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After years of periods that were as regular as clockwork, everything began going crazy when Denise Crandall turned 40. "When I started getting very heavy periods every two weeks I thought, 'This is ridiculous,' and went to see my gynecologist," says Crandall, a 42-year-old mother of two active boys, 12 and 9, who lives in Manhattan Beach, California. She was also suffering from crippling migraines and would sometimes awake in the middle of the night drenched in sweat.
When a series of tests ruled out all the scarier possibilities, such as uterine cancer, it became clear that Crandall was going through perimenopause, the transition between normal menstrual cycles and full-blown menopause. Her doctor prescribed birth control pills, which steadied the hormone swings that were causing her symptoms, and Crandall felt like her old self again. "It's heaven," she says.
Many women in their early 40s and even mid-30s are caught off guard by symptoms like Crandall's that they don't connect to the menopause transition -- from early hot flashes that feel a lot like fever to menstrual bleeding that becomes more or less frequent, heavy, light, or just plain unpredictable. These changes may come on gradually and often mimic PMS: feeling cranky, anxious, and depressed; gaining weight; having trouble sleeping; being exhausted. Some might also signal serious conditions that aren't related to menopause.
But they're most likely connected to the wildly fluctuating levels of estrogen and progesterone women get as the ovaries begin to shut down.
"Perimenopause" is a term that gets tossed around a lot without people knowing exactly what it means. As Crandall learned, doctors define it as the transition period when normal menstrual cycles begin to change in frequency and duration and ending at menopause, which you reach after 12 months with no period. Although menopause is technically just one day in your life (after that you are "postmenopausal"), you can be in perimenopause for 10 years or longer, during which time you are still very much capable of becoming pregnant. The average age for reaching menopause not brought on by surgery or chemotherapy is 51.4, according to JoAnn V. Pinkerton, MD, medical director of the Midlife Health Center at the University of Virginia. Only about 1 percent of women reach it before 40 and an additional 5 percent between 40 and 45.
Perimenopause's swings in hormone levels are what spark abnormal bleeding. Expect two distinct phases: First, periods become shorter and come closer together as the egg sacs (follicles) in the ovaries produce less progesterone. Over time, estrogen production also drops and women enter the later stage: "Women are still producing some estrogen, but it's not enough to necessarily stimulate the endometrium and ultimately result in a period," says Isaac Schiff, MD, a professor of obstetrics and gynecology at Harvard Medical School. This makes periods even more unpredictable and other symptoms more intense. Intervals between periods can be shorter or longer, and blood flow may be scanty to profuse.
As ovulation becomes more erratic, diminishing levels of progesterone (the hormone that prevents too much tissue buildup in the uterus) may lead to longer and heavier periods. You might go a few months without a period and worry you're pregnant -- and then get one again. Or you might actually be pregnant.
Although fertility declines with age, women in their 40s are second only to teenagers in their rate of unintended pregnancies, says Dr. Pinkerton, who is also on the board of the North American Menopause Society. "Because they are not ovulating regularly, perimenopausal women are at risk for getting pregnant throughout their cycle, even when they are bleeding," she says. "As a consequence, they really need to be conscientious about contraception."
Decreasing hormone levels also increase vulnerability to some diseases. Lower estrogen levels make the body start to lose bone faster than it can replace it (the greatest loss in women not on hormone therapy [HT] is in the six years after menopause and then the decrease levels off), which in turn increases the risk of osteoporosis. There may also be changes in blood cholesterol levels, such as a rise in the "bad" LDL cholesterol and a decrease in the "good" HDL, which make us more susceptible to heart disease. They also produce other uncomfortable symptoms -- eyes may get drier, night sweats can cause insomnia, and vaginal tissue can become thinner, with lessened lubrication, which can make sex uncomfortable.
Unpredictable periods and haywire hormones can also inhibit libido, making women less interested in having sex. Recent research indicates that about a third of pre- and postmenopausal women have sexual problems. Yet other studies suggest that our menopausal status isn't the sole culprit: Too much stress and other problems with mental and physical well-being can also be factors.
