E9: 7 Domains of Menopause

All Women Who Live Long Enough Will Experience Menopause

My retirement was a slow, steady decline. Kind of like what menopause is, is a phased retirement. It's a slow retirement from your reproductive life. Phased retirement. That's what menopause is. Your Phase 1 is all about sex and babies and partnering or not partnering and being social. Then when it's over, phased reproductive retirement, that's menopause. You kind of slip into not being fertile and having more irregular periods. Then it's over. But it's really not over.

All women who live long enough will experience menopause, the last period and the decline of hormones made by the ovaries. It happens at about 50 for most women, and it isn't usually an all of a sudden kind of thing. Unless the ovaries are removed surgically, the usual course is for periods to become a little irregular, then more irregular, and then stop over several years.

End of "Menses" ... End of Menstrual Bleeding

We talk a lot about bleeding in the "7 Domains of Health." It is bleeding too much or too little that brings us to care. It is menstrual blood that's a taboo, even just a little one when we talk about feminine hygiene products. It's bleeding to death that's the number one cause of maternal mortality around the world, and bleeding defines our reproductive life. And when it stops, it defines menopause. That's what the word means. End of menses, end of menstrual bleeding, the end of fertility, the end of child-bearing. Only your own heart beats.

In many cultures where menstrual blood is a bigger taboo, women might only assume a position of power in their community after their bleeding time is over.

There's a mistaken sense by some that women who are cycling having periods cannot be trusted with power as they're too emotional, but I'd say I've seen lots of guys get emotional, so it's not just a girl thing.

In our own culture and in the U.S., it's hard to know, because we're a multi-cultural society, what culture we are talking about. But women often fear menopause because it's a reflection of aging, and aging women are not always seen as attractive to the opposite sex. That usually means men, because attraction for men is often linked with potential fertility. Even if it isn't recognized as the focus of sex, but that's the underlying urge, is to make babies. So, menopausal women who look older don't look fertile, and women spend a lot of time and money and makeup and surgery and stuff to make themselves look younger.

Physical Symptoms of Menopause

So, why do only women orcas and pilot whales have females that live so long after their reproductive lives are over? The animals with whom we share 95% of our DNA, and that's gorillas and chimpanzees, do not have a long time after their menopause.

Some of the things that human women have in common with orcas and pilot whales is that females run the family pod and the species has language. Orcas have language. The females live a long time, and that helps their children have more children. The moms can teach.

Kristen Hawkes at the University of Utah has proposed the Grandmother Hypothesis: that humans developed genetic differences from chimpanzees that had allowed them to live long after their menopause because they had language and mothers help their daughters become more successful mothers.

But menopause is the end of ovulation and predictable ovarian function, and the ovary still makes hormones, but just in smaller amounts. For some women, the abrupt cessation of ovarian function is associated with immediate symptoms like hot flushes and longer-term symptoms like vaginal dryness and urinary symptoms. These can vary significantly and affect the quality of life for women.

But women at menopause also complain of stiff and painful joints, like osteoarthritis, but these symptoms often get better with estrogen replacement, suggesting that these symptoms arise from lack of estrogen.

So, while not all women experience some or any of these symptoms, they are troublesome. And then there's the sense that the brain isn't working as well as it did. Women, they have great brains. They remember stuff. They remember people. They remember names. They remember where they're supposed to be. They're multitaskers. And when that isn't working, we notice.

And for some women, their brain is more irritable. Lights are too bright. Sounds are too loud. Things set them off. All of this can be associated with hot flushes or with the sleeplessness that comes with hot flushes.

How Hormones Affect the Brain and How the Brain Affects Hormones

The ovary continues to make hormones in smaller and smaller amounts and not very predictably. Many women have a few symptoms, but some women experience hot flushes and difficulty sleeping and concentrating. And making sure that the brain works well was one of the top concerns of women coming to our Midlife Women's Clinic.

Today, in The Scope Studio, we're joined by Dr. Sarah Berga, and she has a special expertise in neuroendocrinology, how hormones affect the brain and how the brain affects hormones. 

 

Dr. Jones: Thanks for joining us, Dr. Berga.

Dr. Berga: It's a great pleasure to be here, Kirtly.

