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  •   What is Perimenopause?

    Dr. Mary J. Minkin
    Dr. Mary J. Minkin is a big fan of estrogen for her patients. (Doug Healey for The Washington Post)
    By Sandra G. Boodman
    Tuesday, March 17, 1998; Page Z12

    Pat Reilly was sitting in her doctor's waiting room leafing through a women's magazine when she experienced a frisson of recognition. There, in an article on women's health, was an explanation for some of the problems Reilly, then 45, had been experiencing.

    "Since I turned 40 my migraines had gotten a lot worse, and I thought it was because my kids were teenagers," recalled Reilly. She had also been coping with unpredictable menstrual periods and volatile mood swings.

    "But when I read that article, I realized I was in perimenopause," said Reilly, referring to the largely ignored years during a women's forties, when the gradual process leading to menopause begins.

    While menopause is widely believed to be a time of physical and psychological upheaval marked by hot flashes, insomnia, unpredictable bleeding and mood swings, these problems are actually the province of perimenopause, the years before menstruation stops, during which production of the female hormone estrogen begins its steady decline. Perimenopause has become the object of increased scientific interest as well as the reason for an increase in visits to doctors by women in their forties seeking reassurance or relief from their symptoms.

    "Women come in with a whole bunch of concerns at this time of life," said Kirtly Parker Jones, chief of reproductive endocrinology at the University of Utah School of Medicine.

    At the suggestion of her obstetrician-gynecologist, who thought she might need more estrogen, Reilly began taking low-dose birth control pills to regulate her menstrual periods. When her migraines didn't seem to improve, her doctor prescribed an estrogen patch.

    "I feel good on it," said Reilly, 48, who also takes medication to control her high blood pressure and a new anti-migraine drug once her headaches start. Reilly said that since she started taking estrogen, the headaches from which she has suffered for more than 20 years seem to have dissipated. "I just have a better outlook, and I'm much happier and nicer to be around. I've found the right thing for me."

    So, it seems, have a growing number of her peers, women in the first wave of the enormous baby boom generation born between 1946 and 1964 who are now reaching perimenopause and menopause. The first of the 38 million female boomers are now turning 52, one year older than the average age of menopause, which is defined as one year without a period. By the year 2000, 19 million women will be between the ages of 45 and 55.

    As they have before, the baby boomers, the largest generation in American history, are focusing new attention on a phase of life that, until now, has received little notice.

    In the past few years, permimenopause has become the subject of a spate of new books, including one, to be published in May, that is touted as "a wake-up call for the confusing years before menopause [that] can start as early as 35 . . . and require special emotional, dietary and health guidance." Medical conferences are being held on perimenopause, and a plethora of new products, mostly drugs, is being aggressively marketed to women seeking to alleviate the more troublesome or inconvenient symptoms associated with perimenopause and aging. In addition to hot flashes, the most common symptoms include night sweats, insomnia, memory disturbances, menstrual irregularity, depression, weight gain, plummeting sex drive and vaginal dryness.

    "This is a huge market," said Susan M. Love, a Los Angeles breast cancer surgeon who just turned 50 and is the author of one of the new books about perimenopause and menopause published last year. "As usual, as the boomers move through an age, we analyze it and write about it and redefine it."

    Like Reilly, growing numbers of perimenopausal woman, at the behest of their physicians, are turning to hormones earlier. A decade ago obstetrician-gynecologists rarely prescribed estrogen to women before menopause. Now some are telling their patients that taking estrogen earlier, in their late thirties and forties, may alleviate troublesome symptoms and also protect their bones from osteoporosis and their hearts from coronary artery disease.

    "There's definitely a new push" to use estrogen more liberally, said Mary Jane Minkin, a clinical professor at the Yale University School of Medicine and the author of a 1996 guide to menopause and perimenopause. "One of the reasons for doing this is that if you wait until menopause you've got a lot of ladies" who have been suffering unnecessarily with insomnia or other treatable problems.

    The message has not been lost on drug companies, which in the past year have introduced three new low-dose birth control pills that are now being used to stabilize irregular midlife menstrual periods and to treat other perimenopausal problems.

