One of the things we’ve learned about menopause is that lower estrogen levels mean more than vaginal dryness, decreased libido and painful intercourse.
Perimenopause brings vast changes to a person’s life that can begin months or years before menopause. This transition is in some ways more difficult due to the dramatic fluctuations in the reproductive hormone levels during perimenopause. During this time, reproductive hormones are sometimes underproduced and sometimes overproduced as opposed to menopause when the reproductive hormones are at constantly low levels.
We used to think perimenopause started only months before the onset of menopause. Now we know perimenopause can begin four to eight years before menopause. Patients in perimenopause typically begin experiencing many of the symptoms associated menopause: hot flashes, night sweats, mood swings, trouble sleeping, vaginal dryness and more.
Managing the symptoms of perimenopause is an important way to significantly enhance quality of life for our midlife patients. In those without contraindications, continuous, low-dose birth control pills can provide a low, steady, continuous source of estrogen, thus treating the symptoms and providing needed contraception.
Menopause and estrogen
Menopause officially begins when periods spontaneously cease for 12 consecutive months with no other cause for amenorrhea. In North America, the median age of menopause is 51, with most ranging between 45 and 55.
One of the things we’ve learned about menopause is that lower estrogen levels mean more than vaginal dryness, decreased libido and painful intercourse. Less estrogen also can affect the bladder and urethra, potentially resulting in pain and burning with urination, urinary frequency and urgency and an increase in bladder and kidney infection. Patients often don’t associate these symptoms with menopause. Collectively, these vaginal and urinary symptoms are known as the genitourinary syndrome of menopause (GSM). Fortunately, there are a variety of vaginal moisturizers, lubricants and low-dose estrogen creams, gels and suppositories that effectively treat urinary and vaginal symptoms of menopause. For patients with mobility issues, ospemifene (Osphena) can offer GSM symptom relief in oral tablet form.
Many patients and couples are troubled by hypoactive sexual desire disorder (HSDD) during perimenopause and menopause. While there are some newer medications like bremelanotide (Vyleesi) and flibanserin (Addyi) to help with HSDD during perimenopause, we are still limited in options for addressing the complex issue of libido during menopause. This is frustrating for patients and providers given that half of all patients experience at least one sexual symptom of menopause.
Endogenous estrogen also benefits bones, the heart and the brain. In addition to hot flashes and night sweats, the loss of ovarian estrogen during menopause can result in a “brain fog,” making concentration and finding words difficult. Menopause also can mean less time spent in deep sleep. As a result, the quality of sleep becomes less restorative, which can be both distressing and disruptive.
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Also distressing is the weight gain that comes with perimenopause and menopause with hormone changes and a decrease in metabolism. The extra weight is redistributed differently. Instead of added pounds accumulating on the hips and thighs as it does for younger women, the extra weight collects around the abdomen.
Menopausal hormone therapy
Fortunately, while the indication for the use of menopausal hormone therapy (MHT) is moderate to severe hot flashes, osteoporosis treatment and/or vaginal atrophy, MHT also offers the side benefit of treating many of these other concerning symptoms of low estrogen. It is the estrogen component of combined hormone therapy that treats the symptoms of menopause while the progestin component protects the uterus from endometrial cancer. Patients with a uterus should not be given estrogen-only therapy.
Moreover, when started within 10 years of the last menstrual period, in healthy patients without contraindications, MHT is both safe and effective. When we give hormone therapy for menopause, we don’t want to use the lowest dose possible, we want to give the lowest effective dose for the shortest period of time needed (generally five years). Giving a subtherapeutic dose of estrogen that does not address the patient’s hot flashes or night sweats is not addressing symptoms that can be truly detrimental to a person’s quality of life.
Choosing when to transition off MHT can be tricky and requires an individualized approach. In general, MHT can be used with minimal risk in patients without contraindications up to age 59. Contraindications to menopausal hormone therapy include history of breast cancer, coronary artery disease, stroke, previous venous thromboembolic event, active liver disease and undiagnosed vaginal bleeding. When no contraindications are present, the North American Menopause Society (NAMS) and the American College of Obstetrics and Gynecology (ACOG) agree that the use of menopause hormone therapy should consider the individual patient’s clinical symptoms and risk-benefit ratio. These groups agree that symptomatic individuals may benefit from extended use beyond age 60 or even 65 with close clinician follow-up.
As patients transition off MHT, and for those who cannot or choose not to use MHT, there are effective and safe non-estrogen therapies to treat hot flashes and night sweats. These include low-dose gabapentin, selective serotonin reuptake inhibitors (SSRIs), selective serotonin-norepinephrine reuptake inhibitors (SNRIs) and clonidine. Similarly, low-dose vaginal estrogens are highly effective at relieving the genital and urinary symptoms of menopause.
Women typically live to 75 and beyond, therefore they are living more than a third of their lives in menopause. That’s a long time to live with distressing symptoms. Education is some of the most potent medicine we have: education for the patient, the partner, the family and for the provider. It’s important we stay informed and offer patients the best treatments available to address the many symptoms of menopause.
Tamara L. Callahan, M.D., is a gynecologist with Norton Women’s Care.