Menopause is having a moment. Once spoken about in hushed tones — if at all — conversation surrounding this life transition is now entering the mainstream, with Gen X and older millennials leading the way.
But with celebrities and influencers peddling solutions online, and dubious supplement companies jumping on the menopause bandwagon, discerning fact from fiction when it comes to this phase of life feels more challenging than ever.
What is menopause?
According to Taniqua Miller, M.D., a board-certified OB/GYN and certified menopause specialist with Revival Women’s Health in Decatur, the average age for the onset of menopause is 51 in the United States. Menopause is clinically defined as 12 consecutive months of no menstrual bleeding.
“This kind of retrospective definition is really tricky for folks, because it takes an average of four years after symptoms to reach menopause, but people can experience them for 10-plus years,” she said.
That cluster of symptoms before menopause is called perimenopause, but there is no official blood test or medical method to diagnose it, explained Lillian Schapiro, M.D., a board-certified gynecologist at Ideal Gynecology in Buckhead.
Early perimenopausal symptoms include worsening premenstrual syndrome (PMS), sleep disruption, and brain fog. Because people often have regular menstrual cycles during this time, they may not notice or recognize these symptoms as the precursor to menopause.
“By the time you get to your early- and mid-40s, women often have kids, are caring for aging parents, and their careers are at their busiest,” explained Schapiro.
“So if you put your coffee down and don’t remember where you put it, is it because you have 18 things to do before you leave the house and are distracted by your cell phone, or is it because of the drop in hormone levels?”
The closer to menopause, the more severe these symptoms become. Skipped menstrual cycles, hot flashes, night sweats, more severe PMS, and dramatic mood swings are all common in the latter stages of perimenopause.
Finding the right care
These symptoms are easy to miss or mistake for other common health issues, which makes it critical to discuss what you’re experiencing with a trusted medical provider.
“In an ideal world, I would love it if every time you went in for your well-woman exam after the age of 35, someone was asking you about these symptoms, but it doesn’t really happen very much,” said Miller.
She recommends tracking symptoms with a journal or notes app to determine length, frequency, severity, and emerging patterns. Key symptoms to track include PMS that lasts for several days, worsening anxiety or depression, or disruptions to personal relationships and routines.
“If you’re feeling like this is impacting your life, or you’re losing a whole week every month, that’s probably not okay,” Miller said.
Unfortunately, there is no obstetrics subspecialty in perimenopause and menopause, and only about a third of U.S. OB/GYN residency programs offer a menopause curriculum.
Miller is a certified menopause specialist through The Menopause Society, a nonprofit organization dedicated to providing menopause training and resources for healthcare providers. The society also offers a directory of certified practitioners.
Navigating treatment options
According to Miller, “only 5% to 7% of women who are even eligible for hormone replacement therapy (HRT) are actually on it, and that number was way higher before the 2002 Women’s Health Initiative study.”
The U.S. Food and Drug Administration approved the earliest version of HRT for menopausal symptoms in 1942. It became a mainstream treatment for menopause in the 1960s. By the 1990s, more than 40% of postmenopausal people ages 50 to 69 took HRT, until usage plummeted in the wake of a now-controversial 2002 study linking hormone therapy to increased risk of breast cancer, heart attacks, and strokes. Subsequent researchers, however, found the evidence in that study to be overstated.
HRT is available in a variety of delivery methods, including pills, transdermal patches and creams, suppositories, and intrauterine devices. The primary hormone included in these therapies is estrogen, which “helps with mood, sleep, hot flashes, bone density, skin elasticity, vaginal dryness, and gastrointestinal symptoms,” said Schapiro.
For people with a uterus, taking another hormone – progesterone – is necessary to prevent endometrial cancer. Unopposed estrogen causes thickening of the uterine lining that can become malignant. For many people, taking progesterone also improves mood and sleep quality.
While HRT can mitigate the most common perimenopausal and menopausal symptoms, like hot flashes and mood swings, it does not return hormones to baseline, pre-menopausal levels.
“The goal of HRT is symptom relief and raising hormone levels enough to stay above the threshold where symptoms hit, not restoring the levels you had while cycling regularly,” explained Miller.
The exception, said Miller, is younger people who experience surgical menopause or primary ovarian insufficiency, who do receive HRT at levels matching what their bodies would normally produce until they reach the natural age of menopause.
Other symptom-relief solutions
HRT is not a one-size-fits-all solution. Many people have to try a variety of delivery methods and doses before finding the right combination that works for them. For others, side effects like breast tenderness or breakthrough bleeding outweigh the benefits.
According to Miller, alternatives to HRT include antidepressants like Lexapro, Zoloft, and Prozac, which are often effective at relieving common perimenopausal and menopausal symptoms such as night sweats and mood changes.
Both Schapiro and Miller agreed that with or without HRT, lifestyle factors can help people cope with the transition into menopause. They recommended regular weight-bearing exercise, eating a healthy diet, mindfulness practices, and cognitive behavioral therapy to supplement any hormonal or medical interventions.
“There’s so much transaction around hormone therapy now, you get a prescription and you go out the door, and it’s not fulfilling the expectation as maybe it’s being sold, but it’s just one tool in the toolkit with many options,” said Miller.
And while finding relief from symptoms that interfere with everyday activities is important, no pill or exercise or diet is going to transform the body back into its younger form.
“I want my patients to know it’s okay to lean into what it means to age, what it means to go through this phase of life,” said Miller.
