Menopause Management in Metairie, LA

Vasomotor symptoms, commonly referred to as hot flashes / flushes or night sweats, can be intense.  Women experience a sensation of extreme heat in the upper body, particularly the face, neck, and chest. These episodes, which typically last 1-5 minutes, can be characterized by perspiration, flushing, chills, clamminess, anxiety, and, on occasion, heart palpitations.  Studies show 87% of women experience these symptoms on a daily basis, with approximately 33% experiencing 10 hot flashes per day.  The precise cause of vasomotor symptoms is poorly understood, but many experts believe they result from a disturbance in the temperature-regulating system in an area of the brain called the hypothalamus, triggered by a decline in estradiol (estrogen).  Hot flashes and night sweats can be triggered by small elevations in core body temperature.  The median duration of vasomotor symptoms is 4 – 10 years, but in some women, they never resolve without treatment. Bioidentical hormone therapy can reduce or eliminate vasomotor symptoms in peri- and postmenopausal women.

Vaginal atrophy refers to a thinning of the vaginal tissue, with a loss of elasticity and flexibility in the vaginal walls and a reduction in superficial epithelial cells (the skin cells that line the vagina). The North American Menopause Society estimates that 10-40% of menopausal women will experience one or more symptoms of vaginal atrophy. Bothersome symptoms and conditions include vaginal or vulvar dryness, discharge, itching, painful sex (dyspareunia), vaginal tears, narrowing of the vaginal opening, and increased urogenital infections due to changes in vaginal pH. Vaginal atrophy can have a detrimental effect on a woman’s quality of life, self-esteem, and sexual intimacy. Bioidentical hormone therapy can improve or reverse vaginal atrophy.

Decreased or absent sex drive is part of a symptom constellation referred to as genitourinary syndrome of menopause.  Genitourinary syndrome of menopause involves not only vulvovaginal atrophy (thinning of vulvar and vaginal tissue), but an entire spectrum of genital, sexual, and urinary symptoms associated with declining levels of circulating estrogen and other steroid hormones that occur during menopause.  Testosterone is the main driver of libido (sex drive).  Androgen (testosterone) levels in women peak in the mid-twenties, decline steeply in the early reproductive years until the mid-thirties, and level out around age sixty, at which point no further decrease is observed.  By age 40, testosterone levels are around 50% of what they were in a woman’s twenties.  Other factors that can contribute to a reduction in menopausal female sexual function are stress (both physical and emotional), fatigue, chronic pain, medical conditions, medications, substance abuse, increasing responsibilities as one gets older, long work hours, dissatisfaction with one’s body, or discord within the relationship.  The only medication proven to improve libido and orgasm in menopause is testosterone therapy.  In women, there is not a particular blood serum level or a lower limit of testosterone or its precursors that is diagnostic of decreased female sexual function. Bioidentical testosterone therapy can improve sex drive and orgasm in many women.

Fatigue is often reported by women in menopause.  Physical fatigue may make walking up stairs or exercising more difficult.  Mental fatigue can lead to difficulty thinking, concentrating, remembering, or making decisions.  It is increasingly common in the later stages of the menopause transition with one study showing that fatigue in women was reported by 20% of women before perimenopause, 47% of women in perimenopause, and 85% of women in menopause.  Fatigue may be due to hormonal changes that occur during the transition into menopause.  During perimenopause, estradiol and progesterone levels fluctuate and this can affect other hormones, including adrenal and thyroid.  An imbalance in any of these hormones can cause fatigue.  Another issue is poor-quality sleep or insomnia that can lead to tiredness during the day.  Stress due to demands at work or at home in women in this age group can also worsen fatigue.  Additionally, sleep apnea (which leads to waking up in the middle of the night), sleep disorders, stress, anxiety, and certain medications can cause fatigue in menopause.  Hormone therapy can help many women with fatigue.  It reduces hot flashes allowing women to get better sleep, which could have a positive effect on energy.  Lifestyle changes are also important.  These include regular exercise, limiting caffeine and alcohol, having a regular sleep routine, and engaging in mind-body practices such as yoga or tai chi. Bioidentical hormone replacement therapy can improve fatigue in many women.

