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Menopause Is Neither a Disease, nor a Disorder: Interview with Professor Lubna Pal

Menopause is the age-related loss of female reproductive function. Here, Lubna Pal describes what a woman’s body goes through during the menopause and its impact on women's health.

What does a woman’s body go through during the menopause?

I’ll start with saying that menopause, just like puberty, is a normal phase of life, and that it’s not a disease, it’s not a disorder. 

The body goes through changes in puberty as well as during the menopause. Just like in puberty, there is a big upheaval in our hormonal profile as well as the body undergoes some physical changes. 

Physical changes experienced at and after menopause are driven by declining levels of estrogen and progesterone and can be seen to set in a few years before the final period happens. 

Menopause is said to have occurred when there have been no periods over a 12-month period in the setting of low estrogen levels. Testosterone levels in postmenopausal women are almost the same as in perimenopausal women.  

There is a gradual decline in ovarian function as a woman approaches menopause. Menopause is a continuum. Women in early menopause are different from women in late menopause, both in their hormone profile, in their symptoms and in their bother. 

Within the first two years of the last menstrual period the body is dealing with the absence of estrogen, and menopause symptoms are more common: hot flushes, night sweats, sleep problems are much more common in the year before the last menstrual period and in the few years after the last menstrual period. 

But as a woman goes further into menopause, tissue effects of low estrogen start to dominate, and vaginal dryness becomes worse as the woman ages. Bone loss also happens rapidly within the first two years of menopause. A woman may lose up to 20% of the bone mass within the five years of menopause. 

I think we need approach menopause as a physiological state that can be burdensome in some, but not in all.

It is important to understand that aging is happening at the same time as a woman is progressing along menopause and many of the consequences of menopause can be attributed to aging itself. 

Weight gain happens and women may gain up to 10 pounds within a few years of the last menstrual period! Some studies have suggested that women who choose to continue or to use hormonal therapy may be gaining less weight than women who haven’t been on hormonal therapy. That, however, doesn’t mean that hormonal therapy should be used as a weight-loss medicine! Women should be aware of this tendency to gain weight. 

To sum up, post-menopause is a continuum, it’s normal, that’s not a disease. Many women don’t suffer from menopause symptoms. Many women are at the peak of the careers and lives at the time when menopause happens. I think we need approach menopause as a physiological state that can be burdensome in some, but not in all.  

How to overcome menopause symptoms?

Menopause symptoms don’t happen 100% of the time. Some women experience them but are not burdened by them. Other women suffer from them. 

It’s important to define the level of burden of the symptoms. 

And we have a plethora of options to address these symptoms. Hot flushes, night sweats and sleep problems are caused by declining estrogen. Giving back estrogen is a very effective way of addressing these symptoms, particularly if they are severe enough to affect the quality of life, and if there are no contraindications to the use of hormone therapy. 

The choice of hormonal therapy must be individualized to the needs of the patient and benefits versus risks of therapy must be weighed in each case. There are some very safe ways of delivering hormones in the right dose to the right person to minimize the burden of these symptoms. 

Step #1 is identifying burden of symptoms that affect quality of life.

Step #2 is to choose the right tool to address the symptoms and reassure the patient that there are hormonal and non-hormonal approaches to address the symptoms. 

Hormonal approaches by far are more effective than the non-hormonal approaches. But the choice of non-hormonal approaches should be prioritized for patients who are either concerned about using hormones or have risks related to hormones use. 

For example, patients who have personal history of breast cancer may be worried about risk of breast cancer recurrence with estrogen therapy. These patients should be reassured and preferentially offered non-hormonal strategies as first line approach. 

Lastly, vaginal symptoms can be very effectively addressed with vaginal therapy which has minimal to no risks even for breast cancer survivors. 

Parsing out the symptoms, knowing that there are so many options, a patient and a healthcare provider should have an open dialogue to choose the best working strategy. 

Can hormonal therapy help to beat mood swings? 

This is a tricky question because mood swings per se are NOT considered menopause symptoms. When you are premenopausal, some women experience PMS where women may experience more anxiety, more stress related to fluctuations of hormones.

And the women who experience PMS are more likely to experience perimenopausal symptoms. The assumption is that the symptoms emerge due to fluctuating levels of hormones - when menopause happens, the hormone profile becomes a "flat line" and hence mood swings should improve. However poor sleep and night sweats have been tied to worsening psychological wellbeing in perimenopause and early menopause, and in this situation, improved psychological wellbeing follows effective symptom control.  

If you are experiencing mood swings in post-menopause you need to understand what can be contributing. Poor sleep, lack of rest is a big contributor to emotional stress. 

In conclusion

And our approach to menopause should be: what can we do to maximize health?

And maximizing health should be about maintaining physical activity to counteract the tendency to gain weight, improve our bone health, minimize the bone loss, optimize our calcium intake, and optimize our general well-being. 

Vaginal dryness doesn’t have to be uncomfortable. There are a lot of ways how to address the symptoms of vaginal dryness and maintain satisfying, trouble-free sex life.  

It’s important to understand what changes are happening, what burden I as a woman may experience and start conversation around those problems. 

Individualizing approach to these common health issues is important.

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