Ask a Nurse Practitioner is a blog series from Adriatica Women’s Health. In this series, our nurse practitioners will answer health-related questions that are most important to women today. In this month’s article, Jennifer Nuspel, a Board-Certified Nurse Practitioner, breaks down menopause: what it is, how it can affect you, and what you can do to minimize its symptoms.
Ashley: While this discussion is about menopause, there are actually three different stages of the process. Please tell us a bit about the three stages: perimenopause, menopause and postmenopause.
Jennifer: Perimenopause is the time in a woman’s life that precedes actual menopause, which is when a woman has gone a full 12 months without bleeding. For most women, the perimenopausal period lasts for a few years as cycles become more irregular and infrequent. Postmenopause simply means a woman has completed the 12 months without a menstrual cycle.
A: What are the common symptoms of each? Is it typical to experience all of the symptoms at some point or just a few?
J: The answer really is it depends! Every woman is different. A small percentage of women make it through the menopausal transition with little to no symptoms. For most women though, they experience varying degrees of at least a few of the symptoms of menopause. Most women at least notice a “change in their thermostat.” For a lot of women, this looks like hot flashes or night sweats, but some women tell me they were always cold prior to menopause and they no longer feel cold. Women also frequently complain of weight changes, particularly more fat deposits in their lower abdomen in spite of no changes to diet or exercise.
Some women notice changes in their mood. For some women, this can mean more irritability and for others less. Another common complaint is mental fog and just not being able to focus as clearly as they previously were able to. Women can also notice changes in vaginal comfort and moisture levels during intercourse.
A: How does menopause affect day-to-day life? How can a lack of estrogen affect your heart, bladder and bones?
J: The reality is, estrogen does a lot of good things for our bodies that we often do not give it enough credit for. It makes our skin smoother and can be protective against a lot of conditions we see that go along with aging. The flipside of this is that menopause is a natural transition and we are not intended to have the same levels of hormones from puberty until death.
A: How does menopause increase your chances of developing osteoporosis? What can I do to protect myself from this diagnosis?
J: Developing osteoporosis is a multi-factorial process. Unfortunately, genetics play into the development of it as much as the loss of estrogen, race, BMI, and smoking habits. We do know that for most healthy women, we generally do not need to start screening for osteoporosis until about age 65 unless they have other risk factors. We generally will start to see some changes in bone composition about five years after the loss of estrogen either from natural menopause or the withdrawal of Hormonal Replacement Therapy (HRT).
The best prevention for osteoporosis is a daily Vitamin D supplement and regular weight bearing exercise such as walking or jogging — other exercises are great, but bones like gravity!
A: What’s the best treatment plan to minimize the symptoms of menopause and are there any risks to these plans?
J: Individualized with each woman. My general approach is to try non-hormonal methods and progress to HRT as needed.The Women’s Health Initiative gave us a lot of guidance in the use of HRT in post-menopausal women for management of vasomotor symptoms (night sweats/hot flashes). It’s generally considered safe until age 60, however, risks of breast cancer and cardiovascular disease increase significantly after age 60. Therefore, we try to wean women off no later than age 60, though often will try after about five years of HRT.
Some women have a return of vasomotor symptoms with weaning off. Therefore, I prefer non-hormonal methods personally as a first therapy, since they’re easier to stop eventually. Antidepressants in low doses work very well for symptoms. Remember, all therapy is aimed at reduction of vasomotor symptoms only. Prevention of osteoporosis or other health benefits of estrogen is not an indication to start HRT, but antidepressants can cause a little nausea or drowsiness in the first week of therapy.
A: Do you recommend HRT?
J: Every woman is different — I believe in an individualized treatment plan for relief of symptoms. For some women, HRT is the right choice, and other women choose to approach menopause differently.
A: Who shouldn’t take HRT?
J: Women who have a personal history of breast cancer or who have a history of blood clots, known as deep vein thrombosis or a pulmonary embolism, should not take products that contain estrogen. Additionally, women who have a history of heart attack, stroke or certain types of blood clotting disorders should avoid estrogen.
A: How long do prescription treatments take to “kick in?”
J: Most begin working within a few days but will peak gradually over 4-6 weeks.
A: Is there a natural remedy to lessen the symptoms?
J: There are several non-hormonal options to help manage menopausal symptoms. Therapy is primarily aimed at reducing/eliminating hot flashes and night sweats. There are antidepressant options, as well as phytoestrogens and herbal remedies.
A: Does making any lifestyle changes minimize symptoms? Quit smoking? Eat healthy/vegan?
J: A heart healthy diet and reduction/elimination of alcohol and tobacco are always beneficial. Cardio 30 minutes a day/5 days a week is a goal for all adults. Most women struggling with abdominal fat during menopause see the most benefit from a diet low in processed foods/simple carbs. HRT doesn’t seem to help belly fat.
A: If a women’s sex-drive decreases during menopause, how can she get it back?
J: Female libido is such a complex issue regardless of age. For most women, sex really begins in our head and then manifests into the act itself. Regular exercise and self-care are huge to boost natural testosterone production. Again though, low levels are to be expected in menopause as our ovarian function (where our sex hormones are made) winds down. There are currently no FDA approved treatments for low libido in post-menopausal women. This includes testosterone therapy as well, which is approved in other countries, but not the U.S.
A: Is birth control necessary during menopause?
J: Although the risk of pregnancy is low during the perimenopausal period, it is still possible. The choice of contraception is individualized to each woman based on preference and health history. Once a woman has reached 12 months from her last menstrual cycle, contraception is no longer necessary.
A: If sex is painful during menopause, what can be done to lessen it?
J: Lubrication is key! Using a lubricant, such as coconut oil, can avoid most of the discomfort. For some women, additional vaginal estrogen is also necessary to maintain vaginal elasticity and prevent discomfort. We also offer the Monalisa Touch Procedure, a non-surgical and minimally invasive in-office treatment to treat vaginal dryness associated with menopause.
A: Why would someone younger than 52, the average age of menopausal women, experience menopause symptoms?
J: For various reasons, genetics play a role. If all the women in your family experience menopause at a younger age, you are more likely to as well. Surgeries or medical treatments that affect ovarian function can start the menopause process early too. A lot of women start to notice night sweats prior to menses for years before they start missing menses as a sign of menopause. A lot of patients in their 40’s start mentioning this to me. Not necessarily a good way to gauge time to menopause though, just a common concern.
A: Does having a period at a relatively early age increase the likelihood of early menopause?
J: Not in my experience.
A: How long will menopause last?
J: Every woman is different. Most experience symptoms to varying degrees for several years.
A: What, if anything, can/should be done to speed up the menopausal process?
J: Unfortunately, nothing.
A: If a patient thinks they are entering menopause, should they make an appointment with their gynecologist or wait and bring it up during their next annual appointment?
J: It really depends! Menopause is a normal, natural transition so if they are feeling well and generally tolerating the transition, they can bring it up at their next annual. If the vasomotor symptoms are affecting their quality of life because they are not sleeping well and thus are irritable, which can affect relationships, they can always make an appointment to discuss concerns, testing or treatment.