OB/GYN

Midsouth Wellness Guide

Health Expectations in Perimenopausal Women

By Riad Homsi, M.D., FACOG
Just For Women
The perimenopausal and the menopausal years are a period of marked change in womens lives, which will affect their physical appearance, feeling of well-being, psychologic outlook, and sexual function. As of the year 2000, 40 million American women are postmenopausal, and this number is expected to increase by another 3.5 millions during the next decade. This increase in the menopausal population is related to both an increase in the life span (mean life expectancy of about 84 years) in this era of modern medicine and the arrival of the post World War II baby Boom generation into the menopausal age group. With this increase in life span, one third or more of a womans life will be lived after she reaches menopause. Over the centuries, menopause has been called many names, including the change of life, the time of life, Indian summer, the climacteric. The term menopause is derived from the Greek words meno (month, menses) plus pauses (pause, cessation) or, taken jointly, pause in menstruation. By denition, menopause is achieved after 12 months of no periods following the nal menstrual period (FMP).In the Western world, menopause occurs at an average age of 51.4 years with a range from 40 to 58 years. Perimenopause The transition from the menstruating years to nonmenstruating years is not necessarily a smooth or sudden event as the term menopause (FMP) suggests. In reality, many women are intermittently complaining of symptoms for many years during this time. This period of menopausal transition or perimenopause is the period covering this decline in the function of womens ovaries until its complete cessation at menopause. No one knows exactly why menopause occurs when it does, but it could happen because of the signicant reduction in the number of eggs in the ovaries. Every woman is born with one to two millions of these eggs, but only about 500 of them will be used for ovulation and possible pregnancy. The rest of them will degenerate over time and die as part of a natural process called atresia or cell death. At puberty, only 100.000 eggs are present. This number is reduced to somewhere between a few hundred and a few thousand at the approach of menopause. It appears that the rate cell death is steady until about age 37 and then accelerates. It is during this period (5-15 years before menopause) that the production of estrogen (female main hormone) will become erratic and unpredictable. This changing level of estrogen in this transitional period is responsible for most of the symptoms encountered during this period. Physical changes in Perimenopause: Most symptoms that occur at perimenopause as disturbances of varying severity are termed acute since they will not typically continue long into the postmenopause. These changes are, for the most part, perfectly normal and natural. Other changes resulting from lowered hormones may have long term consequences, including increased risk of osteoporosis and possibly cardiovascular disease. A-Sleep Disturbances: One third to one half of women 40 to 54 years old report sleep problems. Poor sleep (insomnia) in midlife women can include difculty falling asleep or staying asleep through the night or awakening prematurely without being able to resume sleep. Most studies of peri- and menopausal women and sleep reveal that sleep disturbances occur mainly in women most bothered by nighttime hot ash and/or night sweat activity. Besides ovarian hormonal changes, many midlife women also experience signicant life challenges (e.g. job related stress, loss of life partners through divorce or death, caregiving for young and/or old family members etc...).Sleep disturbances can also be due to painful chronic illnesses at this age such as arthritis, bromyalgia, gastrointestinal problems, heart and lung disease, thyroid and psychiatric conditions. B-Vaginal changes: As women approach menopause, the decline in ovarian hormones, mainly estrogen, may result in some vaginal changes, although not all women develop troublesome symptoms. The gradual decrease in estrogen results in thinning of the supercial layer of the vagina and ultimate loss of vaginal elasticity. With that comes decrease in blood ow to the vagina and decrease in secretions. This results in decrease lubrication and ultimate itching, irritation, pain during intercourse and bleeding. C-Mood swings: Studies suggest a greater incidence of mood disturbances in perimenopausal women than in postmenopausal women. Many perimenopausal women report distressing symptoms of irritability, tearfulness, lack of sleep, fatigue, and decreased memory and concentration. Most women become used to their own hormonal rhythm during their early years. However, during the perimenopause the rhythm changes. Ovarian hormonal uctuations can be stress provoking. Many women nd that the unexpected timing and extent of these changes with the added midlife stressors and other hormonal changes (hot ash/night sweat) with the sleep disturbances often result in fatigue, irritability and blue moods. D-Sexual changes: the problems related to female sexual dysfunction which are most commonly reported by perimenopausal women are inadequate lubrication with sexual arousal, a need for more time and more sexual stimulation to achieve vaginal lubrication, pain upon penetration and ultimately loss of sexual desire. Other sexual problems that may begin during the perimenopausal years and exacerbate over time include diminished sexual responsiveness, loss of clitoral sensation, decreased frequency of orgasm with coitus, and when orgasm occurs ,a less intense orgasmic response.Vaginal lubricants or moisturizers used at the time of coitus are effective in eliminating vaginal dryness and subsequent pain during intercourse. The use of low dose birth control pills for menstrual irregularities in this age group often improves the vaginal lubrication and alleviates sexual difculties. These pills also provide contraception and for many women, eliminating the fear of an unwanted pregnancy adds to their sexual enjoyment. E-Hot Flashes: It is a sensation of intense heat of the upper body, arms, and face. The hot ash is followed by ushing of the skin in these areas and then generally by profuse sweating. It is the second most frequent perimenopausal symptom (after irregular cycles), reported by as many as 85% of perimenopausal women. It is the hallmark of perimenopause.Hot ashes can occur infrequently (monthly, weekly) or frequently (hourly). Approximately 10-15% of women have very frequent hot ashes. Women who have hot ashes usually do so for 3 to 5 years, but some women have hot ashes only for a few months. Some women report hot ashes years before menopause. Typically, these hot ashes occur in conjunction with menses. Hot ashes typically stop without treatment, but there is no reliable method for determining when this will occur. The available treatments do not cure hot ashes, but they can

