A Conversation with Dr. Ezra Dori, Obstetrician/Gynecologist
Menopause is a highly under-recognized life shift. It is not talked about enough and not given enough airtime even in the doctor's office.
This conversation will explore what actually happens to a woman's body during menopause. The ovaries that produce hormones responsible for pregnancy - estrogen and progesterone - slow and ultimately stop. Menopause is the bodyâs way of recognizing this life stage.
The average age of menopause, defined as when vaginal bleeding has completely stopped for over one year- is 51 or 52 and the age range is 45-52. Perimenopause starts 5 years prior and during this phase a woman undergoes sharp changes in her cycle and may begin to experience some of the symptoms of menopause.
Primarily, menopause is a change in reproductive physiology. Typically, a menstrual cycle is 28 days. Some women, due to conditions like polycystic ovarian syndrome, have irregular cycles. Cycles vary greatly from woman to woman. Some women may have longer or shorter cycles; and for other women, an irregular cycle is their normal cycle.
During the perimenopause years, there is a change in whatever pattern exists. The days of menstruation begin to get shorter, as the period starts the process of tapering off.
An important question to consider during perimenopause is, âIf someoneâs normal cycle is abnormal how do we then define abnormal, versus normal periods?â Itâs not always so easy to figure out. Any abnormality should be discussed with a doctor. Usually people start to bleed irregularly in perimenopause and it can be confusing. If a woman is bleeding in greater volume and there is staining between cycles, a thyroid issue could be the cause. There may be fibroids in the uterus that could cause a polyp - a small, benign growth.
Doctors need to distinguish between abnormal and normal bleeding. Sometimes the irregular bleeding indicates a pregnancy. It often happens that women approaching perimenopause years come in because they are concerned about a new pattern in their period and find that it is due to an unexpected pregnancy.
In the case of a possible abnormality the protocol is to complete a thyroid check to determine if hormone levels are within normal range. Next we will prescribe a transvaginal ultrasound in order to see the depth of the lining of the uterus, specifically the contour of the uterus. Typically the lining is thin. A thicker lining could be cause for further investigation. We also look at ovaries during the ultrasound. If there is warranted cause for further testing we will complete an endometrial biopsy which gives us a lot of information - and this procedure is much more modern and less invasive than it was two decades ago. It is performed in the office and it takes about twenty minutes. It does get somewhat uncomfortable, so taking a tylenol before is recommended. Weâll also do a blood test. We use all the data gathered to put a whole picture together to form next steps of treatment. The data points us in the best direction of how to proceed.
Before you turn to natural interventions to alleviate symptoms of menopause, verify with your doctor that you have no other medical concerns. As a patient, youâre essentially partnered with your doctor about your health. The goal is to be diligent and comprehensive and make sure nothing was missed.
In review, to address a suspected abnormality in the bleeding pattern at this time, the protocol is: medical history, pregnancy test, ultrasound, endometrial biopsy, and blood tests. Usually, we find benign tissue, a clear pap smear, thyroid and blood count is normal and we simply tell patients to keep an eye on symptoms. For the minority of people in whom we discover something out of the ordinary, we need to find out what further interventions are needed.
Symptoms of Menopause and Quality of Life:
These symptoms can be tricky to explain because sometimes the changes are emotional, not strictly physical. Symptoms vary greatly from person to person. Some women do not have hot flashes and some have severe episodes, along with vaginal dryness.
For a woman in her 40âs, presenting with hot flashes, dryness, and irritability, often a low dose birth control is prescribed.
In some cases, a low dose hormone replacement therapy is prescribed. Women tend to be cautious of hormone replacement therapy. There are risks and benefits involved that need to be considered with your doctor, however crossing a busy street poses greater danger than hormone replacement therapy.
Emotional Component of Perimenopause and Menopause
It is important to recognize that life is busy. Managing a family, household and career is significant and can impact hormone levels. The start of menopause is similar to first weeks postpartum which can have highs and low and sometimes low-grade depression. The first line of defense in regulating moods and emotions is to decrease caffeine and sugar consumption, and set aside time for exercise which has a great impact on mental health. Monitoring diet and exercise is a super simple yet effective and impactful intervention. Diet and exercise are basic interventions that sometimes get overlooked. Studies have shown that 30 minutes of exercise has a similar effect to taking an antidepressant.
