Before the Change

Women expect menopause; it’s the hormonal changes beforehand that blindside them.

“I felt like I was living in someone else’s body,” says Debbie Greenberg, 45, who three years ago began having heavy periods, days-long headaches and “brain fog.” “I didn’t know what was going on. I had no clue. I wondered if I was cracking up.”

When her gynecologist identified her symptoms as part of perimenopause, Greenberg says, “it was validation.”

Perimenopause, a term that has largely displaced “premenopause,” is the hormonal and physical changes leading to menopause, commonly defined as 12 months without a period. After that, a woman is considered postmenopausal.

For some women, the approach of this hormonal milestone offers a stark reminder that even at the prime of life--when they have mastered the juggling of jobs, kids and relationships--their bodies are aging.

For those who may have postponed motherhood, it’s hard to accept that their supply of eggs capable of producing a child is dwindling.

Still others are troubled by losing control over their bodies and moods as their hormones fluctuate wildly.

Dr. Marcie Richardson, an obstetrician-gynecologist who directs a menopause consultation service in Boston, says women come to expect certain patterns from their hormones, such as premenstrual syndrome.

“When these things are all over the map,” she says, “that’s very disturbing for women.”

Adding to their frustration is the lack of answers to their perimenopause questions.

Even doctors are at a loss to predict when it will begin or how it will affect efforts to become pregnant.

Nor can they say whether women will have a rough time getting through it. Most have only mild symptoms; others have astonishingly disruptive effects.

Doctors can’t even agree on when a woman should seek help. Some doctors suggest she consult a physician at the first sign of menstrual changes; others advise waiting until symptoms become bothersome, such as missing periods or having hot flashes.

But there are signs that knowledge about this transitional time is growing: Doctors now can offer women better ways to cope.

“Twenty years ago, if somebody had hot flashes and skipped a few periods here and there, we didn’t have good treatments for them,” says Dr. Isaac Schiff, chief of obstetrics and gynecology at Harvard-affiliated Massachusetts General Hospital.

As recently as 30 years ago, many of these women routinely underwent hysterectomies--surgical removal of the uterus and sometimes the ovaries. The women now hitting perimenopause, he says, “are not going to settle for a hysterectomy.”

Various coping strategies are available, but regardless of what course a woman chooses, she should do so carefully. After menopause, her ovaries will no longer make estrogen, which has bolstered her bones against osteoporosis, her heart against rising cholesterol and heart disease--and, as mounting scientific evidence is showing, her brain against Alzheimer’s disease.

Perimenopause provides an opportunity to assess her health and choose a strategy that will protect her for the third of her life following menopause.

Physical Cause and Effect

Think of perimenopause as puberty in reverse. During puberty, brain chemicals switch on a girl’s ovaries, starting a cascade of physical changes that herald her entry into womanhood. At perimenopause, the ovaries begin to run out of eggs and stop responding to those chemicals, a natural progression leading to menopause.

The transition to menopause varies among women, as does the onset of puberty, says Dr. Margery Gass, director of the menopause and osteoporosis center at the University of Cincinnati College of Medicine. “To some it was rocky; to others it was a piece of cake.”

Although most women reach perimenopause at about age 46, it can occur as early as 35 or as late as 55, doctors say. Smoking can speed up onset by two years.

Perimenopause can last a few months or up to a decade. Some doctors say the age at which a woman’s mother reached menopause can help predict when her periods will stop; others say that holds true only if menopause was particularly early or late.

Schiff of Massachusetts General says women shouldn’t rush to a physician at the first sign of menstrual irregularities, unless they’re very symptomatic. “We don’t have enough doctors for that,” he says, “plus we don’t want to cause undue anxiety.”

Dr. Charles Hammond, chairman of OB-GYN at Duke University in Durham, N.C., advises that menstrual cycles lasting fewer than 21 days or bleeding lasting more than 10 days merit a medical consultation. (Menstrual cycles generally run about 28 days.)

