What is Menopause?

Menopause is technically defined as the moment that you have gone 12 months without a period.

Your menses have paused.

The moment afterwards you are post-menopausal.

How Old Are You When You Go Through Menopause?

Menopause generally occurs in the late 40s to early 50s.

The average age of menopause is 51.

But you are most likely to go through menopause at the same time that your mom did.

The peri-menopause (or “climacteric”) years generally last about seven years, but can be longer.

Surgical Menopause

Surgical menopause occurs when your ovaries are removed.

You will immediately go into menopause (because you won’t have any ovaries to produce your estrogen, progesterone, and testosterone).

Your doctor will almost always put you on hormonal support at least until the time that you would have naturally gone through menopause.

Medically Induced Menopause

Medically induced menopause occurs with chemotherapy or radiation treatment of the ovaries.

If chemotherapy causes your ovaries to stop functioning, you will immediately go into menopause.

Similar to surgical menopause, your doctor will almost always put you on hormonal support at least until the time that you would have naturally gone through menopause.

Several drugs can also temporarily induce menopause (like Lupron and Synarel), but when you stop taking them their actions are reversed.

What Happens to My Hormones During Menopause?

During the years leading up to menopause (and even after) your hormones will be in flux to a greater degree than they have been since puberty.

It is not only the hormones that are in flux during peri-menopause (or climacteric), but also the hormone receptors.

Your body is being remodeled.

During Peri-Menopause

• The number of eggs in the ovaries will be very low
• Follicle Stimulating Hormone (FSH) will be very determined to continue promoting ovulation, so its levels might go up to try to help your body release the remaining eggs
• Your period cycle length could become shorter or irregular
• Estrogen generally does not begin to decrease until 6-12 months before true menopause, and then there are big sweeps of high and low
• Progesterone begins to decline before estrogen. So some of the estrogenic signs of menopause are actually just reflecting the change in ratio of progesterone:estrogen. Creating a relative estrogen dominance.
• When estrogen levels are too low to be able to form an endometrial lining, your period will stop.

What Are the Symptoms of Menopause?

Common symptoms of perimenopause in the United States are:

• menstrual irregularities
• hot flashes
• night sweats
• sleep disturbances
• palpitations
• joint pain
• vaginal dryness
• urinary tract infections
• skin dryness, thinness, increase wrinkles
• loss of hair on head
• new hair growth on face and body
• acne
• decreased libido
• mood swings
• impaired memory & cognition

Every woman experiences menopause differently.

The only symptom some women experience is that they stop having a period.

What are Hot Flashes?

Hot flashes (and other vascomotor symptoms like night sweats, insomnia, and palpitations) reflect the body’s inability to hold temperature in a steady state. There is escape of temperature regulation causing a decrease in temperature and the brain responding with a vasomotor surge to increase temperature, but over-shooting in its exuberance.

This poorly understood process suggests dysregulation of the brain in a region called the hypothalamus.

The hypothalamus regulates body temperature and has a lot of estrogen receptors.

70-80% of women in the US report hot flashes during the years around menopause.

Hot flashes will impair sleep quality, and not getting enough sleep will promote irritability.

What Causes Hot Flashes?

• Serotonin?
  • Estrogen stimulates the production of serotonin and endorphins.
  • After menopause there is a 50% decrease in serotonin, but an upregulation of receptors involved in thermoregulation in the hypothalamus
  • When serotonin levels go down, norepinephrine increases and this disturbs the hypothalamus’s ability to regulate temperature
  • Treatment with selective serotonin reuptake inhibitors (SSRIs) appears to improve hot flashes
• Kisspep Neurokinin B & Dynorphin signaling system?
  • This system controls secretions of gonadotropins (that regulate ovarian function) and connect to the main thermoregulatory center in the hypothalamus called the median preoptic area.
• Calcitonin Generated Peptide (CGRP)?
  • This is the most powerful vasodilator in humans.
  • It is localized int he cholinergic sympathetic nerves of sweat glands primarily in the upper body
• Absolute estrogen levels are not solely responsible for hot flashes since there is no correlation between levels and event

How Does Menopause Affect Cardiovascular Health?

There is no causal link between menopause and an increase in cardiovascular risk except for women who experience early menopause (before 45).

As women and men age, their risk for cardiovascular disease increases.

The risk continues to be greater for men than for women after menopause.

At all ages it is important to care for your heart by

• Walk daily working up to 1-2 hours
• Eat lots of vegetables, legumes, seeds, nuts, cold water fish
• Maintain an ideal body weight
• Stop smoking
• Keep stress low
• Have fun!

How Does Menopause Affect Bone Quality?

Osteoporosis is a conditions of your bones in which there is low bone mass and deterioration of the microarchitecture leading to fragility and increased probability of fracture.

What causes osteroporosis?

Osteoporosis is caused by an imbalance of the body’s ability to make bone vs. degrade bone.

