Menopause is defined as the complete absence of menstrual periods for 12 months. The average age for it is still age 51. Women with the above symptoms are experiencing peri-menopause. The ovaries transition from working relatively predictably to irregularly, before effective ovarian function finally ends. It is a time when the hormones estrogen and progesterone, made by the ovaries, are often out of sync.
To fully understand this process, it helps to know what hormones do in a normal menstrual cycle. Before a woman reaches menopause, her ovaries contain thousands of immature follicles. With proper hormonal stimulation, these follicles have the potential to develop into eggs. During each menstrual cycle, a number of follicles are stimulated. One will reach maturity. This mature follicle (egg) will be released from the ovary during ovulation.
To reach maturity, follicles must be exposed to just the right amount of estrogen. This is determined by a number of factors. The action of FSH (follicle stimulating hormone) is most important. FSH is made by the pituitary gland in the brain.
The first day of menstrual bleeding begins a cycle. Estrogen levels rise for about 14 days, stimulating the follicle. Estrogen is also largely responsible for building up the lining of the uterus. After ovulation, the estrogen level remains quite stable until it drops rapidly just before menstrual bleeding.
Progesterone, on the other hand, is only made after ovulation has occurred. When the egg is released from the ovary, a sac is left behind. This is known as the corpus luteum, or ‘white body’. It is the corpus luteum that makes progesterone – just enough to last about 14 days.
Progesterone ensures that the lining of the uterus is ready for an egg to implant. If the egg is not fertilized, the corpus luteum runs out of progesterone. This, together with a decline in estrogen, triggers menstruation.
During peri-menopause, the ovarian follicles become less responsive to FSH. In some cycles, an egg does not mature so ovulation does not happen. In these cycles, estrogen levels continue to rise and build the lining of the uterus. However, without progesterone the lining becomes unstable. It may break away in small amounts, triggering spotting. Often, the lining builds up enough that when it finally does break away, the flow can be very heavy and last a long time. Periods may come every two weeks, or sometimes not for six weeks or longer.
In other cycles, ovulation still occurs. However, estrogen and progesterone levels drop so low just before menstruation that menopause symptoms, such as hot flushes, occur. Most women have their first hot flushes while still having fairly regular periods. A woman’s first hot flushes most often occur just before menstruation begins.
The transition into menopause is a natural change as women age. However, drastic changes to periods may cause worry and frustration. A woman may ask her doctor for assistance. First, the doctor will make sure that there are no signs of an overgrown endometrium (lining of the uterus), cancer, large fibroids (non-cancerous growths of the uterus), or thyroid or bleeding diseases. A few medications can then be tried to regulate periods or stop them altogether.
Women can try the same oral contraceptive pills that prevent pregnancy to regulate periods that are irregular or too long. These medications contain both progesterone and estrogen hormones. They prevent the egg from being released for fertilization, and stop the lining of the uterus from growing too thick. Oral contraceptive pills may also preserve bone density, and reduce risk of cancer of the ovary, endometrium, and possibly colon.
Women can choose how to take this type of medication. It can be taken for 21 days at a time, one pill a day, stopping for seven days to have a lighter period. It can also be used without a break, which will stop periods all together. The same medications come in the form of skin patches and vaginal rings.
A woman and her doctor can decide which treatment is best based on how often she wants to take it. Oral contraceptive pills are taken every day, at the same time of day. Patches are changed weekly, and vaginal rings monthly.
Some women prefer the levonorgestrel IUD as it stops vaginal bleeding completely. It can also be left in place for up to five years. This is a great option for women who want to stop their periods and cannot use combination hormone treatment safely. The doctor inserts this intrauterine device into the uterus through the vagina. This can be done in the usual clinic setting. The hormone in the device reduces the monthly thickening of the uterine lining and the bleeding. Although considered an expensive option (a one-time payment of about $350 is needed), the levonorgestrel (Mirena®) IUD works out to about $70 per year of use. Compare this to the $230 to $285 cost per year of use of combined oral contraceptive pills. It may take up to three months before the medication significantly regulates and reduces bleeding. Women who bleed heavily during peri-menopause may notice that it is not controlled right away.
A rare but serious negative effect of progesterone and estrogen combination treatment is the formation of blood clots. This may cause strokes, heart attacks, or even death. The complication can occur in nine to ten out of 10,000 women. The risk is double compared to women of the same age who are not on this treatment. However, the same risk of blood clots due to hormones increases six to 60 times during the natural state of pregnancy and shortly after delivery.
The risk of blood clots means that not all women can try combination treatment. If you have had a blood clot before or have a blood clotting disorder, have migraines with aura, or are a smoker (especially over age 35), you should not be on progesterone-estrogen therapy. This also applies to women with uncontrolled high blood pressure, breast cancer, liver disease, coronary artery disease, or previous stroke. All of these conditions greatly increase the risks.
For some women, contraception is not a concern, the menstrual cycle is regular and the goal is to reduce menstrual bleeding. In this case, consider non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen or ibuprofen. This treatment must be taken at the start and continued throughout the period. It can reduce bleeding volume by 20 to 50 per cent. Another way to reduce bleeding is to take the hormone progestin for 12 to 14 days every month, or use it every day to stop periods. Other medications treat heavy bleeding by blocking the breakdown of blood clots. They can be taken during a period, and are appropriate for some women, especially if the periods are very heavy. Gonadotrophin-releasing hormone analogs and androgenic steroids, such as danazol, have also been used. However, they are not considered usual and may not be as effective.
Most women can take combination progesterone-estrogen treatment safely until menopause or around 55 years of age. As the hormone treatments alter the natural period cycle, it is difficult to know when menopause actually happens. A woman has several options when deciding when to stop using medication to treat irregular and heavy periods. One is to stop treatment and see if her periods return. During this time, she will need to use a non-hormone form of contraception like condoms. If she does not have a period after one year, she is postmenopausal. Blood hormone levels can also confirm that menopause has occurred, but only when the woman is not taking combination therapy.
Some women have heavier and longer periods during menopause due to fibroids or an overgrown lining of the uterus. These women may need surgery to remove the fibroids, or the entire uterus. Another procedure, endometrial ablation, can be done to remove the bleeding lining of the uterus. These surgeries have been available for many years, and can greatly improve quality of life.
Talk with your doctor about changes in your period during peri-menopause. Your doctor can reassure you about concerning symptoms. If action is needed, your doctor can advise you on the right treatment, or refer you to a specialist called a gynecologist.