This feature was written by Studio MSP writers. While some of our advertisers were sourced, no advertiser paid to be included.
In an episode of The Daily podcast last year, New York Times writer Susan Dominus reflected on how her article “Women Have Been Misled About Menopause” ignited a firestorm of discourse around the elusive nature of menopause: “At a time when we have the right to feel seasoned, women are thrust into the role of newbie, or worse, medical detective in charge of solving our own problems.” So why does modern medicine keep overlooking this inevitable phase of life that comes for every healthy woman in her midlife? And why don’t we have as much information about menopause as we do about going through puberty?
Our health care system, admittedly, has a lot of catching up to do. “There are probably still only 2,000 Menopause Society–certified practitioners in the entire U.S., and 100 percent of those of us who were born with a uterus will go through menopause,” says Dr. Sophia Yen, founder of Pandia Health, a doctor-led birth control service provider. “A policy suggestion I had was that we mandate at least one hour of menopause training so that your eye doctor, your heart doctor, your endocrine doctor have some knowledge of menopause.”
Despite the scarcity of menopause-specific support, local providers are stepping up to the challenge of educating themselves and their patients about changing hormonal health. Ahead, they explore the lesser-known aspects of perimenopause and menopause, how these changing seasons impact fertility, where the pendulum currently swings on hormone replacement therapy, and the emerging and established solutions available to help women navigate these transitions.
Perimenopause
Is This Just Normal Fluctuation—or The Change Before The Big Change?
Any person with a uterus will tell you that hormones are never really in homeostasis; in any phase of life (and this goes for men, too), you almost always have more of one hormone than another. Which is why the transition to perimenopause is confusing—downright maddening!—for women. While you’re still cycling and having your periods, you may also be experiencing menopausal symptoms like hot flashes and night sweats. Think of it as trying to catch the wind—your hormones are always changing direction, leaving you feeling disoriented and out of sorts.
While there is no magic-bullet test to tell you if you’ve started perimenopause, infrequent periods are usually the first telltale sign. Dr. Hannah C. Nordhues of Mayo Clinic Women’s Health says that symptoms of perimenopause typically last seven to 10 years. “This is a time of significant variability in hormones—for this reason, testing hormone levels is usually unreliable and unhelpful,” she says. “None of this happens in a vacuum. This is also a time when women are often trying to balance a career, family, aging parents, and other health concerns.”
“Irregularity” can mean periods that are getting closer together or farther apart, shorter or longer, and heavier or lighter, adds Dr. Andrea Messina of HealthPartners. In addition, women in their early to late 40s (occasionally late 30s, even) may also experience hot flashes, night sweats, insomnia, fatigue, weight gain and body changes, mood changes, anxiety, vaginal dryness, decreased libido, dry hair and skin, and joint aches (“to name a few!”).
“If your clinician is receptive to discussing perimenopause and options available to help manage symptoms, great,” says Messina. “Sometimes it’s just a matter of acknowledging this transitional time and providing follow-up if symptoms worsen. And sometimes a referral to a gynecologist or clinician who specializes in menopause is warranted.”
Pro Tip
Addressing menopause-related symptoms with your practitioner can often take up to 30 minutes or more. Schedule an appointment separate from your annual exam to get all of your questions answered.
Are Lifestyle Changes the Only Answer to my Woes?
Doctors agree that this season of life serves as a great opportunity to establish healthy habits with sleep, diet, and exercise routines. Becoming more invested in yourself means being more tuned in to bodily changes. According to the Mayo Clinic, perimenopause presents a time of greater susceptibility to osteoporosis and heart disease—try to lean into low-fat, high-fiber foods like fruits, veggies, and whole grains, along with calcium-rich foods. Aim to exercise for 30 minutes on most days of the week to strengthen bone density and elevate mood (it’s also been shown to reduce hip fracture risk in older women). And sleep, as always, is queen.
However, some symptoms can’t be managed or regulated via lifestyle changes. “There are many options to manage symptoms and optimize long-term health, so don’t feel like you need to suffer through these symptoms for the next decade,” says Nordhues. “Reaching out to a qualified health care practitioner who can guide your choices is the best way to go.” She adds that health care practitioners certified by The Menopause Society are more likely to provide evidence-based and guideline-directed care.
Formerly known as The North American Menopause Society, The Menopause Society provides a certification to clinicians who pass a written test and continue their menopause education as long as they are a Menopause Society Certified Practitioner (MSCP). “The website has great information for patients and a ‘find a provider’ section,” says Messina. “While there are still not enough providers available, the specialty is growing.” At any rate, keeping a line in with a trusted provider is key during this period of constant change.