October 2007 Midsouth Wellness Guide

Midsouth Wellness Guide

offer symptomatic relief. A number of factors, called triggers, affect the frequency and /or severity of hot ashes. These triggers include stress, hot or spicy food, hot drinks, alcohol, caffeine, and certain medications. However, women should not presume that hot ashes are only due to approaching menopause but could be due to other medical conditions. F-Irregular uterine bleeding: Changes in both menstrual ow and frequency are the hallmarks of the menopause transition. About 90% of women experience 4 to 8 years of menstrual cycle changes before menopause. Most report irregular menses that are attributed to decreased frequency of ovulation and uctuating levels of ovarian hormones. As women approach menopause, menstrual cycle changes can be subtle. A variety of menstrual patterns are possible including lighter or heavier bleeding, bleeding for less than 2 days or more than 4 days, cycle shorter than 21 days or longer than 28 days, or skipped menstrual cycles. In general, each woman will report a pattern that is irregular for her. Low dose BCP may be benecial to regulate the cycles. G-weight Gain: During the menopause transition, many women gain weight. The average amount of weight gained during this period averages about 5 lbs. This gain is not related to hormone therapy but rather to aging and lifestyle. Body fat accumulates throughout adult life, and most women in the western world will continue to accumulate body fat during the peri- and potmenopause, adding to the fat already there. Muscle mass decreases with age and this loss seem to accelerate after menopause, given the more sedentary lifestyle of older women. Burning fewer calories through less physical activity also increases fat mass and weight gain. Although research suggests that age, rather than menopause, is associated with weight gain, there is some evidence that menopause may be related to changes in body composition and/or fat distribution. Several studies have shown that menopause is associated with increased fat distribution in the abdominal region. H-Decline in Fertility: Many women in western countries are delaying childbearing. Those aged 35 or older are considered to be of advanced maternal age. A signicant decline in fertility occurs in women around 35 to 38, or 10 to 15 years before menopause. In addition, advance maternal age(AMA) is associated with increased risk for spontaneous miscarriage, increased risk for genetic abnormalities in the baby and increased risk for pregnancy complications(preterm labor, diabetes , hypertension, etc). Despite a decline in fertility during perimenopause, women should be aware that pregnancy is still possible. The perimenopause woman is not totally protected from an unplanned pregnancy until she has reached menopause so contraception is important in this age group. Screening in perimenopause: Perimenopause is also a period when certain key issues in preventive health care can be implemented that can have signicant impact during the postmenopausal and geriatric years. A-Thyroid screening: Thyroid problems affect almost 3% of the US population and are particularly prevalent among women and the elderly. The primary function of the thyroid gland is to produce hormones that regulate the body metabolism. All women at midlife and beyond E-Screening for certain cancers: Cancer is the second leading cause of death in women in the US after heart disease. Nearly 80% of all cancers are diagnosed at age 55 or older. Women have a 1 in 3 lifetime risk of developing cancer. Peri- and menopause is not associated with increased cancer risk.However, since cancer rates increase with age, women in midlife and beyond should be evaluated for their risk of cancer of the breast, colon, ovary, and cervix. should be screened for thyroid malfunction, with testing repeated every 5 years or sooner if symptoms develop using a special blood test called TSH. B-Diabetes screening: Diabetes, even when asymptomatic, can cause long term complications. Patients with one or more of the following risk factors should be screened for diabetes including family history, obesity, ethnicity (i.e. African American, Hispanic and Native American), and history of diabetes in pregnancy, high blood pressure or high cholesterol. The diagnosis requires a fasting level of at least 126mg% or random glucose of at least 200mg% on more than 2 occasions. If normal, glucose screening should be performed every 3-5 years in patients at risk. C-Cardiovascular screening: Cardiovascular disease (CVD), especially coronary artery disease remains the leading cause of death in women.CVD is a largely preventable disease. Women should be aware of their personal risk levels. High blood pressure and high cholesterol are 2 major modiable risk factors. The Blood Pressure (BP) should be checked regularly. The optimal level should be Systolic BP<120 and Diastolic BP<80. If it is less than 130/85, it is considered normal and should be checked in 2 years. If it is less than 139/89, it