Other Physical And Mental Changes At Midlife - The Symptoms Of Menopause: Menopause Managing The Change Of Life

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Other physical and mental changes at midlife

Some common midlife changes that are often attributed to menopause are not necessarily related to the fluctuating or decreasing hormone levels of menopause. The four most commonly reported changes include mood changes and depression; insomnia or other sleep problems; cognitive or memory problems; and decline in sexual desire, function, or both. Other physical changes that crop up in the middle years include weight gain, urinary incontinence, heart palpitations, dry skin and hair, and headaches. For these, a hormonal link is possible, but has not been proved. Consider the fact that men, who don't experience a dramatic drop in hormone levels in their early 50s, often notice many of these same symptoms!

Mood swings and depression

Studies indicate that mood swings are more common during perimenopause, when hormonal fluctuations are most erratic, than during the postmenopausal years, when ovarian hormones stabilize at a low level. No direct link between mood and diminished estrogen has been proved, but it is possible that mood changes result when hormonal shifts disrupt the established patterns of a woman's life. These changes can be stressful and may bring on "the blues." Mood swings can mean laughing one minute and crying the next, and feeling anxious or depressed. These changes are transient, however, and do not usually meet the criteria for a diagnosis of clinical depression, a more profound dysfunctional emotional state.

Over their lifespan, women have more depression than men. But there is no evidence that decreased estrogen alone causes clinical depression. In fact, a study in Psychosomatic Medicine in 2001 found that menopausal status is not associated with symptoms of depression, such as feeling sad, irritable, anxious, or hopeless. Although women who have had previous episodes of depression may be vulnerable to a recurrence during perimenopause, menopause in and of itself does not cause clinical depression. The incidence of depression in postmenopausal women is not any higher than at any other time in life.

Disrupted sleep from night sweats can cause a woman to feel fatigued and irritable. Also, remember that perimenopause coincides with many of life's stresses — children who are teenagers or leaving home, peaking professional responsibilities, illness or death of elderly parents, and aging itself. These events, combined with unpredictable hormonal changes, can leave a woman feeling fatigued, overwhelmed, and out of control.

Treating mood swings. Many women choose to make lifestyle changes before turning to medications. Taking care of yourself by getting more sleep, exercising regularly, and using stress-control methods can all help even out your mood. For an herbal approach, St. John's wort may have some mood-elevating effects, although studies have been conflicting. Prescription antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), effectively moderate moods.

Memory and concentration problems

During perimenopause, women often complain of short-term memory problems and difficulty with concentration. Some earlier observational studies found that women ages 65 and older who had been taking estrogen therapy had higher scores on tests of mental functioning than did women who had not used estrogen. But the Women's Health Initiative found that hormones seemed to increase the risk of dementia and cognitive problems. And other research suggests that stress may be more closely linked with memory problems than hormonal fluctuations.

Treating memory and concentration problems. Just as it isn't clear what causes memory and concentration problems, there is no obvious remedy. Brain and memory experts recommend that people with these issues work to keep their brain functioning at its peak by taking on new and interesting challenges. Use your mind in many different ways. Do crossword puzzles. Learn a new musical instrument or sport. Play chess. Read more books. Learn a new language or how to use the computer. The idea is to challenge your brain in new ways.

Insomnia

Disrupted sleep is a common complaint during perimenopause. Whether hot flashes during sleep cause sleep disruption is not completely clear. Some women report that they perspire so profusely that they soak the bed linens and wake up. Others sleep right through their hot flashes. At least one study showed that hot flashes disrupt the most restorative form of sleep, known as REM, even if the woman doesn't wake up. Although some studies suggest that hot flashes are a cause of sleep disruption, a more recent study has disputed this.

Insomnia also can be a problem for women who don't have hot flashes. Some women may have difficulty falling asleep, but a common pattern is to sleep for a few hours, awaken too early, and not be able to fall back to sleep. Whether sleep disruptions are due primarily to hormonal changes is currently unknown. Sleep cycles change as people age, and insomnia is a common age-related complaint. The problem is a troublesome one that can leave sleep-deprived women fatigued, tense, irritable, and moody. Insomnia is not a trivial matter, as sleep problems also have been associated with heart attacks and congestive heart failure.

Treating insomnia. Medications are available for temporary treatment of insomnia, but you can also take some practical steps to improve your chances of getting a good night's sleep (see "Sweet dreams," below). If hot flashes are keeping you awake, trying a treatment for hot flashes may also improve your sleep (see "Treating hot flashes").

