Understanding the Symptoms That Occur During the Menopausal Transition

Menopause begins 12 months after your last menstrual period, in the U.S., the average age is 51. However, hormonal changes typically begin 4-7 years earlier. This period of change, called perimenopause,  is associated with sweeping and fluctuating changes in hormone levels. Symptoms vary from person to person and include:

Irregular periods: This is usually the first sign. The frequency of your periods may become less predictable, and the flow may be heavy or light.

Hot flashes and night sweats: These are sudden feelings of heat, usually most intense over the face, neck and chest. They can cause you to sweat profusely. Some women have a rapid heart rate or chills as well. The actual mechanism behind hot flashes is not yet completely understood but is related to low estrogen levels causing sensitization of the hypothalamus. In response to warm temperatures, the overly sensitive hypothalamus may respond by inducing a hot flash to cause sweating in an attempt to ultimately cool the body.

Sleep problems: You might have insomnia or find yourself waking up more often during the night.

Mood changes: Hormonal changes can often lead to increased anxiety, irritability, or feelings of sadness.

Vaginal Symptoms. During perimenopause, less estrogen may cause the tissues of the vulva and the lining of the vagina to become thinner, drier, and less elastic or flexible—a condition known as “vulvovaginal atrophy” . Vaginal secretions are reduced, resulting in decreased lubrication.  Reduced levels of estrogen also result in an increase in vaginal pH, which makes the vagina less acidic, just as it was before puberty.

Breast changes. Breasts become less dense during midlife, as glandular tissue declines and fatty tissue increases with aging. This decrease in density makes mammograms easier to interpret.

Decreased libido: Some women experience a drop in sexual desire during menopause.

Dry skin, mouth, and eyes: The decrease in estrogen can affect moisture levels in various parts of your body.

Hair changes. The shift in the balance between androgen and estrogen levels can also lead to excessive hair growth in areas of the body where hair follicles are especially sensitive to androgen, such as the chin, upper lip, and cheeks. Many midlife women report the sudden growth of single, thick (often dark) hairs on their chin, while others may notice downy peach fuzz–like hair on their face. 

Treatment

Medications are often used to treat perimenopausal symptoms. Medications are not medically necessary but are used to manage bothersome symptoms. 

  • Hormone therapy. Systemic estrogen therapy — which is commonly prescribed in pill or skin patchform — remains the most effective treatment option for relieving perimenopausal and menopausal hot flashes and night sweats. Depending on your personal and family medical history, your doctor may recommend estrogen in the lowest dose needed to provide symptom relief for you. If you still have your uterus, you’ll need progestin in addition to estrogen. Systemic estrogen can help prevent bone loss.
  • Vaginal estrogen. Estrogen can be administered directly to the vagina using a vaginal tablet, ring or cream. This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissue. It can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms.
  • Antidepressants. Certain antidepressants related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs) may reduce menopausal hot flashes. An antidepressant for management of hot flashes may be useful for women who can’t take or wish to avoid estrogen for health reasons or for women who need an antidepressant for a mood disorder.
  • Gabapentin (Neurontin). Gabapentin is approved to treat seizures, but it has also been shown to help reduce hot flashes. This drug is useful for women who can’t use estrogen therapy for health reasons and for those who also have migraines.
  • Fezolinetant (Veozah). This medicine is a hormone-free option for treating menopause hot flashes. It works by blocking a pathway in the brain that helps regulate body temperature.

Other recommendations include:

  • Switching to heavier/thicker moisturizers to combat skin dryness. Products containing hyaluronic acid are recommended because they help to increase the moisture content in your skin
  • Incorporting weight training using weights or body weight which helps to prevent the age associated loss of muscle mass, and increases testosterone which can have benefical effects on mood and libido
  • Using a lubricant during partnered sex and/or masterbation 
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