is considered high normal and should be checked in 1 year. Any reading over that is considered abnormal if it is obtained at two or more sittings. Asymptomatic women should be screened for lipids (fats) in their blood. If the values are normal, screening should be repeated every 5 years. Lipid tests include a fasting level of LDL (bad cholesterol), HDL (good cholesterol), total cholesterol and Triglyceride. The goal is to have a low Triglyceride, low total cholesterol, low LDL and high HDL.The different values can be classied into categories depending on the association with other risk factors (family history, smoking, diabetes) and treatment offered. D-Osteoporosis Screening: Women approaching menopause should be evaluated for their risk of osteoporosis especially that the peak of bone mass is achieved around the age of 35-40 years. After that, women lose calcium form their bone at a steady state. Risk factors include race (Caucasian is at higher risk than African American), family history, lifestyle (like nutrition, physical activity, smoking, and alcohol) and perimenopausal hormonal changes that increase the rate of bone loss. Currently, bone mineral density (BMD) is the preferred non invasive method available to assess bone quality. The North American Menopause Society recommends that BMD be done in all women over the age of 65, and in those under 65 if they have other risk factors including a history of fracture, low body weight (<127 lbs) or a history a rst degree relative who has experienced a hip or vertebral fracture, or have other causes of secondary osteoporosis i.e. medication (Steroids). At present, mammography is the only screening test available for breast cancer. The present recommendation is an annual mammogram starting at age 40. For high risk women, screening should begin earlier (age 3035). Colon cancer is the third leading cause of cancer death in the US after lung and Breast cancer. Screening is recommended to start at age 50 or earlier if there are risk factors (e.g. family history). The screening includes the yearly testing of stool for blood (Fecal occult blood testing-FOBT), or exible sigmoidoscopy (camera with a light in the lower part of colon) every 5 years or colonoscopy (camera with a light in the entire colon) every 10 years. Of course, these time frames can be changed depending on the risk factors. Cancer of the ovaries causes more death than any other cancer of the genital organs, primarily because it is usually detected in an advanced stage. There are no satisfactory screening tests available for ovarian cancer. The blood test Ca 125 is not specic or sensitive .The American cancer society recommends that all women over the age of 40 should have an annual pelvic exam. The mortality from cervical cancer has dropped sharply over the years due to the increase use of Pap smear, which becomes an essential part of a woman comprehensive yearly exam, especially over the age of 40. Lifestyle modications in perimenopause: Perhaps the most important step a woman can take in her perimenopausal years is to plan for some lifestyle modication. A-Smoking: It is responsible for more than 142,000 death annually in women in the USA.Smoking cessation is the single most important change a woman can make to reduce her risk of disease especially coronary heart disease and cancer (especially lung and cervical). Smokers tend to reach menopause up to 2 years earlier than nonsmokers, increasing their risk for disease at an earlier stage. Smoking is also associated with more rapid bone loss in women resulting in increased risk of fracture. Smoking also jeopardizes dental health. Nearly all smokers acknowledge that tobacco use is harmful to their health, but they underestimate the magnitude of their risk. B-Alcohol: Women are more affected by alcohol than men due to many factors, including having less water in their bodies to dilute the alcohol, fewer enzymes to digest the alcohol, and hormonal differences that may affect the absorption. Alcoholic beverages, along with cigarette smoking and use of snuff and chewing tobacco, can cause cancer of the mouth. Women who consume 1 to 2 drinks daily may be at increased risk of breast cancer. High levels of alcohol use(dened as more than 7 drinks per week:1 drink equals 12oz beer,4 oz wine, or 1 oz liquor) may increase certain risks such as high blood pressure, stroke and heart disease. It has also been shown to increase risk of falls and hip fracture. Drinking moderate amount of alcohol can cause hair and skin to appear dull and can worsen acne and dandruff. It can also lead to weight gain through its empty calories without nutritional content. C-Exercise: Recent national surveys report that less than 20% of US women aged over 45 participate in regular physical activity. When performed regularly, activities such as brisk walking,running,aerobics,dancing,tennis,a nd strength training can help the heart, muscles, bones, balance and weight.New guidelines suggest that 30 minutes of moderate exercise(which can be divided into

