Menopause Definitions
What exactly is menopause?
The definition of menopause is simply that you have gone 12 consecutive months without any menstrual bleeding. That's it! So if you make it 11 months without a period, but then have 2-3 days of bleeding, your 12-month clock resets again. The average age this occurs to someone with a vulva is around 51 years.
What about perimenopause?
This is a very gray area. Technically it begins with "variability in the length of the menstrual cycle," and then ends 12 months after the last period (Lambrinoudaki 2022). So, not exactly helpful for anyone who already has an irregular cycle, or who is taking birth control or has an IUD, etc.
However, some definitions will place the start of perimenopause as whenever you experience a greater than 7-day change in the length of your cycles for two consecutive periods (Santoro 2020). For many people though, especially if they are not tracking their cycles closely, this will first show up as a missed period.
Of course, there are MANY other causes of missed periods that need to be considered, especially if you are less than 45 years old. These can range from thyroid dysfunction to polycystic ovarian syndrome (PCOS) to other hormonal disorders. Please talk to your doctor if this applies to you!
What about induced or surgical menopause?
Menopause can also come VERY quickly for some of us for various medical reasons. Typically this is either due to surgical removal of the ovaries (+/- the uterus) for various reasons, or chemotherapy/radiation for cancer. Unfortunately this is such an abrupt change for the body, that the consequences can feel more severe in the body and have longer-term implications than spontaneous menopause. Due to the depth and breadth of this topic I won't be able to discuss it in detail here. Hopefully if this has happened to you, you already have a close relationship with your doctor who is helping you manage this very abrupt hormonal change! And, the majority of the recommendations and information in this article will still apply to you.
Perimenopause
How do I know if perimenopause has started?
See above about the "definition" of perimenopause based on your menstrual cycles. If you aren't sure, you can also have some hormonal testing done. Especially if you are between the ages of 40-45 and you start noticing changes in your cycle, or feel like you are having perimenopausal symptoms, you can have your follicle stimulating hormone (FSH) levels checked. This typically isn't indicated if you are over 45, as we can assume you have begun the transition into menopause by then. Additionally, hormonal levels vary so wildly during perimenopause, that you need to remember that your levels on any given day or just a snapshot in time. They are not necessarily good predictors of your overall hormonal trend. If you are under 40 and feel like you are already experiencing the menopause transition, then you definitely need to talk to your doctor. You will want to be assessed for something called primary ovarian insufficiency (POI), which only affects 1% of people with vulvas of reproductive age. But if this happens to you, then you definitely need prompt diagnosis and medical management to help your body thrive into your later years!
How long does perimenopause last?
On average, this transition lasts between 4-8 years for most of us (NAMS).
What do perimenopausal symptoms feel like?
Of course I am sure you have heard a WIDE variety of symptoms that can be attributed to menopause. This is because we have estrogen receptors in so many areas of the body, and so many types of body tissues, that it affects almost all of your body systems. The most common symptoms to watch out for include:
Vasomotor symptoms. These include hot flashes and sleep disturbances. This can lead to fatigue, insomnia, and irritability. The underlying reason for these symptoms is mostly rapid constriction and dilation of the blood vessels in response to the changes in hormone levels. Typically hot flashes start in perimenopause and can last 4-5 years after you are officially in menopause. And, one important thing to note, is that the severity of these symptoms is correlated with increased risk for heart disease and diabetes.
Sleep problems. These can occur as a result of hot flashes/night sweats, but also independently of them, again due to hormonal fluctuations.
Cognitive dysfunctions and mood disorders. You may notice your memory isn't what it used to be, poor concentration, or difficulty multitasking. This can also correspond with feelings of anxiety & depression, mood swings, and irritability.
