What is Menopause?

You know you’re in menopause when the sound of sweat dripping on the floor keeps you awake at night!

Actually, the official start of menopause is declared when a woman has gone twelve consecutive months without a menstrual period. On average this occurs around age fifty-one, but menopause can occur naturally anytime between ages forty and sixty. Premature menopause refers to menopause occurs naturally before age forty. Menopause can also be artificially induced through radiation, hysterectomy (and/or removal of the ovaries), or by chemical means.

Knowledge of hormone actions and interactions during menstruation is essential to understanding how hormone deficiencies and excesses can develop in menopause. No discussion of menopause would be complete without looking at the action of hormones in the menstrual cycle. During menstruation, female sex hormones (e.g. estrogen and progesterone) rise and fall with regularity. The cessation of menses at the time of menopause changes the rate and patterns of hormone release. There are a couple of ways of looking at the menstrual cycle. The first looks at the changes in hormone activity over an average 28-day cycle.

Follicular Phase

This phase starts on day one, which is the first day of bleeding, and continues until just prior to ovulation, around day 13 or 14. During the follicular phase a number of follicles within the ovaries begin to ripen or mature. The ovaries contain up to a million follicles at birth but only one follicle is selected each month to produce an ovum or egg. Rising levels of the pituitary hormone, FSH, or follicle stimulating hormone, allow this one, dominant follicle to develop. Levels of estradiol and estrone also start to rise. When the dominant follicle begins to develop around day 9, estradiol (the primary estrogen of the menstrual cycle) levels rise sharply and continue to rise until about day 13.

Ovulatory Phase

The estrogen peak near day 13 triggers the release of the pituitary hormone LH or luteinizing hormone, which stimulates the release of the egg from the dominant follicle. This is called ovulation. The purpose of ovulation is to release an egg for fertilization by sperm. The ovulatory phase lasts approximately 72 hours. Release of the egg from the dominant follicle signals the start of the luteal phase.

Luteal Phase

After the release of the egg, the dominant, now ruptured, follicle is transformed into the corpus luteum. The corpus luteum is responsible for producing the other major hormone of the reproductive/menstrual cycle, progesterone during the luteal phase. Progesterone levels rise sharply until about day 21. Estradiol and estrone levels also rise in the luteal phase, but to a lesser extent. If fertilization doesn’t occur, the levels of all three hormones start dropping around day 25 and menstruation is triggered to start on or about day 28.

Proliferative and Secretory Phases

Another way of looking at the menstrual cycle is from the standpoint of the endometrium or lining of the uterus. In this view, a rough analogy to a house can be drawn. The proliferative phase is the house construction phase in which the lining of the uterus, or endometrium is built up in preparation to receive a fertilized egg. After ovulation (release of an egg), the lining of the uterus changes under the influence of progesterone, in preparation to receive a fertilized egg. If fertilization doesn’t occur, the lining of the uterus undergoes additional changes and is sloughed off or shed during menstruation. The house is torn down and the process starts over again. Approaching Menopause—Peri-Menopause

The first signs that menopause is approaching often appear when a woman is in her forties. Peri-menopause literally means “around menopause” and refers to the years immediately preceding menopause. Changes in menstrual cycle regularity and/or the appearance of symptoms generally signal the start of peri-menopause. As women age, the number of viable ovarian follicles decreases. It becomes more difficult to stimulate the remaining follicles to release an egg. Still, the body struggles to stimulate ovulation by increasing FSH and LH production. Occasionally, FSH and LH succeed in developing a follicle to maturity and ovulation occurs. However, as menopause nears, these attempts are increasingly ineffective and the menstrual cycle begins to sputter. Menstrual periods become irregular as a result of repeated failures to ovulate. Missed ovulation leads to an excess of estrogen over progesterone, because the follicle did not rupture, no corpus luteum exists to produce progesterone. Consequently, symptoms of estrogen excess, like headache, fluid retention and irritability can occur. Declining estrogen and progesterone levels can change the frequency, length and intensity of menstrual periods. (Note: irregular periods and heavy bleeding can be signs of a more serious condition. Please contact your physician if you experience these symptoms.) The changes in hormone balance can result in a variety of symptoms. In the end, the few remaining follicles are too worn out to respond, and menstruation ceases entirely. The change has begun!

Symptoms of Perimenopause

• Fatigue
• Less able to handle stress
• Weight gain
• Headaches
• Mood swings
• Loss of sex drive
• Irregular Periods
• Fibrocystic/Tender breasts
• Uterine fibroids
• Fluid retention
• Depression
• Irritability

Am I in Menopause?

When women start to miss periods, they often wonder whether they’re in menopause. In such cases, physicians sometimes check FSH and LH levels. Unfortunately these tests are notoriously unreliable. High levels of FSH and LH are signs the body is trying to stimulate ovulation, but these findings don’t reveal whether or not the effort will be successful. If ovulation takes place, and progesterone is produced by the corpus luteum, then menstruation can occur. In other words, high levels of FSH and LH may be signs that a woman is close to menopause, but these levels may also be high in peri-menopausal women with irregular menstrual cycles.

When ovulation stops altogether, estrogen and testosterone production drops and there is a general slow down of ovarian function. Since the corpus luteum is no longer formed, monthly production of progesterone ceases. The ovaries continue to produce small amounts of these hormones, but the adrenal glands become the principal source for post-menopausal hormones. Many women do just fine with adrenally produced hormones, and do not experience debilitating symptoms of hormone deficiencies or imbalances. Others are not so fortunate. Hormone Changes In Menopause

Estrogens

Despite the fact that estrogens are routinely prescribed for menopause, many women don’t require them at all. In fact, some menopausal women are estrogen dominant and have too much estrogen relative to progesterone. Estrogen dominance can arise due to the drop in progesterone and accumulation in bodily tissues of estrogen-like chemicals called xenoestrogens (herbicides, pesticides and petroleum by-products). In his book, What Your Doctor May Not Tell You About Menopause, Dr. John Lee lists a number of symptoms associated with estrogen dominance: loss of sex drive, depression, fatigue, fibrocystic breasts, foggy thinking, headaches, irritability, memory loss, and fluid retention. If any of these symptoms sound familiar, it could be because they’re common symptoms of menopause. In other words, taking estrogen could make the symptoms of menopause worse for some women! The balancing effects of progesterone are key to resolving the issues of excess estrogen.