Unfortunately, symptoms are the only guide. The blood test that looks at follicle stimulating hormone (FSH), a female hormone that identifies fertility, only indicates whether you have passed menopause.
For women who take oral contraceptives, figuring out what's going on can be even more complicated because these drugs smooth out hormonal swings. And though they prevent you from ovulating, most still cause the monthly shedding of the uterine lining that seems like natural menstruation.
Experts recommend that women on the pill periodically take an FSH test at the end of a pill-free week, starting around age 50, to see whether their levels mean they've reached menopause. The reason it's important? Oral contraceptives can be as much as four times stronger than HT; you don't want to take them if you no longer need them. On the flip side, HT doesn't dampen ovarian function: You can still get pregnant taking it.
Bear in mind that you may have to take the FSH test more than once to know for sure that you've passed through menopause. "That's because the ovaries don't die in one fell swoop -- they usually sputter near the end," says Steven Goldstein, MD, a professor of obstetrics and gynecology at New York University School of Medicine and author of Could It Be...Perimenopause?
So what can you do to get through perimenopause if your symptoms are causing discomfort or distress? Start by identifying and changing behaviors that may provoke or intensify them, says Nancy Fugate Woods, PhD, dean of the School of Nursing at the University of Washington, in Seattle, and a menopause expert.
This is also a good time to take stock of your health habits and make needed lifestyle changes that not only can smooth this transition but also prevent problems later on, says Mary Jane Minkin, MD, a gynecologist at Yale University School of Medicine and author of A Woman's Guide to Menopause and Perimenopause. Eat better, exercise more, drop those excess pounds, and stop smoking, if you haven't already done so.
Here's a rundown of what helps ease the symptoms that bother many women:
Hot flashes. Focus on avoiding known triggers -- anything that elevates core body temperature, including hot weather, hot beverages, and spicy food. Keep your bedroom and workplace cool, drink cold beverages, and dress in loose layers so you can take off clothes if necessary. Cut down on coffee and alcohol; both cause blood vessels to constrict, which can contribute to hot flashes. And take a deep breath: A deep-breathing technique called paced respiration, in which you take slow, deep, full breaths, can avert hot flashes if you feel one coming
Insomnia. Go to bed and get up at the same time every day. Avoid drinking alcohol or caffeinated drinks for six hours before bedtime. Exercising early in the day will help sleep; avoid exercising in the evenings, which can get you too revved up. And stop smoking, if you haven't already: One of the many bad effects that nicotine has on health is that it's a stimulant that makes it harder to fall asleep. Be aware, though, that insomnia is also a common side effect of nicotine withdrawal. Eventually this side effect goes away.
Heart disease. To counteract the hormonal changes that could raise cholesterol levels, eat low-fat, high-fiber foods -- fruits, vegetables, and whole grains. Get at least 30 minutes of aerobic exercise most days of the week.
Bone loss. Eat a diet rich in calcium: foods such as dairy products, fortified orange juice, salmon, almonds, and soybeans. According to the National Osteoporosis Foundation, women over age 50 need 1,200 milligrams of calcium and 800 to 1,000 IUs of vitamin D daily, using supplements to augment what they don't get from food. (Those under 50 need 1,000 milligrams and 400 to 800 IUs, respectively.) Stimulate bone tissue and improve your balance with 30 minutes a day of weight-bearing exercise, such as brisk walking, jogging, hiking, stair climbing, step aerobics, dancing, and racquet sports. Too busy for that? Ten minutes at a time can do the trick.
Weight gain. Out-of-whack hormones aren't why women tend to gain five to eight pounds during perimenopause. Metabolism slows as we age, and men can pack on pounds, too. "But there's an excellent antidote to this -- it's called exercise," says Dr. Minkin. "It'll boost your metabolic rate and increase your lean muscle mass, so you burn more calories." Do at least 30 minutes a day, if possible.
