The Wisdom of Menopause

by Christiane Northrup

  The quick answer is this: if you have reason to ask, then it probably is.

  WHAT IS HAPPENING IN YOUR BODY:

  HORMONAL CHANGES

  Menopause is officially defined as that point in time when our periods stop permanently. A woman undergoing natural menopause really has no way of knowing whether any given period is truly her last until a year has passed. As menopause approaches, cycles can become quite erratic, and it’s not uncommon for several months to go by between periods. By the age of forty some of the initial hormonal changes associated with perimenopause (peri means “around” or “near”) are well under way. Research has shown, for example, that by age forty many women have already undergone changes in bone density, and by age forty-four many have begun to experience periods that are either lighter and/or shorter in length than usual, or heavier and/or longer. About 80 percent of women begin skipping periods altogether.1 In fact, only about 10 percent of women cease menstruating altogether with no prolonged period of cycle irregularity beforehand. In an extensive study of more than 2,700 women, most experienced a perimenopausal transition lasting between two and eight years.2

  MOTHERHOOD OVER FORTY

  Thanks to a variety of factors (including women delaying childbearing because of their careers), the number of older mothers today is skyrocketing. In the past thirty years, the number of women over forty giving birth to their first child has jumped from 1 in 600 mothers to 1 in 77 mothers. When a woman is going through menopause, her focus is turned inward, so attending to the needs of a five-year-old can be challenging when all she wants to do is go into a cave and meditate. (An excellent resource for older mothers is the book Hot Flashes, Warm Bottles: First-Time Mothers over Forty [Celestial Arts, 2001] by therapist Nancy London, herself a midlife mother.)

  On the other hand, the research of Harvard professor Ellen Langer, Ph.D., documented in her book Counterclockwise (Ballantine, 2009), reveals that older mothers actually live longer. Dr. Langer explains that this is because they are primed to act and feel young by the cues they receive in their environment, because they’re always around younger people. The flipside of this concept is also worth considering: when people expect us to act old and disabled, we do!

  Unless you’ve gone into menopause abruptly because of surgery or medical treatment, perimenopause can be thought of as the other end of a process that began when you first started your periods. That first menstrual period is usually followed by five to seven years of relatively long cycles that are often irregular and frequently anovulatory. Eventually, in the late teens or early twenties, cycle length shortens and becomes more regular as a woman reaches her prime reproductive age, which lasts for the next twenty years or so. In our forties, our cycles begin to lengthen again. Though most of us have been led to believe that twenty-eight days is the normal cycle length, research has shown that only 12.4 percent of women actually have a twenty-eight-day cycle. The vast majority have cycles that last anywhere between twenty-four and thirty-five days, and 20 percent of all women experience irregular cycles.3 Two to eight years prior to menopause, most women begin skipping ovulations. During these years, the ovarian follicles, which ripen eggs each month, undergo an accelerated rate of loss, until the supply of follicles is finally depleted. Research suggests that, in this culture at least, the acceleration in follicle loss begins around age thirty-seven or thirty-eight. Inhibin, a substance produced by the ovaries, decreases, which results in rising levels of FSH, the follicle-stimulating hormone produced by the pituitary gland. (This doesn’t mean you can’t get pregnant. For further information about fertility during this time, see my book Women’s Bodies, Women’s Wisdom, chapter 11, “Our Fertility.”)

  Contrary to the standard belief, our estrogen levels often remain relatively stable or even increase during perimenopause. They don’t wane until less than a year before the last menstrual period.4 Until menopause, the primary estrogen a woman’s body produces is estradiol. However, during perimenopause the body starts making more of a different kind of estrogen, called estrone, which is produced both in the ovaries and in body fat.

  Testosterone levels usually do not fall appreciably during perimenopause. In fact, the postmenopausal ovaries of many women (but not all) secrete more testosterone than the premenopausal ovaries.

  On the other hand, progesterone levels do begin to fall in perimenopause, often long before changes in estrogen or testosterone. As I will discuss below, this is the most significant perimenopausal issue for the majority of women.

