going through the transition. Our visit was lengthy and I believe useful for this woman. When she left, she thanked me for providing some very valuable information. One piece of information she found useful at this initial visit was the transitory nature of this change. She had thought that her old self was lost forever and received tremendous relief from knowing that these hormonal fluctuations were not permanent. Unfortunately I could not guarantee when these symptoms would abate, but they will abate in time. Managing that time is very much an individual discussion.
It is important that women feel comfortable discussing the changes they are experiencing with their physician or other healthcare provider. Take advantage of the resources now widely available to arm yourself with knowledge about this important time in your life. As our knowledge grows, our fears will lessen and we will be better able to navigate this and further transitions in our lives.
Yvette Smith, MD, MPH, FACOG, is board certified in obstetrics and gynecology. She has been employed by Atlanta Women's Specialists since 1991.
