UNDERSTANDING
PERIMENOPAUSE
&
MENOPAUSE
PERIMENOPAUSE
Gradual decline of ovarian reserve 8+ years prior to menopause
Definition by STRAW Criteria: time of hormonal changes at 2-8 yr prior to menopause
Early: consistent 7+ day variability in cycle
Late: intervals between periods 60+ days
LABS:
Gradual decline in progesterone over years
Estradiol is erratically high/low initially, eventially drops low
MENOPAUSE
Most women will enter menopause between the ages of 45-55
Early menopause: younger than 45
Clinical definition of menopause: 1 year after your final menstrual period*
*Addressing symptoms & therapy should not be based on this single definition
No labs are required to diagnose menopause but usually FSH is very high and estradiol is very low
Postmenopause: every day after your date of menopause
COMMON SYMPTOMS
IN BOTH
PERIMENOPAUSE & MENOPAUSE
Hot flashes, night sweats
Brain fog/memory decline/difficulty with concentration
Mood: anxiety/depression
Fatigue
Insomnia/sleep disturbances
Weight gain
Loss of libido, vaginal dryness, pain with intercourse
Reduced bone mineral density (usually asymptomatic at this stage)
If you are suffering from these symptoms, you are not alone.
Unfortunately, we see this list commonly in patients who come to us.
7 years ago when patients on HRT came to us and described how hormone therapy had restored their lives, we were listening.
Their experiences did not add up with the well known Women’s Health Initiative (WHI) studies and standard clinical guidelines.
We began monitoring hormones then but promised to expand to prescribing hormone therapy when we had extensively studied the literature and completed menopause & HRT training – to know we were offering our patients the safest and most beneficial options whether general practices and guidelines had caught up or not.
WHERE ARE YOUR HORMONES COMING FROM IN MENOPAUSE?
Ovaries will no longer make estradiol or progesterone, but they continue to make testosterone (gradually declines with age)
Adrenal glands will now take over androgen production. These androgen hormones will convert mostly in fat tissue to estrogens.
90% of the postmenopausal estrogens will be made in peripheral fat tissue.
If there was ONE POINT to understand about menopause-
This is NOT limited to the reproductive system
Estrogen, progesterone, and testosterone affect
ALL of our organs.
BENEFITS OF
ESTROGEN THERAPY
Reduces risk of osteoporosis and fractures
Reduces cardiovascular risk
May improve muscle mass
May improve sleep
May improve cognition
Better weight management
Improves mood
Improves skin elasticity and health
May reduce hair loss
May reducing joint pain
Reduce hot flashes
Improve vaginal dryness, pain with intercourse, vaginal health
Reduces/prevent recurrent urinary tract infections
BENEFITS OF
PROGESTERONE THERAPY
Prevention of endometrial hyperplasia and endometrial cancer
Improves bone mineral density (promotes new bone growth)
Improves mood disorders (particularly anxiety)
Improves sleep
Reduces hot flashes
May have brain protective effects
A LITTLE ABOUT TESTOSTERONE…
While men have much more, this is not only a male hormone.
Women have more androgen receptors than estrogen receptors.
To glimpse what this hormone is doing, we have to understand androgen receptors in women are found in:
Hair follicles, skin, brain, spinal cord, nerves, eyes, ears, thyroid,
cardiovascular tissue, breasts, lungs, uterus, vagina, bladder,
gastrointestinal tract, kidneys, liver, adrenal glands,
muscle, joints, fat tissue, bone, and other endocrine glands
Yet the only approved indication by clinical guidelines for treating a woman who has measured very low testosterone levels is:
Hypoactive Sexual Desire Disorder
They acknowledge the importance of correcting all other hormones, yet do not have enough evidence testosterone levels are important for women.
At the menopause clinic, proper testing and treatment around this will be a personal discussion with our patient. We do avoid supraphysiologic dosing as there can be serious consequences down the road with this.
There are also risks to consider with hormone therapy. These are generally outweighed by the benefits, but should be discussed thoroughly with your doctor. Many of these risks can be mitigated by product type and route of administration.