  The prevailing message appears to be this: although reproduction is no longer the goal, there continue to be important roles for these so-called reproductive hormones—vital, health-enhancing roles that have nothing to do with making babies. Evidence for this can be seen in the fact that steroid hormone receptors are found in almost every organ of our bodies. Estrogen and androgens (like testosterone) are important, for example, in maintaining strong and healthy bones as well as resilient vaginal and urethral tissue. And both estrogen and progesterone are important for maintaining a healthy collagen layer in the skin.

  PERIMENOPAUSE IS A NORMAL PROCESS,

  NOT A DISEASE

  The main thing to keep in mind about perimenopause is that it’s a completely normal process, not a disease to be treated. But in order for her body to continue producing levels of hormones adequate to support health, a woman must be optimally healthy going in—physically, emotionally, spiritually, and situationally. In other words, her future well-being depends not only on the health of her physical body, but also on her nonphysical support system, both of which are a reflection of how she cares for herself today and how she has lived up to this point. Because perimenopause occurs at the midpoint of our lives, it is a very good time to take stock and make sure that we are doing everything possible to restore or build our health.

  Despite all the media focus on supplemental hormones—which ones to take, what dose, natural versus synthetic, and so on—it is important to bear in mind this often-forgotten fact: a woman’s body begins life fully equipped to produce all the hormones she needs throughout life. All of the so-called sex hormones (estrogen, progesterone, and the androgens) are manufactured from the same ubiquitous precursor molecule—cholesterol. In addition, our bodies also have the ability to convert one type of sex hormone into another. So, for example, estrogen can be converted into testosterone, and progesterone can be converted into estrogen. Whether or not these conversions actually take place depends upon our body’s minute-to-minute needs, our emotional state, our nutritional state, and so on.

  What all this means is that not every woman will need or want hormone supplementation. In many cultures hormone supplements are infrequently prescribed, yet women in those cultures rarely have uncomfortable perimenopausal symptoms. How can this be?

  First of all, the ovaries only slow down; they do not shut down. Moreover, a woman’s body is designed to produce estrogen, progesterone, and testosterone at other sites besides the ovaries, and it is ready and willing to increase or mediate the output from those auxiliary sites when the need arises at midlife. Research has shown, for example, that estrogen, progesterone, and androgen are produced in body fat, skin, the brain, the adrenal glands, and even peripheral nerves! But whether or not adequate production occurs depends on what else is going on in a woman’s life.

  If, for example, a woman is under significant stress—if she is overworked, if her diet fails to meet her body’s needs, if she is physically ill, if she smokes and/or drinks, if she is avoiding spiritual issues that are beckoning her, or if she is involved in relationships in which the energy outflow is not matched by the energy coming back—then she may find that her ability to keep up with the demands on her endocrine system is diminished. It will remain so unless and until she is able to implement some changes in those areas of her life that need work. The result may be a tumultuous midlife transition, fraught with her own individual combination of symptoms—from headaches, hot flashes, bloating, and fading libid
o to mood swings and sleep disturbances.

  Given the nature of our current culture, with its ever-accelerating pace of life, about 75 percent of perimenopausal women have symptoms of menopause that are uncomfortable enough to cause them to seek relief, whether through supplemental hormones, dietary change, exercise, or alternative therapies. If a woman finds that she needs supplemental hormones in order to reestablish a physical and emotional comfort zone, this should not be seen as a personal failure. Rather, it is a wake-up call and an opportunity to implement much-needed change. A woman in this situation might want to consider accepting what I like to call a dusting of supplemental hormones—just enough to provide her with the support she needs for comfort and health, and no more. At the same time she would also be wise to pay attention to the messages her body is sending. It is asking for more than just a prescription or a supplement.

  FIGURE 7: HORMONE-PRODUCING BODY SITES

  The healthy body is equipped to produce all the hormones a woman needs throughout her life. This natural ability can be supported or thwarted, depending on lifestyle patterns and the state of a woman’s health—physically, emotionally, spiritually, and situationally.

