Menopause & Peri-menopause

EARLY PERI-MENOPUASAL SYMPTOMS:  

- In the early peri-menopausal phase, estrogen is HIGH and progesterone is LOW (Hint! giving you bioidentical progesterone in the post-Peak phase of your cycle may make you feel much better). 

• Irregular menstrual cycles  
• Menorrhagia (heavy periods) 
• Fatigue 
• Insomnia
• Sore breasts
• Headaches (migraines) 
• Joint pain
• Irritability 
• More prone to anxiety and/or depression

LATE PERI-MENOPAUSE to POST-MENOPAUSAL SYMPTOMS: 

-Towards the end of peri-menopause and once menopause has passed (no period for one full year) estrogen is LOW and progesterone is LOW (Hint! treatment may be replacing both estrogen and progesterone using bio-identical hormone. I will also pay close attention to your bone health and recommend screening for Diabetes as well as Cardiovascular Disease). 

• Hot flushes (vasomotor symptoms) 
• Vaginal dryness
• Dyspareunia (painful sexual intercourse)
• Genitourinary changes (urogenital atrophy), such as urinary incontinence, vaginal, bladder, rectal prolapse (organs falling down). 
• Hyperinsulinemia which can contribute to weight gain especially around the mid-abdominal aeaa "belly fat" and Diabetes. 
• Bone loss often occurs due to hypoestrogenemia (low estrogen in the blood). 

The Swan Study  (Study of Women's Health Across the Nation) followed 3302 women ages 42 to 52 for fifteen years, as they progressed through their reproductive lifespan, through perimenopause (ie: "menopausal transition") and into their post-menopausal years. The research was conducted in multiple academic centers across the nation beginning in 1996, which resulted in over 600 publications and book chapters by 2021. There are several other articles currently pending approval. 

In 2012, Dr. Siobán Harlow and colleagues developed the STRAW Staging System (STaging of Reproductive Aging Workshop), using the SWAN data, which is now considered the gold standard method of characterizing the stages of the woman's reproductive years though late post-menopausal years. The STRAW Staging system categories changes in the menstrual flow, hormone levels, number of ovarian follicles and vasomotor symptoms.  

Most often an initial appt with a NaPro provider will be one FULL HOUR in length. Generally speaking, NaPro appts will follow a typical protocol. However, every individual is different and your situation may warrant a more expeditious process. Please know, the Creighton Model Charting is very important. Your CrMS chart will help direct your NaPro provider as to what diagnostic tests and imaging tests should be done and what treatment plan would be most appropriate for you, personally. For more detailed information about what a typical NaPro diagnostic evaluatin will look like, please click the button below. 

I will be asking you to tell me very specifically how much you are bleeding. An example of a "detailed flow" is: M, M, H, L, L, VL/B

TAMPON or PADS: 

• Very Heavy (VH): changing a full pad/tampon every 1-2 hours
• Heavy (H): changing a full pad/tampon every 3-4 hours 
• Moderate (M): changing a full pad/tampon every 5-7 hours
• Light (L): changing a full pad/tampon every  8-12 hours
• Very Light (VL): changing pad/tampon less than every 12 hours

MENSTRUAL CUP MEASUREMENTS

• Very Heavy (VH): 60 cc in a 24 hours
• Heavy (H): 40 cc in 24 hours
• Moderate (M): 20 cc in 24 hours
• Light (L): 10 cc in 24 hours
• Very Light (VL):  5 cc in 24 hours

**The Diva Cup comes in 20, 30 and 32 ml cups 32 being the largest but other cups may vary. 1 ml = roughly 1 cc 

Other important information about your flow: 

• Tail End Brown Bleeding (TEBB): brown bleeding at tail end of period. 
• Premenstrual bleeding: pink spotting or brown spotting at the prior to a full period starting. 
• Intermenstrual bleeding: bleeding between periods. 

