It’s hard to believe, but the first landmark study of women’s perceptions of menopause (Neugarten, 1965) found that, “Not knowing what to expect” was midlife women’s greatest concern. Since that time there has been an explosion in scientific, and popular, publications pertaining to menopause. Women now are well acquainted with menopausal signs and symptoms. They know what to expect. So the question has shifted to “If it’s not menopause, then what is the cause of my menopause-like symptoms?” Let’s examine some of the more common symptoms and see what else might be at fault.
Irregular or absent menstrual periods
While a few women will suddenly reach menopause, or the last natural period, most will have sign posts for the upcoming change. The most common sign is marked menstrual changes. The official definition of “perimenopause” is the four to five years before last menstrual period. Perimenopause also includes the first year of no periods following the last menstrual flow. Marked menstrual changes are considered to be: cycle length between flows more than seven days different from normal, and/or more than 60 days of no periods.
There can be other reasons for missed, or irregular, periods. It is possible to conceive right up until the last natural period. If birth control is not being used, pregnancy must be ruled out. If pregnancy is not detected then the next most common cause of menstrual changes is missed, or late, ovulations. In a normal cycle, estrogen is produced all month. Estrogen is responsible for building up the lining of your uterus so you have something to shed each month.
In a normal cycle, progesterone production increases following ovulation and release of an egg.. Progesterone “stabilizes” the uterine lining in preparation for possible implantation of a new pregnancy. If you are not pregnant that month, the levels of estrogen and progesterone fall, triggering the release of the uterine lining–your period. So, if you do not ovulate, the estrogen build up of the lining continues, but without the usual ovulation associated progesterone. Thus, the hormone levels don’t decline, and the lining stays up inside the uterus–your missed period.
One can enter a pattern of non-ovulation at any time after menstrual periods first begin. Causes for not ovulating are multifold: thyroid problems, pituitary problems, ovarian cysts, physical stressors (eg sudden increases in exercise, crash dieting), emotional stressors (problems with parents or boyfriends/girlfriends, exams), increased body weight, anorexia, rotating shifts at work, etc. Yet as women move into their 40′s one of the most common causes for not ovulating regularly is “old eggs”–the aging of the remaining follicles in their ovaries. This possibility for erratic ovulations can make the diagnosis of menopause more difficult. If one is experiencing irregular or missed periods at any age it is important to check with a GYN, or other healthcare provider, to help make a correct diagnosis.
Flashes are the second most often reported symptom by perimenopausal women. Hot flashes and night sweats can onset during perimenopause, and generally peak during the first two years after the last menstrual period.
Hot flashes have been linked to abrupt changes in estrogen levels. Typically they are seen during the hormone swings of perimenopause. Yet other medical conditions can prompt flashes and/or night sweats. These include: hyperthyroidism, infections (eg HIV/AIDS, TB, malaria), some types of cancers (eg pancreas, adrenal gland, leukemia), generalized anxiety/panic, and autoimmune disorders. Many women have noted a sensation of flushing when the sympathetic nervous system (“fight or flight” response) is activated. Even being a heavy cigarette smoker can be linked to more hot flash activity as smoking decreases blood estrogen levels. Lastly, some medications (eg serotonin [SSRI]antidepressants, raloxifene, and others) have been noted to prompt flashes. If your flashes appeared after starting a new medication be sure to ask your pharmacist if flashes are noted as a possible side effect.
One study (National Sleep Foundation, 2002) confirmed what many midlife women have suspected. Perimenopausal and postmenopausal women do have less sleep, marred by shortened sleep hours, and more problems with either difficulty initiating sleep or remaining asleep. While night sweats are a prime suspect in the problem of poor sleep, sleep disturbances can arise from other sources.
Physical causes of poor sleep include sleep apnea and other problems with breathing, digestive problems such as gastro-esophageal reflex disorder (“GERD”), painful conditions such as arthritis or diabetic neuropathy, and hyperthyroidism. Some medications (eg asthma drugs, steroids such as prednisone, Dilantin, and stimulants) have side effects which alter sleep architecture. Psychological causes for insomnia can comprise high stress life events, and/or depression, anxiety, or psychosis.