Sweet dreams With age come changes in sleep stages and reduced levels of chemicals that promote sleep, such as melatonin and growth hormone. At midlife, hot flashes seem to rob some women of much-needed sleep. Maintaining healthy sleep habits can help. Wake up and go to sleep at about the same time every day, even on weekends. Avoid caffeine or alcohol within three hours of bedtime. Avoid exercise close to bedtime; it can overstimulate you. Stop smoking. Stay cool in the evening — don't take hot showers or baths before bed. Use the bed only for sleep or sex. Relieve stress, depression, or anxiety with exercise or relaxation techniques. If sleep problems persist, psychotherapy or medication may help. Keep the bedroom quiet and at a comfortable, cool temperature when you sleep. Seek treatment for conditions such as arthritis or congestive heart failure that can disrupt sleep. If this is an ongoing problem, ask your physician about having a sleep evaluation study.

Low sexual desire

Sex drive may decline at midlife for a variety of reasons. Diminished estrogen or age-related changes in circulation may reduce blood flow to the genitals and cause a decrease in sensation. Vaginal dryness or thinning can make intercourse painful. And women who have sleep problems may feel too fatigued to be interested in sex. Urinary incontinence may cause embarrassment that diminishes the appeal of sex. Concern about changes in physical appearance and body image can also reduce sex drive.

A 2001 study in Fertility and Sterility showed that during perimenopause, not only did women's sexual responsiveness decline, but their partners also had a significant increase in sexual performance problems. As a result, women in the study said they didn't feel quite as warmly toward their partners as they had earlier in the relationship. As women in the study entered the postmenopausal years, they reported further decreases in sex drive, sexual responsiveness, and frequency of intercourse. They also had more pain during intercourse and said their partners' performance problems had worsened.

Sex drive may be more closely associated with testosterone (a type of androgen) than with estrogen, and it's long been assumed that low blood testosterone levels lead to low sexual desire. However, a 2005 study in the Journal of the American Medical Association found no link between blood androgen levels and sexual function. There is much more to be known about female sexuality. And sexual identity is highly individual. The good news is that many women continue to enjoy their sexuality for decades after menopause.

Treating low sexual desire. Some women with low sexual desire appear to benefit from estrogen. Testosterone replacement is another option; however, in late 2004, the FDA refused to endorse a new testosterone patch for women, citing a lack of long-term safety data. The patch and other drugs designed to enhance desire, sensation, or both are still under study. But it's important to realize that libido isn't driven by hormones alone. It's quite possible that, as Ann Landers has said, "The most important sex organ is the brain." Lifelong perceptions about sex and the quality of relationships also have a profound impact on women's sexual function at midlife. Some women don't have a partner. Some have partners who are themselves suffering from sexual dysfunction; this, too, may play a role in the woman's declining interest in sex. Talking with your partner about each of your needs and expectations can go a long way toward helping solve this problem. If talking is too difficult, counseling with a trained sex therapist can help pave the way.

Weight gain

Although weight gain is a significant issue for a lot of women in this age group, there's no clear evidence that it's a direct result of hormone changes or even age. A 2004 study in the American Journal of Epidemiology of more than 3,000 women found no link between menopausal status and weight gain or an expanding waistline. Instead, the classic middle-age spread seemed to stem from a variety of factors, including the fact that older women (and men) are simply less physically active. There is also some speculation that weight gain in midlife is due, in part, to a slowdown in metabolism.

Treating overweight. Many strategies are available for losing weight (see "Tipping the energy balance"). For women who have yet to gain excess weight, the best strategy is to try to avoid gaining by exercising and eating right. Measure your waistline regularly and try to prevent any increase. As your waist size grows, so does your risk of heart disease and diabetes. Walking, swimming, or other aerobic exercise is your best bet because it helps prevent accumulation of fat at the waistline. (See "Menopause and healthy living" for additional information on diet and exercise.)

Urinary incontinence

Up to 30% of American women ages 50–64 have problems with urinary incontinence, compared with, at most, 5% of men in the same age group. The disproportionate impact on women is from the effects of vaginal childbirth on pelvic tissues and basic anatomical design differences between men and women.

Decreased estrogen may cause or contribute to thinning in the lining of the urethra, the tube that empties urine from the bladder. Problems may include a more frequent need to urinate, a sudden urge to urinate even though your bladder is not full, pain during urination, the need to urinate more often during the night, and urine leakage when sneezing, coughing, or laughing. Urinary problems persist and worsen in postmenopause because changes in the urinary anatomy occur with general aging as well as estrogen loss. Some other causes of urinary incontinence include bladder and urethral infections, muscle weakness caused by aging or injuries during childbirth, and some types of prescription medication.

Treating incontinence. Bladder training may be useful for urge incontinence. This entails holding urine for five minutes after feeling the urge to void and increasing the holding period by five minutes each week. Eliminating diuretic beverages such as coffee, tea, and alcohol as well as citrus juice and other bladder irritants may also help. Pelvic floor exercises, known as Kegel exercises, can be effective. They involve repeatedly contracting and releasing the pelvic floor muscles used ordinarily to halt urination. Although estrogen was previously thought to help incontinence, research suggests that this isn't the case. Talk with your doctor about your treatment options, which include lifestyle habits, medications, and surgery. A urogynecologist is a specialist with training in woman's incontinence issues.

