Peri-Menopause- AKA “The Abyss”
By: Rebecca Levy-Gantt
Tags: Health, Perimenopause, Midlife, Womens Health

It seems to me, the lifespan of a woman can be divided into several distinct time frames: There is:

The Age of Reproduction — approximately age 16 to 42

The Age of Menopause — approximately age 52 until forever

….and then there is that time period in between the two — about age 43 to 52, which can be referred to as the Age of Peri-Menopause. I lovingly refer to it as THE ABYSS. Why? Because an abyss is an endless hole — a deep and seemingly on-going chasm. An abyss also describes the “regions of hell, conceived of as a bottomless pit”. In my experience, as an ObGyn for the last 20+ years, this is exactly the way women in this age group describe what it feels like to be perched on the edge and almost falling in.

When a woman is in The Age of Reproduction, it is fairly easy to understand the role of the gynecologist — it is often as simple as a choice between two opposite plans — Either “Help me have a baby”, or “Help me to NOT have a baby”……to boil it down to the simplest elements— fertility vs contraception.

When a woman is in The Age of Menopause, it is also often fairly simple to come up with a plan, which will almost always include “Treat my menopausal symptoms”, and “Keep me healthy throughout my older years”.

BUT — when women are in the Age of Peri-Menopause, it is almost always a complicated mix of seemingly random symptoms and processes that are in need of attention. I have heard the following: “I think I’m going crazy”. “My hormones are all out of whack”. “I cannot get out of bed”. “I have suddenly gained 15 pounds”. “I have constant fuzzy brain”. “ I’m in a bad mood all the time”. “I don’t know what’s happening to me!” THIS is the gynecologist’s complicated dilemma — — and the one where I have had to come up with a true plan of action to help women who find themselves “falling” into this hole.

This truly is a time period where women are unlucky enough to have many of the well-known menopausal symptoms (hot flashes, insomnia, vaginal dryness, leaky bladder, low energy) and at the very same time (sometimes on the same day!) the shock of having periods that remind them of their teenage years — — heavy, irregular, painful, clotty and just plain annoying. It seems the pendulum swings up and back, one day causing depression, fatigue and the realization that the next stage of life has arrived, and the next day causing the return of all the hormonal rage and irritability that they thought had vanished with their youth. This truly creates the feeling of an ABYSS for many women.

So what is actually happening? What can you do, if anything to prepare for this time, and to feel better as the hormonal and bodily changes start to occur? And how can you avoid feeling like you are always on the “edge of the ledge” and about to fall in?

First, just a basic scientific explanation about why these changes start to occur around this time of life. Everyone has heard that when a woman reaches age 35, she is considered “elderly” from a reproductive viewpoint. We, as obstetricians, are not using this term arbitrarily, just to be mean to older mothers (although, I am sure some of us may be). We focus on age 35, because that is around the time that women naturally become less fertile. This is when they tend to ovulate less frequently, less regularly, or sometimes not at all. That makes it more difficult for some to conceive naturally, but that also has a very real effect on the body’s hormonal balance. Progesterone is the naturally-occurring hormone that is made as a result of ovulation. Fewer ovulations= less Progesterone. Less Progesterone = irregular periods, insomnia, bloating, and irritability. At this very same time, the ovaries continue making Estrogen, the other ovarian-produced hormone. Estrogen’s job is to build a lining inside the uterus, just in case there is a fertilized egg looking for a place to implant. (Your uterus doesn’t know that you’re getting older!!) So the Estrogen is produced, the lining builds up, but without the Progesterone the lining doesn’t know what to do. It builds up, sometimes for months at a time, and then falls off — -hence the well-known floods of bleeding that tend to occur in this period of time. Sometimes the lining just falls off a little-at-a-time — -hence the pattern of spotting or bleeding irregularly throughout the month — -or for what seems like months on end.