  The bottom line is this: before you take something to relieve menopausal symptoms, acknowledge and listen to your body’s inner wisdom in creating those outward symptoms. They are uniquely yours. How your hormones behave during perimenopause and how your body and mind respond to hormonal changes is as personalized as your fingerprints.

  THE THREE TYPES OF MENOPAUSE

  Imagine that you are standing at the foot of a beautiful mountain. You can see the light shining from behind the peak, and you’re eager to enjoy the view from the top. There are three ways to get there: you can take the gradually sloping, winding path, which may require you to climb over a few rocks now and then. You can take the short path up, which is much more difficult and will require more equipment and technical support. Or you can skip the climb altogether and have someone else take you up via helicopter—which sounds easy until you realize that your muscles and organs will not have had the time or the conditioning to cope with the cold and lack of oxygen at the summit.

  ~ NATURAL MENOPAUSE (the sloping, winding path) occurs gradually, usually between ages forty-five and fifty-five, in a woman who has at least one of her ovaries. Duration, in most cases, is five to ten years, though the entire process sometimes takes up to thirteen years. During this time, periods may stop for several months and then return, and they may increase or decrease in duration, intensity, and flow. All other things being equal, women who are going through a natural menopause may or may not need any treatment for the sake of physical comfort, because their overall health may be strong enough, and their transition may be occurring gradually enough, for their bodies to keep up with the changing demands. It will depend, in other words, on what else is going on in their bodies and in their lives.

  ~ PREMATURE MENOPAUSE (the short path) occurs somewhat faster as well as earlier, in women in their thirties or early forties who have at least one ovary. Approximately one in a hundred women completes the menopausal transition by age forty or younger. She may have an illness (such as an autoimmune disease or nutritional deficiency) or some chronic stress (including excessive athletic conditioning) that has adversely affected hormonerelated reproductive functions. Duration usually is shorter than natural menopause, one to three years. Because the transition is quicker, and because the early change is often linked to a preexisting physical condition, there is a strong likelihood a woman undergoing premature menopause will need supplemental hormones during the adjustment.5

  ~ ARTIFICIAL MENOPAUSE (the helicopter ride) can occur quite abruptly, induced by surgical removal or disruption of the reproductive tract (including removal of ovaries or surgical disruption of the blood supply to the ovaries), by radiation or chemotherapy, or by administration of certain drugs that induce or mimic menopause for medical reasons (such as to shrink uterine fibroids).

  Even tubal ligation has been shown to lower progesterone levels for at least a year following the procedure.6 (The newest tubal occlusion procedure, Essure, is not likely to have this effect because it doesn’t alter ovarian blood supply.) And many women who undergo hysterectomy with preservation of their ovaries experience symptoms of hormonal change—in addition, of course, to the loss of their periods.

  Current estimates are that approximately one in every four American women will enter an abrupt, artificial menopause. Because there’s no opportunity for gradual adjustment to the hormonal drop-off, the symptoms of artificial menopause can be severe and debilitating. Almost invariably, supplemental hormone therapy is elected in order to alleviate physical discomfort.

  PATTI: Artificial Menopause

  Six weeks after vague symptoms (night sweats, weight loss, and a persistent rash in her bikini area) had been misdiagnosed at an urgent-care center as “perimenopause and stress,” Patti, a forty-one-year-old single mother and owner of a small business, was diagnosed with Hodgkin’s disease, a type of lymphoma. Two six-week courses of chemotherapy left her feeling temporarily exhausted and without her curly blond hair … but cured. The one side effect that turned out not to be temporary was the loss of her periods.