This is a time of significant variability in hormones—for this reason, testing hormone levels is usually unreliable and unhelpful…. None of this happens in a vacuum. This is also a time when women are often trying to balance a career, family, aging parents, and other health concerns.Dr. Hannah C. Nordhues / Mayo Clinic Women’s Health
How Does Perimenopause Affect Fertility?
As your hormone production begins to taper in the decade before menopause hits, fertility potential declines. But it doesn’t mean your chances of getting pregnant are automatically low. According to the American College of Obstetricians and Gynecologists, around one in 10 women will get pregnant per menstrual cycle by age 40.
Beyond your age—fertility peaks in your 20s, then gradually declines after that—your chances of conceiving depend on a few different factors: if you’re in the early stages of perimenopause, if your anti-Mullerian hormone and estrogen levels have remained relatively unchanged, if you’re still having a period.
According to a study published in the Upsala Journal of Medical Sciences, your chances of getting pregnant within a year without assisted reproductive technology are about 75 percent at age 30, 66 percent at age 35, and 44 percent at age 40.
“Women are born with all of the eggs they will ever have, and throughout a woman’s lifespan, the egg supply continues to be depleted until empty—which is menopause,” says Dr. Jani Jensen of Reproductive Medicine and Infertility Associates (RMIA). “While some hormonal methods of contraceptives like birth control pills stop the process of ovulation, they do not slow down reproductive aging.”
Egg loss, she says, still continues in the background. She suggests that any male partner be evaluated to make sure his sperm health is good, as a third of fertility issues are related to male factors.
“My biggest piece of advice is to be proactive if pregnancy is desired,” says Dr. Samantha Witta of OBGYN Specialists. “It’s never too early to meet with your OB-GYN to discuss family planning goals so we can help you map out that journey.”
While some hormonal methods of contraceptives like birth control pills stop the process of ovulation, they do not slow down reproductive aging.Dr. Jani Jensen / Reproductive Medicine and Infertility Associates (RMIA)
How is Birth Control Different Now Than in My 20s—and When Do I No Longer Need it?
The range of available contraceptives on today’s market includes injections, implants, and plastic and copper devices. It’s normal that a birth control that served you well 10 years ago may eventually no longer be the right fit. As women age, we often change up our birth control due to evolving health conditions or lifestyle factors that may up our risk with certain options.
“Every birth control option available to women in their 20s is available to women in their 30s and is considered safe,” says Witta. “While it’s always important to seek regular care, some health conditions that become more prevalent with age, like high blood pressure, may pose some increased risks with certain birth control options.” She adds that staying up to date on health maintenance visits is the best way to ensure medication safety.
Doctors say that turning 40 is the perfect time to check in with your primary care provider or OB-GYN to make sure your birth control is still working safely and efficiently—especially if you’re on the pill. Many women in their 40s switch to low-dose birth control, as it levels off estrogen and progesterone, significantly decreasing perimenopausal symptoms.
If you’re thinking about discontinuing birth control, doctors want you to be aware of a couple of important factors. “When women stop using hormonal contraception, they should resume getting regular menstrual periods within three months,” says Jensen. “This is true even for long-standing use. If, for example, you stop birth control pills and do not have a period after three months, you should be evaluated to determine why you’re not ovulating.”
She says it could be related to low egg supply, a condition like PCOS (polycystic ovary syndrome), or a problem with your thyroid. It could also be related to abnormal levels of other reproductive hormones, like prolactin.
Menopause is defined as 12 consecutive months without a period in women who aren’t actively using birth control or have another medical condition that causes their period to stop. “Many women in their 40s [and older] may not realize that hormone therapy can be in the form of oral contraceptives, progesterone-releasing intrauterine devices, micronized oral progesterone, or vaginal estrogen,” says Dr. Indy Lane of Allina Health. “The right option is based on the symptoms for which a woman is seeking treatment—women deserve to be educated about all of the options that are available to develop an individualized treatment plan based on the risks, benefits, and their personal treatment goals.”
When women stop using hormonal contraception, they should resume getting regular menstrual periods within three months. This is true even for long-standing use. If, for example, you stop birth control pills and do not have a period after three months, you should be evaluated to determine why you’re not ovulating.Dr. Jani Jensen / Reproductive Medicine and Infertility Associates
Pro Tip
Be wary of advertisements for supplements targeting menopausal symptoms—many aren’t regulated by the FDA. While vitamin D, calcium, and magnesium are often recommended to patients, it’s best to check in with your doc beforehand.
Menopause
What is Hormone Replacement Therapy?
Hormones are chemical messengers that are secreted directly into the bloodstream, carrying signals through the blood to target organs, skin, muscles, and tissues in the body. They’re responsible for regulating myriad processes, like metabolism, sleep, sexual function, growth and development, and reproduction. When estrogen levels fall, hormone replacement therapy (HRT) can help claw back some of those lost hormones—these come in the form of pills, patches, and creams, or via an intrauterine device (IUD).
