About Hormones Women What is Menopause?
What is Menopause? Perimenopause? Post-menopause?
Words used to describe a woman in transition from having regular menstrual periods to not having them at all can be confusing. Terms like ‘premenopausal,’ ‘menopausal,’ and ‘postmenopausal’ are often used to mean, in that order, the years before menstrual irregularities happen, the stage when periods have recently stopped completely, and the years following this transition that continue for the rest of her life. Sometimes, the term ‘the climacteric’ is used to describe the period when the change in menstruation occurs.
Confusion comes when we examine the technical definition of menopause: the cessation [stopping] of menses for 12 months. Literally, those words mean that on the last day of the twelfth month after a woman’s last period an isolated event begins and ends - menses. Does that mean a woman is postmenopausal on the next day and was premenopausal the day before? Recent studies demonstrate that the process of reproductive aging in a woman is more continuous—like all aging processes. Therefore, we prefer different terminology.
Allow us a brief digression into physiology
So you will understand what happens to a woman’s reproductive system as she grows older, it is necessary for us to review what is normal in a menstrual cycle. The menstrual cycle’s purpose is to prepare the lining of your uterus so a fertilized egg can be implanted and begin a pregnancy. To prepare the lining, the pituitary gland releases follicle stimulating hormone (FSH) to make the ovaries start producing estradiol (the principal estrogen produced during the menstrual cycle). FSH also collects one of your immature eggs (called follicles) and stimulates it to mature and become the one that will be discharged from your ovary. Estradiol motivates the cells lining your uterus to multiply and thicken the uterine wall. In normal menstrual cycles, this stimulation continues for about 14 days. After that the increased level of estradiol generates a surge in the pituitary hormone called luteinizing hormone (LH). The LH then causes you to ovulate, or release an egg from one of your ovaries. That egg moves down the nearest fallopian tube and into the uterine cavity where it is expecting to be fertilized. Meanwhile, back in the ovary that produced the egg, your corpus luteum starts manufacturing progesterone. Progesterone both stabilizes the lining of the uterus and prepares it for implantation after the egg is fertilized by a sperm. If the egg is not fertilized, it will not implant and the corpus luteum will simply stop producing progesterone after about two weeks. Without progesterone, your uterus sheds its lining causing you to bleed to remove the unused lining. Your cycle ends with your “period” and starts anew.
A woman's menstrual cycle over her lifetime
A woman’s cycle does not continue unchanged from her first period to her last. There are several of stages of change during her lifetime:
Menarche is the age at which an adolescent woman has her first period. Often, there are menstrual irregularities and less than optimal fertility. But, over the next few years, she begins to ovulate regularly. A woman has the most fertile during her late teens and through her twenties.
A woman’s ability to get pregnant and subsequently deliver (her reproductive capacity) starts to decline as she enters her thirties, and especially after her mid-thirties. Her production of estrogen decreases slightly on average, and her progesterone production in the second half of the cycle can also decrease. Still, she usually continues to ovulate and menstruate regularly and normally, even if her reproductive ability is diminished.
During the ensuing five to ten years, a woman's menstrual cycle can become quite disrupted. Estrogen levels can swing from exceedingly high (above the normal when she was young) to so low that there is virtually no estrogen produced, just like in the menopause. These high-low swings can create alternating sensations and symptoms. Her breasts may be enlarged and tender while she feels bloated and irritable when estrogen is dominant. When her estrogen levels plunge, she can have hot flashes, confusion or lack of concentration, memory problems and vaginal dryness. At the same time, she may experience menstrual cycles with no ovulation, and therefore, no progesterone production to stabilize the estrogen and keep her periods regular. Sometimes too, there is no bleeding (causing worry that a pregnancy has occurred or menopause has started). No bleeding can be followed by heavy or dysfunctional bleeding with severe cramps (dysmenorrhea). In recent years, the medical field has adopted the term ‘perimenopause’ to indicate the symptoms that occur in the 5 to 10 years prior to menopause.
Menopause, as defined, can only be clarified after the fact. It only exists the day after a woman has gone twelve months without having a period. At that point, her estrogen levels have been so low for so long that the lining of her uterus is not stimulated enough to build up and shed so her periods no longer occur. The symptoms of continual low estrogen level are the lack of flux between times of heavy bleeding with breast tenderness and having no periods with reduced breast swelling. Constant low levels can cause increased hot flashes that most women start to experience during perimenopause and both concentration and memory problems. Bone loss accelerates at this stage as well. In the first five years after menopause a woman loses bone at a faster pace than at any other time in her life. She may also have intensified symptoms of perimenopause, including vaginal and skin dryness, decreased libido, and diminished mood and energy.
Five years after menopause, a phase often referred to as 'post menopause,' a woman's body settles into its lower estrogen state, bone loss slows—although it continues--and many women become accustomed to the symptoms. Regrettably, damage to the many organ systems that require estrogen continues. As a result, rates increase for cardiovascular disease, osteoporosis, bone fracture, diabetes and Alzheimer's disease.
You can see that the 'pause' in 'menopause' refers only to a specific point concerning menstrual periods. In truth, the aging of a woman's reproductive system is a continuous process that generally starts in her early thirties. An anti-aging medical approach knows this and intervenes before menopause actually occurs to treat both symptoms and long term consequences that happen with less than optimal hormone levels.
When do we begin an anti-aging approach to reproductive aging? Which of the various options for hormone replacement do we use? We will address these questions in the upcoming sections.
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