Our Bodies, Ourselves (110 page)

A popular myth is that once your periods become irregular in perimenopause, you can't get pregnant anymore. Because of this myth, women in perimenopause have a much higher rate of unplanned pregnancies than you would expect. Even if your periods are lighter or shorter than they used to be or you are skipping them for months at a time, you may still be fertile and can potentially get pregnant. If you have sex with men and don't want to become pregnant, you will need to use birth control until you have gone without a period for at least a full year—and some experts recommend up to two years for women who reach postmenopause in their forties. For more information, see
Chapter 9
, “Birth Control.”

Some experts question the use of estrogen-containing birth control methods during perimenopause. According to Jerilynn Prior, “Estrogen levels average higher in perimenopause because the feedback loops that normally control it are not consistently ‘working.'” That could mean that using hormonal forms with four-times-higher estrogen doses may not reliably suppress the body's estrogen levels. Thus these methods could produce an estrogen “overdose.”
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She suggests barrier methods (condom, diaphragm, cervical cap) plus vaginal spermicide, or the Mirena progestin-carrying IUD, as other possible contraceptive options.

© iStockphoto.com/ Daniel Bendjy

Hot flashes are legendary signs of perimenopause and for some women can continue well into postmenopause, though 20 to 30 percent of women never have them at all. A woman experiencing a hot flash will suddenly feel warm, then very hot and sweaty, and sometimes experience a cold chill afterward. Hot flashes are thought to be due to a change in the brain's control mechanism for body temperature.
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Some women experience a more rapid pulse rate, a feeling that the heart is jumping (palpitations), or increased or decreased blood pressure. There is increased blood flow to surface blood vessels, so the hands get hot, and sometimes there is a visible reddening of the skin that moves from the chest up to the face. Some women feel panicky.

If I get a feeling of mild nausea and a surge of anxiety that isn't related to anything that's happening at the moment, this usually means I'm about to have a hot flash. Oh yes, and it starts to feel as though the shirt on my back is made of weighty material, even if I'm wearing a summer blouse
.

Hot flashes may begin long before cycles become irregular; you may start to feel warmer at night before other changes begin. They may even occur around your period or after childbirth. Hot flashes can continue for some years after periods end. Forty-five percent of women still have them five to ten years after periods stop, and a few of us have them into our seventies. Each woman has her own hot-flash script: the frequency; the triggers; how the hot flash starts and finishes; how often flashes come; and how long they last. An occasional mild hot flash may be easy to ignore, but some women find flashes acutely uncomfortable, distracting, and even embarrassing. One fifty-two-year-old woman describes her hot flashes:

It's not like I'm feeling “a little warm”—it's like I'm on fire, and I don't care if anybody else is around, I still want to strip off all my clothes to get cooler
.

Hot flashes sometimes cause enough perspiration to soak nightclothes and sheets (night sweats), and they can disturb sleep.

Heavier women's hot flashes tend to be more frequent and severe than thinner women's, because the increased subcutaneous tissue acts as insulation and prevents heat loss. Hot flashes are the body's attempt to get rid of heat, and those of us who are better insulated often have more difficulty doing so. Recent studies indicate that weight loss can reduce hot flashes.
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If hot flashes are bothering you, you can adopt various strategies to reduce the discomfort.

• Dress in layers (especially breathable or natural fibers), so you can shed or add clothes according to how you are feeling.

• Identify your personal triggers, and attempt to avoid them. Spicy foods, hot drinks, alcohol, caffeine, and anxiety are common triggers.

• Carry cool water with you and drink it regularly. Keep your environment cool with fans or air-conditioning.

• Avoid stress as much as possible. Learn to decrease your response to stress—through meditation, or practicing slow, deep abdominal breathing several times a day, for example. When a flash starts, use the slow, deep abdominal breathing method or other forms of the relaxation response.

• Do something active that increases your heart rate for thirty minutes a day.

• Try putting a cold pack under your pillow at night so when you wake up with a hot flash you can turn your pillow over and it is nice and cool.

• Wash your hands in cool water at the start of or after a hot flash; it will cool you off and make you feel cleaner.

• If you are a smoker, get help in quitting. Smokers tend to have more frequent and more intense hot flashes.

Some women try nutritional supplements (such as soy products), botanicals (such as red clover), antioxidant vitamins (such as vitamin E), and herbal preparations (such as black cohosh, Saint-John's-wort, and Chinese herbal medicine). Most are safe for short-term use (up to six months), although if you are trying phytoestrogens they are probably more safely used when
taken as food rather than as pills or supplements. Some of these remedies seem to help, but well-designed studies have often been unconvincing. All studies of hot flashes using a placebo show a placebo effect (as many as 30 percent or more of women feel better even on inert tablets). Women taking alternative remedies should tell their health care providers so they can stay alert to possible interactions with other medications.

Taking estrogen has been shown in multiple randomized trials to relieve hot flashes in postmenopausal women, and progestins such as medroxyprogesterone are effective as well. (No study has proved anything more effective for perimenopausal hot flashes than a placebo.) However, data from the Women's Health Initiative show that the most widely used estrogen-progestin preparation increases the risk of stroke and other serious illness. Recently presented but not yet published randomized control trial data show that oral micronized progesterone (Prometrium) effectively treats night sweats and hot flushes in postmenopause.
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If you are considering hormones, it is important to be aware of the most recent research on which forms are safest. For a detailed discussion, see
“Hormone Therapy—Yes or No?.”

