By Shaun Denise Biggers, MD
Many of us think of menopause as something that happens to a woman during her 50s. While it is true that the median age that a woman stops having her menstrual cycle is 52, menopausal symptoms often begin up to 10 years before a woman’s menstrual cycle stops. What that means is that during her 40s, many women experience significant symptoms of menopause. These symptoms can be as obvious as a hot flash or as subtle as mild fatigue. They also include mood changes, sleep disturbances and decreased libido.
Although 40 is the new 30, it is hard to feel that way while having a hot flash! If these symptoms start to affect your quality of life, there are some treatments and therapies that can help.
What’s Happening to My Hormones?
A woman is born with all of the eggs that she will ever have. These eggs are located in the follicles, which are found within the ovaries. The main hormones produced by the ovary are estrogen and progesterone. As the last of these follicles either ovulate or die, ovarian function fails and menopause occurs. During this time, levels of the female hormone estrogen decreases. Many of the typical symptoms of menopause are directly related to this decrease. Most physicians have focused on estrogen replacement when treating symptoms of menopause, and this does resolve most of these symptoms. For perimenopausal women who are still having their menstrual cycle, this time is more complicated than a mere decrease in estrogen. Progesterone levels decrease as well.
As the menstrual cycles start spacing out or skipping months, there can be virtually no progesterone production for months at a time. Estrogen and progesterone are like the yin and yang of the female reproductive system. Prior to menopause, they must exist in an appropriate balance. Progesterone is actually a precursor on the steroid pathway to the production of estrogen, so progesterone is important for the body’s normal production of estrogen. Progesterone also affects the androgen (testosterone and DHEA) and cortisol pathways as well.
The bottom line is that there are reasons why the symptoms of menopause can be wide-ranging. Changing ovarian hormones affect a variety other hormones. There are also receptors for these hormones on a variety of tissues in the body. That is why what seems like a simple change in reproductive hormones can have such a significant effect on the rest of the body.
What Can I Do About These Symptoms?
Every woman has her own unique constellation of menopausal symptoms. In menstruating women, these symptoms can often be cyclic, often occurring a week or so before the menstrual cycle. Hormones levels are changing on a continuum with age, but at the beginning, a woman may not need hormones to help out with symptoms. The goal during this time is to try to ease symptoms with some lifestyle changes or supplements that work and have minimal side effects or risks.
The first thing to do is really simple, but unfortunately may be one of the most difficult: Get 8 hours of sleep at night. You also have to eat a well-balanced diet. Increased levels of aerobic exercise, which causes a release of beta endorphins, often helps as well.
A variety of over-the-counter supplements are sold claiming that they help with menopausal symptoms. Many of these supplements have not been adequately studied to determine their true effectiveness and they are not FDA regulated. But, there is some evidence that the following supplements may be helpful:
- Black Cohosh
- Vitamin E
- Soy products
- Evening Primrose Oil
The important thing to remember is that there is no evidence that women need to take these supplements. Menopause is not a disease to treat. What we are treating with these supplements is the symptoms of menopause. If those symptoms do not go away after trying these methods for several weeks, then that treatment should be discontinued. If symptoms persist and continue to affect the quality of life, then there are still a few things to consider before taking systemic hormones. Hormones do work, however, and creams and gels may provide new ways for women to treat their menopausal symptoms.
We have traditionally used oral hormones for the treatment of many hormonal issues in women, but there is increasing evidence that the best route for using hormones may be through the skin. If the hormones are appropriately absorbed through the skin, they immediately enter into the bloodstream without the first-pass effect of the GI tract and liver, which occurs when hormones are taken orally. The liver metabolizes oral hormones and produces metabolites, which may be good or bad, but the transdermal route (through the skin) is more direct. There are a variety of FDA approved transdermal estrogens such as estrogen patches, creams and gels. There are fewer transdermal progesterones.
