Is it menopause or just life?

Midlife for most women is one of the most stressful times of life. Many of us have teenagers or preteens who require a lot of our time. We are their cheerleaders, chauffeurs and confidants. At the same time, many of us have aging parents who need our attention. Add in a career and a partner, and there is little time left for self-care.

Midlife is also the time when many women start to experience hormonal changes associated with perimenopause. In the U.S., the average age of menopause (defined as having no period for one year) is 51. However, symptoms may begin many years before the actual cessation of the menstrual cycle. These symptoms can be numerous and include hot flashes, night sweats, decreased libido, difficulty sleeping, vaginal dryness, pain with sex, mood changes, muscle pain, joint pain, memory issues, weight gain and many more.

With all the stressors many women in midlife are often facing, is it any surprise that it can be difficult to tell whether we are experiencing perimenopause or just life?

The midlife overlap

It is rare that a female suddenly stops menstruating. More commonly, her cycle becomes irregular. Bleeding episodes become farther apart as ovulations space out and are less frequent. When our hormones do not cycle regularly, we often develop withdrawal symptoms from lack of estrogen and progesterone. This can trigger many symptoms of perimenopause. A gynecologist or women’s health professional can help parse out the details in these situations.

Of course, other common medical and psychological diseases need to be ruled out, including things like metabolic syndrome, diabetes, thyroid disease, sleep apnea, neurodegenerative diseases, arthritis, depression, anxiety, etc., and don’t forget to consider pregnancy in sexually active women, even at midlife.

According to the sixth edition of The Menopause Society’s textbook, “Menopause Practice: A Clinician’s Guide,” vasomotor symptoms (VMS), including hot flashes and night sweats, are the most common complaints in perimenopause. The pathophysiology of VMS is debatable but likely includes sudden changes in hormone levels.

Managing symptoms

Menopausal hormone therapy (MHT) is the gold standard to treat VMS. MHT includes several different formulations, but estrogen is most often included in the treatment of VMS. Progestogens are needed when a woman still has a uterus to help prevent endometrial carcinoma, although there are studies of progestogens alone relieving symptoms. MHT is not without risks, just like any medication.

Other medications to treat VMS are available as well, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), gabapentin, oxybutynin and a newer class of medications called neurokinin B antagonists, which work on the thermoregulation center in the brain.

There are non-pharmaceutical ways to treat perimenopausal symptoms as well. For example, The Menopause Society (formerly The North American Menopause Society), notes that the evidence-based lifestyle interventions of both cognitive behavioral therapy and hypnosis can help decrease vasomotor symptoms.

Pelvic health & sexual wellness in midlife

Another common set of symptoms typically seen in midlife years are vulvar and vaginal symptoms, including urinary incontinence, especially when coughing, laughing or sneezing. There are several types of urinary incontinence, some of which can be treated with medication or surgery. This diagnosis comes after a thorough history and physical exam.

Most women are familiar with Kegel exercises, which have shown up to a 70% improvement in symptoms when performed properly. Women with diagnosed urinary incontinence can work with a physical therapist; the therapist can come up with a home exercise program, including Kegels, to strengthen the pelvic floor muscles and improve symptoms.

Female sexual disorders (FSD) also increase in the perimenopausal years. Testosterone levels decrease throughout life in both men and women, and there is some data to suggest testosterone therapy may improve women’s sexual health. As of this writing, there is no FDA-approved testosterone medication for women in the U.S. Therefore, topical products approved for men are sometimes used for women at a significantly decreased dose. There are FDA-approved medications for certain FSDs, but the cost is high, side effects and contraindications are significant, and the improvement is small.

Because of FSDs, many women in midlife experience painful intercourse. The decrease in estrogen causes the vaginal and vulvar epithelium to atrophy, often making intercourse feel like sandpaper is being rubbed on the genitals. The loss of estrogen also increases the risk for vaginal, vulvar and urological infections. MHT via low-dose medication applied vaginally is the most effective treatment. Other options include lubricants, oils and even hyaluronic acid.

Cognitive & physical changes

Brain fog and memory issues tend to be more noticeable and frequent as we age. The brain is filled with estrogen receptors, especially in the prefrontal cortex and hippocampus. Studies cited in “Menopause Practice” show that learning time and memory are slower in late menopause compared to pre-menopause and normalize after the transition.

Recommendations to help keep the brain healthy and stave off dementia include primarily lifestyle modifications, including sleep hygiene, regular exercise and dietary changes, among others. MHT is currently not recommended for women to prevent dementia, but much research is still needed in this area.

Muscle and joint pain are common complaints in midlife, affecting more than 50% of women, according to “Menopause Practice.” The differential diagnosis of arthralgia is vast. Issues that should be evaluated in a perimenopausal woman may include thyroid disorder, vitamin D deficiency, medication side effects (including statins and bisphosphonates) and osteoporotic fracture. The good news is that if the pain is menopause-related, it is transient and should resolve on its own. Arthritis itself is very common as we age, so the aches and pains may be caused by my multiple etiologies.

A better quality of life

Keep in mind that not everything in perimenopause is due to hormonal changes and therefore replacing hormones doesn’t always alleviate all symptoms. Midlife can be incredibly stressful. That stress alone can lead to insomnia. At the same time, night sweats may wake that perimenopausal woman every night, also leading to insomnia.

By breaking down what is truly bothering us and what decreases our quality of life, a well-trained healthcare professional can walk through this time with patients, offering insight and management options to decrease uncertainty and offer solutions. A good resource for patients is The Menopause Society’s Menopause Practitioner Search Tool, where women can search for clinicians who are Menopause Society Certified Practitioners (MSCP). Physicians who are interested in becoming MSCPs can learn more on The Menopause Society website.

Related reading:

Doctor, podcaster, advocate: Meet the DO redefining women’s health care

The DO Book Club, May 2024: ‘Perimenopause for Dummies’