Heart palpitations

Some women have complained of heart palpitations during perimenopause. Heart rate has been shown to increase by 8–16 beats during a hot flash, but more research is needed to determine how heart rate may be affected by hormonal fluctuations during perimenopause in the absence of hot flashes. Some women do report that heart palpitations improve with hormones or get better after menopause. Little is known about this phenomenon, but women are sometimes mistakenly diagnosed with heart disease and prescribed unnecessary medication.

Treating heart palpitations. Treatment depends on the cause of your heart symptoms. The role of hormones in regard to heart symptoms has not been well studied. Talk with your doctor about your symptoms and possible treatments.

Dry skin and hair

Many women experience dry skin and hair at midlife. While some research suggests that declining estrogen levels may contribute to dry skin, it may also be the result of cumulative sun exposure or smoking. With age, the skin's ability to retain water and produce oil diminishes, too. But there is little evidence that decreased estrogen is directly involved in causing skin to dry and wrinkle.

Treating dry skin and hair. Because these conditions are so common, many remedies are available. Protect your skin from sun exposure with sun blocks, hats, and clothing. Use moisturizers and hair conditioners, especially in the dry winter months. Buying a moisturizer is one case in which the old adage "you get what you pay for" doesn't hold true. Inexpensive and effective moisturizers are widely available and often equal or superior to high-end products. For instance, petroleum jelly is an inexpensive and highly effective moisturizer for skin that is extremely dry.

Headaches

Hormonal changes have been linked with headaches. It's not uncommon to hear premenopausal women complain of "menstrual migraines" around the time of their periods; some women who get migraine headaches say their migraines improve during pregnancy. Experts believe that changes in estrogen levels in the blood, rather than a consistently low level, may trigger migraines. The erratic hormonal fluctuations that precede menopause can make some perimenopausal women especially susceptible to migraines.

Headaches of all kinds can be triggered by a number of things, including smoke and pollen, alcohol, sleep deprivation, certain foods such as chocolate and aged cheeses, or stress. These triggers may be more likely to induce a headache when hormone levels are fluctuating. Women who have had frequent menstrual headaches may find that the problem worsens during perimenopause. However, some women say their headaches get better or even stop in the postmenopausal years.

Treating headaches. Treatment depends on the cause and type of headache. Identifying headache triggers and taking steps to avoid them is a good first step. Talk with your doctor about what kind of medication may be best to treat your kind of headache. Some women find other techniques, including biofeedback or acupuncture, to be helpful. Some experts find that timed supplemental estrogen can be helpful with cyclic headaches.