There are various nonhormonal medications that women have tried for problematic hot flashes. Keep in mind that there is no evidence at this point that using any of the nonhormonal medications for months or years is safer than hormone therapy.

Antidepressants
. Studies have indicated that relatively low doses of some antidepressants can be more effective at preventing hot flashes than a placebo (and about 70 percent as effective as estrogen). The drug tested most extensively has been low-dose venlafaxine (Effexor), although others such as paroxetine (Paxil) and fluoxetine (Prozac) also seem to work. However, long-term safety data on such use are absent. In addition, the studies producing the most positive results were conducted with women who had breast cancer, and negative results were reported more often by women without breast cancer. Further study on women without breast cancer is needed.
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Antidepressants are perhaps most appropriate for hot flashes if you also need treatment for depression. They come with their own unknowns and potential side effects, including sleep difficulties, lowered sexual interest, and difficulty reaching orgasm, and some women have difficulty when they try to stop taking them.

Gabapentin
. A seizure medication used for pain control, gabapentin has been used with some success to treat hot flashes, but it, too, has side effects to consider, including nausea and fatigue. It is often most appropriate for hot flashes in women who also need the medication for pain.

Clonidine
. The antihypertensive clonidine has also been used to treat hot flashes. Antihypertensives are perhaps most appropriate for hot flashes if you also need treatment for high blood pressure. If this treatment is taken in doses that are effective, women without high blood pressure may experience dizziness or dry mouth.

New methods
. There have been reports of success in treating recalcitrant (stubborn) hot flashes using a nerve block in the neck (stellate ganglion block), although this more invasive approach demands caution and further study.
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Sleep disturbances are common in both perimenopause and postmenopause. Most commonly, a woman will fall asleep without a problem, then wake up in the early-morning hours and have difficulty getting back to sleep.
Women who experience hot flashes or night sweats tend to have insomnia more often than those who don't. Sleeplessness can cause fatigue, irritability, and a feeling of being unable to cope. Getting enough sleep is critical to overall good health.

For more dependable sleep, you may want to try these lifestyle changes:

• Cut out caffeinated beverages (coffee, tea, colas, and chocolate), especially after about three
P.M
., as caffeine stays in the bloodstream at least six hours. Caffeine is a stimulant that interferes with sleep and leads to more frequent urination.

• Avoid smoking. Tobacco is a stimulant.

• Avoid or limit alcohol consumption. Although alcohol is initially a sedative and makes one sleepy, it becomes a stimulant as it is metabolized, resulting in fragmented sleep and the need to urinate during the night.

• Go to sleep at about the same time every night.

• Exercise regularly. Exercising during the day or early evening can relieve tension and help promote sleep. Avoid doing anything strenuous just before bed.

• Take a hot bath, listen to music, or read before bed.

• Filter out noise and light. Close doors and windows, use earplugs, or use a soothing sound machine. Use room-darkening shades or an eye mask to block light.

Valerian has long been used as an herbal sleep remedy and has shown benefit in some, but not all, clinical trials. Evidence is strong that melatonin works for jet lag and sleep problems due to changing work schedules such as shift work, but the data are not clear on regular insomnia.
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(Using melatonin that is synthesized rather than made from animal products avoids the theoretical risk of exposure to viruses.) Some women find antihistamines such as dimenhydrinate (for example, Dramamine), diphenhydramine (Benadryl), and chlorpheniramine maleate (Chlor-Trimeton) helpful. Some women try sleeping pills, but as these can be habit-forming and stop working after prolonged use, they are best used occasionally, not regularly.

If your sleep disturbances persist, you may want to discuss medical relief with your health care provider. In some women, oral micronized progesterone helps to decrease the time it takes to fall asleep, increase early night rapid eye movement sleep, and increase total sleep time without causing morning changes in alertness or brain function.
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Both estrogen and low-dose antidepressants in the tricyclic family can relieve insomnia for some women. Be sure to learn about the effects and long-term impact of these medications.

Sometimes it is worth consulting a sleep specialist. Sleep conditions such as apnea and restless leg syndrome can contribute to sleep difficulties, and a sleep study may be necessary to diagnose them.

Vaginal dryness is sometimes a problem in early perimenopause. This could be related to the fact that some women do have low-estrogen episodes during this stage.

As estrogen and progesterone levels decline in late perimenopause and postmenopause, vaginal walls frequently become thinner, drier, and less flexible and more prone to tears and cracks. (This can be particularly true for women who have never given birth or have had only C-sections during childbirth, as vaginal birth gives the walls a lasting stretch.) Less lubrication is produced, so it can also take longer to become moist during sexual activity. Penetration may be uncomfortable or even painful and can lead to irritation. If tissues become very delicate, vaginal
wall bleeding may result from friction associated with sexual activity. Women who have what many clinicians refer to by the term vaginal atrophy (thinning and inflammation of the vaginal walls, also known as atrophic vaginitis) may end up completely avoiding intercourse or other insertive sex because of the discomfort. One fifty-six-year-old woman says:

Forget intercourse! After menopause, I couldn't even ride my bicycle anymore—my vagina always felt sore
.