Our Bodies, Ourselves (109 page)
Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
© Donna Alberico
I just want more! More time free of kids to focus on my work; more time to myself; more passion in my marriage or from somewhere else
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Our experience can be profoundly influenced by our social/cultural context, in which we often encounter negative stereotypes of aging and discrimination against women. In a society that seems to value us primarily for our reproductive role, the end of our biological capacity to reproduce (unless we resort to the more extreme assisted reproductive technologies) can diminish our worth in others' eyes. Economic realities impair the ability of many of us to get the exercise, sleep, food, and medical care that are part of taking good care of ourselves. And Western society overvalues youth and beauty, setting them as a sexist standard for measuring women's worth. Once we are perceived as aging, we become prime targets for expensive or risky antiaging treatments, from wrinkle creams and Botox to face-lifts and liposuction.
The most important signs of midlife for me were the physical changes that made me realize that I was not young: vision loss, lack of sexual appetite, hair texture thinning, skin changes, and some wrinkles. I couldn't count on my looks anymore. My body was changing; what was the rest of my life going to be like?
The social realities of sexism and ageism can make it more difficult to deal with the sexual and reproductive changes that occur naturally in the middle years. These cultural messages have little to do with hormones and can't be treated with medication. We need to educate ourselves about the menopause transition and develop a critical perspective in order to resist the cultural messages that surround us. We can proceed with increased confidence as we become informed consumers and know that we are not alone. In fact, the support we receive from friends, family, and colleagues is critical in navigating this life transition well.
The transition of perimenopause begins anywhere from your late thirties to age sixty and can last from one to ten years. Women who smoke tend to reach menopause earlier than nonsmoking women. Other than that, the only consistent factor that roughly predicts when you might start perimenopause is the age at which your mother went through what used to be called “the change.”
It can be difficult to know whether you've entered perimenopause, because the hormonal fluctuations of that transition begin while menstrual periods are still regular. And it is difficult to use estrogen and progesterone or other hormone tests to indicate whether you are in perimenopause. These tests are not reliable indicators, because the ovaries often work unpredictably during perimenopause and reproductive hormone levels normally vary from hour to hour and day to day.
Endocrinologist Jerilynn Prior, founder of the Centre for Menstrual Cycle and Ovulation Research (cemcor.ubc.ca), a nonprofit research center in Vancouver, British Columbia, developed the following list of nine changes common to early perimenopause. If, despite regular periods, you have any three, she suggests you can assume you have begun perimenopause.
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EXPLORING CULTURAL DIFFERENCES IN WOMEN'S EXPERIENCES
Do women's experiences of perimenopause and menopause vary with ethnicity or cultural background? Most research done about menopause has been with white women, says Dr. Eun-Ok Im, a professor of nursing at the University of Texas at Austin. Dr. Im's four-year national study looked at ethnic differences in menopausal symptoms reported by white, Hispanic, African-American, and Asian-American women. Among the study's 2010 findings: African-American women were more likely to report hot flashes; white women were more likely to report more mood and memory changes; and women of Japanese and Chinese origin were more likely to report fewer menopausal symptoms in general.
Dr. Im notes that while past studies have shown white women to be concerned about menopause as a “harbinger of physical aging taking them away from society's youthful ideal,” the study found they are becoming more optimistic about menopause, with many seeing it as an opportunity to rethink their lives and redefine themselves. Some even mentioned relief and benefits when going through menopause.
“A possible reason for the positive changes in the way white women look at menopause might be that the recent women's health movement has educated women to accept menopause as a normal developmental process, allowing them to refocus on themselves,” said Dr. Im. African-American, Hispanic, and Asian-American women already reported being more optimistic and positive about menopause than white women. In Dr. Im's study, many black women said that they were raised to be strong and accepting of a natural aging process. They viewed menopauseâcompared with other difficulties in their livesâas just another part of life to endure. Hispanic women spoke about getting support from family and friends during the menopausal transition. Findings also strongly suggest that there are subethnicâChinese, Korean, Indian, Filipinoâdifferences in the menopausal symptom experience of Asian-American women, and more studies are needed in this area.
How much the reported variations are due to genetic makeup, diet, expectations, or something else is still unknown, but Dr. Im believes findings like the ones in her study will work to eliminate ethnic biases and inequity in menopausal symptom management and promote culturally competent care for menopausal women.
An ongoing multiethnic study, the Study of Women's Health Across the Nation (
www.swanstudy.org
), also found that “African American women are more positive towards the idea of menopause than women of other ethnicities.”
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White women in this study noted more muscle aches, difficulty sleeping, and irritability than women of other backgrounds.
1. New-onset heavy and/or longer flow
2. Shorter menstrual cycles (less than twenty-five days)
3. Newly sore, swollen, or lumpy breasts
4. New midsleep wakening
5. Increased cramps
6. Onset of night sweats, especially around menstrual flow
7. New or markedly increased migraine headaches
8. New or increased premenstrual mood swings
9. Weight gain without changes in exercise or eating
Many women breeze through perimenopausal changes, while for some the hormone fluctuations create a range of mild discomforts discussed in detail below. For about 20 percent of us, the hormones fluctuate wildly and unpredictably, with spiking and falling estrogen and declining progesterone causing one or more years of nausea, migraines, weight gain, sore breasts, severe night sweats, and/or sleep trouble in what one researcher who experienced these discomforts calls “ovarian chaos.”
