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What is the difference between perimenopause and menopause?
Important Definitions:
Menopause: defined as the permanent cessation of menstrual cycles, which is confirmed when the woman has not had a period for one full year. The average age is of menopause is 51.
Peri-menopause: the time period preceding menopause, which begins approximately 3-4 years prior to the woman's final menstrual period (FMP). Oftentimes women may experience a number of physiologic changes that may affect her quality of life.
Hormone: a substance released into the blood stream at one tissue site that will travel through the blood to a distant site where it exerts it effects. We will discuss 6 hormones:
- Follicle-stimulating hormone (FSH): secreted by the pituitary gland deep in the center of the brain. FSH goes to the ovaries and "stimulates follicular" growth. Hence its name tells you its function. FSH increases in peri-menopausal period.
- Luteinizing hormone (LH): also secreted by the pituitary gland. LH will spike just prior to ovulation in response to increased estrogen from the follicle and trigger ovulation and the subsequent formation of the corpus luteum. The corpus luteum secretes progesterone, which will target the endometrium (inner wall of the uterus) and prepare the lining for a pregnancy. LH will decrease in peri-menopause.
- Progesterone: secreted by the corpus luteum within the ovary during the post-ovulatory phase (NaPro term: post-Peak phase). Progesterone will decrease in peri-menopause.
- Estrogen: estradiol (E2): primarily secreted by the ovaries in the pre-ovulatory phase (pre-Peak phase) of the menstrual cycle. E2 will rise initially during peri-menopause, but subsequently it will be depleted. The "hypoestrogenic" state of the woman will increase her risk of osteoporosis (thin bones). Estrone is another type of estrogen, which is secreted by fat tissue in the post-menopausal period; it is also secreted by the adrenal glands. High estrone levels can cause increased belly fat which can in turn increase your risk of heart disease, diabetes, high blood pressure, and high cholesterol.
- Inhibin A/B: hormones secreted by the granulosa cells of the ovarian follicle during the late reproductive years before the onset of peri-menopause. Inhibin B is a marker which reflects the number of eggs in the ovaries. Thus during peri-menopause Inhibin B will decrease.
- Anti-müllerian hormone (AMH): also secreted by the granulosa cells. This hormone inhibit the recruitment of follicles from the resting pool in order to allow for the selection of one dominant follicle each menstrual cycle. As the ovarian reserve decreases in the peri-menopausal period, AMH will decrease.
Bioidentical hormones: hormones that are have an identical molecular structure to hormones naturally made by your body. NaPro providers will recommend this type of hormone supplementation for many reasons discussed below.
Menopausal Hormone Therapy (MHT): the practice of replacing a woman's hormones to treat her peri-menopausal and/or menopausal symptoms. NaPro providers prefer bio-identical hormones.
When will symptoms to begin and how long will they last?
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.
The STRAW Staging System
Reproduced with permission from :Harlow SD, Gass, M, Hall JE, et al. Executive Summary of the Stages of Reproductive Aging Workshop + 10: Addressing the Unfinished Agenda of Staging Reproductive Aging. J Clin Endocrinology Metab 2012. Copyright 2012 The Endocrine Society.
What will the NaPro appointment be like?
Your appointments at MyCatholicDoctor with me will be one FULL HOUR in length. Generally speaking, NaPro appts will follow a typical protocol as outlined below. However, every individual is different and your situation may warrant a more expeditious process. Please know, the Creighton Model System (CrMS) is very important. Your CrMS chart will help direct me to what diagnostic tests and imaging tests should be done and what treatment plan would be most appropriate.
First Appt: I will take a comprehensive medical history and provide you with education about normal healthy reproduction and oftentimes about a condition I suspect you may have after we have talked a while.
I will order a pelvic ultrasound which I will ask you to schedule on day 5 of your next menstrual cycle. I will order a series of laboratory tests. Click the "laboratory tests" button below to learn more.
If you are still having periods, you will be asked to begin charting your menstrual cycles using the Creighton Model System (CrMS). Please choose a Fertility Care Practitioner (FCP) by clicking the "Fertility Care Practitioners" button below. The goal will be for you to chart your cycles for two mos, then we will draw post-peak hormone panels. You can read more about the hormone panels on the Patient Handout page (Handout#3).
If you are not cycling or you are having only three periods a year, I would start you on bioidentical progesterone replacement right away, which can help many symptoms, such as: insomnia, irritability, anxiety and depression. 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 monthly "withdrawal bleeds", which will get lighter and lighter as time moves forward. Women almost always feel great all month, even when taking their progesterone only ten days every mos.