Dr. Jones: So, what happens to the brain when it doesn't get estrogens anymore?

Dr. Berga: We've been studying that for quite a while. And one of the things is the neurons start to pull apart and start to shrivel.

Dr. Jones: Oh, no.

Dr. Berga: Yeah. And the disconnection actually means the brain works slower. You don't really see people losing their intelligence as much as they speak more slowly, they process information more slowly, and they do sometimes forget where their keys are.

Dr. Jones: Oh, that doesn't sound very good. So, menopause happens midlife around 50 when already our brain is aging some. Many women are fearful about taking estrogen after menopause. They've heard all kinds of things. Can you help reassure me now that my brain is falling apart? Reassure me that it's going to be okay if it's not too late.

Dr. Berga: So, the Women's Health Initiative really did put some scare out there for estrogens, and it's true that we need to use them judiciously and how they're used really does matter. So, you want to get the right kind at the right time and the right dose, and that is actually something we can do now.

We can measure estradiol, the estrogen made by our ovaries. We can know if we're giving too much or too little, and we can also see using neuroimaging the effects of giving back the right amount of estradiol. So, now we're pretty informed and we can do this in a wiser way than we could before.

Dr. Jones: Part of the issue is not waiting forever.

Dr. Berga: Correct.

Dr. Jones: And part of the issue is getting the right dose of the right product. How do you know?

Dr. Berga: The best estrogen for us as humans is estradiol, and it needs to be in what we call a physiologic range. So, it needs to be above 40 and probably below 100 picogram per ml, and that safe range seems to be safe for most everybody. In fact, if we use estradiol transdermally, there are studies showing that it actually reduces the risk of stroke and blood clots. So, it is a matter of titration and using it wisely.

When people take products and they don't know what levels they're achieving or they don't even know what kind of estrogen they're getting, then it's a little hard to be reassuring.

Dr. Jones: Now, the next question, of course, for me is if women have a uterus and they're taking estrogen, they need to take a progestin, a different hormone, to help protect the uterus against building up too much of the estrogen. And progestins, we know, have effects on the brain, too. What do we know about that?

Dr. Berga: So, progestins aren't so happy for the brain. High doses of progestins actually make the brain a little sad and a little blue and a little darker in some ways. So, we want to give the least necessary to protect the uterus, and we have some clever ways to do that.

One is the progestin-bearing IUDs, and they might be the right answer for many people, particularly people that are going through the transition. So, they still might need birth control, but they might be sort of perimenopausal and having symptoms intermittently. We can give them the Mirena or some equivalent for the uterine protection and for birth control, but also add some estradiol on top of that, and then they can just smooth away menopause.

Dr. Jones: Oh, that's what we want. We just want a smooth menopause, particularly for the 50- to 65-year-old who's the woman who's having the most symptoms, who's got the most to lose by not having the brain that she wants, I think.

Dr. Berga: Right. So, there was a study done in Utah using Utah women looking at hormones and showing indeed that if you took hormones for about 10 years after menopause, you ended up deferring or delaying or not developing dementia, all-cause dementia.

Dr. Jones: Right. That was the Cash County study. So, Cash County has a lot of people who live well. They work hard, and they live long, and they don't move from that beautiful place up in the mountains. So, they're a perfect group of people to study and they don't drink and they don't smoke very much.

Thanks, Dr. Berga.

Dr. Berga: My pleasure.

Women DO NOT Go Crazy at Menopause

Dr. Jones: Now, when I think about what the literature says about midlife, it suggests, and Freud was the worst one about this, that women have involutional melancholia, meaning when their ovaries quit working, they get sad. So, let's debunk the myth that women at menopause go crazy, because, in fact, they don't.

That's an unfortunate thing that was prompted by Freud, who said that women suffer involutional melancholia as the ovary involutes meaning becomes menopausal, women go crazy, because, in fact, women don't.

For many women, it's actually a time of great emotional stability. Women are at their most depressed and anxious in their 30s and 40s. And that's not counting teens, because teens are having their own issues. But we're talking about women-women, not teen-women.