Two women, two choices Just as every woman is unique, no two menopause experiences are exactly alike. Many factors can influence a woman's decisions regarding whether to try hormone therapy, at what dosage, and for how long. Severity of symptoms, family health history, lifestyle, and professional responsibilities all come into play, as the following two stories describe. Sylvia: Stopping hormone therapy after 20 years Sylvia, now a retired school psychologist, started taking Premarin (estrogen alone) in her late 40s and stayed on the drug for two decades. Like many women, she decided to quit after the results from the Women's Health Initiative (WHI) were released in 2002. After tapering off Premarin, she began having hot flashes every other day or so, but they gradually subsided over the next few years. This is Sylvia's story: I decided to take hormones in part because of my mother. When she reached her mid-40s, she became very anxious and paranoid. Maybe it was a coincidence that these emotional problems surged as she approached menopause. But my father and I suspected the changes were related, at least in part, to her hormone levels. This was in the early 60s, when hormone therapy was just becoming popular. But my mother didn't like doctors or taking medication. Within four or five years, she began to return to her old self, but her difficult experience had a big effect on me. When I reached my late 40s, I began feeling anxious. Because I'm a trained psychologist, I recognized that my symptoms were bordering on obsessive-compulsive disorder. I went to my gynecologist and told him that I needed something to help me calm down. He prescribed Premarin, and I tell you, within one month, I was back to my normal, calm self. Even stressful things didn't bother me. For example, I was vacationing in Greece and I lost my return plane ticket. Instead of panicking, I just dealt with the problem. I remember being concerned about uterine cancer, because my maternal grandmother had died of uterine cancer at age 47. When I mentioned this to my doctor, he said, "Oh, we can take care of that if it happens. I'll just give you a hysterectomy!" Fortunately, that wasn't necessary. I continued to take estrogen, and after I retired, I volunteered to participate in the Women's Health Initiative. Here's something I can do to help humanity, I thought. I was in the dietary-modification component of the study and was selected to follow a low-fat, high-fruit, -vegetable, and -grain diet, and I did that for another 10 years while staying on estrogen. Then, in 2002, I and all the other volunteers received a letter about the early termination of the hormone arm of the WHI because of the increased risk of heart disease and breast cancer. I went online to find out more, and then went to see a new, younger, female gynecologist, because my other doctor had retired. She agreed that I should taper off the hormones. So that's what I did, cutting back to one pill every other day, then every third day, and then once a week. It took about six months to stop completely. Soon after, when I had my first hot flash at age 67, I wondered, did I do the right thing? I also got a little bit of the old anxiety back, but it's now gone away. I noticed that I tended to get hot flashes when I was in a large group of people or when I was under stress. My husband didn't believe that I was really getting them until he saw the perspiration on my face! I tried eating soy products, which are supposed to help. I was drinking two glasses of soy milk a day and eating lots of tofu salad. But it didn't really seem to make a difference. Now, after three years, I notice the hot flashes only occasionally, usually in the evenings. All in all, stopping the hormones wasn't really that difficult for me. Nancy: Stopping and starting again For 53-year-old Nancy, hot flashes were far more bothersome than a brief warm flush. When she entered menopause around age 49, her hot flashes became so frequent and severe they affected her professional life. As executive director of a nonprofit cancer organization, Nancy found that her daytime hot flashes made her uncomfortable and anxious. Nighttime hot flashes disrupted her sleep, leaving her exhausted and mentally foggy. After starting hormone therapy, she felt much better within weeks. She took a low-dose estrogen (.025 mg/24-hour Climara patch) plus natural progesterone (Prometrium) for a year and a half, but after she tapered off the medication, her hot flashes returned with a vengeance, and she began taking the hormones again. She plans to taper off again, sometime within the next year or so. This is Nancy's story: For me, the decision to take hormones was a quality-of-life consideration. I understand that there's a slight increased risk, but my hot flashes were so disabling that taking hormones is absolutely worth it for me. My work involves public appearances and occasional meetings with high-level politicians. As many women know, even a minimally stressful situation — talking to people whom you are trying to persuade, for example — can trigger a hot flash. I was totally unable to prepare for or control them. I needed to be clear-headed and responsive. But if I had a hot flash during an important meeting, I'd flush and sweat and my brain would do a little blip. It would undermine my confidence and effectiveness. But it wasn't just during the day. There was a period when I would get hot flashes every 20 minutes, like clockwork, between the hours of 2 and 4 a.m. I was exhausted all the time, which made my job even more challenging. I started using a low-dose estrogen patch (Climara) and progestogen (Prometrium) tablets, as recommended by my gynecologist. She was extremely informative and walked through the information and statistical data on hormone therapy with me. Both are bioidentical hormones, the same as the ones made naturally by the body, which makes sense to me. After a while, the dose I was taking stopped working, so we upped it a little bit, which did the trick. The results from the WHI came out after I had been taking hormones for about a year. Because of the work I do, the findings about breast cancer were not that surprising to me. I had already planned to start weaning myself off hormones at 12 months. But unfortunately, I wasn't "done" yet. My symptoms came back. In this phase, I felt more misdirected anxiety connected to the hot flashes. For instance, I'd wake up with a hot flash and worry about something totally inconsequential. Part of this could have been connected to the fact that I was under significant personal stress at the time, as both a family member and a co-worker were dying of cancer. I started on an antidepressant, which I had heard helped some women with hot flashes. This medication helped me get through a difficult six months, but the hot flashes did not subside. I'm a big believer in the mind-body connection and I meditate regularly, usually 20 to 30 minutes every morning. I also do yoga and deep-breathing exercises. But these habits had no effect on my symptoms — in fact, the hot flashes interrupted my practice. I've tried some other alternatives, including Estroven, an herbal product that contains phytoestrogens. I took the recommended dosage for a full six weeks, but it had no effect. Neither did 400 mg of vitamin E, which I took twice a day for weeks. I had intended to try acupuncture and Chinese herbs, but I was at my wit's end and instead went back on hormones because I knew it would help me. We have a lot more information on the side effects of hormones than the possible side effects of many different herbs. I feel that I am making an informed decision. My grandmother died of breast cancer when she was in her 40s. She was the inspiration for the work I do. My mother also died young, of heart disease, so I don't know whether she might have developed breast cancer. Because of my family history, and the fact that I didn't have children, I realize that I may have a higher-than-average risk of breast cancer. That plays into my decision of being cautious about using hormones. I am planning to taper off again. But if I try to quit and find that the hot flashes haven't subsided, I won't hesitate to go back on the hormones. Hormone therapy has made that big a difference in my quality of life.

Last updated:	August 13, 2007