The change before menopause

Aging: Perimenopause signals the approach of well-known physical changes, but the problems don't have to be taken stoically.

January 21, 2001|By Jane E. Allen | Jane E. Allen,Los angeles times

Women expect menopause; it's the hormonal changes beforehand that blindside them.

"I felt like I was living in someone else's body," says Debbie Greenberg, 45, who three years ago began having heavy periods, days-long headaches and "brain fog." "I didn't know what was going on. I had no clue. I wondered if I was cracking up."

When her gynecologist identified her symptoms as part of perimenopause, Greenberg says, "it was validation."

Perimenopause, a term that has largely displaced "premenopause," refers to the hormonal and physical changes leading to menopause, commonly defined as 12 months without a period. After that, a woman is considered postmenopausal.

For some women, the approach of this hormonal milestone offers a stark reminder that even at the prime of life -- when they have mastered the juggling of jobs, kids and relationships -- their bodies are aging.

For those who may have postponed motherhood, it's hard to accept that their supply of eggs capable of producing a child is dwindling.

Still others are troubled by losing control over their bodies and moods as their hormones fluctuate wildly.

Dr. Marcie Richardson, an obstetrician-gynecologist who directs a menopause consultation service in Boston, says women come to expect certain patterns from their hormones, such as premenstrual syndrome.

"When these things are all over the map," she says, "that's very disturbing for women."

Doctors are often at a loss to predict when perimenopause will begin or how it will affect efforts to become pregnant. Nor can they say whether women will have a rough time getting through it. Most have only mild symptoms; others have astonishingly disruptive effects.

Doctors can't even agree on when a woman should seek help. Some doctors suggest that a woman consult a physician at the first sign of menstrual changes; others advise waiting until symptoms become bothersome, such as missing periods or having hot flashes.

But doctors can offer women better ways to cope.

"Twenty years ago, if somebody had hot flashes and skipped a few periods here and there, we didn't have good treatments for them," says Dr. Isaac Schiff, chief of obstetrics and gynecology at Harvard-affiliated Massachusetts General Hospital.

As recently as 30 years ago, many of these women routinely underwent hysterectomies -- surgical removal of the uterus and sometimes the ovaries. The women now hitting perimenopause, he says, "are not going to settle for a hysterectomy."

Various coping strategies are available, but regardless of what course a woman chooses, she should do so carefully. After menopause, her ovaries will no longer make estrogen, which has bolstered her bones against osteoporosis, her heart against rising cholesterol and heart disease -- and, as mounting scientific evidence is showing, her brain against Alzheimer's disease.

Think of perimenopause as puberty in reverse. During puberty, brain chemicals switch on a girl's ovaries, starting a cascade of physical changes that herald her entry into womanhood. At perimenopause, the ovaries begin to run out of eggs and stop responding to those chemicals, a natural progression leading to menopause.

The transition to menopause varies among women, as does the onset of puberty, says Dr. Margery Gass, director of the menopause and osteoporosis center at the University of Cincinnati College of Medicine. "To some it was rocky; to others it was a piece of cake."

Although most women reach perimenopause at about age 46, it can occur as early as 35 or as late as 55, doctors say. Smoking can speed up onset by two years. Perimenopause can last a few months or up to a decade.

Women shouldn't rush to a physician at the first sign of menstrual irregularities, Schiff says, unless they're very symptomatic. "We don't have enough doctors for that," he explains, "plus we don't want to cause undue anxiety."

Coping strategies for dealing with perimenopause changes vary enormously. Some women "don't want to be the least bit uncomfortable," says Dr. Allison Leong, a Santa Monica, Calif., gynecologist. Others, she says, choose to get through it the old-fashioned way: "They just gut it out."

Many women think they need to be stoic -- they feel guilty about turning to medical interventions, even with severe symptoms.

"These women should not feel they are 'copping out' by taking hormonal or other treatments," says Dr. Nanette Santoro, who does perimenopause research at Albert Einstein Medical Center in the Bronx, N.Y. She says about 10 percent of women have "killer hot flashes, memory loss and generalized misery throughout the process.

"If providing symptom-based treatment makes short-term quality of life better for a symptomatic, perimenopausal woman," she says, "Why not?"

Although some researchers say long-term hormone replacement therapy can increase the risk of breast and uterine cancers, many doctors say it can reduce the risk of ovarian cancer and rheumatoid arthritis.

Some women can't take estrogen, including those with a history of blood clots or those with high risk of breast cancer.

Hot flashes can be tamed with Megace, a synthetic progesterone approved in breast cancer treatment, or the blood pressure drug clonidine, marketed as Catapres.

Although there are scant studies to rely upon, many doctors use the newest generation of antidepressants, the selective serotonin reuptake inhibitors such as Prozac, to help some women, especially those who will not or cannot take birth control pills or estrogen.

For some women, the approach of this hormonal milestone offers a stark reminder that even at the prime of life their bodies are aging.

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