Perimenopause & Menopause
By Dr. Joshua Gonzalez
Illustrated by The Sex Ed
As a sexual medicine specialist, I see patients every day who have misconceptions about perimenopause and menopause. Now that science, diet and lifestyle habits have expanded our life spans, many women will spend up to 1/3 of their entire existence in perimenopause and menopause. My hope in writing this is to bring some clarity about your peri- and menopausal years and to educate you on the safe treatment options that can help make these years a fulfilling time of your life.
The Basics
Menopause is a life stage that officially starts once a person ceases having menstrual cycles.
Menopause happens to everyone with a menstrual cycle, but just as there is no “normal” when it comes to length, flow or experience of a period, this new stage of life can vary considerably for everyone.
Symptoms of perimenopause can appear several years before menopause. This typically occurs in your 40s but can happen much earlier in some. Irregular periods can be one of the first signs of perimenopause. Typically, this irregularity occurs over the course of months to years. Many younger, non-perimenopausal women already have irregular periods, but new irregularities in your menstrual cycle, especially if associated with some of the other perimenopausal symptoms listed below, are something worth discussing with your doctor.
Both perimenopause and menopause can present in many different ways. For instance, so-called “hot flashes'' can be very subtle. Classically, they involve a sudden feeling of warmth in the upper body. The skin can redden. You may start to sweat. Some people can experience nausea, anxiety or a sense of panic. If you have never experienced hot flashes, you’re lucky. However, you still may experience other common menopausal symptoms.
Menopause affects your whole body. It can alter your energy, mood, cognitive function, bone health, muscle strength, sex drive, etc.
Let’s Break it Down
Menopause occurs naturally in all women, but some start this process earlier due to external factors. Smoking and genetics can influence the timing of menopause. Smokers typically start menopause about 2 years earlier. Menopause can also result from certain medical or surgical interventions. Removal of the ovaries or treatments such as radiation or chemotherapy can induce early menopause.
Menopause is defined as the end of the reproductive years and involves the cessation of menstruation. Women are considered to be in menopause once they have missed their period for 12 consecutive months. Most women experience menopause between ages 40 and 58. The average age is 51. Even so, physical changes that occur during menopause can begin years before your last period. This transition phase is called perimenopause and may last for 4 to 8 years.
Perimenopause usually starts in a woman's 40s, though it can start in her 30s or even earlier. It is characterized by a gradual decrease in hormone production by the ovaries. In the last 1-2 years of perimenopause, as you approach menopause, the drop in hormone production speeds up. Perimenopause may last anywhere from a few months to many years. Irregular periods are common in perimenopause and women will sometimes also experience classic menopausal symptoms, but often to a lesser degree.
Hormones play an important role in the body and slowly decline as one ages. During perimenopause, you may start to experience symptoms related to hormone irregularity. But once in menopause, hormonal production ceases in a more substantial way. Typically, estrogen is often assumed to be the leading cause of menopausal symptoms. But testosterone and progesterone (or lack thereof) are also involved.
Genitourinary syndrome of menopause (GSM) is a new term that describes various menopausal symptoms and signs including genital symptoms (dryness, burning, and irritation), sexual symptoms (lack of lubrication, discomfort or pain, and impaired function), and urinary symptoms (urgency, dysuria, and recurrent urinary tract infections). GSM replaced the terms vulvovaginal atrophy and atrophic vaginitis because they did not cover the full spectrum of symptoms often experienced. Many, if not all, of these GSM symptoms are related to hormonal deficiencies.
The Diagnosis & Symptoms
As with many things in medicine, diagnosing (peri-)menopause starts with a careful history. As perimenopause and menopause can present in a lot of different ways, asking about and discussing a variety of symptoms is critical. Here are some of the most commonly reported symptoms of (peri-)menopause:
irregular periods
bloating, weight gain + slowing of metabolism
thinning hair + drying of skin
loss of breast fullness
hot flashes
GI dysfunction
osteoporosis + muscle aches
cardiovascular disease
decrease in or lack of libido
pain with sex
dryness or decreased lubrication
persistent urinary urgency, frequency, or other irritative urinary symptoms
recurrent vulvovaginal/urinary infections
mood fluctuations + increased anxiety
orgasmic dysfunction
sleep disturbance
If you are experiencing any of these, even if you’re “too young for menopause,” mention it to your doctor. It may not be the beginning of menopause, but it’s worth investigating.
The physical exam can further validate suspected menopause. Examining the genital tissues, especially when done under magnification, can be enlightening. Often you will see chronically red and irritated tissue. Other areas may be atrophied or painful to the touch. A vaginal swab may also confirm that there has been an increase in the vaginal pH, another common finding in menopause.
Certain laboratory studies can also be helpful in making the diagnosis. Classically, a woman’s FSH (follicle-stimulating hormone, a pituitary hormone regulating the ovary) remains elevated and her estradiol (the body’s primary estrogen) remains low when she is in menopause. But both of these hormones can fluctuate a great deal during reproductive years, so relying on a single snapshot may be misleading. For example, a low FSH level in someone having hot flashes and changing periods does not eliminate the likelihood that they may be in perimenopause. Thyroid disease can also mimic perimenopause so it is important to screen for this as well. I often say, “The tests should always match the person.” Meaning: the diagnosis should only be made when a person’s laboratory studies match their clinical picture.