WHY WE TEST:
After decades of practicing medicine, we know the standard “one size fits all” approach does not work.
Current practices argue that it is sufficient to treat symptoms and ignore levels. We disagree.
Patients come to us from different practices with extremely high levels of unmonitored hormones, while others have levels which remain below the menopausal range despite treatment. Neither are asymptomatic, and neither are benefitting from the assumption that absorption and hormone metabolism will be the same in all. We test, adjust, and offer continued monitoring.
Hormonal Replacement Therapy is not the single answer alone. Your hormones work in symphony with the rest of you – in order to do this properly – we can’t leave your HPA axis, HPO axis, and thyroid stuck in dysfunctional patterns.
We look at your hormone production & metabolism, adrenal health markers, inflammation, and detoxing capacity to understand where to meet you in hormone replacement. When hormones can be optimized to match your needs, you will find benefit from a dose designed to your own body.
Ongoing cardiovascular, endometrial, breast, and bone surveillance is necessary.
How do you metabolize your estrogen? This is a critical question to address for both hormone replacement therapy as well as to reducing modifiable risk factors for breast cancer and endometriosis. Mammogram screening is an important tool, but we choose to take a proactive approach with our patients – evaluate their estrogen metabolism pathways, and then work to optimize these paths. These efforts can reduce the risk of developing breast cancer in the future.
One of the reasons we gain weight in perimenopause –
As ovarian estrogen drops, FSH stimulates
FAT tissue growth
since fat tissue produces compensatory estrogen
YET, HRT in this critical period of weight gain
is often DELAYED
YES, hormones are fluctuating at this time, but
that just means
we need to learn to test properly
We are in an epidemic of hormonal dysregulation over the past 50 years –
from severe PMS/PMDD to PCOS & endometriosis to infertility to adrenal dysfunction to
severe and earlier menopause and perimenopause transition.
We need to treat this conscientiously.
Guidelines still don’t recommend testing for perimenopause or menopause since it’s complicated and difficult to decipher.
Yes, it IS complicated,
but that just means the medical community needs to
TRY HARDER FOR WOMEN –
We absolutely DO test with complete evaluations
Testing has been proven reliable when done properly*
*We will be providing details on this with research study references.
MORE IMPORTANTLY,
THE “NO NEED TO TEST” ATTITUDE CAUSES HARM
BELOW ARE A FEW CASES WE HAVE SEEN
55 yo female in menopause x 6 years with hot flashes – her baseline estradiol without hormone therapy is in the luteal range of a premenstrual woman. (yes, this can happen if aromatization to estrogen in fat tissue is high)
A/P: She already has unopposed estrogen which increases her risk for uterine cancer. Blindly placing her on additional estrogen therapy would be poor practice and may worsen symptoms as her night sweats are not due to estrogen deficiency.
59 yo female in menopause, history of hysterectomy on estradiol therapy. Her serum and urine 4 spot testing of estradiol show she is in the menopausal range.
A/P: We know from clinical studies the goal range required to achieve bone protection and other clinical outcomes. How many years has she lost taking a subtherapeutic dose? This scenario is common
49 yo female in menopause – her baseline levels are in menopausal range, but evaluating her estrogen metabolites – her 4-OH-E1 is high – in the luteal range of a premenopausal female.
A/P: High 4-OH-E1 increases the risk of breast cancer. Improving her detoxing pathways are important prior to starting HRT
43 yo female, irregular cycles, very high stress due to young children and caring for elderly parents, and demanding job with long hours – she is started on HRT without looking further at thyroid function, adrenal function, vitamin levels, lifestyle factors, or nutrition.
A/P: While HRT could still be the right option, this should never be assumed without properly addressing other possible culprits that once corrected, could normalize her own hormones.
Additional Resources for Patients:
The materials and content mentioned on this site are intended as general information and should not be used as a substitute for personal medical advice, diagnosis, or treatment. This website does not qualify as creating a provider-patient relationship between us and any user of the website
Menopause care- Perimenopause Treatment- Menopause specialists- Menopause clinic