Weight gain during menopause is largely due to the changes in the hormonal milieu that leads to an increase in total body fat and an increase in abdominal fat.  This pattern is associated with an increased risk of cardiovascular and metabolic disease and adversely impacts the health-related quality of life and sexual function.  Studies in mice indicate that lack of ovarian function is associated with decreased energy expenditure, enlarged fat cells, and development of fatty liver.  When given estradiol, they were protected from enlarged fat cells, fatty liver, and insulin resistance (which can lead to diabetes).  Overall, menopausal hormone therapy is not associated with increased weight or fat mass gain.  In fact, studies indicate a reduction in overall fat mass with hormone therapy, improved insulin sensitivity, and a lower rate of development of type 2 diabetes mellitus.  Leptin is a hormone that typically increases as the fat mass of an individual increases.  One study in postmenopausal women showed that women who did not take hormone therapy had an increase in total and percent body fat and centralization of fat distribution.  Serum leptin levels paralleled this increase, resulting in significantly higher levels 1 year after the study.  Women treated with hormone therapy were protected against these changes. 

Sleep disturbances affect approximately 61% of menopausal women, according to the National Sleep Foundation.  Sleep disturbances increase in prevalence during the menopausal transition, with the most common complaints being nighttime awakenings.  The SWAN study demonstrated that women commonly have difficulty falling and staying asleep during this time.  These findings were worse in women with the lowest estradiol (estrogen) levels.  Studies also show that menopausal women have a higher apnea-hypopnea index (a measure of the number of pauses or other abnormalities in breathing) and lower oxygen concentration in the blood while sleeping.  Additionally, they have greater arousal of the cortical area of the brain which is partially explained by the frequency of hot flashes.  SWAN data shows that women with moderate-severe hot flashes are almost three times as likely to report frequent nocturnal awakenings compared to women without hot flashes.  Self-reported vasomotor symptoms are consistently associated with poor self-reported sleep quality and chronic insomnia.  Not all women who have menopause-related sleep problems complain of hot flashes, so there may be a common mechanism in the central nervous system (brain) that accounts in part for these sleep disturbances.  Insomnia is the most severe type of sleep disturbance (difficulty falling asleep or staying asleep), occurring three or more times per week and causing significant distress and daytime consequences.  Twenty-six percent of perimenopausal women meet criteria for this diagnosis, with almost 50% having short sleep duration.   Evolving data show an association between menopausal insomnia and unfavorable nighttime blood pressure and heart rate profiles.  Sleep disordered breathing is characterized by snoring, upper airway obstruction, poor airflow on inhalation, and excessive daytime sleepiness.  The greater prevalence after menopause might be due in part to loss of the protective effects of female reproductive steroid hormones, especially progesterone which stimulates respiration, as well as changes in fat distribution after menopause.  Women also experience a decline in melatonin and growth hormone, both of which have effects on sleep.  Just as psychosocial distress, stressors, and poor health can lead to sleep disturbances, sleep disturbances can lead to poorer health and quality of life, depressed mood, and reduced work productivity.  A study of 936 women found that insomnia symptoms were the most problematic menopausal symptoms to affect daily life and work performance.  Lifestyle changes can be beneficial.   Limiting caffeine and reducing alcohol is very important.  Although alcohol may help some people go to sleep, it lowers sleep quality and can trigger hot flashes.  Having a regular sleep routine is also valuable. Try to go to bed and wake up the same time every day.  Avoid daytime naps.  Avoid using screens or devices before bed.  Relax with a warm drink or bath before bed.  Engage in mind-body practices such as yoga or tai chi to lower stress and improve energy and sleep.  Hormone therapy is also very beneficial. 

Mood disorders affect many peri- and postmenopausal women.  In the United States 1.3 million women reach menopause annually.  Twenty percent will develop depression at some point during menopause.  It often first occurs during the menopausal transition, and according to the Harvard Study of Moods and Cycles, women who entered perimenopause were twice as likely to have clinically significant depressive symptoms as women who had not yet made the menopause transition.  Depression during perimenopause is likely due to fluctuating or declining estrogen (estradiol) levels in part.  Estrogens act in the central nervous system (brain) to stimulate the production of neurotransmitters (signal molecules), particularly serotonin and norepinephrine.  It also prevents the breakdown of these mood boosting hormones.  New-onset panic disorder, worsening of preexisting panic disorder, new-onset obsessive compulsive disorder (OCD), relapse of OCD, and exacerbation of bipolar disorder may occur and are thought to be related to fluctuations in hormones as well.  A certain subset of women seems to be predisposed to experience mood disturbances triggered by hormonal fluctuations.  This group includes women with a history of mood disorders or of premenstrual and postpartum mood-related symptoms. Bioidentical hormone replacement therapy can improve mood in many peri- and postmenopausal women, often reducing or eliminating or the need for psychiatric medications.