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For this group, perimenopause can be enormously disruptive both physically and emotionally.
Most women successfully alleviate any discomforts of perimenopause and beyond through nonmedical self-help approaches such as meditation, yoga, relaxation, regular exercise, healthful food, enough sleep, and support from family and friends. It helps, too, when colleagues at work are understanding of sudden hot flashes or the days when lack of sleep makes it harder to concentrate.
Other womenâespecially those for whom perimenopause is particularly difficultâmay choose a balance of nonmedical and medical solutions. Health care providers who are well informed about perimenopause can be important partners in thinking through the options. This chapter presents what is known about the risks and benefits of different approaches so that you can choose the approaches that work best for you. It's important to remember that perimenopause and postmenopause are not diseases; they are life phases for every woman. And even the most difficult perimenopause does end.
The following figure, based on work by the gynecologist Nanette Santoro, helps to explain the hormonal fluctuations of perimenopause. The first row shows what happens to the four major female reproductive hormonesâestrogen, progesterone, FSH, and LHâin a typical menstrual cycle. The second row is based on samples collected by a perimenopausal participant every day for six months. Notice that the estrogen levels for this woman go up higher relative to progesterone levels than is ever seen during regular cycles. This is probably why some perimenopausal women experience “estrogenic” effects such as fibroid growth, heavy menstrual bleeding, breast tenderness, and an increased response to psychological stressors.
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The perimenopausal years have often been seen as a time of estrogen deficiency, but this information gives us a more complex and accurate picture.
Premenstrual syndrome (PMS)
Some women report more severe premenstrual discomforts (PMS) during early perimenopause, when cycles are still reguar, such as swollen or tender breasts, water retention (bloating), anxiety, sleep disruption, or irritation. Whether you have had such discomforts for years or are just beginning to have them now, you can typically look forward to relief later in perimenopause, when your periods become irregular, and certainly by postmenopause, when the hormones level out. For more information on menstrual discomforts such as mood changes and severe cramps, see “Physical and Emotional Changes Through the
Menstrual Cycle.”
HORMONE LEVELS
Adapted from a graph prepared by Nanette Santoro, MD
One common menstrual change in early perimenopause is shorter cycles, usually averaging two or three days less than usual but sometimes lasting only two or three weeks. It can feel as though you're starting a period when the last one has barely ended. In later perimenopause, you may skip a period entirely, only to have it followed by an especially heavy one (this is known as flooding). Occasionally, menstrual periods will be skipped for several months, then return as regular as clockwork.
The hormonal ups and downs of perimenopause can be the cause of almost any imaginable bleeding pattern. When estrogen is lower, the uterine lining gets thinner, causing the flow to be lighter or to last fewer days. And when estrogen is high in relation to progesterone (sometimes connected with irregular ovulation), bleeding can actually be heavier and periods may last longer.
Menstrual irregularities are a normal part of this stage in a woman's life and rarely require medical intervention. (For abnormally heavy bleeding, see below.) If you and your caregiver decide that efforts should be made to regulate your cycles at this time, be aware that while oral contraceptives are sometimes prescribed for menstrual irregularities, the use of progesterone alone can be a milder intervention. Progesterone can be used to manage the imbalance of estrogen and progesterone. A clinician can prescribe
progesterone or its synthetic cousins, progestins, to be taken the last fourteen days of the cycle. This replaces the progesterone that would normally be secreted in an ovulatory cycle and helps to create a more regular bleeding pattern. (For a
discussion of peri
- and postmenopausal hormone therapy in the United States, the potential harms and benefits, and differences among the hormonal treatments currently available.)
About 25 percent of women have heavy bleeding (sometimes called hypermenorrhea, menorrhagia, or flooding) during perimenopause. Some women's menstrual flow during perimenopause is so heavy that even supersized tampons or pads cannot contain it. If you are repeatedly bleeding heavily, you may become anemic from blood loss. During a heavy flow you may feel faint when sitting or standing. This means your blood volume is decreased; try drinking salty liquids such as tomato or V8 juice or soup. Taking an over-the-counter NSAID such as ibuprofen every four to six hours during heavy flow will decrease the period blood loss by 25 to 45 percent.
Don't ignore heavy or prolonged bleedingâsee your health care provider if it persists. Your provider can monitor your blood count and iron levels. Iron pills can replace losses and help avoid or treat anemia.
Other medical treatment may include progesterone therapy or the progestin-releasing Mirena IUD, which is known to reduce menstrual bleeding. If your health care provider suggests hysterectomy as a solution to very heavy bleeding during perimenopause, you may want to try these and other less invasive approaches first. Removal of the uterus is an expensive and irreversible step
with many effects
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Heavy bleeding during perimenopause may be due to the estrogen-progesterone imbalance. Also, polyps (small, noncancerous tissue growths that can occur in the lining of the uterus) can increase during perimenopause and can cause bleeding. Fibroid growth during perimenopause can sometimes cause heavy bleeding, especially when the fibroid grows into the uterine cavity. If very heavy bleeding persists despite treatment, your provider should test for possible causes of abnormal bleeding. (For
more about the causes
of abnormal uterine bleeding as well as the pros and cons of various treatment options.)