Longitudinal studies, where a large group of women is followed through the transition into menopause, have contributed the best information about mood swings. The women in such studies are not presenting at their doctor’s office with specific complaints of mood problems. Rather they are living their daily routines and are surveyed using questionnaires, or interviews. Earlier studies (Kaufert 1992, McKinley 1992, and Woods 1997) found that a prior history of mood disorders, including PMS/PMDD, helped predict who was likely to become depressed during perimenopause. As might be expected, poor health, and increased levels of life stressors, made depression more likely to occur.
Interestingly, when the presence of severe hot flashes/poor sleep, and a history of prior depression were controlled for when analyzing the women’s data an interesting fact was found. The greatest incidence of down moods was in the perimenopause, not in pre-menopause (Bromberger 2003) or post-menopause (Freeman 2004). It would seem that there is a time of increased vulnerability to mood swings as one approaches menopause.
Other causes of mood swings can include: unrecognized clinical depression or anxiety, life stressors unique to midlife (eg new medical problems, changes in relationship or parental dynamics, one’s aging parents needs, etc.), low thyroid, and endocrine disorders. If one is experiencing mood swings which are impacting her quality of life, it is important to see a healthcare provider for an assessment of physical and psychological causes.
Vaginal dryness can arise at any age. Frequently it is seen in breastfeeding women as low estrogen levels are triggered by the hormone of lactation, prolactin. Some young women using DepoProvera as a contraceptive can also develop lowered estrogen levels and experience vaginal dryness. The sensation of vaginal dryness, when due to lowered estrogen level is marked by both decreased lubrication, and thinner, more fragile vaginal tissues. The vaginal pH will be more alkaline. Fewer of the beneficial, hydrogen peroxide producing lactobacilli will be present.
Other medical conditions which can create vaginal dryness include: benign pituitary mass, diabetes, and Sjogren’s syndrome. Medications such as Lupron, antihistamines, diuretics, or drugs which create dry mouth (eg tricyclic antidepressants) have the potential to create vaginal dryness as well. Radiation therapy may prompt vaginal dryness and tissue fragility. Yeast infections, or vulvar dermatology problems (eg lichen planus, or lichen sclerosus), can be interpreted as a dry, uncomfortable feeling in the vagina. Even poor lubrication due to genital pain, or inadequate sexual arousal, can create a subjective sensation of vaginal dryness.
It is common with hot flashes to experience an increase in heart rate during the flash. Increased heart rates can also arise when one is stressed, anxious, or having a panic attack. There are cardiac conditions where heart rate can dramatically speed up or actually become quite irregular. If one is experiencing irregular or very elevated heart rates it may necessitate an electrocardiogram (ECG), a treadmill ECG, or a monitor to be worn for 24 hours to detect the arrhythmia.
Is There a “False Negative” on a Test for Menopause?
One can be in perimenopause and have blood tests which do not confirm that diagnosis. This is the reason many healthcare providers chose not to do such tests routinely. There are blood tests (eg inhibin B) used in research settings which are very sensitive indicators of ovarian aging. But the two most common tests FSH, (follicle stimulating hormone) and estrogen (estradiol), are subject to swings in and out of “normal” range.
With ovarian aging it can take much more FSH to push the ovary to produce normal, “young women” levels of estrogen. In general an FSH level greater than 20 mlU/ml suggests approaching menopause. The problem arises when the increasing FSH levels push the ovary to create more estrogen. The resulting spike in estrogen pushes FSH levels back down. This is similar to a thermostat turning off once the heat in the room has returned to an appropriate temperature. Thus, if your GYN were to draw an FSH or estrogen level they would look normal—whereas several weeks before the FSH would be higher than 20 and the estrogen less than 40. This unpredictable variability makes diagnosis of perimenopause less reliable than, say, a blood sugar to rule out diabetes.
Some GYNs will add an additional blood test called LH (lutenizing hormone) which also becomes higher at menopause. However, this increase in LH happens later in the menopause transition so it is not very helpful in early perimenopause.
Finally, the journey into menopause can take a varying amount of time. One source maintains that the range of years during the transition can be from “zero to ten years”. Up to 20% of women will enter menopause without significant symptoms. While I would hope that this would be the case for you, any significant symptoms should be assessed before being reflexively attributed to menopause.