Conversely, there are symptoms that are clearly linked to a lack of estrogen. Vaginal dryness and incontinence are two common signs of estrogen deficiency. Brain fog and depression are also signs of a lack of estrogen, since the main estrogen, estradiol is needed to transport glucose into the brain. Without this fuel, the brain slows down. Sometimes adding a little progesterone can improve these symptoms, because progesterone makes the estrogen receptor more available to estrogen. Still, some women require small amounts of estrogen to relive the symptoms associated with estrogen deficiency.

Progesterone

Production of progesterone drops dramatically at menopause. Other tissues still produce tiny amounts of progesterone but the major source, the ovarian corpus luteum, no longer exists in the absence of ovulation. The abundance of xenoestrogens in our diets probably contributes to estrogen dominant/progesterone deficient symptoms observed in menopause. Symptoms of progesterone deficiency parallel those of excess estrogen: loss of sex drive, depression, fatigue, fibrocystic breasts, foggy thinking, headaches, irritability, memory loss and fluid retention. Normalizing the balance between progesterone and estrogens is essential to resolving these symptoms, and may even help prevent certain diseases from developing.

Androgens Recall that testosterone is the principal androgen, and DHEA and androstenedione are androgen precursors. Androgen precursors are hormones on their way to becoming androgens (e.g. testosterone).

Testosterone

Testosterone levels can be significantly reduced in menopause if adrenal function is low. Low testosterone levels in women are associated with low sex drive, less physical pleasure from intercourse and a diminished sense of wellbeing. Restoring testosterone to normal levels often improves these symptoms. Normalizing testosterone levels may also prevent bone loss and increase bone density. The drop in testosterone at menopause can dramatically affect a woman’s mood, sex drive and energy.

DHEA

Dehydroepiandrosterone (DHEA) deficiency is not associated with any accepted symptom pattern, but women with low baseline levels of DHEA sulphate (storage form of DHEA) reported an increased sense of well-being, decreased depression and anxiety, increased sex drive, and increased satisfaction with sex when given supplemental DHEA. Low levels of DHEA are also often associated with chronic health problems including chronic fatigue, hypertension and insulin resistance, as well as hypothyroidism or low thyroid. (Unfortunately, DHEA is not available in Canada, nor can it be legally imported from the U.S. where it is available without a prescription.) DHEA levels decline with age and for many women supplementation with ADHEA restores energy, improves immune function and increases mental sharpness.

Androstenedione

Androstenedione deficiency results in lower levels of testosterone and estrogens since androstenedione is the primary source for postmenopausal production of these hormones. There are no recognized deficiency states associated specifically with androstenedione, but symptoms of estrogen and/or androgen deficiency are likely.

Cortisol

Cortisol production by the adrenal glands increases in response to stress. High cortisol levels are associated with numerous symptoms including weight gain, feeling ‘tired but wired’, memory problems, depression and bone loss. This can lead to unstable blood glucose levels, fatigue, and increased susceptibility to infection. If the stress is severe enough, or lasts long enough, eventually the adrenal glands become depleted and fail to produce enough cortisol.

Depletion of the adrenal glands from chronic stress can result in inadequate production of cortisol, DHEA, and androstenedione. Low cortisol levels are associated with fatigue, low blood sugar, allergies, cold body temperature, aching muscles and poor exercise tolerance. Women who have had their ovaries removed (surgical menopause) are particularly at risk for repercussions from adrenal exhaustion, as they are entirely dependent on the adrenals for hormone production.

Finding the Right Balance

Ovarian output of estradiol (the most potent of the estrogens), progesterone and testosterone drops when a woman hits menopause and the adrenal glands become the primary source of these hormones. But, even women with significantly reduced levels of hormones, can glide through menopause without experiencing any unpleasant symptoms. What is it that separates the lucky from the unlucky? Clearly, the dwindling supply of hormones is only part of the story. Maintaining a proper balance of hormones is also crucial. Too much of one hormone relative to another can lead to unpleasant symptoms. Knowing this, it should be common practice for the physician to investigate symptoms, look for imbalances and restore the balance.

Lifestyle and dietary issues also contribute to menopause symptoms. Women with healthy adrenal glands, balanced hormones, a healthy diet, and an active lifestyle generally have the best experience of menopause. Having an accepting attitude about the aging process also helps to make menopause a positive experience. Christiane Northrup’s book on The Wisdom of Menopause is an excellent resource on the mental, emotional and spiritual aspects of menopause.

Summary

Knowing that hormone excesses and deficiencies are common in menopause, it is likely that some women will need to rebalance their hormones not only with lifestyle changes but also with hormone replacement therapy. Studies like the Women’s Health Initiative (HTML Life after HRT) have shown that not all conventional HRT strategies are beneficial. The question is where did hormone replacement go astray? One of the key issues is the type of hormones used. The next chapter looks at how the use of bioidentical hormones (identical to what the body produces naturally) differs from conventional HRT strategies. Chapter 4 also looks at when to use HRT, what mistakes were made in the past, and how we can learn from these mistakes and move forward.

To read more you can order this book, You’ve Hit Menopause: Now What? 3 Simple Steps to Restoring Hormone Balance.