Menopause and Perimenopause: What Happens, Symptoms, and When Hormone Therapy Is Indicated

Hello, I am Dr. Isabel Viña Bas, physician and Scientific Director at IVB Wellness Lab.

Perimenopause and menopause are two of the stages that raise the most questions. When does menopause actually start? Why do hot flashes, brain fog, mood swings, or insomnia appear? What can we do to navigate these changes? When does hormone therapy make sense, and when can other tools help us?

The first thing I want to make clear is that menopause is not a disease. It is a physiological process in which the ovaries progressively deplete their function and the body has to adapt to a new hormonal environment.

However, just because it is a physiological process does not mean that every woman experiences it the same way.

Some women experience hardly any symptoms, while others go through changes that significantly impact their quality of life. That is why understanding what is happening inside our bodies is the first step toward deciding how to support them.

What is menopause and how does it differ from perimenopause?

The menopause is defined as the moment when a full year without a period.

The perimenopause, en cambio, es la etapa de transición que rodea a la menopausia. Puede comenzar varios años antes de la última menstruación y prolongarse durante un tiempo después.

During this stage, significant hormonal changes occur. The ovaries progressively deplete their activity, and estrogen levels begin to decrease.

That's why I like to explain it as a sort of late adolescence: our body is adapting to a new hormonal state.

And, just as no two adolescences are alike, no two transitions to menopause are alike either.

Some women experience hot flashes, irritability, brain fog, sleep disturbances, vaginal dryness, or changes in body composition. Others go through this stage with very few symptoms.

Both situations are normal.

At what age does menopause occur?

Physiological menopause usually occurs between the ages of 45 and 55 years old 51 years old.

When it appears among the 40 and 44 years old, hablamos de menopausia precoz.

Under 40 years of age, it is referred to as primary ovarian insufficiency.

These situations require a different approach than physiological menopause.

Si una mujer tiene menos de 45 años y deja de menstruar durante varios meses, no debemos asumir automáticamente que se encuentra en menopausia. Existen otras causas que pueden alterar el ciclo menstrual y que son potencialmente reversibles.

Por eso, en estos casos puede ser necesario valorar parámetros como:

• Prolactin, ya que una elevación puede suprimir la menstruación.

• TSH, because changes in thyroid function can also affect your cycle.

• FSH and estradiol, to evaluate the hormonal axis.

• Hormona antimülleriana, to assess ovarian reserve.

If premature menopause or primary ovarian insufficiency is ultimately confirmed, a hormone replacement therapy until reaching the average age of menopause, siempre que no existan contraindicaciones.

In these cases, we are not just talking about treating symptoms: we are replacing hormones that should be naturally present at this stage of life.

¿Por qué aparecen tantos síntomas durante la perimenopausia?

Menopause doesn't happen overnight.

During perimenopause, the ovaries gradually decline in activity, and estrogen levels can fluctuate wildly.

I like to explain it with a very simple example: imagine you have a bottle of ketchup that is almost empty. You shake it, and nothing comes out. You shake it again, and suddenly, a large amount comes out.

Something similar can happen with the ovaries.

There are cycles where there is still significant estrogen production, and symptoms such as the following may appear:

• Fluid retention.

• Very heavy or prolonged periods.

• Síntomas premenstruales más intensos.

• Irritabilidad.

• Mood swings.

And as menopause approaches and the decline in estrogen predominates, other more characteristic symptoms appear:

• Hot flashes.

• Night sweats.

• Sleep disturbances.

• Niebla mental.

• Cambios en el estado de ánimo.

• Sequedad de la piel.

• Itching

• Vaginal dryness.

• Recurrent urinary tract infections.

This explains why perimenopause can feel so confusing: one month you might feel one way, and the next you might experience completely different symptoms.

Estrogens are not only involved in fertility

One of the fundamental ideas for understanding menopause is that estrogens are systemic hormones.

They do not act solely on the reproductive system.

They have receptors in different tissues and are involved in functions related to the brain, metabolism, blood vessels, skin, mucous membranes, and bones.

Therefore, when estrogen levels drop, changes can appear in different parts of the body.

And this explains why menopause can manifest in so many different ways. 

Why do brain fog and mood swings occur?

Estrogens play an important role in the brain.

They promote the synthesis and action of the serotonin, related to well-being, and they are also involved in the dopamine, related to motivation and the feeling of reward.

In addition, estrogens are involved in neural connections and promote the production of brain-derived neurotrophic factor, related to the maintenance and development of neural connections.

When estrogen levels drop, especially during the first few years, the brain has to adapt to this new hormonal environment.

That is why the following may appear:

• Brain fog.

• Dificultad para concentrarse.

• Memory impairments.

• Mood swings.

• Sadness.

• Lack of motivation.

This situation does not have to last indefinitely. The brain is capable of adapting to the new hormonal environment, which is why these symptoms can be especially pronounced during the first few years. 

Why is exercise so important during menopause?

Here you'll find one of the most important tools to support this stage: physical exercise and, especially, the muscle.

Exercise can independently promote the production of serotonin, dopamine, and brain-derived neurotrophic factor.