Heavy bleeding, which can produce anemia, could signify development of uterine growths called fibroids or precancerous conditions. And thyroid abnormalities, which often become apparent in this period of a woman’s life, should be ruled out as well.

For Carmen Porta of Glendale, excessive bleeding signaled something was amiss. A scientist who works for a biotechnology company, Porta, 49, noticed the changes three years ago and began reading up on the Internet.

This past September, her periods began to get so close together that “I would bleed for about 10 days and then four days later I would get it all over again.”

She was depressed, emotional and irritable much of the time: “Everything bothers you, and you cry at the drop of a hat.”

The menstrual flow was so heavy that at times she’d excuse herself from meetings nearly hourly to hurry to the restroom and change her sanitary pads and tampons, a problem shared by several women interviewed for this story.

Four weeks ago, after much deliberation, she began taking low-dose birth control pills and, she reports, “this is the first month that has been normal.” Coping strategies for dealing with these changes vary enormously. Some women “don’t want to be the least bit uncomfortable,” says Dr. Allison Leong, a Santa Monica gynecologist. Others, she says, choose to get through it the old-fashioned way: “They just gut it out.”

Many women think they need to be stoic and feel guilty about turning to medical interventions, even with severe symptoms.

“These women should not feel they are ‘copping out’ by taking hormonal or other treatments,” says Dr. Nanette Santoro, who does perimenopause research at Albert Einstein Medical Center in the Bronx, N.Y. She says about 10% of women have “killer hot flashes, memory loss and generalized misery throughout the process.”

“If providing symptom-based treatment makes short-term quality of life better for a symptomatic, perimenopausal woman,” she says, “Why not? Better living through pharmacology.”

A Balancing Act

Women are increasingly having to balance the potential benefits of medical intervention against the side effects and potential risks, which may become more worrisome as they get older.

Although the common wisdom used to be that birth-control pills were not advisable after the age of 35, doctors now say those containing estrogen and progesterone can even out hormonal levels while preventing pregnancy.

Their usage must be monitored, however, and often adjusted. In addition to causing breast tenderness and water retention, the pills can make women have periods forever and mask the onset of menopause. (And smokers cannot take hormones because they drastically increase the risk of stroke.)

At menopause, hormone replacement therapy can provide needed estrogen at about one-fifth to one-sixth the dosage found in contraceptive pills.

Although some researchers say long-term hormone replacement can increase the risk of breast and uterine cancers, many doctors say it can reduce the risk of ovarian cancer and rheumatoid arthritis.

Some women can’t take estrogen, including those with a history of blood clots or those with high risk of breast cancer.

Among them is Susan Friedman, 48, of Los Angeles, whose mother and grandmother had breast cancer. She has begun a five-year course of tamoxifen to reduce her cancer risk. Now she’s coping with the dual effects of perimenopause and the drug: “Right after I take it, I get a [hot] flash,” she says.

Although tamoxifen often halts a woman’s periods, Friedman’s continue, but with very heavy flow. To counter the effects of waning estrogen, she takes calcium and a cholesterol-lowering drug, exercises regularly and has added more soy foods to her diet.

Greenberg, a manager for a Manhattan accounting firm, also must avoid estrogen, in her case because it would promote growth of her uterine fibroids. She’s found some relief with a progesterone skin cream, derived from wild yams, that has stabilized her fibroids and alleviated her headaches. She’s coping with night sweats, another common side effect.

Symptoms can also be addressed individually. For vaginal dryness, women may want to try lubricants and moisturizers, or if those don’t work, prescription estrogen creams, tablets and rings. Irregular bleeding may be helped by 10 days of progesterone.

Hot flashes can be tamed with Megace, a synthetic progesterone approved in breast cancer treatment, or the blood pressure drug clonidine, marketed as Catapres.

