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Women and Menopause
by Dr. Abraham Kryger, MD, DMD

What are the stages of menopause?

Menopause is actually defined as the period beginning twelve months after a woman's last menstrual cycle. This is the point when a woman is not "going through" menopause but is "in" menopause.

The stages of menopause depend upon the reason for which the onset of menopause occurred. When menopause is induced by a surgical procedure or by radiation or drug therapy that causes damage to the ovaries, then the stages of menopause are different than those associated with natural menopause which occurs in all women, usually in the fifth decade of life.

Women may have induced menopause for various reasons, including the surgical removal of both ovaries, a procedure called oophorectomy. A hysterectomy, in which the uterus is removed from the woman's body, will also induce menopause.

When a woman has an oophorectomy or a hysterectomy the body is suddenly and artificially prohibited from producing the hormones that are normal during the fertile years. This sudden shift means that menopause happens immediately, and there is not the usual period, sometimes of over five years, in which the body gradually loses fertility and enters into menopause.

This transitional period, which those who experience induced menopause do not go through, is called perimenopause or pre-menopause.

The first step towards menopause is brought when the ovaries start decreasing the amount of estrogen, progesterone and testosterone that your body produces. When a woman is in her late thirties, the amount of progesterone that her body produces begins to diminish. This decrease in hormone production may also create a decrease in libido when compared to how a woman felt in her twenties and early thirties. With this decrease in progesterone comes a decrease in fertility. Perimenopause is described as the onset of typical menopausal symptoms, even though a woman is still ovulating. Early signs of perimenopause include uneven rise and fall of hormone levels. Such abrupt changes in hormones often create mood swings, irritability and sensations of heat called hot flashes.

You will join the ranks of women who, in a room with a constant and comfortable temperature, suddenly start ripping off clothing and throwing open windows. The good thing about hot flashes is that people will understand what you are going through, as many women have endured these changes before and many women will endure the changes after you.

Hot flashes usually last between thirty seconds and five minutes. The intensity of hot flashes varies and their frequency and duration can also change as you continue transitioning into menopause. Sometimes a hot flash feels like a warm blush, and sometimes it is intense enough to wake a woman up out of a deep sleep. The latter is called a night sweat. Night sweats can also be a cause of the trouble that many women face during preimenopause of getting a good night’s sleep.

The rise and fall of hormone levels is a cycle to which most women find themselves accustomed, having endured the hormonal changes that accompany a fertile cycle; however it often happens unpredictably during perimenopause, causing PMS-like symptoms.

The clearest transition into menopause comes with the variations in a woman’s menstrual cycle. Eventually you will stop getting periods altogether, but it can take a period between one and five years of gradual adjustment before your body stops its menstrual cycle completely.

Your period could go in any direction during this transitional time. Your flow may be heavier than normal; it may be lighter than normal; your period could come at closer intervals, and it may come at longer intervals. Some women have spotting between periods. You may have shorter periods of bleeding than normal, or you may have longer periods of bleeding than normal. Reassuring, isn’t it?When twelve months have passed, and you have not had a period, you have now exited perimenopause and entered technical menopause. At this point, your ovaries no longer produce estrogen or progesterone, and no more eggs are released. You can throw away any stained underwear, condoms (unless they are being used for STD protection), and birth control pills.

As a woman progresses toward menopause, hormone levels rise and fall unevenly, but the general trend is towards a decreased production of hormones. This causes certain symptoms of menopause to become more persistent in the later stages of perimenopause, and to persist into the postmenopausal years.

Symptoms may include vaginal dryness and thinning of the vaginal walls. This dryness can make sexual intercourse painful; however, couples have great success by incorporating lubricants and oils into their lovemaking.

Women also become gradually more susceptible to urinary tract infections. Some women find that they begin to have bladder weakness, and have trouble holding in their urine. Kegel exercises strengthen your vagina, helping to prevent incontinence while increasing the pleasure derived from sex.

The various stages of menopause, including perimenopause and post-menopause are natural.. Perimenopause can last over five years, and some of the stages that begin during that time continue into the post-menopausal stage of life. As your body adjusts to changes in fertility and hormone production, however, the more tumultuous stages of menopause, such as hot flashes, will diminish. These stages and their accompanying changes are natural.

"Hormonal therapy is a good treatment for many teenage and adult WESTPORT, CT (Reuters Health) Sept 13, 2001. As a woman ages and progresses from perimenopause to postmenopause, her sexual functioning declines significantly, according to results of an 8-year longitudinal study conducted in Australia.

Dr. Lorraine Dennerstein and colleagues of the University of Melbourne in Victoria began their study in 1991, enrolling women who were between 45 and 55 years old and who had experienced menses in the previous 3 months.

During the ensuing 8 years, 197 of the women underwent the menopausal transition. Two other subsets served as control groups, one comprising 44 women who remained pre- or early peri-menopausal for 7 years and another that included 42 women who were postmenopausal for over 5 years.

As reported in Fertility and Sterility for September 2001, the subjects completed the Personal Experiences Questionnaire annually, which included questions regarding feelings for one's partner, sexual responsivity, frequency of sexual activities, libido, partner problems, and vaginal dryness/dyspareunia.

All three groups exhibited declines in sexual responsivity, as assessed by questions regarding arousal, orgasm, and enjoyment during sexual activities.

During the entire transition period, women also experienced problems with their partner's sexual performance. From late perimenopause to postmenopause, libido and frequency of sexual activities decreased, while vaginal dyspareunia increased.

Dr. Sheryl Kingsberg, of Case Western Reserve University School of Medicine in Cleveland and spokesperson for the American Society for Reproductive Medicine, agrees with the conclusion of Dr. Dennerstein and her associates, that both aging and the menopausal transition affect women's sexual responsivity.

In an interview with Reuters Health, Dr. Kingsberg lauded the researchers' use of a validated, reliable measure of sexual functioning. She wanted to add, however, that a woman's sexual functioning comprises three components: physiological drive; cognitive expectations, beliefs and values; and motivation.

"The motivation component includes all the psychological, interpersonal issues that create her interest in being sexual with a partner," Dr. Kingsberg said. "She may have sexual drive, but if she has lost interest, that is going to impact the frequency [of sexual activity] and her responsivity."

Dr. Kingsberg urged physicians to "tease out" the components of a woman's sexual dysfunction. She suggested that doctors ask themselves, "Should I be looking at her hormonal status? Are there age and physical problems, or is it more an issue of what is going on in the woman's life?"

She emphasized that simply providing a medical treatment when cognitive or motivation issues may be involved, is inadequate. Both the physician and the patient will feel like failures.

"Physicians don't need to be an expert in sex therapy," she added. "The biggest help is to ask, delineate the problem, then make the appropriate referrals if that's indicated."

"By asking a patient to schedule a consultation, then to report back to the doctor, that makes the patient feel cared about, that she's in good hands, and that her problem is important," Dr. Kingsberg concluded.

© Fertility and Sterility , September 2001;76:456-460.