Decline in cognitive function (memory changes, brain fog, word-find problems, difficulty focusing or concentrating) is more common near menopause, a phase marked by a decrease in hormone levels, especially estrogen.  Subjective cognitive decline is one of the most frequent complaints of women undergoing the menopause transition, with a 44%-62% prevalence. Examples include difficulty retrieving words or numbers, forgetting the purpose of a behavior (e.g., entering a room and not knowing why), losing one’s train of thought, and overlooking appointments.  Changes in women’s cognitive performance is consistently linked to the menopause transition.  Hot flashes, depression, and anxiety have been linked to perimenopausal decreases in cognitive performance.  Cortisol increases after a hot flash and higher cortisol levels are associated with memory impairment.  Some studies have reported an increased risk of dementia by up to 23% with late menarche (onset of menstrual cycles), early menopause, and a short reproductive period.  The decrease in estrogen levels during the menopause transition disrupts the brain by affecting mitochondrial function (small organelles that regulate metabolism), deposition of a beta-amyloid (a substance which is associated with Alzheimer’s disease), and communication between neurons in the brain.  Other potential mechanisms involved in estrogen’s ability to protect neurons include modulation of the production and activity of neuropeptides and neurotransmitters (brain signaling molecules), reduced cell death of neurons; modulation of neuronal growth; antioxidant properties; and modulation of the brain’s immune system.   Low-grade inflammation has been identified as a possible cause of cognitive decline.  In postmenopausal women, inflammatory markers are often elevated and can be normalized following treatment with hormone therapy.  Several studies have reported that prolonged lifetime estrogen exposure results in better cognitive outcomes.   Testosterone also protects the neurons of the brain, lowers inflammation, and reduces beta-amyloid.  Studies have shown an association between learning and memory and concentrations of testosterone administered to postmenopausal women.  Improving sleep, using mnemonic devices, or engaging in physical activity may lessen menopause transition-related cognitive difficulties. Bioidentical hormone replacement therapy may help improve cognitive function in peri- and postmenopausal women.

Dermatologic changes (dry skin and hair loss) are not uncommon in menopause.  Thinning of the various layers of the skin, as well as loss of collagen, elastin, and hyaluronic acid occur in women as they age.  Collagen decreases in quantity and quality due to increased breakdown associated with a reduction in female reproductive hormones.  It can decrease as much as 30% in the first 5 years following menopause.  Ultimately, this leads to a decrease in distensibility and loss of tonicity, creating deeper facial creases.  Skin cells, known as keratinocytes, change in shape as well.  This results in an increase in the number and size of pores as well as an increase in the development of age spots.  The overall volume of the hypodermis (the bottom most layer of the skin) decreases due to a loss of subcutaneous fat.  The combined effects of all these age-related changes can result in dry, itchy, thin, wrinkled, and sagging skin.  Estrogen (estradiol) increases collagen and skin thickness by inhibiting enzymes known as matrix metalloproteases which break down collagen, and by stimulating proliferation of keratinocytes.  It acts as a natural antioxidant, protects against inflammation, increases skin hydration and elasticity, reduces wrinkles, and enhances wound healing by increasing blood flow.  Higher levels of estradiol result in a more youthful appearance.  While there is less literature on declining levels of progesterone, testosterone, dehydroepiandrosterone (DHEA), and human growth hormone (HGH) in relation to their effects on skin aging, studies have demonstrated that replacing these hormones leads to thickened skin and restored elasticity.  Subjects supplemented with both estrogen and progesterone exhibited an increase in skin surface lipids (fats), which was not seen among subjects supplemented with only estrogen.  This may be due to progesterone’s ability to stimulate sebaceous glands activity.  Subjects perceived this increase in skin surface lipids positively, believing it to create a more youthful glow.   Testosterone has been shown to increase skin thickness and collagen production.  One study showed patients treated with testosterone in combination with estrogen had a collagen content 48% higher compared to the content in untreated women.  DHEA improves skin in women in terms of hydration, thickness, sebum production, and pigmentation. Bioidentical hormone replacement therapy can improve skin issues in many peri- and postmenopausal women.  

Female pattern hair loss (FPHL), also known as female androgenetic alopecia, has a peak incidence following menopause with a prevalence of up to 29% in women ages 70 to 89 years.  This type of hair loss is due to miniaturization of the hair follicle, but why this occurs is not clear.  Some experts theorize the effects of dihydrotestosterone (DHT), a hormone made from the conversion of testosterone, on hair follicles contributes to FPHL.  Nevertheless, DHT levels are normal in most women with FPHL. Others theorize it may result from increased sensitivity to DHT since DHT levels are often normal, or to lower estradiol levels since this hormone declines and FPHL increases during menopause. Bioidentical hormone replacement therapy may help with hair loss and texture in some peri- and postmenopausal women.

