Navigating Perimenopause: Tips from Our Urogynecologist

Today, we're discussing how Dr. Angel Marie Johnson, our urogynecologist and the director of our Women's Health Center, treats women going through perimenopause and menopause.

What is menopause? What's the average age?

DR. JOHNSON: Simply put, menopause is when a woman goes 12 consecutive months without having a period. She is now in menopause and can no longer get pregnant. The average age for menopause is 52.

The time during this transition is known as perimenopause, which typically starts in a woman's forties (but can occur as early as a woman's late thirties). The range for perimenopause varies—it could be six months or six years (or longer) or something in between.

What happens during perimenopause? What are some conditions that your patients experience?

DR. JOHNSON: During this transition to menopause, a woman will produce less estrogen. And this reduction in estrogen can result in vaginal dryness, vaginal irritation, and/or pain with intercourse.

Women may notice they are getting more UTIs as well. On average, women get one to two UTIs a year, but if a woman notices she's getting UTIs more frequently, this could be due to the transition, since the vaginal area changes because of the reduction in estrogen. (Note: chronic UTIs can happen for other reasons unrelated to perimenopause, which is why it's essential you speak to a doctor.)

Some women develop pelvic pain. Others experience overactive bladder or worsening bladder function. Still others might experience insomnia or mood changes.  Hot flashes are common, which is a sudden onset of feeling warm or overheated for 30 seconds to a couple of minutes, followed by feeling cold or as if you have cold chills.

During the menopause transition (aka perimenopause), it's normal for a woman's menstrual cycle to become irregular. It can be light one month, where the quantity is that of light spotting, or it can change over to heavy bleeding with large clots and prolonged bleeding. The driving factor leading to the irregularity is ovulation, meaning whether or not the body is releasing an egg, which it may not do every month as you get closer to menopause.

Given there are so many different types of conditions that result from perimenopause, how do you approach treatment?

DR. JOHNSON: The symptoms above are in no way exhaustive; they include the most common symptoms reported in my practice.

When it comes to treatment, I start with the basics: stress relief, good sleep hygiene, making sure that you're well hydrated, making sure that you're exercising regularly and eating a balanced diet—all things that seem obvious, but these basic needs  tend to be neglected when a person is stressed or in transition. So I remind patients to go back to the basics. They must take care of themselves in order to restore health.

Are there certain foods that can help women during perimenopause?

DR. JOHNSON: Yes and no. The data is conflicting in this area, although the food will not hurt them. Phytoestrogen is a dietary estrogen that occurs naturally in certain foods. So increasing your consumption of these foods can be beneficial. You don't need to go overboard, either. Simply incorporate some into to your diet. Foods include flax seed, tofu, soybeans, berries, and even dried fruits. (Here's a good list of foods containing phytoestrogens.)  

If basic lifestyle and dietary changes don't help, what else can women do?

DR. JOHNSON: For specific conditions, we have further treatment options. You'll find links below to articles or videos where I discuss how I treat various conditions:

For women dealing with depression due to perimenopause, certain low-dose antidepressants can help (this would be for women where the constellation of symptoms is causing them significant bother and dysfunction in their lives).

Other therapies include hormone replacement therapy (HRT). Hormone replacement is low dose estrogen in the form of a pill, gel, or patch that can help replace a little bit of the estrogen that the body is no longer producing. (Note: I don't commonly recommend hormone replacement.)

Is there a perimenopause or menopause blood test?

DR. JOHNSON: A diagnosis of perimenopause is typically based on symptoms and age. As for menopause, as I mentioned earlier, the true definition of menopause is the absence of a period for 12 consecutive months.

We can check blood work and look at hormone levels, but there's no menopause "number." There's a range that would indicate "Yes, you're likely in menopause," but there's no cut off based on blood work or based on hormones. It's more of, "You didn't have your period for 12 months. You're in menopause. Or you're reporting these specific symptoms and you're in your mid-forties. You're experiencing perimenopause. Let's work on treating the symptoms and easing you through this transition."

I do recommend that women talk to their female relatives—mother, grandmothers, aunts, older sisters—to see what their experience was like, because that could indicate what the woman can expect, but even that isn't scientific. Perimenopause is as complex and unique as each woman out there.

[Editor's note: In January 2020, new research published in the Endocrine Society's Journal of Clinical Endocrinology & Metabolism suggests that blood tests could soon replace menstrual periods as a gauge for when a women is nearing menopause.]

Once a woman is officially in menopause, meaning she hasn't had a period for 12 consecutive months, do the symptoms improve naturally? Or will she need ongoing treatment for certain things?

DR. JOHNSON: The short answer: It depends, and that's why menopause is tricky.

For example, if a woman experiences overactive bladder during perimenopause, the symptoms probably aren't going to disappear simply because she's reached menopause. So if you made lifestyle changes to effectively treat your overactive bladder (like limiting caffeine and avoiding wine, for example), you'll need to stick with these changes for the rest of your life.  

For many patients, the hot flashes go away, the insomnia goes away, and things like that do resolve, but you never know how long it might take.  Some women are fortunate, and don't have a rough menopause transition. And then you have other women who are in significant distress, "What is this? What is going on? I don't feel like myself. I don't like this!" And that's really challenging because I can't say, "Don't worry, it will only last six months or a year" because I don't know. No one knows. It varies greatly from woman to woman.

So as a physician, I present all the different treatment modalities that have any evidence behind them, and say, "What will work best for you? Let's partner, and let's make this happen. And let's get you through this part of your life."

Working with someone like me—a urogynecologist who is trained in female pelvic medicine and whose focus is on improving a woman's quality of life—can bring relief to you during this natural transition as your body ages. Bottom line: you're not alone, and I want to help.

Thanks, Dr. Johnson!

Are you a woman dealing with symptoms due to perimenopause or menopause? Are you in the greater Boston area? If yes, consider making an appointment with Dr. Johnson.

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