There's a time before menopause when the ovaries have stopped working, where hormones are on and off and on and off, the perimenopause. And that's a time for women who have been vulnerable to hormones going up and down. These are women who've had post-partum depression and they're women who've had PMS, that they might be more irritable, they might be more anxious, and they might be more depressed. But once menopause has happened, most women are not more depressed.

So, late 50s and 60s women are often in the happiest time of their life, although there are good studies that show that women are more likely to experience grieving during this time because, as you can imagine, their parents and their friends are starting to die. But they don't get depressed and they don't necessarily get anxious just because of menopause. I think that's a myth that's way past time to getting debunked.

Now, I would say that women who are having a lot of hot flushes can be irritable or cranky. So, the irritable and cranky brain, which we talked a little bit about when we talked to Dr. Berga can be associated with hot flushes themselves or the sleeplessness, because you all know that when you haven't slept for night after night, you get irritable and cranky.

So, whether it's the effect of hormone withdrawal on the brain, like a drug, like narcotics withdrawal or other withdrawal that people experience that the brain really likes, withdrawal of that hormone can make the brain irritable, or whether it's related to sleeplessness is a complicated question. But it doesn't make women crazy and it doesn't make women depressed. And if they're irritable, this thing that they're getting cranky about is probably worth getting cranky about.

But if the kids are tucked in and the partner is okay or gone, that's the time women can listen to their own heartbeat.

Women After Menopause Are Powerful

Now, I may remember this misappropriately, however, Isak Dinesen was a famous writer and she was most famous for her book "Out of Africa," but she had a quote that went something like this: "Women when they are old enough to be done with the business of being women and can lose their strength must be the most powerful creatures in the world."

So, for me, I think that's the scope about women. Women get power after menopause. Women get power after midlife. Women get power after they stop being obsessed with how they look and whether they're sexy or not and having babies and raising their children. It's appropriate to be focused on that at the appropriate time of life, but when that's over and they can let loose their strength, must be the most powerful creatures in the world.

So, thinking about the social domain . . . we talked a little bit about evolutionary domains and different societies and how menopausal women actually come into their own after they stop bleeding and having kids, but who runs the family reunions and who runs the PTAs and who runs the church groups and who runs all the small non-profits? It's usually post-menopausal women. They're the ones who get stuff done.

So, post-menopausal women are really important for your family, your neighborhood, your society, your town. And I'm saying the country. So, let's think about post-menopausal women as members of Congress or members of the Senate or in the White House. And they don't have to be post-menopausal. They could be pre-menopausal, too.

Financial Health After Menopause

Let's talk about stuff my mom never told me. I'd say my mom wasn't particularly great on finances. In fact, she used to borrow from my babysitting money at the end of the month because she didn't have enough in her food allowance from my dad. So, I think she really didn't have a sense of where the money was, where the money wasn't, because my dad took care of that and gave her a monthly food allowance, which back in the late '50s and early '60s, that's actually the way a lot of times things went in this country. So, my mom never told me about how to run my finances.

Now, having said that, when my mom died, I found that she had her finances in perfect order. So, somewhere between the time that I left home and the time that she died, she became very smart about money. She knew exactly where to put it and she knew where it was and she knew where it wasn't and she knew where to protect some for herself and she knew where to protect some for kids.

So, becoming smart about money in midlife becomes really important. Financial health is something that many women in their midlife start thinking about, and it's not the ovaries that are making you think about it now. In fact, more life is behind you than ahead of you, and your parents are dying, unfortunately, and friends. And so, you start thinking about growing older and what you have to support you. A lot of women know where the money is or isn't and know what they need to do to secure their financial future. But around the country, more women don't know about their finances than do.

So, for many women, they have put all their savings into their family, all their money into their family and their kids' education. But this is the time to turn the kids loose, make them do it on their own so that you can secure your own future. Unless you want to be dependent on these kids, this is the time to let them start paying for themselves and you need to start saving for your own future.

If you aren't the person in your household who knows where all the money is and how much is spent and how much is owed, it's time to know that. Sit down with your partner if you live with someone and make sure that you have an honest discussion about what you have and what you don't have and what you owe.

Now, many couples don't talk about money, and money is the most common source of marital discord, but now is the time to figure out what there is and what there isn't.