Vaginal dryness. Over-the-counter vaginal moisturizers, such as Replens, can relieve dryness and itching. Lubricants like K-Y Jelly or Astroglide can make intercourse less painful. Vaginal estrogen can also relieve symptoms. Studies show that exercise enhances one's sex life by maintaining blood flow to genital tissues. And having sex regularly also helps maintain vaginal lubrication and comfort.
Dry eyes. Lubricating eyedrops may alleviate that scratchy feeling. Eating at least four servings a week of food that contains omega-3 fatty acids, such as tuna, salmon, sardines, herring, flaxseed and canola oil, soybeans, and walnuts, can reduce the risk of dry eye by nearly 17 percent. Though the research has been on food, you can also try using omega-3 fatty acid supplements (flaxseed oil). Although there are no official recommendations about how much people should take, some doctors suggest choosing one that provides 2 to 3 grams in a daily dose.
If lifestyle changes don't do enough, consult your gynecologist. Low-dose contraceptives are normally the best bet to restore hormonal balance. Some doctors prescribe Loestrin 24 Fe, which contains 20 micrograms of estrogen per pill. The NuvaRing 21-day vaginal insert also delivers a consistent low dose of birth control hormones.
"[Low-dose birth control products] can diminish estrogen-deficiency-related symptoms, such as heavy bleeding, mood swings, inability to concentrate, sleep disturbances, vaginal dryness, and free-floating anxiety," says Dr. Goldstein.
If you can't tolerate estrogen -- some women get migraines or breast tenderness -- low doses of progesterone alone may do the trick. "It's fine for a year or two," says Dr. Minkin.
For women who don't want to or shouldn't take birth control pills because they have a strong family history of breast cancer or have had it, they smoke, or tend to form blood clots, there are a number of other alternatives to try. Hot flashes can be tamed by some of the newer antidepressants, such as Effexor (venlafaxine), or older ones, including Prozac (fluoxetine), as well as the epilepsy drug Neurontin (gabapentin) or clonidine, a blood-pressure medication. (Ask about side effects before trying; some are much milder.) Antidepressants also blunt mood swings sparked by hormonal spikes and treat bouts of depression.
Judicious use of prescription sleep medications can help insomnia. Be sure you're taking the right medication for your sleep problem. Long-acting drugs, such as Ambien CR, Halcion, or Lunesta, which aim to get you to sleep through the night, may just make you feel groggy in the morning if you take one at 1 a.m. because you can't fall back asleep after being awakened by night sweats. A better choice: short-acting Sonata.
And because it's still possible to get pregnant, it's important to practice birth control. Pills or a vaginal ring are still the most foolproof methods of preventing pregnancy, and they have an added benefit of easing perimenopausal symptoms.
But for middle-aged women, whose fertility is greatly diminished, barrier methods, such as a diaphragm, spermicides, condoms, or a sponge, can generally work just as well.
No matter how you experience it, perimenopause can be a confusing time of life. "Most women would benefit by having a doctor help them sort this out," says Nanette Santoro, MD, a professor and director of reproductive endocrinology at the Albert Einstein College of Medicine, in New York City. "A reproductive endocrinologist or a gynecologist who is a menopause specialist can usually provide the best advice."
Don't assume abnormal bleeding in your 30s or 40s is due to perimenopause. In 21 percent of cases there's a different reason. Irregular periods can be a sign of an underlying gynecological problem, such as uterine fibroids or excessive growth of the lining of the uterus. In rare instances, abnormal bleeding can signal cancer of the cervix, which can be detected by a Pap smear, or uterine or vulval cancer, both of which are diagnosed by a biopsy, in which a doctor takes a tissue sample to see whether it is cancerous. "Women need to get regular gynecological checkups," says Dr. Minkin. "They should get a Pap smear and a pelvic exam once a year."