***** Do not take unless under medical supervision *****

• V-Magic® Vulva Balm is an organic, hormone-free vulva moisturizer that relieves dryness and irritation.
• Revaree® by Bonafide is a hormone-free vaginal insert that helps moisturize the vaginal mucosa and decrease dryness. 
• Magnesium Glycinate can help with insomnia, migraine headaches and painful periods, but we should check your mag levels and follow them. Very high magnesium can cause heart problems and neurological problems. 
• Vitamin D3 can help with anxiety, but we should also check your levels about every 3 mos to keep them between 50-75. Vit D is a "fat soluble" vitamin. Very high levels can be toxic. Low levels can be harmful for your bones and overall general health. 
• Post-Peak (or cyclic)  bioidentical progesterone replacement can help with many symptoms, such as insomnia, irritability, anxiety and depression. If you are cycling monthly, progesterone replacement will be timed to your Creighton Model System chart to be taken at bedtme on P+3 through P+12, every month. However, if you are no longer cycling or if you are having less than three periods per year, I will have you take the progesterone from the 1st day of the month through the 10th day of month, to simulate a natural rise and fall of progesterone and to induce a "withdrawal bleed". The withdrawal bleed will protect your endometrium from thickening, a condition known as "endometrial hyperplasia". Endometrial hyperplasia can easily become a pre-cancerous or even cancerous condition of the uterus. Bioidentical progesterone can be purchased through a retail pharmacy (eg: CVS, Walgreens, Walmart, etc... it is called "micronized progesterone" as a generic, also known as "Prometrium". Pts can also purchase this via a compounded pharmacy (cash pay only). 
• Bio-identical estradiol: many providers are very open to prescribing estradiol to perimenopsusal/menopausal women. However, the practice of medicine is an art. Personally, I feel strongly that I can manage your symptoms quite well using the other remedies you see listed here. The transdermal estradiol patch is a "bioidentical" type of estrogen, which I do freely use for my Functional Hypothalamic Amenorrhea patients. However, I do not prescribe any estradiol in any form for my perimenopausal women. Estradiol replacement in perimenopausal women carries an increased risk of inducing endometrial hyperplasia, which can lead to pre-cancerous or even cancerous condition. Additionally, all estradiol carries a risk of increasing clot formation (albiet mild). Clots can form in your veins, and then migrate through your blood vessels to your heart and cause a heart attack and/or up to your brain and cause a stroke and/or to your lungs and cause a pulmonary embolism. Again, the risk is very small, but this has been consistently demonstrated over time even with low dose estradiol. 
• Phytoestrogens: according to the National Cancer Institute (NCI), a phytoestrogen is an estrogen-like substance found in some plants, but it is not estrogen, and it may actually have "anti-cancer" effects. Phytoestrogens loosely attach to estrogen receptor sites, which allows them to "stand in" for estrogen when levels are low or "block" estrogen when the levels are high. Phytoestrogen-rich foods (in order of amount): Flax seeds, soy beans, soy milk, soy yogurt and tofu; sesame and sunflower seeds; multigrain and flax breads; hummus; garlic; mung and alfalfa bean sprouts; dried apricots and dates; olive oil; almonds; green beans and blueberries. CAUTION: again, personally, I do not recommend taking soy products, due to the risk of inducing endometrial hyperplasia. 
• Flax seeds: 2 Tbs of freshly ground organic flax seeds daily can help with hot flashes. You may wish to read a study here (2012) My patients have consistently reported to me that this has been helpful. Hot flashes can be really annoying, but oftentimes they are somewhat short-lived. 
• Maca Root helps with low libido. You may wish to read some small studies here (2015) and here (2010). Personally, I don't think the studies are convincing, but I don't believe Maca Root is harmful. 
• DHEA supplementation can help with low libido. However, I use this very judiciously, and this would only be recommended if your blood levels of DHEAs or testosterone are lower than they should be. There are well-documented unwanted side effects. DHEA supplementation can also cause irritability, acne, hair growth in the male distribution and lower of your "good" cholesterol (HDL). 
• Insulin Resistance or Hyperinsulinemia (high blood insulin levels): high insulin levels can occur in perimenopausal/menopausal women, which can cause increased abdominal fat accumulation and difficulty losing weight. I do offer to check your fasting insulin levels, and it necessary do a deeper dive and check do glucose/insulin, 3 specimen testing.  Research has shown that a supplement called  myoinositol/dchiro inositol 2000/50 mg twice daily is effective in decreasing mild high insulin levels. Metformin is also very effective and will cost much less. Metformin is what I call an "oldie & goodie" medication, which has been around for a while so we know it is safe. 
• GLP-1 agonist therapy: I do offer weight loss services to women, which does include prescribing Tirzepatide (a GLP-1 agonist), for women who qualify for this medication. For more information please see my Weight Loss webpage. 
• Melatonin 10 mg is great for insomnia. Some current studies indicate this may also have healthy anti-oxidant effects. 
• Gabapentin (Neurontin) can help with insomnia, depression and/or some non-specific pain syndromes. This medication is also an "oldie & goodie". 