    More recently Evista, the first of the new so-called "designer estrogens," was introduced. These drugs, known as selective estrogen receptor modulators, are being marketed as alternatives to Premarin, the best-selling drug in the United States and the leading form of estrogen. This new class of drugs, which is not intended for perimenopausal women, is supposed to offer the bone-building and cardiac-enhancing benefits of estrogen, without the risk of breast and uterine cancer associated with estrogen.

    "Feel Good" Medicine

    Some health experts worry that doctors, and their fortysomething patients, are too willing to medicalize permimenopause, a natural transition that most studies have shown causes the majority of women little, or only temporary, discomfort.

    "I think a lot of this is playing on women's fears that heart attack and hip fracture are just around the corner and that you can't possibly live a healthy life or make it to old age without drugs," said Mary Ann Napoli, director of the New York-based Center for Medical Consumers, a patient advocacy group. "There's a lot of disease-mongering out there."

    "Every woman in the world goes through this, and the vast majority of women put up with the variability of function," Utah's Kirtly Parker Jones said.

    "It's not that we've invented a new disease, or that baby boomers are sicker," added Jones, who is 47. "It's that we want to control more, we want to know more. We have more lifestyle concerns. And I think a lot of women and their doctors choose to treat these problems medically."

    Cindy Pearson, executive director of the National Women's Health Network, a Washington-based public interest group, is concerned that many perimenopausal women are routinely being treated with hormones for problems that may not require them.

    "It's really experimental to offer hormones while women are starting to change," said Pearson, 48. "There's a lot of medical intervention going on and virtually no data [to support it]. We don't even know what's normal during perimenopause because it's never been studied."

    The paucity of data about perimenopause has helped fuel this medicalization, agreed Sherry S. Sherman, director of clinical endocrinology and osteoporosis research at the National Institute on Aging. "There's an awful lot we just don't know," said Sherman, project officer for a large observational study of women in their forties and fifties called the Study of Women's Health Across the Nation (SWAN). The study will examine medical, psychological, cultural and lifestyle factors and will involve substantial numbers of African American women as well as Hispanics and Asian Americans. In the past minorities have been underrepresented in such studies.

    "There is a lot of 'feel good' medicine going on," Sherman added. Much of it is predicated on the notion "that if you take estrogen you'll feel better. Estrogen is a very safe drug, but all drugs have side effects."

    No one knows what will happen to women who begin taking estrogen earlier, in their forties, but some studies have shown that long-term use of the hormone raises the risk of breast and uterine cancer.

    A Harvard study published last year in the New England Journal of Medicine found that taking hormone therapy after menopause reduced a woman's risk of death for about 10 years. After that the benefit of hormone therapy was sharply curtailed because of the rising risk of breast cancer. The researchers also found that the benefit from taking hormones depends largely on an individual woman's risk of heart disease and osteoporosis and vary over time.

    Vague Definition

    Despite the burgeoning interest in perimenopause, there isn't even a consensus about how to define it, Sherman notes. No one knows whether it starts two years before menopause or eight years or, as some of the new books and articles on the subject contend, 15 years earlier, at about age 35.

    "Perimenopause is a very loosely termed word," said Sherman. She hopes the SWAN study, which has enrolled 3,200 women between the ages of 42 and 52 at seven academic medical centers, will answer some basic questions about midlife and will help researchers distinguish between the effects of perimenopause and those of aging.

    Consider weight gain, one of the biggest concerns of women during perimenopause. In fact, basal metabolic rate does slow in middle age, and people need fewer calories to maintain their weight as they age.

    But is the weight many women gain after 40 due to hormonal fluctuations or to increased caloric intake and decreased activity?

    Many scientists, Sherman included, are skeptical that weight gain is a direct result of perimenopause. For one thing, men experience a similar weight gain. A government study of male runners published last year found that during their twenties, thirties and forties, even dedicated runners who logged more than 40 miles per week gained weight and suffered the indignity of expanded waistlines.

    One of the key questions the SWAN study, which should provide some preliminary data in the next year, may help answer is why these transitional years are so difficult for some women but not others.

    For decades what little researchers knew about perimenopause and menopause was largely based on data from women who underwent abrupt, rather than gradual, hormonal changes usually as the result of a total hysterectomy. That inevitably colored any discussion of perimenopause and menopause because, as Susan Love notes, these women tend to have more severe symptoms and are at greater risk of future osteoporosis and heart problems.