Symptoms are a guide to what the problem might be:
Bleeding occurs between periods. Mid-cycle spotting can be a side effect of taking oral contraceptives. But if you're not on the pill, it could be a symptom of a benign cervical polyp, a chlamydia infection, or an over- or underactive thyroid (a thyroid problem can lead to lack of ovulation, causing menstrual problems). Your doctor likely will order a thyroid-stimulating hormone (TSH) test to see if your thyroid is functioning normally.
Bleeding is extremely heavy. You're changing tampons and pads every hour or periods last longer than eight days. A thyroid problem may be one cause; a TSH test will show if you have one.
The other likely candidate: fibroids, benign growths in or on the uterus or cervix. A trans-vaginal ultrasound test is often recommended to detect the presence of fibroids inside the uterus.
Fibroids generally shrink after menopause, but if the bleeding is severe, you need to treat it sooner. There are a number of options: You can shrink fibroids with a uterine artery embolization or have them surgically removed with a procedure called a myomectomy. More-drastic choices include a uterine ablation (in which the lining of the uterus is destroyed to stop bleeding) or hysterectomy (removal of the uterus). Hysterectomy renders women infertile and ablation can lead to serious complications if a woman later becomes pregnant.
It's such an appealing idea: Just keep taking your birth control pills and no more periods. Goodbye bleeding, cramps, PMS.
Vacationing women and brides have been doing it for decades. And doctors often prescribe continuous oral contraceptives to ease painful or excessive periods in women with endometriosis, severe PMS, or menstrual migraines. Now, with the recent approval of birth control pills that limit or do away with periods altogether, this option is now available to many more women.
Oral contraceptives Yaz and Loestrin 24 Fe, for example, offer a 24-day dosing schedule that results in lighter periods of four days or less. A pill called Seasonique is based on a 91-day cycle, versus the 28-day cycle of standard pills, reducing periods to just four a year. And Lybrel, which was approved earlier this year, is a 365-day pill that suppresses menstruation completely.
But will we pay a price down the road for tampering with Mother Nature? Many experts don't think so. In fact, researchers estimate that women now have three times as many periods -- about 450 over a lifetime -- as our ancestors, who started menstruating later and spent many more years pregnant.
"There don't appear to be any long-term adverse effects," says Dr. Nanette Santoro of the Albert Einstein College of Medicine. "These pills can cause breakthrough bleeding, which can be a nuisance, but this diminishes over time. And when they work, they're terrific."
Menstrual suppression may even deliver some health benefits. Numerous studies have shown that taking birth control pills can reduce the risk of both ovarian and endometrial cancer up to 50 percent. Scientists speculate that each time a woman ovulates, the release of the egg ruptures the ovary, causing repeated injuries that can make some cells turn cancerous. Halting ovulation can stop this process.
For women with serious menstrual problems, eliminating periods can flatten the sharp hormonal swings that cause excessive bleeding, migraines, and depression of severe PMS that sometimes happen in perimenopause. It can also end the agonizing cramps and bloating of endometriosis sufferers.
Still, stopping menstruation indefinitely is not for all. This group includes women prone to an adverse reaction to oral contraceptives, such as smokers who are over the age of 35 (nonsmokers can safely use them through menopause), insulin-dependent diabetics, and women who have liver or heart disease, high blood pressure, or a tendency to form blood clots. Other poor candidates, says the University of Virginia's Dr. Pinkerton, "are women who are not good about remembering to take a pill every day, those who are comforted by having regular menstrual cycles, or those who don't want irregular bleeding."
One thing that doesn't seem to be a problem: a buildup of the uterine lining. Although natural menstruation sheds the lining every month, birth control pills suppress ovulation. When that happens, the lining thins and may not need to be shed monthly.
From hormone therapy to bone-density worries, heart health concerns to hot flashes, the variety of issues to deal with during and after perimenopause can seem overwhelming. Get the information you need to survive and thrive in midlife.
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