Perimenopause or menopause?

Catherine Clark: What exactly is perimenopause, and how is it different from menopause?

Dr. Sarah Shaw: Such a good question, and the key wording there is how is it different from menopause.

Menopause, which in North America happens on average at 51 years of age, every woman’s a little bit different, is when you have not had a period for 12 consecutive months.

Perimenopause is the four to seven years leading up to menopause, and the key piece to understand here is that in perimenopause, our hormones are very volatile.

Before we start menstruating, you just have these very low levels of hormones. Then girls get their periods, and for the most part, hormones are in a cyclic, rhythmic pattern, and it’s like this beautiful orchestra, roughly around a 28-day cycle.

In perimenopause, those hormones go a little bit crazy. They’re very erratic, and this is what causes a lot of the most challenging symptoms.

Postmenopause, you have very low levels of hormones because your ovaries are no longer producing hormones. You have some levels, but they’re very low and they’re stable.

So that’s the key difference: erratic hormones versus very low, stable levels of hormones.

Jennifer Stewart: What are the earliest signs that someone might be entering perimenopause?

Dr. Sarah Shaw: If you went technically by something called the STRAW criteria, it’s really around cycle changes, so suddenly your period isn’t that 28 days anymore.

Some women get really heavy periods through this time. At some point in time, the periods start lengthening out, but sometimes before that, the periods can get smaller together. So it feels like you’re having two periods in a month, and indeed you are.

So the menstrual changes really start first, but some of the other more subtle symptoms are sleep disruption.

Often hot flashes happen at night, and your hot flashes don’t need to be — you don’t need to be sweating for it to cause a hot flash, and it doesn’t actually need to entirely wake you up.

I find that women tend to think they have to reach some very high threshold before it counts as a hot flash, before it counts as legitimate, before it counts as suffering.

So oftentimes I’ll say, if you have a bed partner, did you used to sleep with pajamas on? You had the covers up. Now your bed partner still does whatever they used to do, and you have your arms and legs out. You don’t sleep with pajamas. You have a fan on your side. You only sleep with the sheet, no sheet.

And often they say, “Well, yeah, that happens.” I’m like, “You are experiencing hot flashes,” even if you don’t entirely wake up. It’s enough. You get this temperature dysregulation.

The menopause symptoms women shouldn’t ignore

Catherine Clark: What are some of the symptoms women should know about during menopause?

Dr. Sarah Shaw: So hot flashes, mood changes, anxiety, depression, brain fog is a big one. Aches and pains.

Some women talk about an anxiety and an irritability. Some women will even talk about a sense of rage, like they feel really angry, and there’s a sensitivity that wasn’t there before.

Those are really the most common symptoms. But there’s over 30 symptoms of menopause, so it really varies, and we have estrogen receptors all over our bodies. So that’s why the symptoms can be so far-reaching.

Some women really have dizziness because we have estrogen receptors in our inner ear. Some women describe heart palpitations. That’s a common one.

It really ranges, and it’s because we have estrogen receptors absolutely everywhere.

And then you see genitourinary syndrome of menopause. So these are changes that we see in the bladder, the vulva, the vagina. It can appear as dryness, pain with sex, increased urinary tract infections, those kind of things.

That tends to start later, and it’s progressive if it goes untreated, but easily treatable.

Brain fog, mental health and what’s happening in the brain

Jennifer Stewart: How do the hormonal changes during this phase affect mental health, including anxiety and depression?

Dr. Sarah Shaw: There’s about a two to 5% increased risk of depression or anxiety during perimenopause. I have very good news for many women after menopause; they describe enhanced mental well-being.

Our estrogen levels change, our progesterone levels change, and our LH levels change. Also, our neurotransmitters in our brain are impacted by our hormone levels. So our serotonin and our dopamine levels change, and those dopamine and serotonin really help to regulate mood, so we can see why it’s not surprising that many women would then present with depression.

We know that women who’ve experienced premenstrual dysphoria, postpartum depression, or have had a major episode of depression previously in their life, they’re much higher risk, and that’s really important to know about.

This is not a matter of women just being sensitive to hormones. Like it truly changes the brain. How the brain uses energy, how much energy it has, impacts our psychological well-being. Like this is happening on a biologic level.

We actually have changes in gray matter and white matter in our brain. So the brain is remodeling. The brain is going through some structural changes during perimenopause and early menopause that make it different.

Catherine Clark: Why does brain fog happen, and when should you worry that it’s something more serious?

Dr. Sarah Shaw: It’s happening in part because of all these changes happening in the brain. It just makes it harder. It’s like a vulnerable time for our brains because there are very real physical changes happening.

The other reason is the symptoms of menopause interfere with our overall well-being. So if you are being woken up all the time, and you have disrupted sleep, that will impact your cognition. There’s no doubt about it.

Typically, when we have brain fog, brain fog through the menopause transition is transient. It’s not dementia. It’s really different from dementia. It is transient. It tends to get better.

When should we be worried that this is dementia? Typically, brain fog is more around distractibility. It’s hard to concentrate. I’m not as efficient as I used to be. Those are the kind of complaints.

You forget someone’s name. It’s more of this simple stuff. So if you can’t find your keys, this is in keeping with brain fog. If you do not know what those car keys are for, that’s a concerning sign. That’s a sign of dementia.

In terms of things we can do about it, there are things we could do about it. So number one, sleep. Make sleep a priority. Optimize your sleep.

Treating symptoms of menopause, and we have very good treatment to treat symptoms of menopause, whether they’re hormonal or non-hormonal.

I see a ton of women with iron deficiency. So if you’re iron deficient, particularly if you’re iron deficient enough to be anemic, you are going to be tired. It’s going to be hard to concentrate.

