Perimenopause is not for pussies!

Hello all you perimenopausal power women out there! I know there are millions of you at any one time, trying to suppress labile emotions, fighting “power surges.” lamenting over vaginas of sandpaper, etc. Even though menopause is not a pathologic process per se, sometimes it sure feels like one! Fear not! You are not alone! I am right there with you!

Let’s shed a little light on the overall perimenopause and menopause process. First, let’s not get all hung up on terminology. For the sake of this blog, let’s define perimenopause as that magical period of time during which the ovary’s waning hormone levels and decreasing population of eggs to shoot out of a corpus luteal cannon cause a variety of unexpected and unpleasant symptoms. Let’s then define menopause as the point when “it’s all over.” The FSH( follicle-stimulating hormone) is consistently over 30. The last egg has left the gate. The uterus has shed its last lining, along with the last hope for babymaking. The last period is at least one year in the rear view window. Although I am going to tell you upfront that just because the last egg left the building and periods have stopped, the symptoms are not completely gone, but we will get to that later.

So, why the heck do we care about hormones anyway? What do they actually do? Do we need them? What the hell is a hormone anyway? A hormone is defined as a regulatory substance produced in an organism and transported in tissue fluids such as blood or sap to stimulate specific cells or tissues into action. It can also be defined as a synthetic substance with an effect similar to that of an animal or plant hormone. What? Heh? Let’s narrow this down and talk about the big 3: Progesterone, Estrogen, and Testosterone. These are the key hormones in our bodies, all of which are made by the ovaries. Yup, that’s right, even testosterone. It’s not just for guys anymore ladies. So now let’s talk about what each one of those hormones does. As it turns out, hormones help with over 400, that’s right 400,bodily functions. To go over all 400 would be a little bit beyond the scope of this blog, but let’s at least break some of the main ones down. I bet there are some that will surprise you.

Let’s start with estrogen. So, estrogen alone has like 400 different functions in the body. They include the following: 1) simulate the production of choline acetyltransferase( an enzyme that helps fight Alzheimers), 2) increase metabolic rate( don’t we all miss this one?), 3) improve insulin sensitivity, 4) regulate body temperature( hello hot flashes), 5) maintain muscle, 6) reduce risk of cataracts, 7) aids in formation of neurotransmitters like serotonin which decreases depression, irritability, anxiety, etc and 8) maintain bone density. Ok so you get it. There are a ton of things that estrogen plays a role in.

Now there’s progesterone. It helps with many things too, although it is not quite the rock star that estrogen is and has been vilified and then praised back and forth in many studies. Let’s talk about a few of the good things it can do. It helps balance estrogen. It helps to improve sleep. It has a natural calming effect. It helps lower high blood pressure. It increases metabolic rate. It can help the body use and eliminate fats. It is a natural diuretic. It also protects the uterine lining from excess estrogen effects. These are just some of the things that progesterone can do.

Then there is testosterone. Yes ladies. I was shocked too when I first learned that my ovaries made testosterone. Isn’t that for dudes only? Nope. We need testosterone too! Testosterone helps increase our sexual interest. It increases our sense of emotional well-being. It increases muscle mass and strength. It helps maintain memory. It helps stop skin from sagging. It elevates norepinephrine in the brain. It helps decrease excess body fat. Sounds pretty great right?

Ok, these hormones sound pretty useful don’t they? I can see why we would miss them when menopause comes and they all start circling the proverbial drain like a clump of hair in the shower. Keeping these hormones in balance is pretty key to our quality of life, if nothing else, as well as keeping some important bodily functions on track. When they get out of balance we start feeling pretty miserable. I get that some very important, although in my opinion skewed, studies have really muddied the waters as far as how to approach menopause and hormone therapy. I for one, remain a fan of hormone therapy in the right patient with the right risk profile who is also compliant.

So what happens when these hormones all start decreasing and /or getting out of balance? That’s right! The road to menopause has begun! That’s when we start getting all the traditional ones like mood swings, hot flashes, and vaginal dryness. But let’s not forget some of the lesser known symptoms like flatulence( farting too much), palpitations, hair growth on our faces, weird dreams or not sleeping at all, osteoporosis, peeing on ourselves, or forgetting what we were saying. I mean. Who doesn’t enjoy announcing your presence in a room with a not-so-silent, deadly episode of farting? Yup, we can blame menopause whenever we let one rip ladies. Enjoy!

So when can we expect this little bundle of change joy? Well, average age of onset of menopause in a non-smoking female in the United States ranges from 35 to 55. That is a huge range. Average duration of the transition of perimenopause into menopause ranges from 6 months to several years. The expectation is that once you are in menopause, you should be symptoms free right? Well, this may be true in terms of some of the symptoms like hot flashes, but I can tell ya that there are still days that I fart like a champion and can’t fall asleep despite a bottle of Benadryl. Ok. I am kidding. I do not drink a whole bottle of Benadryl, but you get the point. On the other side of the coin, I have some unfortunate patients who are still having hot flashes into their 80s and swear that they would die without their estrogen patch.

Take heart, ladies! There are options to restore your quality of life. A lot of women out there are afraid of hormone therapy, but it is a viable option. Current national recommendations say to use the lowest dose for the least amount of time, whatever the hell that means. It has always sounded a little obtuse to me. I do use hormones in my practice, after I have counselled the patient on the pros and cons, evaluated their personal risk profile and their family history, and have assured myself of their compliance. Some of my patients are on traditional/commercial hormone therapy. What I call traditional hormone therapy is the prescription hormone therapy that your insurance covers like estrace, provera, etc. Some of my patients are on bioidentical compounded hormone therapy. The differences between the two are not as extensive as one would think. I know that people like to refer to bioidentical hormone therapy as more natural, but be careful of the word natural. I think sometimes that people hide behind the word natural as if it implies some kind of increased safety. That is not necessarily the case. There are plant based products on both sides. There are possible side effects and risks on both sides. Estrogens are estrogens, whether they come from horse pee or yams. Both of them affect body receptors. Personally, I think that the one advantage bioidentical hormones have over traditional hormones is that I can individualize dosing in hundreds of different ways, as opposed to the 4 or 5 dosing regimens available with most commercial hormones.

Hormone replacement therapy really is the best option for quality of life. Having said that, some of my patients cannot take hormones because of their own personal risk profile. No biggie. We have other options. Sometimes I use herbs, vitamins and supplements. Sometimes I use serotonin uptake inhibitors like Prozac. I realize that Effexor is what is in vogue right now, but I prefer Prozac any day. It is the only one with a weight loss side effect and the weaning process is a lot less brutal when you are ready to be off of it. If I can be less emotional, less hot flashy, and lose some weight in the process? Count me in! We can protect your bones with other medicines like Alendronate or Denosumab so we have that covered as well. We will get you through somehow!

To sum up, menopause can sometimes really get you down. It’s not a disease. It’s a transition. You are still you! Those hormone imbalances can overtake you, put you on the emotional roller coaster from hell, make you sweat and win you first prize in a flatulence contest. The process is different for everyone….but we have the tools to help you get through it. Happy farting!

Dr. Katz

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