Wednesday, February 23, 2011

How do I know if I am going through menopause?

This is a question that millions of women ask themselves and also ask their gynecologist. How do I know if I am going through menopause?
Menopause – means that menstrual periods have stopped because the ovaries can no longer produce eggs or hormones.
Going through menopause – refers to the 12 month interval since the last menstrual period. This is because after 1 year without a period, a woman is no longer “going through” menopause. Instead, she is now on the other side so to speak, she is now post-menopausal.
Pre-menopause (peri-menopause) – refers to erratic and unpredictable periods and hormonal symptoms, starting from a few months to a few years before the onset of menopause.
Menstrual Function
To understand menopause requires some basic knowledge of female biology. The ovaries start producing eggs about age 12 or so, this is when many young girls experience their first menstrual period. Egg production usually continues once every 28 days until about age 50 (with many exceptions, such as pregnancy, breast-feeding, hormonal imbalances, etc.).
Estrogen and Eggs
Estrogen is the most important female hormone. It is responsible for female sexual characteristics and it is the loss of that estrogen leads to most of the symptoms of menopause such as hot flashes, night sweats, loss of sex drive, hair loss, mood swings, and more.
Mother Nature has inextricably linked the production of estrogen to the production of eggs. This is the key to understanding menopause which is the inability of the ovary to produce eggs or estrogen. When there are no eggs and no estrogen, there are no periods.
But, the ovaries often approach menopause in an erratic manner. Sometimes egg production and estrogen production stop at the same time. This leads to the abrupt cessation of menses, but this is not how most women enter menopause. Most of the time egg production stops and estrogen production fluctuates, or both egg production and estrogen production fluctuate.
Hormonal “Roller Coaster”
When egg production and/or estrogen production fluctuate, this can lead to a “roller-coaster” of hormonal symptoms: irregular bleeding, periods every 14 days, mood swings from one extreme to another, hot flashes that come and go, loss of sex drive, flushing, sweating, sleep disruption… the list is long! But, these symptoms are NOT menopause. Not yet. These symptoms are characteristic of the peri-menopause. These symptoms are what bring most women to the doctor! Treating this condition requires significant hormonal expertise, and many doctors do a poor job of it. Peri-menopause is NOT menopause, and cannot be treated the same way menopause is treated.
Blood tests – “Doctor, please check my hormone levels”
I get this request almost every day, and I always find it a bit challenging. We can draw blood tests, and these blood tests will tell us what the hormone levels are at that exact moment. But the tests will not tell what the hormone levels were yesterday, or what they will be tomorrow. Testing hormone levels is like testing blood sugar levels. They can be high, or low, or stable, or fluctuating. Knowing one set of numbers might not be so helpful.
One important test is the FSH level. FSH stands for Follicle Stimulating Hormone. This is a hormone produced by the pituitary gland, a grape-sized gland in the brain. FSH tells the ovaries to make a follicle, which is what the egg grows in. The follicle makes the estrogen and also makes and releases the egg.
The FSH is usually a low number, less than 10. Many labs state that an FSH over 40 is consistent with menopause, but this has to be explained further.
Rolling Hills
FSH is like the gas pedal on your car. Approaching menopause is like driving on a hilly road, up and down, with the up hills getting longer and steeper as you get closer and closer to true menopause. You need more gas to go up those hills. This means the body has to increase the release of FSH to get an egg produced. The body is capable of producing very large amounts of FSH, and for a very long time. This explains the “roller coaster” of fluctuating hormones.
On the way to menopause the FSH will go above 40, but the body may still be able to produce the egg. Therefore, the eggs and periods have not stopped yet. As the hill gets steeper, you press the gas pedal all the way to the mat. Maybe the car will get over this hill, this time, and thus another egg will be released. Thus, you can have an FSH above 40 and still make eggs.
One day, with the “pedal to the metal”, you will not make it over that hill. The FSH will be high, no egg will be released, and no period will occur. This could be it, the onset of menopause. But maybe not. Maybe, with enough time, keeping that pedal down, the car will inch its way up the hill. It might take a few months, but amazingly, it does it (your body does it, I mean)! One more egg has been produced, so this is still not menopause yet!
No More Periods
There comes a time when your body will produce huge amounts of FSH, but there will be no more eggs. This is true menopause -- a permanent and irreversible condition, where the ovaries can no longer produce any estrogen or any eggs. Menopause occurs on average about age 51; however, some women even at age 57 will still have menstrual periods.
How do we know that the body is permanently done producing eggs?
I have seen patients stop having periods for 10 months and then start up again. They were not done with menopause. Statistics show that if a woman goes 12 months without a period, she is extremely unlikely to ever have another period. This is how we know someone has gone through menopause. Some women have ALL of the symptoms of menopause for months; no periods, hot flashes, all of it, and yet sometimes their periods return and these symptoms disappear, for a while. This is still not menopause
The answer
Thus, the answer is: 12 months. This is a medical definition based on statistics! 12 months without a period equals menopause. You are going through menopause once you enter this 12 months without-a-period phase. Your symptoms and your blood tests might show menopause, but your periods could come back. If they do, it’s not menopause. If they don’t come back it is menopause. Once you have gone 12 months without a period, you are no longer “going through menopause.” You are now done. You are post-menopausal. The roller coaster is over. No more hormone fluctuations. But, now you have to deal with the next 30 years of your life, without hormones (or maybe not).
Future articles will include how to treat peri-menopause, how to treat menopause, use of alternatives to hormones, and also various pros and cons of different hormonal therapies.

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