You can get help with this. There are a number of organizations that can help you if you don't have your own financial advisor. Even your own local United Way can put you in touch with free financial advisors that can help you think about your future. Do you have any social security? How much do you have? Do you really know how to live on a budget? Do you know how much Medicare is going to cost? And although you're not there yet, for ladies in this menopausal transition, you're going to be there soon and you've got maybe 15 years to get things tucked in. So, get it tucked in.

Environmental Stressors Linked to Earlier Menopause

I haven't talked much about environmental health because it's really hard for me to link up environmental health with midlife except to say there's some suggestion that pollutions in the environment may cause egg quality decline and may be associated with less fertility later in your reproductive life. And we know that cigarette smoking is associated with earlier menopause.

So, as air quality gets worse and worse, it will not be a surprise to me, if air quality has the same inflammation effects as cigarette smoking on the lungs, that it may have the same effect on the ovaries, which means that we'll have earlier menopause. It's time for us to stand up and stand out and be heard about what we can do about cleaning up our environment, in particular air quality in the home and in your neighborhood and in your city and on the planet.

Listen to Your Own Heartbeat

Well, finally, but not at all last, it's time to listen to your own heartbeat and find out where you're most connected to something bigger than yourself.

I think women at midlife and menopause finally have the time to think about their own spirituality. Menopause often opens a window to women creatively and spiritually. Raising a family, raising a business can significantly suck the creativity out of you and be diverted appropriately to very important stuff, like kids and businesses and work. But now, it's your time to listen to your own heartbeat. It's time to connect with something bigger than yourself. It's time to become wise.

And most people, to become wise, you have to have lived a little before you can get the 30,000-foot view, unless, of course, you're the Dalai Lama and you've already had many, many previous lives. But for most of us who haven't had many previous lives, this is the only life we've got and this is the only life we know. And you have to live some before you can become wise.

Part of that wisdom is coming to a sense of what matters matter, and that becomes important when you think about your own spirituality.

This is Midlife. This is Menopause

Well, I want to talk about brains. We talked about brains with Dr. Berga, but my midlife brain and my friend's midlife brains, we always sit around and say, "Oh, gosh, my brain isn't what it used to be," or, "Oh, gosh, I forgot where I put my keys."

Women are acutely aware of what they can't do anymore. Usually, it's finding names and proper nouns and nouns. Because women are so verbal, they remembered a lot more than men did, and this is a fact that you can actually show in testing, that women's verbal memories are better than men. So, when they start losing this verbal memory, they get nervous.

Women come to me and say, "I can't remember names anymore and I can't remember where my keys are. Do you think I'm getting dementia?" And I say, "No, but I want you to think about how to keep your brain healthy."

• Teach what you know how to do best. That's what we talked about what menopause is all about. What is it that you do best? And that's what language is for in our long lives. So, teaching, whether it's a recipe or if it's gardening or whatever it might be, take the opportunity to teach what you do best. Teaching requires your brain to do more than doing.
• Learn something new. I'm learning a lot of new things because I only have maybe 10 more years of a really great brain. And this is the time, if you have time, to learn some new things.
• Keep your friends close. One of the biggest predictors of a great brain, a great intellect, into aging is friendships and smiling and optimistic outlook. So, catch up with friends and family that you haven't seen for a while. Strengthen relationships that will sustain you as you get older. There are lots of women out there that you can just talk about menopause with. So, chit-chat, complain, whine, laugh about all the things that you're whining and laughing about.

The best way to protect your brain against dementia is to keep physically active, eat your fruits and veggies, keep your blood sugar and blood pressure under control, and hang out there with your friends and laugh.

So, here you are, ladies. This is your time. This is midlife. This is menopause. This is your menopause haiku.

 

Faucet of blood off
My body is my own now
Only my heart beats

 

Bad news is that menopause happens, and for some women, they don't feel so good. The good news is that there are lots of safe options for hormone therapy. Talk to your clinician about your symptoms and concerns. And if they aren't up to date on hormones and menopause, see a specialist in menopause and hormones.

You can do slow. Some people do it fast. But wherever you do it, if you live long enough, it's going to get done. So, how to deal with it, how to cope with it, how to be positive about it. I was really positive about it, so good for me. Hopefully, good for you.

And this is the 7 Domains of Menopause. Bye-bye.