Category: perimenopause

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

Crying by the dumpster outside of Olga’s

I just have to relay this story a patient told me the other day. Let me set up the scenario. So, this patient has a large family. Her children’s ages range from elementary school to college. Some of them are still at home. Some are off at college. She has always had a close relationship with her kids. You could even say that she values them even more than she values herself. She is a perimenopausal woman with let’s say more than her share of hormonal and mood lability, as all of us perimenopausal and menopausal women do. To say that she can be oversensitive at times is probably true. We all can. Let’s add to that the fact that college age kids who have moved out have a very different sense of what is appropriate and acceptable with regard to conversation and “house rules” than elementary age kids do. It’s a recipe for absolute peace and harmony right? That was rhetorical. Of course it isn’t.

Ok now that I have the stage set, let’s look at what happened. The college kids came home for the weekend, one of whom had not been home in months. The whole family goes out to dinner. My patient is super excited to see everybody and hang out. She has already had an emotional day and she can’t to hug the college kids and maybe even play with her daughter’s hair like she used to. She gets totally rebuffed. Now she is already hurt and trying to hide it while they are all sitting there eating, but the hurt is slowly welling up, threatening to take over just the same. Then the conversation starts and she hears her older children making conversation that is just plain uncomfortable for her. She is not sure if they are just trying to be sarcastic and funny or just plain hurtful. When she tries to interject, they just look at her like she is from another planet with that “What’s the problem” expression. Finally, she feels herself losing emotional control and announces that she is going to just go home rather than cause some sort of fight during what was supposed to be a nice family night out. They look at her and laugh and remind her that she doesn’t have a car because they drove. By then she is really embarrassed but can’t back out now and leaves the restaurant, only to find herself crying outside by the restaurant dumpster.

Oh the humanity. That story completely sucks right? It embarrassing. It’s humiliating. There is miscommunication everywhere. The kids probably didn’t realize that the mom was already emotional. The mom probably didn’t realize that the kids were just trying to act grown up and show off their intellectual prowess. It’s just a no win scenario. You are thinking to yourself, I would never do that. I say au contraire! I am willing to bet that there are a lot of moms out there that have been in a similar situation. C’mon you can admit it. Being a mom to college age kids or any kids that have moved out of the house is way harder than you think. Whatever scenarios you thought you had handles when they were teens living at home have paved the way for a whole new set of scenarios to slog through best you can. They have been living on their own without supervision.( Yes that’s right. I am saying that dorm resident advisors are not all they are cracked up to be.) They have been setting their own rules and curfews. They are probably having sex. They have linked up with all kinds of kids from all over the world with all kinds of opinions that you probably don’t share. On top of that, those opinions may or may not be based on any known facts, but they sound cool to spout out with their friends. You as the mom are no longer their primary influence and you are definitely not as cool as they once thought you were now that their horizons have widened. Ugh! Now add on top of that the fact that you are probably at least perimenopausal if not postmenopausal with hot flashes, labile moods and fluctuating hormones and, even on a good day, you could rocket from singing with the radio to screaming or bawling your eyes out in less than 10 seconds. These are the kinds of elements that lead up to the story from above. These are the kinds of elements that foster miscommunications and misunderstandings of epic proportions if you are not conscious of what’s at play. My poor patient and her family were set up from the start from both ends. She was all emotional and ready to bond ” with her babies.” . The kids were ready to joke and act like their interpretation of grown ups. It was set up to fail.

Raising college age kids sounds like a misnomer doesn’t it? A lot of people think that once they are 18, your job is over. Likewise, a lot of college age youth think that they are ready to be fully in charge. Well, neither perspective is really accurate. Our kids will always be our kids and we will always be their parents. We will always have some level of investment in how they end up in the world. That being said, we also have to be ready to modulate our mutual roles in a way that is acceptable to both parties if possible. Sometimes it is not possible, but we have to at least try. As much as I miss picking up my kids and tossing them into the air or playing with their hair and cuddling, I realize that they are just not as up for it as they used to be. I can try to resort to emotional blackmail, but it won’t get me anywhere. I have to realize that these things don’t mean that they don’t love me or love me any less. They are just evolving in how they chose to bond with me. I can sit there hoping that one of them is going to jump into my lap one day and want me to read them a story, but it is not likely to happen. Instead, we might have a conversation about politics(yuck) or what’s going on at school or I just listen to long, what they think is eloquent, speeches about what is important to them at the time. I am just kidding, I love hearing about what is important to them an I love to watch how their thought processes change over time and the evolution of their responses to certain situations. What I don’t love, is if those speeches turn snarky, satirical and hurtful without purpose. If they do, it is up to me to remind them that no matter what opinion they have, it is still their responsibility to voice it responsibly and remain a good human being. Sometimes, as they are espousing away, they don’t even realize that the person listening might think they are just being a jerk, rather than impressing the with their intellectual brilliance. In terms of voicing things responsibly, I also realize now that I am better off if I give people a heads up if I know I am having a perimenopausal emotion buffet day before I head off to any family outings. This system is not fool proof, but it is worth the effort, if you want to still bond with your kids as they get older. The old adage by Khalil Gibran says that ” If you love somebody, let them go for if they return, they were always yours. If they don’t, they never were. ” I think this means that we have to loosen the reigns and adapt a bit within reason as our kids get older. Then hopefully, they will come back some day, realizing just how cool we really were the whole time! Have a fantastic day everyone!

Dr. Katz