There are pretty simple solutions to either of these problems (or any other bleeding patterns which seem to be a result of the production of an irregular amount of Progesterone.) Replacing Progesterone, in a cyclic fashion (for 14, or 21 days of the month), or on a daily basis, or even taking it in a birth control pill — or using other forms of hormonal contraception — are all solutions geared to tell your body — “I can control these hormonal fluctuations by taking or using the very hormones that my body does not know how to make in a proper cycle”. It is not “giving in” or “giving up”…..it is TAKING CONTROL of a body that is — at least temporarily — a bit out of control from a hormonal point of view.

Of course, it’s not ALL about the hormones. As cliche as it may sound, lifestyle and general health habits will have a huge effect of the state of well-being at this time in a woman’s life. If there hadn’t been a strong foundation, and a commitment to take care of your body and your general health prior to entering the peri-menopausal years, then it will absolutely be more difficult to make it though these transitional years being and feeling well.

I read a quote on a sign at a physician’s office recently. It said, “Those who think they have not the time for bodily exercise, will sooner or later have to find the time for illness”. So true. There is really no way around it — the studies all say so. The ONE lifestyle decision you can make to live longer and healthier is to exercise. You can exercise as much as the guidelines say you should — -150 minutes a week of cardiovascular exercise plus 2 days of strength training — or as little as you allow yourself to do. But you MUST get moving! Exercise, along with a healthy diet: (Low in processed foods and sugar, high in protein, vegetables and whole grains — and LOW IN ALCOHOL) provides the foundation to get your body ready for the menopausal transition. If you haven’t started before the hormones diminish, it will be that much harder to start a new program later on…but, really it’s never too late. Exercise to prevent weight gain, to keep your bones strong, to reduce your risk of cancer, to reduce your risk of heart disease, and to slow cognitive decline.

Another extremely important component of health at any time in life, but especially at this transitional time, is stress management/stress relief. Women in mid-life, also known as the “sandwich women” are so busy taking care of aging parents, teenage children, jobs, and spouses that they are often exhausted with little time for self-care. Saying “yes” all the time is tiring, and takes a huge amount of time and cognitive energy. Stress management involves finding a passion — something that feels uplifting, interesting and enjoyable. Something that is just for YOU. It can be yoga, dance lessons, gardening, or socializing — -even just stopping for a 15-minute cup of coffee on the way home for work, before the barrage of evening responsibilities begin. There must be something that helps lower the stress in every day life, or the years moving forward and into menopause will prove to be less happy, less healthy and even MORE difficult, as the stress of changing hormones becomes an added burden.

I find that women are often turning to the internet or to friends to find out which supplements that they should be taking as mid life approaches. They try herbs, potions, packages of vitamins, cleanses, “detox” regimens — -all in an effort to keep their bodies from aging. But most of these expensive regimens are just that — expensive and unproven, sometimes dangerous, and unlikely to provide any benefit. There are, however some supplements that DO at least have medical evidence behind them — they are few, simple, and inexpensive. I recommend that anyone who does not get needed Calcium from their diet take it in a supplement form. Recommended doses are 600mg daily. If not eating fatty fish 2–3 times per week, a fish oil supplement is a good idea (can be Omega-3 fatty acids, so as not to be burping up fish afterwards). Vitamin D, which is almost impossible to get from the diet, should also be supplemented, as many women are deficient and will never know it. 800 International Units daily is recommended. Other than those three, except in certain situations where there is a true deficiency or other medical condition, most other vitamins and minerals should be able to be obtained from a healthy, varied diet. Save your money!

With a thoughtful combination of stress management, proper diet, exercise, supplements and hormonal balance, the transition from reproductive life to menopausal life does NOT have to be a decade of teetering on the edge of the ledge, swinging on a pendulum, or constantly worrying that there must be something terribly, horribly wrong. With kids growing up, moving away, and retirement looming, it can be the the healthy and exciting entryway to the decades where the focus will increasingly, happily and necessarily be on you!