When most people think about menopause before it happens, the subject seems fairly straightforward. A woman is going through life perfectly normal, having her monthly cycle around the same days apart for decades. Then it suddenly stops. But those of you who have experienced the process know it does not happen this way.
While there is no one way that describes each women’s experience, a common pattern is that the first indication of impending menopause is that a woman will stop ovulating. She may or may not experience disruptions to her normal cycle during this initial issue, but since she is not ovulating, she becomes deficient in progesterone. Most of the progesterone produced by women occurs from the ovary after an egg is released for that particular cycle. If the ovulation does not occur, the progesterone is not produced, leading to a condition called “estrogen dominance”. The estrogen is still being produced at close to the usual amount by the ovaries, but the lack of progesterone allows the estrogen to cause mood swings, hot flashes, fluid retention, and weight gain. Frequently this is called “PMS”. At this point commonly all that is needed to control these symptoms is progesterone itself. This can be done either by topical use (creams) or by oral use, but you have to be sure you are taking bio-identical progesterone, not a synthetic progestin. The progestins that were developed by drug companies to protect the uterus from cancer and bleeding when using supplemental estrogen, but do not have the dozens of other effects that real, bio-identical progesterone has in the human body.
During the later peri-menopause stage, cycles frequently become irregular, usually, initially with short (2-3 week) cycles, and then even later the cycles become prolonged. There might be 6 months or more between cycles. Progesterone can be dosed either on a cycle basis which strives to regulate the cycle or as a continuous therapy, which tends to shut down the cycle before it otherwise would have ended.
The next stage of menopause is the menopause itself. There are multiple definitions of this, but the most common is that a woman is in menopause if she has not had menstrual bleeding for 1 year. At this point, the estrogen level (and sometimes the testosterone level) has typically dropped which causes the cycles to stop. Some women breeze through this and others are almost incapacitated by extreme hot flashes and night sweats. For women who choose hormone replacement at this time of life, it would usually include estrogen and progesterone, with testosterone sometimes needed. The vasomotor symptoms (hot flashes and night sweats) are frequently what causes a woman to seek hormone replacement since the lack of hormones is the direct cause of these problems. Of course, there are multiple long-term benefits in addition to relief of these symptoms.
Post-menopause is defined as the years after the menopause. Since women are living longer these days, the post-menopause time could be a third of their life. Without hormones, several things can happen. Sometimes after 5 years or so, the hot flashes and night sweats will cease on their own, but this is not always the case. Vaginal atrophy and dryness can become a bigger issue. The known long-term benefits of hormone replacement become a more critical factor. These are:
- decreased risk of osteoporosis
- decreased risk of Alzheimer’s dementia
- decreased risk of colon cancer
- better sleep
- improved quality of life
At this point, estrogen, progesterone and possibly testosterone are used to provide relief of symptoms and decreased risk of diseases as listed above.
As you can see, there is no “one size fits all” approach to hormone replacement which works at all stages of life. The exact hormones replaced and the dosages of each of them need to be evaluated throughout the lifetime to ensure that the woman is getting exactly what is needed.