Heart palpitations are irregular heartbeats that are typically more noticeable than regular heartbeats.  During a palpitation, the heart may pound, flutter, race, or beat irregularly.  Palpitations are often short-lived, lasting just a few seconds or a few minutes.  In menopause, they are often accompanied by hot flashes or anxiety.  Heart palpitations are thought to result from diminished estrogen levels that can cause overstimulation of the heart.  This reduction in estrogen production is associated with an increase in heart rate and an increased frequency of palpitations and non-threatening arrhythmias, such as premature ventricular contractions (PVCs).  A premature contraction is a single heartbeat that occurs earlier than normal.  Your doctor should evaluate any new or recurrent heartbeats to rule out any abnormalities, especially if they are associated with shortness of breath, dizziness, or chest discomfort.  Estrogen has multiple beneficial effects on the cardiovascular system.  Oral estradiol (estrogen) acts on the liver to cause an overall increase in good cholesterol or high-density lipoprotein (HDL) and reduction in bad cholesterol or low-density lipoprotein (LDL) and total cholesterol.  Over time, bad cholesterol can accumulate as deposits in your blood vessels that can lead to blockages, interfering with blood flow to the heart.  Good cholesterol, reduces both the amount of bad cholesterol in the body and makes bad cholesterol less able to accumulate into deposits that cause blockages in your blood vessels.  Estradiol also decreases smooth muscle cell proliferation and increases vasodilation in the arteries, both of which lower blood pressure and help prevent blockages.  Finally, it modulates the autonomic nervous system, which works to regulate heartbeat.  A few lifestyle changes that may help decrease the occurrence of menopausal palpitations include reducing caffeine intake, decreasing or avoiding stimulants such as cigarettes and alcohol, and practicing relaxation techniques, such as yoga, mindfulness, and breathing exercises. Bioidentical hormone replacement therapy relieves palpitations in many peri- and postmenopausal women.

Joint pain (arthralgia) is reported by more than half of women around the time of menopause.  For 21% of these women, joint pain is the most bothersome menopausal complaint.  Some experts believe it is due to falling estrogen levels.  An Australian study with 438 patients followed for 8 years showed that postmenopausal women were more than twice as likely to experience aches and stiff joints compared to the premenopausal group.  The most striking link between low estrogen levels and arthralgia has been demonstrated in clinical trials of aromatase inhibitors.  Aromatase inhibitors are medications that lower estrogen levels.  The Airmiles Tamoxifen Alone or in Combination Trial (ATAC) reported that one-third of women who were free of joint symptoms before treatment developed joint pain within the first few months of therapy.  The presence of inflammatory changes in the tendons and joints of women treated with aromatase inhibitors suggests that acute estrogen deprivation may induce a localized inflammatory response.  Estrogen reduces inflammation, protects the joints, reduces cartilage turnover, helps maintain hydration status, and may modulate pain processing pathways.  Menopausal joint pain is often worse in the morning when joints are stiff from being sedentary overnight.  Pain may improve during the day with movement as joints loosen up.  Frequent locations of the discomfort include the neck, jaw, shoulders, elbows, wrists, and fingers.  In addition to stiffness, joint discomfort can include swelling, shooting pains, and a burning sensation after exercising. Lower estradiol levels in women over 50 increase the risk of osteoporosis and osteoarthritis.  In the Women’s Health Initiative (WHI) study, 10739 postmenopausal women who took estrogen were found to have a modest but sustained reduction in the frequency of joint pain.  Additionally, their joint pain scores were lower than women not taking estrogen.  Estrogen users also had significantly fewer hip and knee replacements.  Another study of 842 pre- and perimenopausal women showed that women with osteoarthritis seen on X–ray imaging had lower concentrations of estradiol in their blood than women without osteoarthritis.  Furthermore, a study of 860 healthy postmenopausal women showed that menopause is associated with knee cartilage degeneration seen on MRI films, which can lead to knee pain.  Lifestyle change can help alleviate some joint issues.  It is important for menopausal women to consume 1.2 to 1.5 grams per kilogram of weight per day of protein to maintain muscle mass.  Improved muscle mass helps with balance and bone support.  Regular exercise can help prevent stiff, sore joints.  Low impact exercises may be best including swimming, hiking, biking, and yoga.  Women should also focus on eating a healthy diet that is plant-based, organic and packed with Omega-3, phytonutrients, and antioxidants.  Smoking should be avoided because, among other known health risks, it increases the risk of bone loss and slows or prevents bones from healing properly.  Finally, it is important to stay well-hydrated, as dehydration can contribute to joint pain.  This can be harder in menopause when estrogen levels are low, because estrogen helps you retain fluid.  Try to drink at least half of your body weight in pounds in ounces every day.  For instance, if you weigh 140 pounds, your goal should be to consume at least 70 ounces of water daily. Bioidentical hormone therapy can significantly reduce joint pain in peri- and postmenopausal women.