Genital changes. This is commonly termed "genitourinary syndrome of menopause," or GSM. This is a HUGE topic, but I will touch on the basics here. Basically, this means you may have a wide range of symptoms affecting the vagina, vulva, urethra, and/or bladder due to the decrease in estrogen. These symptoms can include irritation, dryness, burning, urinary frequency and urgency, recurrent urinary tract infections (UTIs), and pain and dryness during vaginal intercourse. Typically, these symptoms don't arise until you are later in perimenopause, but of course can start to show up earlier as well. The REALLY important thing to know is that these symptoms can be very easily treated with a topical estrogen cream. So little of this estrogen gets absorbed that it doesn't affect the rest of your body in a major way, or in the long-term. So if this is occurring to you, PLEASE talk to your doctor about topical estrogen! Most of the time, this is even safe to use in the setting of other medical conditions such as breast cancer.
Menopause
When do I need to worry about osteoporosis?
This is of course a big concern after you reach menopause, and even in perimenopausal times. You reach peak bone mass around age 30, and then see a progressive decline in bone mass at a rate of about 0.7%/year thereafter. In the year leading up to your final menstrual period, this bone loss dramatically rises. Up to the first 3 years of menopause, this bone loss is occurring at a rate of 5% per year. After 3 years, the rate of bone loss declines, gradually slowing to reach its pre-menopausal rate. Typically, you aren't recommended to start regular DEXA screenings for bone mineral density until after age 65, although of course you may need to start earlier depending upon your other health conditions or risk factors.
What about heart disease?
Heart disease is the dark horse of menopause that most people don't give enough consideration. Cardiovascular disease is the number one killer of people with vulvas in North America. And, after age 55, more than half of all deaths of people with vulvas are secondary to cardiovascular disease. You are at a higher risk for cardiovascular problems after menopause depending upon your smoking status, history of diabetes mellitus, blood pressure and levels of cholesterol.
Treatment
I have to admit, this is all very depressing. What can I do about any of it?
Good news! There is actually a lot you can do to decrease the severity of perimenopausal and menopausal symptoms. Just like in pregnancy, this life transition doesn't mean you are doomed to be miserable and "just have to deal with it." We'll touch briefly on medications, and then move quickly onto what is MOST in our control: exercise & movement.
How does hormone therapy help?
For many people, hormone therapy (HT) is a really great option! This is especially true if it is initiated less than 10 years after the onset of menopause, or before you are 60. It helps with so many symptoms:
Vasomotor symptoms, like hot flashes & night sweats
Genital changes, like vulvar atrophy and dryness
Prevents bone loss and osteoporotic fractures
Improves mood and wellbeing
Reduces risk of new-onset diabetes
May reduce risk of cardiovascular disease (if initiated early after the menopause transition)
May prevent cognitive decline (if initiated early after the menopause transition)
Is hormone therapy really safe? What about breast cancer risk?
Unfortunately, there is so much misinformation out there related to a very flawed study performed around 2002. This has caused a large number of people to suffer unnecessarily with menopausal symptoms due to misunderstanding of and misreporting on those study results. Here are the actual risks of HT that have been well-proven over time:
The risk of breast cancer with HT is very small, and decreases after treatment is stopped. It is most prevalent in people taking estrogen AND progesterone, and is associated with longer duration of HT
Oral HT, but not HT delivered via a skin patch, is associated with an increased risk of blood clots
HT may cause a small increase in risk of stroke, more commonly with an oral vs skin patch route
HT started after 60 years of age, or >10 years after menopause, does not have cardiovascular benefits, but also does not cause harm
HT may increase the risk of dementia if started after age 65
What about non-hormonal treatments?
There are MANY other types of non-hormonal medications that can help with menopause symptoms if you wish to (or need to) stay away from hormone therapy. Some options include various types of antidepressants (SSRIs), gabapentin, clonidine, and oxybutinin. And there is certainly a lot of evidence (although not as good as HT) for complimentary/alternative therapies like phytoestrogens, yoga, acupuncture, mindfulness-based stress reduction, cognitive behavioral therapy, etc.
Exercise
I know that exercise can help, but what types of exercise are best?