Although there are scant studies to rely upon, many doctors use the newest generation of antidepressants, the selective serotonin reuptake inhibitors such as Prozac, to help some women, especially those who will not or cannot take birth control pills or estrogen.

Education and Research

A woman approaching the perimenopausal years should carefully choose the doctor who will help her through this stage of life. Ideally, he or she would be a good listener, patient enough to monitor the changing symptoms, and trained in the latest therapies.

“Only about a third of ob-gyns are considered menopause clinicians; the other two-thirds are dealing with other reproductive issues,” says Pamela Boggs, director of education and development for the North American Menopause Society. The nonprofit scientific group has labored to standardize definitions of menopause and perimenopause and encourages doctors to get additional training in menopause treatment.

Sometimes women have formed a bond with the ob-gyn who delivered their children and feel guilty about switching to someone with expertise in perimenopause. But, says Boggs, “It’s almost unfair for us to expect that any one doctor be expert in all stages of a woman’s gynecologic health.”

Even as women and their physicians learn more about perimenopause, researchers worldwide are trying to enhance their understanding of how hormones affect a woman’s physical and psychological well-being, including how changes in hormone levels during perimenopause can worse depression or trigger other mental health problems.

A nationwide perimenopause research project, called the Study of Women’s Health Across the Nation, is among the efforts and is recruiting white, Latino, African American, Chinese American and Japanese American women.

“Most women weather this period of life without much difficulty,” says Santoro, one of the study’s researchers.

But she hopes increased scientific attention to perimenopause will make the passage easier for all women.

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Perimenopause

This transition in a woman’s reproductive life leading up to menopause can last a few months--or a decade.

Changing Patterns

Estrogen, progesterone, follicular-stimulating hormone and luteinizing hormone are the major hormones that control a woman’s menstrual cycle. At left, predictable monthly fluctuations in a woman who has not reached perimenopause. At right, erratic hormone levels in a perimenopausal woman.

Symptoms

Hormones released by the pituitary gland signal the ovaries to make estrogen and progesterone. But during perimenopause, the hormonal system works less efficiently, creating a host of symptoms.

* Irregular periods: shorter or longer cycles, heavier flow.

* Hot flashes or night sweats, often accompanied by heart palpitations.

* Sleep disturbances, including insomnia.

* Fatigue.

* Headaches.

* Memory lapses or concentration problems.

* Depression, mood changes, irritability.

* Vaginal dryness, recurrent urinary tract or vaginal infections, stress incontinence--the leakage of urine when a woman sneezes, coughs or laughs.

* Loss of libido.

* Enlargement of fibroid growths in the uterus or flare-ups of endometriosis.

* Dry skin.

What You Can Do

There are three principal approaches to good health in the perimenopausal years, which can include combinations of the following.

Lifestyle changes every woman should make:

Calcium and weight-bearing exercise protect bones against osteoporosis. Maintaining a healthy weight can control cholesterol and protect the heart. Good nutrition provides important vitamins and minerals for bone and heart health. Stopping smoking is also advised, since it can bring on menopause up to two years early.

Medical interventions:

* Combinations of estrogen and progesterone, such as those found in oral contraceptives, can suppress ovulation, reduce menstrual flow, regulate periods and help such uterine conditions as fibroids and endometriosis. Low-dose hormone replacement therapy can also modify symptoms. Hormones, in either natural or synthetic form, can be given through patches, creams or gels absorbed into the skin.

* Antidepressants that boost serotonin in the brain, such as Prozac, can help with depression, night sweats and insomnia.

* Blood pressure drugs such as clonidine, called Catapres, or methyldopa, called Aldomet, can ease hot flashes.

Alternatives:

Various herbs and supplements can ease symptoms. Black cohosh is used for hot flashes, headaches, mood swings and vaginal dryness; evening primrose oil for regulating moods; red clover for hot flashes. Vitamin E is often used for hot flashes, although scientific evidence is mixed and the vitamin can cause bleeding. Soy foods are believed to reduce hot flashes.