What doctors wish patients knew about menopause

Menopause is a natural phase of a woman's life that marks the end of her reproductive years. While it is a normal and inevitable process, it can bring about significant physical and emotional changes that can affect a woman's overall well-being. Understanding the intricacies of menopause and being aware of the various challenges and opportunities it presents is crucial for women to effectively manage this transition.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, two AMA members took time to discuss what patients need to know about menopause. They are:

• Madelyn E. Butler, MD, an ob-gyn in Tampa, Florida, and member of the AMA Board of Trustees. 
• Lanny Wilson, MD, chair of the Physician Well-Being Program at UChicago AdventHealth Hospitals in Chicago and surrounding suburbs. He also is chair of obstetrics and gynecology at Avalon University School of Medicine in Youngstown, Ohio.

“When we talk about perimenopause, we are talking about the years preceding menopause—usually about a five-year time frame,” Dr. Wilson said.

“What's happening during perimenopause is it's a transition phase from your fertile years to your unfertile years. And it's not something that just kind of happens instantaneously,” Dr. Butler said during an episode of “AMA Update” about menopause. “It happens gradually and it's a period of transition that can last three to eight years. And it's characterized by a decrease in estrogen.”

“When you have a decrease in estrogen, you can have hot flashes, you can have night sweats, you can have anxiety, other emotional symptoms, insomnia, changes in your sex drive, and just a whole host of symptoms,” she explained. “And it's very individual to the patient. So, it's a time of transition and it can last a lot longer than we think.”

“Normal menopause is a gradual transition that takes place over a three-to-eight-year time frame. Usually, in perimenopause or premenopause—whichever word you prefer to use—the periods start becoming a bit more irregular,” Dr. Wilson said. “Sometimes the hot flashes begin in this perimenopausal time frame and some of the other symptoms of full menopause occur, which include night sweats, vaginal dryness, and problems with sleep—for example, insomnia and waking up during the night with hot flashes or cold sweats.

“The vagina contains receptor sites stimulated by estrogen. Without the estrogen stimulating those receptor sites, the vagina begins to dry,” he added. “Rarely, women experience weight gain as well. Since this can be controlled, it shouldn’t be blamed on menopause. It is more likely related to changes in diet and activity than the hormonal changes of menopause.”

“A more subtle kind of change is happening in the bones where the bones begin thinning and become weaker. Early thinning of the bones is called osteopenia,” Dr. Wilson said. “As it gets worse, it becomes osteoporosis. Women with osteoporosis are at increased risk for fractures of their bones.”

“The normal age of menopause occurs around age 51. So, anywhere from about 45 to 55 would be a normal time frame to go into menopause,” Dr. Wilson said, noting “menopause is the time in a woman’s life when menstrual periods have stopped. The diagnosis is made when a woman has not had a period for one year.

“Menopause occurs because the ovaries have stopped producing estrogen and the egg follicles have stopped producing other hormones as well, including progesterone” he added. “Ovulation and hormone production have ceased. So, the ovaries have gone quiet.”

“Natural menopause occurs because as a woman grows older, her ovaries have gradually released the eggs with which she was born,” Dr. Wilson explained. “And so, as the follicles have gradually diminished, along with the eggs that were within them, natural menopause takes place.”

“Surgical menopause occurs when a woman has surgical removal of her ovaries. Oftentimes it occurs during a hysterectomy, but occasionally the ovaries can be removed just by themselves if someone is concerned about ovarian cancer,” he said.

“Chemotherapy or radiation-induced menopause can occur when cancer therapies are directed at the ovaries. The halt to menstruation and fertility are not always permanent following these measures. So, for women in the childbearing years, birth control measures may still be desired until permanent menopause is proven.

“Premature menopause occurs because of a fairly rare condition called primary ovarian insufficiency, or premature ovarian failure. In these instances, a young woman stops having menstrual periods early in life before the age of 40,” Dr. Wilson said.

Patients are “very unprepared in many ways because coalescing with that time of transition, many of them are taking care of elderly, ill parents,” Dr. Butler said, noting that “many of them are dealing with children leaving the home for the first time and career transitions that occur in life.”

“In the middle of all these transitions and all these life challenges, they're experiencing the changes, the hot flashes, the inability to sleep, the emotional changes that occur,” she said. “So, they are unprepared because they don't know that the symptoms can last quite a long time and they don't know what's what.

“Is it stress? Is it the things that I'm going through—just in my life in general? But all of those things create the perfect storm,” Dr. Butler added. “And sometimes patients overlook their need for help, and they don't know how to differentiate what are symptoms of perimenopause and what are symptoms of the stresses that they're facing in their daily life.”

“They know that their cycles are going to stop, but they don't know what to expect leading up to that,” she said adding that “many times they think that it's just going to happen overnight, and they don't understand that some of the symptoms can last for years.”

“We, as physicians, have to take the time to listen to patients and see what symptoms they're experiencing, because every transition is unique to every patient,” Dr. Butler said, noting that “perimenopause and menopause can vary so much from woman to woman because 85% of us will have minimal symptoms.

“But 15% of us will have rather severe symptoms that require treatment. And it can run the whole gamut from emotional symptoms to vasomotor symptoms—which are the hot flashes, the migraine headaches, the insomnia, all of those things,” she added. “So, most of us, thankfully, don’t have significant amounts of suffering.”

“The key here is how the symptoms affect your quality of life,” Dr. Butler emphasized. “If the symptoms are affecting your quality of life, your ability to carry on your day-to-day routine, that’s when we really need to discuss treatment.”

