Q&A

How things have changed around menopause "diagnosis"

Our reproductive systems go through various stages firstly of maturation up to optimal ovulatory function, and thereafter declines over time. The decline can occur in bouts and even pivot at times back and forth between stages. Ultimately, when full ovarian failure has occurred, we stop ovulating.

Briefly, our hypothalamus (in the brain) stimulates the pituitary gland (also in the brain, behind your nose) to produce follicle stimulating hormone (FSH) and luteinizing hormone (LH). These hormones in turn stimulate the ovaries in different manners to produce a mature egg cell which is ovulated. From the ovulation remnant on your ovary, prolactin and estrogen is produced. These hormone provide negative feedback to your hypothalamus and pituitary glands to produce less LH and FSH. This prevents further ovulation. Once the egg cell has not been implanted, the lack of hormones causes menstruation and the estrogen production from the ovary reduces. Now that there is less estrogen and progesterone, the negative feedback is removed, and the brain starts producing LH and FSH again. And so the cycle continues.

When your egg quality and ovarian health declines with age, the amount of estrogen and progesterone produced, sometimes despite ovulation, is not enough, and LH and FSH is not fully suppressed. This starts you on your perimenopausal rollercoaster. Suboptimal suppression may lead to double ovulation and then a massive estrogen spike, or simply insufficient estrogen with prolonged menstrual bleeding. In short, it leads to an unpredictable, chaotic set of hormonal levels that can manifest in multiple ways.

Eventually, the ovaries completely stop ovulating therefore removing any negative feedback, Your body will now start producing more and more LH and FSH in order to try and push out just one more egg cell (beating a dead horse). If this continues for 1 year (with no ovulation or bleed), you are officially in menopause. And it is based on this physiology that the “diagnosis” of menopause has historically been to demonstrate markedly elevated levels of LH and/FSH. Later on, some clinicians started performing progesterone levels, as this seems to decline earlier, serving as an earlier marker for pending menopause.

What makes the interpretation of hormone levels exceedingly difficult in this perimenopausal time frame, is the fact that their levels can be chaotic. Therefore, you could have all the symptoms of menopause, but you have had a double ovulation due to initial suboptimal FSH suppression, and now have seemingly low or even high estrogen levels, which suppress your LH and FSH temporarily.

Therefore, how do we figure out if you are in perimenopause?

Average age of menopause (US data) is 52 with the range of 45-55 years. Perimenopausal symptoms can precede full menopause by 10 years. Therefore, perimenopause should be considered as a cause of new onset symptoms from age 35 years. Now, it is important to remember that there are certain base line screening and examinations that every persons should do as part of the management of their health. New onset symptoms should likely include evaluation of cardiac health, thyroid health and metabolic evaluation, however, hormonal dysregulation should always be considered as a possible contributor.

What is a safe approach?

At some point in you life, not as a person dealing with menopausal considerations, but as a woman wanting to change your lifestyle to enable healthy aging, you need to recognize changes within your body and look at underlying causes.

If you ask yourself, what do women die of, these are the conditions we want to prevent, not only to extend our lifespan, but to life full, productive and happy lives. These are:

Cardiovascular disease and Strokes
Demetia
Diabetes and metabolic disease
Cancer
Lung disease
Osteoporosis

One can argue that numbers 1 to 3 on the list will requires similar interventions as these all by and large represent vascular diseases in some manner. It is therefore essential to evaluate a lipogram, HbA1c (diabetes marker) and thyroid function at baseline. Additional markers may be indicated, as used in various risk scoring systems, which your clinician will evaluate.

Cancer risk from greatest to less incidence is lung, colon, breast, pancreas and ovarian cancers. Again, highly person-specific risk factors should be used to stratify risk and thereby establish an individualized screening and testing plan. However, the use of radiological tests (mammography, ultrasonography, scans etc) can greatly improve longevity through early detection.

Lung disease can largely be reduced by smoking cessation, a this remains the largest risk factor.

Osteoporosis significantly impacts on quality of late life and should be prevented early and/or treated timeously. Detection is through evaluation of family history and specific risk factors, as combined with the bone mineral density test (BMD or Dexa scan).

If all your risk factors have been addressed, we can now ask the next question – how old are you? Now consider, EVERY WOMAN ON EARTH, who survive long enough, WILL go into menopause. Menopause is not a binary condition that happens overnight. Therefore, once we are past our so-called ‘reproductive peak’ in our 20’s, we are all on the decline. If you have completed your family, you can consider supplementing hormones in a more stable fashion, thereby actively reducing your top 6 disease risks, AND skipping the chaos of perimenopause.