Progesterone comes in many forms. The most widely used forms are “synthetic” or not identical to the type of progesterone that our body makes. Most of these have pharmaceutical branding and are FDA-approved, which means they have been well studied and have clearly described progesterone effects on the body. Their risks and benefits are well elucidated. They are, however, not identical to the progesterone that our body naturally produces. Micronized progesterone or USP progesterone is bioidentical (often termed “natural” which is a misnomer as it is synthesized in a lab just like the other progesterones). Although there is a debate over whether bioidentical hormones are safer, bioidentical or micronized USP progesterone do seem to have fewer nuisance side effects associated with it.
Many perimenopausal women who are not ready to commit to full hormone replacement therapy will try OTC progesterone creams. An effective progesterone cream can really relieve many perimenopausal symptoms, but the problem is that most consumers do not know exactly what they are getting. “Wild Yam” creams are made out of the precursor hormones that are used to make many of the bioidentical and synthetic hormones; however, applying this cream to your skin does not reliably increase your progesterone levels. These creams will not work.
There are some OTC creams that actually do have pharmaceutical-grade USP micronized progesterone in them. In the past, it has been thought that the levels in these OTC creams were not significant, but some studies have shown that they actually do have significant amounts of progesterone in them. These creams are not, however, FDA regulated because they are considered cosmetic or beauty items. Because they really do increase circulating progesterone levels, they will often work and women will use them in an unregulated manner. My recommendation is that if you are considering using a progesterone cream that you discuss it with your physician ahead of time.
What Are the Risks of Hormone Therapy?
For most women in their 40s whose bodies are still making estrogen and progesterone themselves, adding a little progesterone will most likely not have any long-term effects. However, we know from the Women’s Health Initiative study in postmenopausal women on combined synthetic estrogen and progesterone that there are increased risks of heart attack, stroke and breast cancer. These risks are low enough that we still routinely prescribe these therapies to women who are suffering from menopausal symptoms – but the risks are a sober reminder that hormones can have long-term effects.
If a woman is taking progesterone and estrogen together, she should take an FDA-recommended dose of progesterone in order to counter the risks of taking estrogen. The recommendation on taking combined systemic hormones by the American College of ObGyn is that you take the lowest dose for the least amount of time to transition you through the symptoms. Short-term use of supplemental progesterone is reasonably safe but it is best to use it after discussing it with your physician.
Sex in Your 40s
There is a myth that women have their best sex in their 40s. For some, that may be true, but for many women, it is the beginning of a decline in libido and in intensity of sexual response that only gets worse with menopause. As gloomy as this sounds, there are some things that can be done.
A topical estrogen cream or gel can reduce the vaginal dryness that occurs with menopause and change an atrophic vagina to that of a 30-year-old’s in a matter of weeks. Only low levels of this get into the bloodstream so that many of the risks of systemic hormone use are not associated with the typical use of FDA-approved vaginal estrogen creams.
Testosterone is the libido hormone. It is what makes us want to have sex. Unfortunately, there is not a consistent body of data showing that supplementing testosterone dependably increases libido for most women. More research needs to be done, but testosterone is often used with traditional hormone replacement therapy and has been found to be effective in increasing libido is some women.
Arousal can be initiated or heightened by a variety of topical sexual arousal creams. Most of these creams are a mixture of some herbal extracts or oils that together cause an increase in the local blood flow to the area where the cream is applied. Most of these creams are applied to the clitoral hood and external labia. The most common ingredients in these creams are:
- L-arginine, an amino acid found to increase blood flow to cutaneous skin
- Peppermint oil
There are also personal lubricants that include these ingredients. The combination of these usually produces a cooling or tingling effect that may help initiate sexual arousal. These are not FDA regulated but are not known to have any long-term side effects. At worst, they could cause some local irritation (test it on your skin before putting it on your genitalia).
The most important thing for helping your libido is actually having sex itself. Most women still have satisfying orgasms even when their libido has decreased. If using these stimulants increases the frequency of having sex, then that is a good thing!