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 Interview with Dr. Isaac Schiff, Joe Vincent Meigs Professor of Gynecology at Harvard Medical School and Chief of the Vincent Obstetrics and Gynecology Service at the Massachusetts General Hospital.
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CBS CARES: What is perimenopause and how is it different from menopause?
DR. SCHIFF: Perimenopause is that time in a woman's life, before menopause, when she starts to run out of eggs and skip periods. So, it's basically a time when her ovaries stop being responsive to pituitary gland stimulation. For perimenopause, she has to skip at least one period, but not 12 or more consecutive periods. Also, in perimenopause, periods and the intervals between periods may get longer or shorter.
Menopause is a permanent end of periods for a woman and occurs when her ovaries run out of eggs and stop producing hormones called estrogens. You're in menopause when you skip at least 12 or more consecutive periods. So, it's menopause if you have no periods for a year.
CBS CARES: How are perimenopause and menopause, respectively, diagnosed?
DR. SCHIFF: Basically by listening. If a woman is 47 and has skipped periods, then I would say to her, "It sounds like you're perimenopausal, and you may start to go through menopause at some point." But even if you skip a period at 47, they could resume and you could have regular periods for years.
A diagnosis of menopause is made through exclusion; in other words, a year of no menstrual flow. If someone skips a period at age 47, you could measure a hormone called FSH (follicle stimulating hormone) and it would be elevated at menopause. If someone skips a period for a month, and is not using contraception, you have to consider pregnancy as a possibility. I wouldn't encourage too much testing; I'd rely on what's happening to the woman. If a woman of 47 skips a period or two and is having hot flashes, the diagnosis is likely to be perimenopause.
CBS CARES: What is the average age that women experience perimenopause, and what are the typical symptoms?
DR. SCHIFF: The average age in the U.S. for perimenopause is about 47 years. Usually, it happens about four years before menopause. Some physicians may not be aware that perimenopause may be accompanied by hot flashes, which can actually be more severe than the hot flashes during menopause. There can also be mood changes.
CBS CARES: For women in their thirties, are there any subtle hormonal changes?
DR. SCHIFF: For these women, the bigger issue is decreasing fertility. There is a slight change in periods in the 30s but not much. However, I wouldn't want a woman in her thirties to think, "Oh my God, I'm going through menopause!" just because she skipped a period. Pregnancy is a more likely diagnosis at that age.
CBS CARES: What exactly causes hot flashes? What causes some women to experience worse hot flashes than others?
DR. SCHIFF: It is thought that the decline in estrogen leads to a change in the set point of the woman's temperature control mechanism. In other words, the body is trying to cool off. So, blood is brought from her organs that produce heat, such as the liver, and they come to the periphery; namely, to her skin over the face and upper body. Her blood vessels expand, allowing for more blood and thus more heat to come to these areas. The woman will now feel very warm and will start to sweat. There will be a loss of heat by radiation, and then, she'll start to feel cold because of the heat loss.
It's thought that the woman who undergoes menopause because of surgery or chemotherapy is the one who has the most severe hot flashes.
CBS CARES: Is hormone therapy used as short-term treatment for perimenopausal symptoms?
DR. SCHIFF: Yes. If a woman is experiencing symptoms of perimenopause and has no contraindications, her doctor might prescribe a low-dose birth control pill, which contains estrogen and a progesterone-like agent. This would give her regular periods and reduce or eliminate hot flashes. If the woman doesn't want to use the birth control pill, another option is a low-dose estrogen skin patch or pill, with just enough hormones to get rid of the hot flashes.
But, women with an intact uterus would need progesterone as well, to protect against endometrial cancer, or cancer of the lining of the uterus.
CBS CARES: Do any non-hormonal treatments exist for perimenopausal treatments?
DR. SCHIFF: Yes. There's a body of literature developing that a class of anti-depressants known as selective serotonin reuptake inhibitors (SSRI's) might reduce hot flashes. They've been used in studies of women who have had breast cancer and therefore estrogens are contraindicated but the women have severe hot flashes.
The drug Bellergal was used in the past and was effective. However, it could be addictive and leads to dry mouth and is not necessarily safe. Another group of agents that were used included drugs like Clonidine. Clonidine is traditionally used for high blood pressure. However, if you used enough Clonidine to rid the hot flashes, the patient would feel very tired.
CBS CARES: Do diet, exercise and a healthy lifestyle help relieve symptoms?
DR. SCHIFF: It's thought that caffeine, alcohol, hot liquids and spicy foods can make hot flashes worse, so you should avoid consuming these.
In general, you should have a healthy diet that is low in fat and, while I'm not a dietician, you should have the usual balance of carbohydrates and fat. Don't smoke, don't overeat, and get enough exercise.
CBS CARES: You mention the importance of diet on a general level, but a lot of women think they should be taking soy and eating yams as a way of boosting estrogen levels. Do you recommend that?
DR. SCHIFF: We don't have data to say that soy and yams, which both contain estrogen-like substances called phytoestrogens, are good. We have evidence indirectly that the traditional Asian diet that has a lot of soy in it may be a contributing factor to why those women have less incidence of breast cancer. But we don't have the flip side-we don't know if North American women start eating more soy whether they will have reduced the risk for breast cancer. In fact, the one study that did suggest that soy reduces the risk for breast cancer comes from Singapore, but it showed that you've got to start eating soy before puberty. That's probably because it affects breast development. So it's a little late by the time a woman goes to see her doctor about menopausal symptoms.
CBS CARES: Let's turn to the subject of menopause. You explained earlier how it's defined, but at what age does it usually start?
DR. SCHIFF: Menopause usually occurs between the ages of 45 and 55, with the average age in the U.S. being 51, but it can occur earlier or later.
CBS CARES: Do women generally go through menopause at the same age that their mothers did?
DR. SCHIFF: There's not a good relation between a mother's age of menopause and her daughter's age of menopause. However, there are certain genetic situations in which the mother has an alteration in the X chromosome, causing an early menopause, and this alteration might be passed on to a daughter. Such situations are rare, though.
CBS CARES: If a woman wants to know, can she have tests to determine if she has that X chromosome alteration and is likely to have an earlier menopause?
DR. SCHIFF: Yes, a woman could have genetic counseling and a chromosome analysis to see if she has, for example, inherited a deletion in the long arm of the X chromosome, which could lead to premature ovarian failure. And Turner's syndrome, also the result of a genetic defect, leads to primary amenorrhea, or absence of periods. Thus, if it happens in a family, one can do genetic testing.
CBS CARES: Is there anything women can do to delay the onset of menopause?
DR. SCHIFF: While it might not be possible to delay menopause, multiple studies show that cigarette smoking triggers early menopause. Women who smoke generally experience menopause about two years earlier than non-smokers.
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