The Treatments
Treating perimenopause and menopause requires a certain amount of expertise, but when considering treatments we don’t always think of perimenopause and menopause as distinct. There are many tools we can employ to help address the litany of symptoms a (peri-)menopausal person may experience, but they work best when custom fit to each individual. Let’s take a minute to go over the various methods we have at our disposal…
Myth: Hormone Replacement Therapy Isn’t Safe
Hormone replacement therapy (HRT) is not dangerous. But unregulated and unmonitored HRT can have consequences. HRT should be treated no differently than any other hormone regimen. Both diabetes and thyroid disease involve replacement of certain hormones (insulin and thyroid hormone, respectively) and often require close monitoring and dose adjustments. HRT, when prescribed in a similar manner, is safe and can have a profound impact on quality of life.
1. Hormonal interventions
Deficiencies in testosterone, estradiol, and progesterone are responsible for many of the bothersome symptoms those in menopause experience. Treatment then should involve (or at least consider) replacement of these very hormones. Traditional HRT regimens often replace the systemic deficiency of estradiol and progesterone. These protocols disregard the importance of testosterone simply because it is ignorantly thought of as a “male hormone.” But that couldn’t be further from the truth. Testosterone is crucial to so many functions in the female body: everything from maintaining energy, muscle strength, and libido to supporting the health of specific genital tissues like the clitoris and vestibule.
We tend to think of hormonal treatments as acting systemically or locally. Systemic therapies are absorbed into the general circulation and can have affects all over the body. This is how HRT can improve mood, energy, muscle strength, etc. Locally applied therapies tend to act locally as their name would suggest. These hormonal therapies, most commonly testosterone, estradiol, or a combination of the two, are applied directly to the genital tissues. Locally applied hormones can help soothe irritated tissues and improve lubrication. As we age, genital tissues atrophy or thin. Those tissues also lose the ability to lubricate effectively. Locally applied hormones can thicken this tissue and restore its ability to lubricate. Improved tissue health and lubrication can help make sex less painful and more enjoyable
2. Behavioral modifications or lifestyle changes
Relaxation and stress-reduction techniques, including deep-breathing exercises, massage, meditation and mindfulness, can be especially helpful in addressing some of the mood and anxiety fluctuations that can occur during menopause. Maintaining a heart healthy lifestyle with well-balanced nutrition and regular exercise can help stave off gastrointestinal and cardiovascular effects commonly seen in menopause and even help improve sleep.
I get asked a lot about supplements for perimenopause and menopause. As the data demonstrating significant improvement from many supplements are lacking, I do not routinely recommend any. Some of the natural supplements that may be helpful include wild yam extract, licorice, St. John’s wort, vitamin B6, black cohosh, ginseng, Dong quai, soy, and DHEA. As there is a paucity of randomized controlled trials studying these various supplements, my advice considering these is always to tread lightly. Because supplements are available over-the-counter, they are assumed safe. However, many of these supplements can carry their own risks. Please check with your primary care doctor and do your own research before consuming.
3. Other interventions
Understanding and evaluating the pelvic floor can be pivotal to helping those in menopause. The pelvic floor is responsible for many functions including urination, defecation, and even orgasm. When the pelvic muscles are dysfunctional they can lead to incontinence, prolapse, and pain during sex. During physical examination, I perform a quick assessment of the pelvic floor muscles and if dysfunction is suspected I will often refer them to pelvic floor physical therapy. Pelvic floor PT may involve manual techniques as well as dilators and/or pessaries. Dilators work to stretch, relax or dilate the muscles and other tissues of the female genital tract. Pessaries are prosthetic devices that can be inserted into the vagina to support its internal structure. They are used commonly in the case of urinary incontinence and vaginal or pelvic organ prolapse. Both of these medical devices can aid in addressing underlying pelvic floor dysfunction.
Lubricants and moisturizers can be helpful in tackling some of the more common GSM symptoms. Both of these treatments are available without a prescription and can help maintain vaginal moisture, restore vaginal pH, and decrease pain during intercourse or other sexual activity. Because not all vaginal lubricants and moisturizers are created equal, it’s worth discussing options with your doctor before trying one on your own.
Energy based therapies have recently gained a lot of attention, but not always for the best reasons. These regenerative vaginal therapies include CO2 fractional lasers and radiofrequency treatment. When used discerningly, they can offer significant improvement in GSM symptoms. Unfortunately they have been overly marketed as “vaginal rejuvenation,” with many women being inappropriately treated, rather than focused on the real goal: restoration of normal function. These therapies shouldn’t be used to make your vagina feel “younger”; they are meant to help regain elasticity and moisture that can be lost during perimenopause and menopause and to decrease pain associated with sexual activity.
I want to highlight here how valuable therapy can be for those going through menopause. Changes in self-esteem, body image, and relationships are common in menopause and it can be helpful to discuss these with a professional. Sex therapy can be especially useful to work on issues specifically surrounding sex and intimacy.
Menopause may be inevitable, but misery is not. Women are spending more of their lives in menopause than ever before and should be afforded an ample quality of life during that time. So I leave you with a few words of wisdom:
If you are experiencing any of the symptoms we discussed, seek help. Frequently these issues are easier to solve when confronted early.
Find yourself an expert. Discuss your treatments with someone who specializes in menopause. Sometimes this involves thinking outside the box. There are a myriad of providers out there who can help: family practitioners, endocrinologists, gynecologists, urologists, pelvic floor physical therapists, and mental health providers. With menopause, it often takes a village.
Educate yourself on your options. The internet can be a wealth of information, but it can also be misguided so take what you read with a healthy grain of salt. Definitely discuss anything you may be considering with your doctor first.
Choose the treatments that make the most sense for you and your symptoms. Treatments tailored to your specific needs will definitely be the most worthwhile.
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