More importantly, the monthly withdrawal bleeds will protect your endometrium from thickening, a condition known as "endometrial hyperplasia". Endometrial hyperplasia can easily become a pre-cancerous or even a cancerous condition of the uterus. Preventing endometrial thickening is the primary reason for giving you progesterone for only ten days every mos.
I personally do not believe in prescribing progesterone on a daily basis, as this prevents withdrawal bleeds, and logically thinking, which will accelerates your risk of developing early osteopenia/osteoporosis. due to inducing a very low estrogenic state earlier in life.
Please consider joining me as I pray for you here.
Second Appt: You will be asked to return to the office in 2 mos for a follow-up appointment to review the results of your imaging and laboratory tests. Together we will also review your Creighton Model System (CrMS ) chart to look for specific biomarkers which will help me make a diagnosis.
Please upload an image of your CrMS chart two days prior to all follow up visits and send to me via the portal.
Please add the length of your post-peak phase and your mucus cycle score (MCS) to the R-hand margin of the chart. Your Fertility Care Practitioner (FCP) will calculate your MCS for you.
During this appointment, you may be asked to begin some supplements and/or medications. If you are still menstruating, we will also discuss drawing a full set of hormone panels. We will make a decision if you should have a peri-ovulatory estradiol panel, a post-Peak estradiol & progesterone panel, or both panels.
Hormone Panels:
- Peri ovulatory estradiol panel: start on CD8, go to the lab EOD for an estradiol draw, until you have one draw post-peak.
- post-Peak estradiol and progesterone panel: P+3, 5, 7, 9, and 11. See Handout #3 on the the Patient Handout webpage
- Hormone panels require 2 mos of CrMS charting AND the patient must be able to confidently identify her Peak day.
Many patients will be asked to consider working with a dietitian or a nutritionist to help optimize your reproductive health. Oftentimes I may also recommend a mental health appointment to help with anxiety, depression and/or disordered eating habits.
Third Appt: You will return to the office in 2 mos to review the results of your hormone panels as well as the biomarkers on your CrMS chart. Most often at this time I will have made one or more more diagnoses to identify the root cause of your symptoms. Together we will discuss a treatment plan, which will be implemented.
Follow Up Appts: You will return to the office every 2 months. During this time, I will conduct a comprehensive medical interview to ensure your symptoms have resolved, and to ensure you are responding well and not having any negative responses to the management plan. Depending on the individual patient and your individual diagnosis, I may need to monitor your progress with serial laboratory tests and/or serial imaging.
At any point in time, if a diagnosis has been made, treatment initiated, and/or you are satisfied with the medical management we have implemented, you can schedule annual or biannual visits, per your choice.
BLEEDING KEY: How do I Measure Period Flow on my CrMS Chart?
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.
What are some other Natural Treatments that may be considered for perimenopausal symptoms?
- 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. See below for more information about bioidentical progesterone.
- 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.
- Flax seeds: 2 Tbs of freshly ground flax seeds daily can help with hot flashes. You may wish to read a study here (2012)
- Maca Root helps with low libido. You may wish to read some small studies here (2015) and here (2010).
- DHEA supplementation can helps with low libido, but this would be recommended only if your blood levels of DHEAs or testosterone are lower than they should be.
- 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 glucose/insulin, 3 specimen testing and then treat you as indicated. 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 very effective. However, this is a medicine that requires a prescription. Metformin is what I call an "oldie & goodie" medication, which has been around for a while so we know it is safe.
- 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".
Discussion about Low Dose Naltrexone (LDN)"
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:
- 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.
- 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 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.
A typical treatment titration regimen would be:
Rx# 1: naltrexone 4 mg:
- take one pill daily x 10 days (4 mg daily total)
- take two pills daily x 10 days (8 mg daily total)
#30 pills total for Rx # 1.
Rx#2: naltrexone 8 mg:
- take two pills daily x 10 days (16 mg daily total)
- take four pills daily x 10 days (32 mg daily total)
#60 pills total for Rx #2.
Rx#3: naltrexone 50 mg (available at either retail pharmacy or compounded)
- take one pill daily
#30 pills total for Rx #3.
*** If we agree on using the full dose, I will document you have been educated to the risks as noted above, and you would like to take this risk. Also, we would plan to use the full dose for only 4-6 mos.