The unpredictable and often difficult transition into menopause is coming under increased scrutiny as the population of middle-age women continues to grow PERIMENOPAUSE

December 14, 1993|By Linell Smith | Linell Smith,Staff Writer

The attorney in her mid-40s was shocked when she suddenly began to suffer from unpredictable hot flashes and intense perspiring. When they occurred during the day, she felt they undermined her performances in court. She told her physician that she was also sleeping fitfully at night and plodding through her days heavy with fatigue.

What's happening to me? she asked her doctor. Aren't I too young for menopause?

When Dr. Marian Damewood checked the attorney's blood, she discovered her patient was in perimenopause, the transitional stage leading up to menopause.

Perimenopause often comes as an unpleasant surprise: Women who feel as if they have achieved a level of mastery in their careers and lives suddenly discover that they are not in control of their bodies. Because of the social taboos that accompany this part of female aging, many are also reluctant to speak openly about it.

"The perimenopausal period is often the most difficult part of menopause," says Dr. Damewood, associate director of the Women's Hospital Fertility Center at Greater Baltimore Medical Center. "Many times women experience symptomology they can't relate to anything else they ever had before. They may have had irregular periods in the past, but they were not associated with hot flashes, vaginal dryness or . . . emotional changes."

Because a low supply of estrogen was causing the attorney's hot flashes, Dr. Damewood recommended estrogen replacement therapy, which relieved the woman's symptoms.

Such treatment is common for women who have passed through menopause. However, physicians are offering it more frequently now to women in their 40s to help with complaints related to decreased levels of estrogen.

Some women feel hot flashes and mood swings. Many find their menstrual cycles come closer together or farther apart. They can have uncharacteristically light or heavy bleeding.

In the United States, the mean age for menopause -- usually defined as a year without menstrual periods -- is 51. However, some women can begin to experience its effects in their early and mid-40s. The process can be even more confusing because each woman goes through the transition differently.

"It's important for people to understand that going into menopause isn't necessarily like switching off a light," says Dr. Howard Zacur, associate professor of gynecology and obstetrics Johns Hopkins School of Medicine and director of the Johns Hopkins Estrogen Consultation Service. "For some women, it may be like that. Then you will have somebody that really has a prolonged transition period into menopause. And then you have someone that's in between."

During the menopausal "window" -- considered age 43 to 57, according to Dr. Zacur -- it is not unusual for women to assume they have entered menopause after missing their periods for several months. Then, suddenly, they will menstruate again.

"If you have a woman who is 60 years of age whose last period was 10 years ago, then that's the individual everyone traditionally would agree is menopausal and unlikely to have another period," Dr. Zacur says.

"But if you're dealing with someone who's 52 years of age and whose last period was six months ago, it's not all that unusual for that person to suddenly have a period . . . It [the unpredictability of the process] helps explain why things aren't as they seem: Why you can seem to be in menopause on a Monday in January but not on a Monday in March."

Despite the intense interest in the subject of the menopausal years -- during the next decade, the population of women between 45 and 54 will jump from 13 million to 19 million -- researchers say that much about this transition remains unknown.

Menopause is the conclusion to the natural -- and lifelong -- process of losing the eggs women store in their ovaries. Women lose a large portion of the 2 million eggs with which they are born before they even reach puberty; roughly 400 eggs are used during a woman's reproductive years.

Each month, the ovaries produce the hormone estrogen before an egg is released. If there is no pregnancy, the hormone progesterone helps begin the process of menstruation. By the time a woman reaches her late 30s and early 40s, the ovarian function begins to decline and women no longer ovulate every month.

These anovulatory cycles can cause menstrual irregularity which can present either lighter or heavier bleeding. When there are no more eggs in the ovaries, the reproductive organs stop producing hormones.

Studies show that women's ovaries begin producing less estrogen around the age of 35. What happens after that, however, is largely uncharted.

"The perimenopause is like a big black hole in women's health," says epidemiologist Trudy Bush, professor at the Johns Hopkins School of Hygiene and Public Health and principal investigator in the nation's first large clinical study of hormone replacement therapy. "Yet there's sufficient evidence that there is a lot going on in women.

'Substantial changes'

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