    Studies based on women who sought treatment for perimenopausal and menopausal problems may be similarly skewed, notes Utah's Jones. "Lots of studies have shown that women who show up in doctors' offices are more anxious, more depressed and have more mental illness" than women who do not seek treatment," she said.

    Unlike puberty, which has well-defined physiological hallmarks, there is no test to determine whether a woman is in perimenopause, because levels of hormones, including estrogen, fluctuate from month to month.

    "There's a lot of mythology to blood tests" of hormone levels, said Yale's Minkin. "I've had people who've been up all night sweating their brains out and their blood tests are totally normal."

    Determining whether a woman's emotional state is a result of perimenopause is even more problematic. Although mood swings, unpredictable rages and depression are commonly thought to be symptoms of perimenopause, they may just as easily reflect other factors: dealing with aging parents and adolescent children, anxieties about aging, problems at work, a rocky marriage or sorrow at the end of fertility.

    "It can be very hard to sort this out," said Minkin. "I've seen women who've been on antidepressants for five years who needed estrogen, and once they got it they improved. But it's stupid for me to treat a depressed woman with estrogen when what she really needs is Prozac, which I can also give her."

    Personal Choice

    Minkin tries to determine whether hormones are needed by taking a careful history.

    "You've got to look at how symptomatic patients are," said Minkin. "I don't push it" for patients who are reluctant to take hormones or worried about increasing their risk of breast cancer. Minkin said she also emphasizes the importance of proper diet and exercise.

    "I'm a very unfancy person," she added. "I give 'em a little estrogen and say, 'Let's see how you do.' "

    One patient Minkin recently treated, a 46-year-old nurse, began taking estrogen because she was worried that her memory problems were jeopardizing her job. Minkin said the woman told her she was having such difficulty that she couldn't remember her best friend's telephone number.

    "If she does well after a month, I'll probably keep her on it," Minkin said.

    Joan Hickey, 55, has been taking estrogen since she was 46. She said she began taking it for a constellation of problems: her memory was faulty, her sex drive had plummeted, and she was anxious and depressed and not sleeping.

    Last summer Hickey, a consultant to Wesleyan University in Middletown, Ct., said she stopped taking estrogen for three months to see what would happen.

    "All my symptoms came right back," said Hickey, who adds that she takes extra estrogen if she feels she needs a physical boost, as she did recently when she spent a week skiing in Vermont. "I'm sure I'll be taking this for the rest of my life."

    Hickey said she's not worried about developing breast cancer. "My mother, who died at 83, had been taking estrogen since she was 45 and never developed it. On the other hand, my sister-in-law, who's 40, has just been diagnosed with breast cancer, and she's never been on estrogen."

    Kirtly Parker Jones estimates that about half the patients who consult her about perimenopausal problems mostly need reassurance that what they are experiencing is normal. Some decide to take low-dose birth control pills to treat unpredictable bleeding, which Jones characterizes not as a medical problem but as a lifestyle problem.

    "I've always been pro-choice," she said. "I don't push estrogen."

    Puberty in Reverse

    One of the largest studies of healthy women to date suggests that perimenopause and menopause may not be a dreaded event in the lives of most women.

    Beginning in 1982, Sonja McKinlay of the New England Research Institute in Watertown, Mass., periodically surveyed more than 2,500 healthy Massachusetts women, the youngest of whom was 46 when the study began. McKinlay found that the "vast majority" of women said they did not regret reaching menopause, nor did they report more health problems or increased use of medical services.

    That was not true for a small group of women in her study, McKinlay found. Those women reported significant medical and psychological symptoms.

    "Right now there is no way to distinguish which women will have trouble from those who won't," said Love. She advises women to remember that most symptoms, such as hot flashes, are transitory and can be treated with diet and exercise.

    "I tell people, 'Remember when you were pregnant? Remember how you felt when you were a teenager?' That didn't last forever and this won't either," Love said. "In a lot of ways perimenopause is like puberty in reverse. What's really most irritating about it is its unpredictability."

    © Copyright 1998 The Washington Post Company

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