In addition, muscle is capable of producing molecules that have effects on the brain.

That is why maintaining good muscle mass is not just an aesthetic matter.

During menopause, strength training can become a tool to support:

• Cognitive function.

• The mood.

• Metabolism.

• Body composition.

• Maintenance of muscle mass.

And the sooner we start taking care of our muscles, the better.

We shouldn't wait until menopause to start working on it.

Why do hot flashes occur?

Hot flashes are one of the most well-known symptoms of menopause, and they also have a hormonal explanation.

Estrogens are involved in the brain mechanisms that regulate body temperature.

Cuando disminuyen, especialmente durante los primeros años, se altera este sistema de termorregulación.

The result is that a temperature that might be completely normal for someone else can trigger a sudden hot flash in us.

Then hot flashes appear, which may be accompanied by sweating and can be especially bothersome at night.

Alcohol can also act as a trigger or exacerbate hot flashes, so reducing its consumption may be considered as part of lifestyle adjustments. 

Which supplements can help during menopause?

Depending on the symptoms, there are different supplements that can be used for support.

The soy isoflavones are one of the supplements with the strongest evidence in the nutraceutical management of menopause.

Depending on the objective, the following can also be used:

• Sage, especially in relation to hot flashes.

• Valerian, especialmente cuando existen alteraciones del sueño.

• Saffron extract, for certain symptoms related to mood and appetite.

• Bacopa monnieri, in the context of memory and cognitive function.

• Omega-3 rich in DHA, por su interés en la función cerebral.

• Zinc.

• L-theanine.

The choice should depend on the symptoms each woman experiences. It is not about taking every available supplement, but about identifying what needs exist and choosing the tools that make sense.

Are soy isoflavones safe during menopause?

This is a point that causes a lot of confusion.

Soy isoflavones are phytoestrogens, but they are not human estrogens.

Their action depends on the estrogen receptors to which they bind, and therefore, they do not replicate the exact behavior of our estrogens in all tissues.

The episode highlights specifically its interest in the nutraceutical approach to menopause and its safety profile.

Additionally, it is noted that soy can act on various tissues associated with menopause symptoms, such as blood vessels, the brain, or mucous membranes.

For this reason, soy isoflavones can be one of the options to consider when a woman wants to manage certain symptoms through supplementation. 

Why does body composition change during menopause?

Otro de los cambios que más preocupan durante esta etapa es la modificación de la composición corporal, especialmente la tendencia a acumular grasa en la zona abdominal.

Estrogens play a role in regulating metabolism and insulin sensitivity.

Cuando disminuyen, cambia el entorno hormonal y metabólico.

Additionally, changes in appetite and sleep disturbances may also appear during this stage.

Todo ello puede contribuir a que resulte más fácil acumular grasa y más difícil mantener la composición corporal que teníamos anteriormente.

Therefore, the approach should not focus solely on eating less.

We need to take special care of:

• Strength training.

• Adequate protein intake.

• Physical activity.

• The quality of the food.

• Rest.

How can we protect muscle mass during menopause?

Muscle is one of the main highlights of this stage.

Maintaining good muscle mass helps improve insulin sensitivity and promotes a healthy body composition.

The essential tool is the entrenamiento de fuerza.

But muscle also needs the necessary nutrients to maintain itself.

That is why we must ensure an adequate intake of protein

• Creatine.

• HMB.

• Vitamin D.

• Taurine.

It's not about replacing training with supplements.

The primary stimulus remains strength training. Supplementation can be used as support when it makes sense within an individualized strategy.

Why does vaginal dryness occur during menopause?

Los estrógenos también tienen un papel fundamental en el tejido vaginal y urinario.

They help maintain the mucous membrane and promote a suitable environment for the microorganisms that make up the vaginal flora.

Cuando disminuyen, pueden aparecer:

• Sequedad vaginal.

• Itching

• Irritation.

• Pain during intercourse.

• Infecciones urinarias recurrentes.

• Urinary disorders.

It is what we know as genitourinary syndrome of menopause.

For these symptoms, there are various options available, ranging from non-hormonal vaginal moisturizers to local estrogen treatments.

If a woman has a medical history that requires extra caution with hormonal treatments, non-hormonal options can be particularly appealing. 

When is menopause hormone therapy indicated?

Hormone therapy can be a very effective tool, but it is not suitable for all women nor should it be used as a preventive treatment in women who do not present symptoms.

The episode identifies four main situations in which it may be indicated:

1. Vasomotor symptoms

hot flashes that affect quality of life.

2. Fracture prevention

Can be used for the osteoporosis prevention

It is important to differentiate between prevention and treatment: hormone therapy is not the treatment for established osteoporosis.

3. Genitourinary syndrome

In women with symptoms such as itching, pain during intercourse, or recurrent urinary tract infections who have not adequately improved with local estrogen treatment, hormone therapy may be considered.

Urinary incontinence is an important exception, as hormone therapy can worsen it.

4. Menopausia precoz o insuficiencia ovárica primaria

In these cases, hormone therapy has a different goal: replace the hormones that should be present until reaching the average age of menopause.