Again, only bioidentical hormones supplementation is offered. Bioidentical progesterone can be purchased through a retail pharmacy (eg: CVS, Walgreens, Walmart, etc... it is called "micronized progesterone" as a generic, also known as "Prometrium". This medication is generally well-tolerated. Some common side effects are quite pleasant, eg: you may feel more relaxed or sleepy and your might find your mood may improves. Some more unpleasant side effects may be: next-day fatigue, nausea, headaches, or dizziness. Most often the unpleasant side effects can be easily managed by taking the medication right before you lay your head down on the pillow and/or changing to a compounded formulation. Please know prometrium and generic progesterone capsules contain peanut oil, so you CANNOT take this if you have a peanut allergy.

Sometimes the Prometrium or generic micronized progesterone that is  purchased will include a package insert which will "warn" of possible birth defects. However, this warning refers to progesterone substitutes that are often prescribed in oral contraception pills, not the bioidentical progesterone we are prescribing.  NaPro providers, who were trained at the St. Paul VI Institute, have been safely prescribing micronized progesterone to many, many women to support pregnancies for over 35 yrs and they have not encountered problems. 

If the oral medication is not strong enough or if the side effects are bothersome, we can try a vaginal suppository. This will be prescribed for you by a specialty pharmacy called a "compounding pharmacy". You can see a list of compounding pharmacies by viewing Handout #21 here.

Sometimes we will have to use progesterone injections. I will ask you to watch this instructional video and choose someone such as your spouse or a close relative who is willing to administer the injections to you. I would also recommend injections be administered in the upper-outer quadrant of the buttocks (shown in the video) and that you alternate sides. Common side effects of the injections are: soreness, itching and/or mild bruising at the injection site, especially if the injection is done too quickly.        

***** Do not take unless under medical supervision *****

Naltrexone (off-label use):   

• Naltrexone is commonly used to help people with addictions avoid alcohol use and or opioid use.  
• This medication is an opioid-receptor antagonist (blocks opioid receptors).  
• Thus, we call this an "off-label" use of this medication, which is somewhat common to do in mainstream medicine. 
• Many NaPro patients report wonderful success using naltrexone to treat PMS. 

I do occasionally use the full 50 mg dose of naltrexone only in very severe cases. Most often I will recommend "Low-Dose Naltrexone" (LDN) for you namely b/c  there has been some discussion among the medical community that if a patient has been on full dose naltrexone for many years, this may present a conundrum if the patient needs opioid medications to control severe pain, such as after a surgery or after a significant injury has been sustained. The concern is twofold: 

1. If the pt is left on the 50 mg of naltrexone, it may be very difficult to manage his/her pain, because the naltrexone is blocking the pain receptors. 
2. Whereas, if the patient is taken off the naltrexone and given an opioid medication to control his/her pain, a regular dose of the opioid (eg; Percocet) may be too much, and the patient may be at a higher risk of respiratory depression (breathing stops) due to a normal dose of an opioid medication now being too potent, because the patient's opioid receptors have undergone a process called down-regulation, which occurs after long term opioid use. 

My recommended treatment for most cases: 

We would start at a very low dose and slowly titrate up to 8 mg daily and see how you feel. The 8 mg dose may be enough for most women. Again, in rare cases, we may continue uptitration to the full 50 mg dose. Naltrexone can only be purchased with a prescription. The Low doses capsules (4 mg to 8 mg) are only available through a compounding pharmacy.  You can view a list of   

compounding pharmacies that I frequently work with here.