October 2007 Midsouth Wellness Guide

Midsouth Wellness Guide

10-minute sessions) on at least 5 days of the week has marked health benets. Exercises can be divided in three categories including Strength training(such as free weights or weight machines which increase bone density and muscle mass),Aerobic (such as low impact aerobic, brisk walking,jogging,cycling which benets the heart) and Flexibility(such as stretching to help maintain exibility and reduce stiffness with aging).Exercise can also have a positive effect on many menopause related complaints. Hot ashes are reported less, sleep is better and it also reduces the osteoporosis risk. D-Nutrition: Nutritional guidelines recommend consuming a variety of foods. Diets should be high in grain products, vegetables, and fruits as well as low in saturated fats and cholesterol. The current recommendations include at least ve fruit and vegetable serving daily, low to moderate use of salt and sugar, limit total fat to less than 30% of total calories, limit saturated fat to less than 10% of total calories, and limit cholesterol to 300 mg per day. The Mediterranean style diet is the most recent recommendation from the American heart association. It emphasizes more root vegetables and sh, replacing beef, lamb, and pork with poultry, eating fruit every day and replacing butter and cream with olive oil. A diet high in cold-water sh (eg, salmon, tuna, and halibut) provides omega3 fatty acids, which are linked to prevention of heart disease. Flaxseeds and axseed oil are other sources of omega -3 fatty acids. Flavonoids and Vitamins antioxidants are found in fruits and vegetables. They also have been linked to lower risk of heart disease and colon cancer. Soy products have also potential effects on reducing heart disease risk. Grains such as wheat, rice, oats, barley, and the foods made from them are recommended at the level of 6 to 11 servings daily. Because of their vitamin and mineral content, it is best to obtain ber from fruits, vegetables, and whole grains rather than from ber supplements. The ber will decrease the risk of colon cancer. Legumes, such as dried beans, pinto beans, lentils, and soybeans, are also rich in nutrients that may protect against cancer. The additional intake of extra calcium and Vitamin D cannot be emphasized especially for bone protection. The RDA recommends 1 gm of calcium and 400IU of Vitamin D for premenopausal women and 1.5 g of calcium and 800 IU of Vitamin D for postmenopausal women. Many women in the perimenopausal transition experience premenstrual symptoms, including uid retention, irritability, moodiness and breast tenderness.Vitamines like B6, B12, and folic acid, derived from fruits and vegetables and legumes are important. In conclusion, these measures, if properly carried out, would help build a solid foundation to ensure good health and vitality that extends well into the postmenopausal years.

Just For Women

Riad Homsi, MD, F.A.C.O.G
Certified Menopause Practitioner A physician just for women of all ages

Specializing in General Obstetrics & Gynecology Services including: Pregnancy Family Planning Infertility Menopause Bladder Problems Bleeding Issues Abnormal Pap Smear Adolescent Gynecology

About the Author

Riad Homsi, MD, FACOG is a Board certied Obstetrician/Gynecologist and Menopause Practitioner. He is the director of the practice Just For Women, located at 80 Humphreys Center, suite 201, Memphis ,TN 38120.For more information, please call (901) 50-STORK or visit www.justforwomendoc.com

6025 Walnut Grove, Suite 400 Memphis, TN 38120 901-50-STORK www.justforwomendoc.com

October 2007 Midsouth Wellness Guide