The answer is yes, yes, and yes. Almost all kinds of exercise help! In fact, one article had this to say about exercise: "Physical exercise is the most powerful non-pharmaceutical fracture prevention strategy in postmenopausal women." (Shojaa 2020) When we are talking about fracture risk specifically and improving bone mineral density, most of us have heard that resistance training is really important. Basically this would be any exercises that including joint movement that increase muscular strength. This can include lifting weights, using resistance bands, or any type of heavy object. However, it also includes body-weight exercises like squats, planks, or even walking. (I will mention though that walking-only programs don't seem to be sufficient to improve bone mass in your lower back, specifically.) The most important aspect of exercise to improve bone density is that it needs to either be using equipment to provide the resistance, or it needs to be "closed-chain" for the body. Meaning, you are either standing up (feet on ground providing resistance/force), or your arms are pushing against the ground or a wall, etc to provide the resistance. So, that means exercises like swimming and biking don't "count" for bone density. They are great though for other types of menopause symptoms!
How much do I need to exercise?
To improve bone density in particular, the answer might surprise you! One systematic review and meta-analysis of 17 articles found that less is more when it comes to resistance training and improving bone density, specifically. They found that <2 sessions of resistance training per week actually produced superior results to 2 sessions or more per week! And, they found that doing resistance training with free weights was superior to using any type of "device." So basically less is more, and you don't need any fancy equipment!
Does exercise help other menopause symptoms?
Yes! Exercise has been shown to help with hot flashes in particular. This is true for both resistance training and exercise such as yoga. And, yoga has been shown to improve overall quality of life during menopause in particular. So, keep up with MommaStrong, throw in some resistance training 1x/week if you aren't already, and consider adding in other types of exercise to help with menopause symptoms if you have time! And know you aren't going it alone—please talk with your doctor if you feel medication, especially hormone therapy, can help you feel better. ❤️
References:
Flores, V. A., Pal, L., & Manson, J. E. (2021). Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment. Endocrine reviews, 42(6), 720–752. https://doi.org/10.1210/endrev/bnab011
Kingsberg, S. A., Larkin, L. C., & Liu, J. H. (2020). Clinical Effects of Early or Surgical Menopause. Obstetrics and gynecology, 135(4), 853–868. https://doi.org/10.1097/AOG.0000000000003729
Lambrinoudaki, I., Armeni, E., Goulis, D., Bretz, S., Ceausu, I., Durmusoglu, F., Erkkola, R., Fistonic, I., Gambacciani, M., Geukes, M., Hamoda, H., Hartley, C., Hirschberg, A. L., Meczekalski, B., Mendoza, N., Mueck, A., Smetnik, A., Stute, P., van Trotsenburg, M., & Rees, M. (2022). Menopause, wellbeing and health: A care pathway from the European Menopause and Andropause Society. Maturitas, 163, 1–14. https://doi.org/10.1016/j.maturitas.2022.04.008
Nguyen, T. M., Do, T. T. T., Tran, T. N., & Kim, J. H. (2020). Exercise and Quality of Life in Women with Menopausal Symptoms: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. International journal of environmental research and public health, 17(19), 7049. https://doi.org/10.3390/ijerph17197049
North American Menopause Society (NAMS): https://www.menopause.org/
Santoro, N., Roeca, C., Peters, B. A., & Neal-Perry, G. (2021). The Menopause Transition: Signs, Symptoms, and Management Options. The Journal of clinical endocrinology and metabolism, 106(1), 1–15.
https://doi.org/10.1210/clinem/dgaa764Shojaa, M., von Stengel, S., Kohl, M., Schoene, D., & Kemmler, W. (2020). Effects of dynamic resistance exercise on bone mineral density in postmenopausal women: a systematic review and meta-analysis with special emphasis on exercise parameters. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 31(8), 1427–1444. https://doi.org/10.1007/s00198-020-05441-w
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