John Browning, MD

A woman’s body is a biological marvel, able to create life by producing eggs for fertilization and then growing and carrying a baby to term in the nine-month process. Over a woman’s lifetime, her reproductive system changes and progresses through three phases: the reproductive years of menstruation, the transitional phase of perimenopause, and then menopause, which signals the end of a woman’s reproductive phase.

The reproductive phase begins with the menstrual cycle, the monthly series of hormonal changes that produces an egg and prepares the body for a potential pregnancy. Menstruation typically starts around age 12, but could begin any time between the ages of 8 and 18.

After many years, a woman’s body will start the transition into perimenopause. Perimenopause typically starts in the early to mid-40s, although some women may start as early as their mid-30s. This phase typically lasts around 8-10 years, when hormone levels of estrogen and progesterone start to fluctuate and eventually decline, exiting the reproductive cycle. While the risk is lower, women can still become pregnant at any time during this phase of life without proper protection.

Perimenopause is a unique journey for each woman. Symptoms vary widely, and the intensity of symptoms can fluctuate with the ever-changing hormonal shifts of estrogen and progesterone. The hallmark symptom of perimenopause is a change in the menstrual cycle. The release of an egg each cycle during ovulation decreases, and women may experience fewer periods overall, alternating lighter and heavier periods, or infrequent longer, heavier periods.

Women in perimenopause may also experience typical menopausal symptoms, including hot flashes, night sweats, vaginal dryness, low desire for sex, sleep disturbances, brain fog, fatigue, joint pain, mood swings, headaches, irritability, anxiety, and depression. During perimenopause, these symptoms often wax and wane. Some women don’t notice any symptoms, and 75-80% of women do not need medical treatment for symptoms.

Menopause, or the end of the reproductive cycle, is when hormone production shuts down and the menstrual cycle stops. This final phase typically occurs in the mid-40s to mid-50s, with an average age of 51. A woman is considered post-menopausal after 12 consecutive months without a period.

Menopause may be more difficult to determine if a woman has had a hysterectomy, but blood testing can help confirm it. If a woman has a hysterectomy, menopause typically happens one to two years earlier. Surgical menopause can also occur if the ovaries have been removed. Typical symptoms include hot flashes, night sweats, difficulty sleeping, diminished sex drive, and sometimes brain fog. Typically, these symptoms last 8 to 10 years, but they can last longer. Vaginal dryness can occur, but usually happens later in menopause.

If you experience any symptoms that are intense and affect your daily life, schedule an appointment with your gynecologist. They will help you understand your symptoms and explain different treatments to help you make an informed decision about what to do next.

Healthy Lifestyle Approach

A lifestyle approach is the foundation to help promote optimal overall health, minimize weight gain, and decrease the severity of symptoms. Women typically lose muscle mass during perimenopause and menopause, as hormonal decline decreases metabolism and makes it easier to gain weight. These approaches can also help manage insulin resistance, which leads to increased belly fat and weight gain and may be a factor during perimenopause. There is a higher risk of severe symptoms for women who have PCOS, are overweight or obese, or have type 2 diabetes.

Healthy lifestyle recommendations include:

• Choosing an overall healthy diet, with lean protein, healthy fat, complex carbohydrates, fiber, adequate fluids, proper portions, and less highly processed foods
• Incorporating regular physical activity, including cardiovascular exercise and strength training, to promote heart health and preserve muscle mass
• Managing stress effectively and incorporating relaxation techniques such as breathwork, stretching, yoga, and hobbies can help improve mood swings and sleep
• Aiming for seven to eight hours of quality sleep each night. Following a sleep schedule, limiting screens, caffeine, and alcohol before bed, and sleeping in a cool, dark room can also promote higher sleep quality.

Hormone Replacement Therapy

Menopausal hormone replacement therapy (HRT) can provide relief for bothersome hot flashes and night sweats, improve sleep, and benefit overall quality of life. HRT also has other potential benefits, including:

• Improve vaginal moisture and any urinary symptoms
• Prevention of bone loss and reduction of osteoporotic fractures
• Potential colorectal cancer risk reduction
• Possible favorable cardio-metabolic profiles in certain patients

These numerous benefits are most favorable when therapy is started near menopause in healthy women with indications. The largest benefits are obtained when HRT is started early, and it is generally recommended to begin HRT within 10 years of menopause or for patients under 60, as there may be increased risks after this time.

Low Dose Estrogen

Low dose estrogen is the primary type of HRT, which can help with hot flashes, night sweats, vaginal dryness, and sleep disturbances. HRT also helps preserve bone density, decreases the risk of colon cancer, decreases urinary symptoms, and helps reduce the risk of diabetes. While there are risks of blood clots and a slight increase in reproductive cancers, starting HRT before age 60 or within 10 years of reaching menopause can decrease overall risk. Low dose estrogen may be delivered in a variety of options, including patches, oral medications, vaginal tablets, or a ring.

Natural Progesterone

Progesterone is also a component of HRT and is useful to help regulate the menstrual cycle, improve sleep disturbances, reduce mood swings and anxiety, and help ease night sweats. If a woman’s uterus is intact, adding natural progesterone with estrogen is recommended and will decrease the risk of endometrial cancer. Synthetic versions of progesterone may increase the risk of breast cancer. Natural progesterone also has many options, including oral medications, injections, creams, vaginal suppositories, and gels.

If HRT isn’t an option, there are other medications that may help.

Vaginal Moisturizers

Vaginal moisturizers with hyaluronic acid restore moisture and are used to address dryness and discomfort. Using a vaginal moisturizer regularly helps maintain moisture over time and generally improves vaginal health. These are typically used one to three times a week or every other day, depending on the severity of the condition and the brand. A vaginal lubricant is a silicone coating used only as a lubricant before sex.

Soy Supplementation

The plant nutrients in soy foods, called isoflavones, contain plant estrogens. These may help some women with perimenopausal symptoms, including hot flashes, irritability, and fatigue, while other women may not notice any benefit. Talk to your provider before trying soy supplements, especially if you have any thyroid issues or a history of estrogenic breast cancer. Since supplements are not regulated by the FDA, do your research before purchasing. Soy foods such as soy milk, tofu, tempeh, edamame, and beans contain plant estrogens and can be easily and safely added to your diet.

Bio-identical Hormones

The American Medical Association and the American College of Obstetrics and Gynecologists do NOT recommend using bio-identical hormones. Recommendations for the type and dosing of bio-identical hormones are usually based on one blood or sputum test, and estrogen/progesterone levels can fluctuate significantly on an hourly or daily basis during perimenopause. Quality control is also an issue, due to no regulatory oversight by the FDA and ingredients typically imported from China.

An annual women’s wellness visit is still recommended for all women during each phase of the reproductive cycle for any needed screens, such as pap smears, a breast/pelvic exam, and discussion of any female-related issues or concerns. Maintaining a solid relationship with your gynecologist over the years can also help catch any medical issues early.

Work with your primary care provider for any symptoms not addressed by your gynecologist, such as anxiety, depression, and headaches. It is important to see your gynecologist immediately if you have symptoms such as prolonged or heavy periods, abnormal vaginal bleeding, breast issues, or pelvic pain. Women’s health, wellness, and overall quality of life are top priorities for all phases of the reproductive journey!