So let’s make sure your iron levels are good, your B12 is good, your vitamin D, you’re not anemic, your thyroid’s okay. Let’s be reassured; those are fine. Those are very easy things to treat, and they should be optimized for all women.

How is menopause diagnosed – and when should you seek help?

Jennifer Stewart: How do you diagnose perimenopause or menopause? Are there actually tests that can diagnose them?

Dr. Sarah Shaw: So you don’t need blood tests to do it. You want to go based on symptoms, cycle length. There’s something called the STRAW criteria.

There’s actually very clear criteria that are set out to tell us where a woman is in that transition from regular reproductive functioning to the end of their reproductive life to perimenopause to menopause.

So we don’t always need to do blood work.

But there’s some cases in which we don’t have those changes in cycle to give us that data. So if a woman’s had a hysterectomy, or if she has an IUD, I actually don’t know where she is in her cycle because we don’t have bleeding to let us know.

In those events, it’s really important to get blood work, and then we’re putting together the clinical pieces, making sure we’re not missing something else like a thyroid problem or an iron problem, and the lab work. And it’s really looking at the whole big picture of what’s happening.

Catherine Clark: When should someone seek medical advice about their symptoms?

Dr. Sarah Shaw: If the question is entering your mind, you absolutely need to seek medical advice.

Women bring in their children, their parents, their loved ones as soon as they think something’s going wrong. They’re very good advocates for everybody else in their life, but we tend to put ourselves last.

I would also say we would all be much better off if we had these conversations proactively before they’re starting to happen. We really should be thinking about health from the perspective of prevention. It is so much easier to prevent chronic disease than it is to intervene when the chronic disease is already in progress.

Treatment options for menopause symptoms

Jennifer Stewart: What are some of the most effective treatment options for managing symptoms that are both hormonal and non-hormonal?

Dr. Sarah Shaw: So the first big category is hormonal medications. The second is non-hormonal medications, and the third is non-pharmacologic.

So non-pharmacologic are all those things we know about lifestyle. So getting enough sleep, getting nutrition, exercise.

Exercise is really one of the keys to longevity, and that goes for our bone health, our muscle health, our physical health, or mental health. In fact, exercise is as effective a treatment for mild to moderate depression as traditional antidepressants.

So, lifestyle needs to be the foundation of anything. I don’t think you can have a genuine conversation with a patient without saying this really needs to be the foundation of your well-being.

Non-hormonal medications — that is growing. Our available medications are growing. Some of the traditional antidepressants like desvenlafaxine, the trade name is Pristiq. Those medications do have some effectiveness for treating hot flashes.

We have medications from neurology. So gabapentin is one that I commonly use.

We have two broad categories of medications that impact NK receptors in the brain, and that’s where hot flashes start. So the one that’s now available in Canada is the trade name is Veoza, and it’s called fezolinetant.

If you have a contraindication, some medical reason why hormones are not safe, then those options are really, really important.

That said, they really only treat hot flashes and maybe mood or sleep. They don’t provide some of the other benefits that hormones might provide.

So hormone therapy is the gold standard for treating hot flashes, and there’s four primary indications for taking hormone therapy: hot flashes, night sweats, genitourinary syndrome of menopause, and the last is prevention of osteoporosis and prevention of fractures.

What women should know about hormone therapy

Catherine Clark: Can you explain the risks and the benefits of hormone replacement therapy? How have things evolved, and what are the actual risks and benefits to women?

Dr. Sarah Shaw: So thank goodness it’s evolved. There was a whole generation of women that missed out.

I want to say really clearly: there’s a difference between systemic hormones, which are in the bloodstream, and local hormones.

Local hormones are like vaginal hormones. Vaginal hormones are safe for pretty much all women across the board. And because they don’t go into our bloodstream, they only work locally. That’s what makes them very safe.

Systemic hormones are different.

When I was in medical school, it was 2002, and the WHI, the Women’s Health Initiative, the results were released. They were actually released prematurely to the popular press, and it really did not give us a nuanced understanding.

So not only do we have a whole generation of women who missed out, we have a whole generation of medical practitioners who missed out on the training, and that has not been corrected yet.

What I was told was, like, two sentences: hormone therapy is unsafe. It causes breast cancer and heart attacks. It’s your job to do no harm as a physician. Don’t prescribe hormones. Take women off it.

So physicians were really filled with fear. Women were filled with fear, and physicians were filled with fear that we could be doing harm.

But we actually know the story. The real story is quite different.

There’s something called the window of opportunity. So if you take hormones within 10 years of your last period and under the age of 60, then hormones have typically the most benefit and the least risk.

The risk of hormones depends on a variety of things, so your baseline risk, your baseline risk for having a heart attack, for having cancer, for having a clot. It depends on the kind of hormone therapy you’re taking.

So, is this hormone therapy that you’re taking by mouth, or through a gel or a patch? So the type of hormone therapy, the dose, those are the main factors, and how far you are from menopause, how old you are; those things change the risk dramatically.

The key risks are breast cancer, but this is really nuanced.

So if you have a uterus and you take estrogen, it needs to be paired with progesterone because progesterone helps keep the endometrial lining nice and thin.

If you’re taking estrogen plus progesterone, we know that there’s about nine more cases of breast cancer per 10,000 women per year.

If you don’t have a uterus, so for example it was surgically removed for some reason, and you take estrogen alone, and this is really key and not well known, there’s actually decreased risk of breast cancer, about seven less per 10,000 women per year.

We also have a risk of blood clots, and I want to say really clearly, your risk of blood clots as a woman, it gets higher for all of us as we get older. All our risks do.

I treat all women as being health literate and intelligent shared decision makers in this process.