Menopause

Menopause is normal and the planned end of ovulation which results in a loss of approximately 90% of estrogen. Women have estrogen receptors throughout their body and therefore just about everything is affected: hair, skin, brain, eyes, joints, bones, heart, vulva, vagina, urethra, bladder.... Although menopause is normal, if you are struggling with any symptoms there are multiple safe and effective treatment options. 

Perimenopause is the time period leading up to menopause and is characterized by fluctuating levels of hormones. At times women may have high levels of both estrogen and progesterone, at other times the levels will be low. Some women are more sensitive to these fluctuating levels than other women and may have more bothersome symptoms. There are effective and safe treatment options for these symptoms.

Hot flashes or night sweats, difficulty sleeping, mood changes, vaginal dryness, joint pain, and weight gain-especially in the abdomen, and dry skin, hair, and eyes.

The Genitourinary Syndrome of Menopause is due to low levels of estrogen in both the genitals and the urinary system. Its symptoms can include vaginal itching, irritation, and pain with sex as well as bladder infections and urinary frequency or urgency. It is very common, yet both under recognized and under treated. There are both prescription treatment and over the counter options available, as well as energy-based therapy such as the vaginal laser.

Over the counter options include lubricants and moisturizers Lubricants are short acting and used during sexual play. Options include water based, silicone based, or oil based. Moisturizers are used for long term relief of dryness. Prescription options include vaginal estrogen, vaginal DHEA, or oral ospemifene. There are also energy based therapies which includes the vaginal laser. 

Both the vulva and the vagina can benefit from treatment for GSM and dilators are also helpful for some women with shortening and/or narrowing the vaginal canal.

Treatment of GSM can include either prescription of vaginal estrogen, vaginal DHEA or the oral prescription of ospemifene. Energy based therapy such as the vaginal laser is another option. The laser treatment does not have as much research and data as the prescriptions do; however, the research that is available states that it is safe and effective. Vaginal laser treatment is a nice option for women who do not want to maintain a regiment of prescription treatment, but it is not covered by insurance and may be cost prohibitive. 

The Menopause Society updated their position statement on hormone therapy in 2022. It reviews the indications and safety as well as types of hormones that can be used. For the majority of women within 10 years of their last period and/or 60 years old or younger, the benefits outweigh the risks.

The Menopause Society updated their position statement on non-hormonal therapies for menopausal symptoms in 2023. It reviews the safety and research available on products and ingredients that are available by prescription and over the counter.

Bioidentical hormone therapy refers to hormones that are chemically similar to what the ovaries were producing or more specifically estradiol and micronized progesterone. Hormone therapy that consists of estradiol and micronized progesterone is FDA approved and available at commercial pharmacies. Compounding pharmacies can also make bioidentical hormones which is a great option for women who want a different dose than what is commercially available, or they have allergy to a component present in the commercially available prescription. Compounded hormone therapy doesn't have the same black box warnings that commercially available hormones do because they are not regulated by the FDA and therefore are not mandated to include the black box warning, this doesn't mean they are safer. Furthermore, there is no good research on compounded hormone therapies' safety and effectiveness although commercially available hormone therapy has undergone vigorous testing and research.

Vitamin D is important for bone health and may play a role in the immune system. The recommended daily dose is 600-800 IU but doses of 1000-2000 IU daily appear to be safe. Vitamin D supplementation appears to be the most beneficial in women who have a deficiency. 

Sleep disorders are very prevalent in both perimenopausal and menopausal women. This includes both falling asleep and staying asleep. One treatment option that has been proven to be effective and has no side effects is cognitive behavioral therapy (CBT). A professional trained in CBT can help a woman change her behaviors and mindset to correct her sleep disorder. 

Heart disease is the #1 killer of women, and the risk of heart disease increases in menopause, especially in women who go into menopause before the age of 45. During menopause women start to have an increase in plaque buildup in their arteries, an increase in blood pressure, and weight gain. In addition, many menopausal women are not exercising regularly or eating a heart healthy diet. At this time although menopausal hormone therapy does not increase the risk of heart disease it is not recommended to prevent heart disease.

Adopting a healthy lifestyle is an effective way to prevent breast cancer. If a woman changes to a plant-based diet, maintains a healthy weight, exercises regularly, and avoids alcohol; she can reduce her risk of breast cancer by 30%!

Low desire for sex is the most common of the female sexual dysfunctions. A woman is diagnosed with Hypoactive Sexual Desire Disorder, or HSDD, when she has a decrease in desire for sex and she is distressed by this low desire. Testosterone is not FDA approved for women, but it has been proven to be safe and effective for the treatment of low desire in menopausal women. The goal of testosterone therapy is to increase desire but still maintain testosterone levels that are within the normal range for women. Consequently, testosterone levels need to be monitored with labs. There are no commercially available prescription options made for women; therefore, the recommendation is for women to use 1/10 the dose of men's testosterone products. 

Mood changes in perimenopause and menopause are common. Anyone with a previous history of anxiety or depression is at risk for a reoccurrence. Likewise, anyone with a history of PMS, PMDD, or pregnancy or postpartum mood changes is at risk for a worsening of moods in perimenopause and approximately the first 2 years of menopause. In addition, not sleeping well, changes in body image, changes in your personal life such as taking care of aging parents or changes in a career or long-term relationships may contribute to negative mood changes.

Weight gain in menopause is very common due to the loss of estrogen that causes a fat redistribution to the abdomen. Menopause also coincides with aging which can cause weight gain from a loss of muscle, decreasing metabolism and women may not be as active as previously. Interventions include diet and exercise but medication may also be helpful. 

There is conflicting information on the necessity of testing menopausal hormones; however, in the majority of situations it is not necessary. Menopause is diagnosed by 12 months in a row without a period or when the ovaries are surgically removed. Perimenopause is the time period leading up to menopause and is diagnosed by common signs and symptoms. Hormone therapy is individualized to women, but women's symptoms and responses to therapy guide the correct dose, not lab values.