  She wrote, “A couple of weeks after the chemo was over, when I began to get some of my energy back, I started having night sweats again. This scared me, because I thought it was the cancer coming back, and I thought my mood swings were just due to the constant worry.” Her internist ran hormone tests and confirmed that Patti had undergone menopause, and she prescribed the appropriate hormone replacement therapy in the form of a skin patch, which gave Patti’s body gentle doses of hormone slowly, throughout the day and night. “I felt much better within just a few days, and I think in my condition—after all I’d been through—it really helped me recover quicker, because my body was pretty traumatized and my mind was frazzled.”

  PERIMENOPAUSE AND HORMONAL LEVELS

  The conventional view of what happens at perimenopause is that estrogen levels plummet. This is a gross oversimplification and too often leads to treatment that can make mildly uncomfortable symptoms worse. In natural menopause, the first hormonal change that occurs is a gradual decline in levels of progesterone, while estrogen levels remain within the normal range or even increase. Because progesterone and estrogen are meant to counterbalance each other throughout the menstrual cycle, with one falling while the other rises and vice versa, an overall decline in progesterone allows estrogen levels to go unopposed—that is, without the usual counterbalance. The result is a relative excess of estrogen, a condition that is often called estrogen dominance—which is precisely the opposite of the conventional view.

  If a woman begins to experience uncomfortable symptoms at this stage, it’s because her body can sense—and attempts to adjust to—that relative estrogen excess. Estrogen excess is also exacerbated by high insulin and stress hormones. Unfortunately, however, there’s a great deal of overlap in the symptoms of various hormone imbalances, and it’s not uncommon for a woman experiencing symptoms of estrogen or stress hormone excess to be given a prescription for more estrogen or even antidepressants. Not surprisingly, her mild symptoms can worsen as a result.

  As the transition goes on, progesterone continues to decline, and eventually estrogen levels may begin to swing widely. The estrogen highs occur because the ovaries have begun to allow entire groups of follicles to grow and mature during successive menstrual cycles, instead of only one at a time, as though attempting to hurriedly “spend” those remaining eggs. (This is the reason why the incidence of twin pregnancies increases with age.) The progesterone decline occurs because fewer and fewer of those maturing eggs actually complete the entire ovulation process.

  Levels of the hormones FSH and LH, which the pituitary gland in the brain normally releases in precisely metered amounts to stimulate controlled follicular growth and ovulation, become erratic as our ovaries start to skip ovulations. Closer to menopause, hormona
l levels start to stabilize. FSH and LH levels smooth out and climb to their new, higher cruising altitude, where they stay for the rest of our lives.

  SYMPTOMS OF DECREASED PROGESTERONE

  AND ESTROGEN DOMINANCE

  ~ Decreased sex drive

  ~ Irregular or otherwise abnormal periods (most often, excessive vaginal bleeding)

  ~ Bloating (water retention)

  ~ Breast swelling and tenderness

  ~ Mood swings (most often irritability and depression)

  ~ Weight gain (particularly around the abdomen and hips)

  ~ Cold hands and feet

  ~ Headaches, especially premenstrually

  IS THERE A TEST I CAN TAKE?

  For years the diagnosis of menopause was simply based on your age and symptoms. Now it’s becoming more mainstream to use laboratory confirmation of your hormone levels. Here’s why: First, as illustrated by the story of Patti, there are illnesses that mimic perimenopause rather convincingly. (Hypothyroidism is another example; see MENOPAUSE AND THYROID FUNCTION.) By having your entrance into the climacteric confirmed, you’ll simultaneously be ruling out an unexpected medical problem. Second, by determining your levels of the relevant hormones—estrogen, progesterone, and testosterone, and possibly DHEA and thyroid hormone as well—you and your health care provider can better determine where you stand in the perimenopausal timeline and what approach to take to your symptoms, if any. One caveat about hormone testing: menopausal symptoms do not necessarily correlate well with hormone levels. For example, many women with low testosterone levels have normal libido. And some women with normal testosterone levels have low libido. Bottom line: I think it’s useful to get your hormone levels tested. But it’s far more useful to tune in to how you’re feeling than to focus on a lab test, which gives, after all, just a single snapshot of an ever-changing process.