The body is constantly creating and destroying.

If creation slows relative to destruction, or destruction speeds relative to creating there will be loss of bone mass.

As we age, bone resorption speeds up.

After menopause there is a decrease in the speed of bone creation due to low estrogen, progesterone, and testosterone relative to the reproductive years.

How to build bone?

• Antagonize your bones. When pushed, your bones will push back (Wolff’s Law).
  • Weight-bearing exercise recruits gravity to push against the bones. When the bones are pushed upon, they push back and this causes growth
  • Building muscles antagonizes the bones because the muscles connect to the bones. The bones will push back and grow more
  • (Having dense muscles also protects against fractures from falls because the muscles will absorb some of the impact)
• Change your lifestyle
  • Stop smoking
  • Reduce alcohol
  • Avoid caffeine
  • Avoid falls
  • Get some sunshine for vitamin D
• Change your diet
  • Avoid junk food and refined carbohydrates and low-quality salt. These pull calcium out of bones
  • Avoid carbonated beverages (even seltzer). They are high in phosphorus which acts in opposition to calcium
  • Don’t overdo animal protein. Calcium is pulled from bones to balance the pH of acidic breakdown products of protein
  • Eat lots of vegetables, especially leafy greens, and beans. These are the best sources of calcium for the body
  • Consider adding fish with bones-in like anchovies, sardines, canned salmon. Eat the bones!
• Consider supplements
  • Calcium, Magnesium
  • Vitamin D, Vitamin K
  • Manganese, Boron, Zinc, Copper, Folate, B6, Vitamin C
• Consider hormone replacement therapy or phytoestrogens like those in soy and lima beans

Peak Bone Mass is Reached by Age 30

Plan for Menopause in Your 20s

Why Do I Have Low Sex Drive with Menopause?

40-50% of women report low sexual desire with menopause.

With menopause, estrogen production decreases 70-80%

During the same time, testosterone production decreases 50%.

However the decrease in testosterone is not related to menopause, but related to aging.

A low sex drive can be associated with change in hormones, increased pain or apprehension of pain with penetration, and stress and busyness of life.

What Can I Do For Vaginal Dryness After Menopause?

As estrogen levels decrease, there is less proliferation of cells in the vagina and vulva, the vagina shortens, and surrounding tissue recedes.

Vaginal dryness is caused by atrophy of mucus-producing glands and thinning of tissue.

Because of these qualities, the lining of the vagina can more easily tear with penetration resulting in pain, itching, bleeding, and burning.

Lubricants provide some alternative when the body’s own lubricating system is not working the same way it used to.

The best way to preserve the vagina and the possibility of having penetrative sex is to use hormonal intravaginal suppositories.

The vaginal mucosa absorbs hormones much better than skin or the GI tract.

You will also have a greater impact on local tissue when you use suppositories.

Is Hormone Replacement Therapy Right For Me?

You need to discuss whether hormone replacement therapy is right for you with your doctor.

Some considerations you may have include your genetic or familial tendency for

• Estrogen related cancers or conditions
• Osteroporosis
• Cognitive decline and Alzheimers

If you decide hormone replacement therapy is right for you, there are still many considerations.

What type of hormone replacement therapy is right for me?

• Conventional Synthetic/animal-based hormone replacement therapy (less expensive, but harder on the body like Provera, Premarin, Estratab, Micronor)
• Better tolerated conventional hormone replacement therapy (less expensive, a bit easier on body, but still has a lot of preservatives and binders like Estrace, Alora, Climera, Ogen)
• Natural Hormones (non-pharmaceutical plant-based without the concerning binders and preservatives like bioidenticals from compounding pharmacies)
• Phytoestrogens are plant sterols that act as weak estrogens or tonifying herbs like black cohosh, dong quai, chaste tree, and panex ginseng

If you and your doctor determine hormone replacement therapy is right for you, be sure and do not take unopposed estrogen conventional therapy.

Taking estrogen without adequate progesterone is hazardous to your health if you are using conventional hormones.

Natural hormones are weaker and unopposed natural estrogen does not appear to have the same effect.

Is Bioidentical Hormone Replacement Therapy Right for me?

Bioidentical hormones (like some conventional hormones) are derived from soy or Mexican wild yam.

• Beta-sitosterol is extracted from soy and converted to estradiol, estrone, estriol, progesterone, or DHEA and testosterone
• Diosgenin is extracted from Mexican wild yam and converted to those same hormones

Bioidentical hormones have the same hormone molecule configuration that our body makes. That means our body recognizes it, knows how to use it, and knows how to dispose of it. While bioidentical hormones are recognizable to the body, since they are not of pharmaceutical grade, this means they do not have FDA oversight so there could be inconsistency in the actual dose received.

Conventional hormones (synthetic or from horse estrogen) do not have the same molecular configuration that our body makes.