Do you have to take hormone therapy for life?

No necesariamente.

Some women use it for a few years and then gradually reduce the dose. Others need to stay on it longer, and others decide to stop earlier.

The important thing is to understand that there is no single duration that is identical for all women.

It often starts during the first few years, when symptoms are most severe, and the situation is reviewed later on.

If symptoms have improved, a gradual reduction can be considered.

And if a woman decides to change her strategy, use supplements, or discontinue therapy, it does not mean she has failed.

The strategy may change as needs evolve. 

Can hormone therapy be used during perimenopause?

perimenopause-associated depression.

Durante los primeros años de esta transición se produce un cambio hormonal importante y los estrógenos influyen sobre la serotonina, la dopamina y el factor neurotrófico cerebral.

Some women may experience depressive symptoms specifically related to this transition.

But it is important to make a distinction: we are not talking about just any depression.

This is a specific situation related to hormonal transition and must be evaluated on an individual basis. 

And what about loss of libido?

A decrease in sexual desire can also occur during menopause.

Estrogen has receptors in different areas of the brain related to motivation and arousal, so its decline can contribute to a decrease in desire.

testosterone can be used for hypoactive sexual desire disorder associated with menopause.

But there is something we must not forget.

If a woman is experiencing hot flashes, not sleeping well, vaginal dryness, painful intercourse, and mood swings, it is logical that her sexual desire would also decrease.

That is why treating libido alone is not always enough.

Need to address the combination of factors affecting that woman's well-being. 

When is hormone therapy contraindicated?

Before starting hormone therapy, it is essential to evaluate your personal medical history.

Situations that contraindicate hormone therapy include:

• Unexplained vaginal bleeding.

• Active breast cancer.

• Certain hormone-dependent gynecological cancers.

• Intermediate- or high-risk endometrial cancer.

• Personal history of pulmonary thromboembolism.

• History of stroke.

• History of acute myocardial infarction.

Furthermore, there are situations where the problem lies specifically in the use of oral estrogens, such as certain blood clotting disorders, Factor V Leiden, a history of migraines, or gallstones.

En estos casos puede ser preferible, cuando la terapia está indicada, utilizar una vía transdérmica.

Therefore, before deciding which treatment to use, the first question should always be:

Am I a candidate for hormone therapy? 

What should be evaluated before starting hormone therapy?

When a woman is a candidate, there are still several aspects to consider.

In the episode, the following points are brought up for review:

• cardiovascular risk

• Carotid artery status.

• Individual breast cancer risk.

• Up-to-date mammogram.

• Bone mineral density.

And there is a fundamental question:

Do you have a uterus?

Porque esto condiciona el tratamiento.

If a woman has a uterus, estrogens must be accompanied by progesterone, ya que los estrógenos estimulan el crecimiento del endometrio.

Progesterone acts as protection against that growth.

If there is no uterus, it is not necessary to use progesterone solely for this purpose. 

What options exist within hormone therapy?

Estrogens can be administered through different routes:

• Transdermal patches.

• For oral use.

• Transdermal spray.

In general, the transdermal route avoids the first-pass hepatic metabolism of oral estrogens and can be particularly beneficial when certain risk factors are present.

Progesterone can be administered orally or vaginally.

There are also other therapeutic options, such as tibolone, which has estrogenic, progestational, and androgenic activity, and may have effects on hot flashes, sleep, mood, libido, and bones.

Another alternative is the combination of conjugated estrogens with bazedoxifene, which allows the endometrium to be protected without using progesterone.

The choice always depends on the individual characteristics, history, symptoms, and preferences of each woman.

Can we combine hormone therapy and supplements?

Yes.

Supplements and hormone therapy do not have to be mutually exclusive.

A woman can use hormone therapy and certain supplements if it makes sense for her needs.

Another may not want to use hormone therapy and choose instead to opt for nutritional and lifestyle strategies.

Another option is to use supplements during one stage and later consider hormone therapy.

And another may reduce or suspend hormone therapy when their symptoms have improved.

there is no single correct strategy for everyone.

The important thing is to achieve the maximum possible benefit with the lowest risk, using the tools that every woman actually needs.

Menopause: Understanding the Change to Better Support It

Menopause is not simply the moment when menstruation disappears.

hormonal transition that can affect different body systems

Hot flashes, mood swings, brain fog, sleep disturbances, changes in body composition, or vaginal dryness all have an explanation related to your new hormonal environment.

And precisely for that reason, the approach does not always have to be the same.

La terapia hormonal puede ser una herramienta muy eficaz cuando está indicada. Los complementos pueden ayudar en determinados síntomas. Y el ejercicio de fuerza, la proteína, el descanso y una alimentación adecuada deberían formar parte de la estrategia de salud independientemente de que utilicemos o no terapia hormonal.

Because it's not about fighting menopause.

It is about understand what is happening and thoughtfully choose the tools that best suit each stage and each woman.

Transforming your health is a matter of applying science consistently, day by day.

 

Hope you like it :)

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