Is HRT Safe?
Doctors have worked hard to break the stigma on HRT after the infamous Women’s Health Initiative (WHI) fallout in 2002, which halted a study on HRT after concluding that risks outweigh the benefits.
“Like most women in the country, the majority of my patients discontinued using HRT and…they suffered,” says Messina. “Since then, the WHI information was found to have flaws and was frequently misinterpreted.”
She says there was a HRT usage uptick in 2016 when the WHI published its findings that addressed the concerns and provided a more accurate interpretation that applied to women who would actually be started on HRT—women in their 40s and 50s, not 60s and 70s like many were in the trial. Then came the New York Times article by Susan Dominus last year, and “our menopause clinic at Park Nicollet is overflowing with patients who have been waiting months to be seen by a menopause provider,” Messina adds.
Studies support the safe use of hormone therapy in women without contraindications, who are less than 60 years of age or within 10 years of menopause. “Synthetic hormone replacement dates back to the 1940s—at one point in history, Premarin was the second most widely sold drug in the world,” says Dr. Alyse Hamilton of Advanced Health and Vitality. Then came a team of doctors and pharmacists who found a way to compound a natural form of hormones—otherwise known as BHRT (bioidentical hormone replacement therapy).
“BHRT became increasingly more popular [after the WHI study] was suddenly halted in 2002 and 2004,” she continues. “As many physicians became fearful of synthetic hormone replacement for their patients, many women began to demand BHRT.”
BHRT uses processed hormones derived from plant sources, and while they are considered more similar to natural hormones than synthetic ones, they should always be used under the guidance of your practitioner.
“Dosing BHRT is both an art and science—hormones are one of the most powerful chemical substances you can put in or on your body,” says Hamilton. “As with all sex hormones, BHRT is meant to be balanced with the other hormones for safety and effectiveness.”
She says that to safely and effectively balance hormones, careful monitoring over time is vital. “We all like to see and feel immediate positive results from our BHRT, but safe and effective hormone balancing is a process…many of my patients are seen every three to four months in the first year.”
Hamilton acknowledges that there has been ongoing controversy over BHRT for decades—many don’t have an FDA-approved stamp on them, but that won’t necessarily stop your provider from prescribing them.
“A most important element is ongoing, careful monitoring of BHRT levels to safely reduce and eliminate negative effects of lost hormones,” she says. As with any other treatment, there is no one-size-fits-all solution. It takes time to determine which combination and which dose work best for you.
How Late is Too Late to Start HRT?
When Messina graduated from her OB-GYN residency program in the ’90s, HRT was likened to the fountain of youth.
“Women had resolution of their hot flashes, slept better, their skin and hair looked younger…. There were some side effects, but most women tolerated it well.”
The fear and confusion sparked by the WHI study continue to cast a long shadow—namely, over a particular cohort of women who were not offered the option of HRT. For those among that “lost generation” who experienced menopause during the great HRT upset and aged out of the treatment—Jensen says it’s best not to panic.
“While menopausal hormone therapy can improve symptoms like hot flashes and benefit bone health, the overall data do not support using it for protecting the heart, preventing dementia, or allowing women to live longer.”
She says that lately she’s been seeing the pendulum swing from messaging that menopausal hormone therapy is dangerous to being plugged by so-called health influencers as a cure-all. “Neither of these extremes is true, and the decision to use or not use menopausal hormone therapy should be individualized for each woman.”
How Legit Are Those Targeted Supplements?
Social media is an unregulated hotbed for wellness culture, and its latest target—menopause supplements—is no exception. Click on just one ad and your FYP will quickly be bombarded with flashy products touting health benefits at every turn. If nonprescription therapies intended to treat symptoms of perimenopause and menopause sound too good to be true, doctors caution, it’s because they are. “As health care providers, the biggest concerns we have for the supplement market is the lack of evidence, regulation, and standardization,” says Nordhues. “I usually recommend patients choose products with a seal for GMP (Good Manufacturing Practice), USP (United States Pharmacopeia), or NSF (National Sanitation Foundation).” While a manufacturing stamp signifies good quality control, it doesn’t mean the supplement has been tested or approved for the indications listed on the bottle. Nordhues says she encourages patients to avoid multi-compound products. “If there is a specific need that can be addressed with dietary supplements, we prefer to use the very minimum number on an evidence-based, personalized strategy,” she says. “Whenever possible, obtain vitamins and minerals through food.”
This article originally appeared in the October 2024 issue of Mpls.St.Paul Magazine.
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