“It’s a rare instance to go into menopause before the age of 40—that’s called primary ovarian insufficiency or premature ovarian failure,” Dr. Wilson said. “To go into menopause before the age of 40 is not good, especially if a person waited until later in life to start their family.”

“And if they go into premature ovarian failure, it’s very unlikely that they’ll be able to get pregnant,” he said. “Plus, when you go into premature ovarian failure, that means the estrogen has decreased and so you’re at increased risk for all those menopausal symptoms as well.”

When it comes to menopause treatments, “it requires a lot of time drilling down to what the patient’s most troublesome symptoms are and what sorts of things you can offer her for help,” Dr. Butler said. “The reason why a lot of people perceive the treatments don’t work is we first try things that are perhaps not prescription.

“There are a lot of proprietary herbal remedies that don’t totally take care of all the symptoms, but they can help with quite a few of the most troublesome symptoms like hot flashes,” she added. “And as long as the patients are informed that it’s going to take the edge off, but it’s not going to totally treat the symptoms, having knowledge of what to expect is very important.”  

“In menopause, the ovaries have stopped producing estrogen, progesterone and another less commonly known hormone in women called testosterone,” Dr. Wilson said, noting “all of these work together to help prevent the menopausal phenomenon.”

When it comes to hormonal therapy, it “is very individualized depending on the patient's personal history, her risk factors, her family history for cancer” and other factors, Dr. Butler explained. “It starts with the different kinds of menopause.”

“Systemic estrogens are a little bit more controversial because they have been associated with an increased risk of breast cancer. And certainly, if a person has a predisposition to uterine cancer, estrogens can stimulate the lining of the uterus and can cause uterine cancer as well,” Dr. Wilson said. “If a person still has a uterus, they must combine estrogen and progesterone to decrease the risk of developing uterine cancer.

“If a person has had a hysterectomy, she can use estrogen only. The North American Menopause Society recommends that we use the lowest dose of estrogen and/or progesterone to achieve our goal, which is helping prevent hot flashes and helping decrease vaginal dryness,” Dr. Wilson said. “So, you want to take the lowest dose amount to achieve your goal and then use it for the shortest amount of time needed to control those bothersome symptoms.”

But remember, “if hormone replacement is required, the recommended treatment is tailored to the individual patient and her medical history,” Dr. Butler emphasized.

“Hot flashes are those sudden feelings of warmth that occur out of the blue that can happen in the middle of the night, usually causing people to awaken,” Dr. Wilson said. “And in addition to the hot flashes, you often get night sweats. So, you’re kicking off the blankets.”

“Luckily, the menopausal symptoms don’t tend to last too long, and the worst symptoms occur during that first year after menopause when the hormones have decreased so much that they are not stimulating the lining of the uterus, causing cessation of menses. However, estrogen is no longer stimulating other areas of the body which contain estrogen receptors such as the breasts, bone, brain, liver, colon, skin, and salivary glands,” he said. “It takes some time for the body to accommodate for the lack of estrogen stimulation to all of these body parts.

“Education about menopause, as we are doing here, and speaking with health care professionals will help women navigate the transition through menopause. When counselling is not enough, there are various things that people can do to help,” Dr. Wilson added. “First of all, women should be aware that there are triggers for hot flashes. Triggers  include such things as caffeine, smoking, warm or tight-fitting clothes, alcohol, spicy foods, hot weather, stressful situations, and even stressful relationships” he said, noting that it is helpful to avoid those triggers as much as possible.

“Women will want to start off using natural, common-sense methods such as avoiding triggers—or stressors—but there are prescription medicines that can be used as well. The most common prescription medicines for hot flashes are various kinds of hormones, especially estrogen,” Dr. Wilson said. “For women who still have a uterus, estrogen should be combined with progesterone.”

“There’s nothing like good, healthy habits. They work to help prevent cancers. They help prevent diabetes. They also help transition into post menopause,” Dr. Wilson said. “There are just so many good things that come from a healthy lifestyle.”

So, drink “plenty of water, rest, exercise and maintain a healthy diet—that means a nice balance of proteins, vegetables and fruits,” he said.

“There are certainly other things that we can do to treat symptoms that really affect her quality of life, like vaginal dryness,” Dr. Butler said. “If you have a patient who’s dealing with cancer, she's had chemo and now she can't have intercourse with her partner, that is something that really affects relationships and quality of life and just satisfaction with life in general.”

“With lovemaking, the partners should use extra lubrication—as part of their foreplay—in order to help prevent trauma during intercourse. Embrace the lubricant!” Dr. Wilson said. “However, if they still find that they have too much vaginal dryness, estrogens can be applied locally.

“A small amount can be applied in the form of a cream to help prevent vaginal dryness,” he added. “If patients have been treated for cancer of the breasts or uterus, however, physicians may be reluctant to use even a small amount of estrogen locally.”

“Hyaluronic acid—a clear gel or suppository—can also be used if vaginal lubricants haven’t sufficiently helped dryness especially in patients who can’t use estrogen due to cancer history,” Dr. Butler said.

“It is important for women going through perimenopause or menopause to not be ashamed,” Dr. Wilson said, noting that “as women transition from the childbearing years through menopause, they’re joining an ever larger group of women, since more and more women are living longer into post menopause.

“It behooves them to welcome each stage of their life, as they transition, knowing that many women have walked the path before them,” he added.

Notably, there is support out there. For example, “there’s a group called the Red Hot Mamas. It is a national organization to help women transition naturally into the postmenopausal years,” said Dr. Wilson.

“And if you have friends or family members who have gone through menopause,” he added, “it’s always good to talk with them. You might find that they are the best counsellors of all.”