Another important factor to consider is home life. Ask yourself, âIs everything OK at home? Am I perhaps avoiding something that needs to be addressed, perhaps with one of my children, in the family routine, or in my relationship with my husband?â. When going through a significant life change such as menopause it is critical to take a step back and evaluate your life holistically, from different vantage points.
After these non-pharma interventions, we may prescribe a low dose antidepressant such as Zoloft just until the moods stabilize. In most cases, itâs a short term prescription.
Paxil, an SSRI, was originally used to treat depression but in low doses, has been shown to be beneficial in managing hot flashes.
Men are also a factor in menopause. Itâs important for men to be very supportive of what their wives are going through and take the symptoms seriously. Husbands are encouraged to come into the office with their wives for their doctor appointments to fully understand and attain the knowledge of the experiences of their wife.
Non Medical/Alternative Interventions
Massage therapy, talk therapy and acupuncture can be very helpful to alleviate symptoms of menopause. With regard to vitamin supplements, often the thought process is: âHow can a natural substance be dangerous?â Yet recently, vitamin A was found to harm fetuses in high amounts. The logical approach is, use moderation, do research and experiment - if something hasnât worked in 30 days, it probably wonât start working.
There are some natural remedies that historically have been effective. Valerian root for mood irregularities, has sedative capacities and is quite effective. Soy based products can be helpful for hot flashes.
Unexpected Pregnancy
In our practice, I usually prescribe birth control until age 50 as I have patients very scared of getting pregnant. I check follicle stimulating hormone (FSH). This test determines ovarian reserve. Weâre looking for a number above 40, indicating that it is highly unlikely that youâll get pregnant. With a low FSH, the chances of getting pregnant in your 50âs are extremely rare. Personally, I donât like women being on birth control for so long because it can start to affect the breasts and have other effects. Some women want to stay on birth control into their 50âs because they feel better on it and can control their periods among other benefits. However itâs important to note that this becomes a shared risk with your provider. Review the pros and cons with your provider and make an informed decision together, not just an emotional one. The risks are not terrible, but make sure to understand them. When I take people off birth control and then they bleed heavily we then need to go through the protocol mentioned earlier to rule out any medical abnormality.
Pregnancy in Later Fertile Years
In our practice, we have had a woman, turning 49, who came in with thinking she had symptoms of menopause and it turned out she was pregnant. She was a new patient and was quite surprised, she was in disbelief. Thank G-d she had a healthy pregnancy and delivered a healthy baby.. The later a woman gets pregnant, the higher risk for a chromosome issue or miscarriage. The miscarriage rate overall is 15-20%
Weâve seen women up to age 46 having a healthy pregnancy and carrying a baby to term. From a medical perspective getting pregnant into your 40âs is fine, assuming you donât have pre-existing conditions such as high blood pressure. We also consider the number of C-sections a woman has had.
Other than the higher risk of a chromosomal irregularity, diabetes and preeclampsia are more common in older pregnancies so the monitoring is closer.
As to whether or not itâs advisable to get pregnant in your 40âs from a halachic standpoint- we recommend to determine on an individual basis with your Rav.
Preventative Medicine During Perimenopause and Menopause Ages
Colonoscopies
Colonoscopy screenings begin around menopause age. People really donât like going to get a colonoscopy, it's very uncomfortable, but it can be lifesaving. Read about diet shifts before you make an appointment- eating differently a few days before the procedure can lessen discomfort. The recommended age to start colonoscopies was 50 for a long time but the recent uptick in colon cancer has caused the starting age to drop to 45. Colonoscopies need to be done every 3-7 years depending on the results, sometimes doctors want to monitor things that come up in the screening, so the interval between tests will be shorter- this is not cause for alarm.
Mammograms
Mammograms usually begin at age 40, sometimes earlier depending on your family history and if you are positive for the BRCA gene. Moving into the 40s, breasts tend to get denser, so sometimes radiologists will want to get a closer look, an ultrasound of the breast may be prescribed. Donât be alarmed by getting called back 6 months or so later. If G-d forbid something unusual comes up in the screening, the follow up will be immediate.
A general practitioner usually will prescribe colonoscopies, another doctor such as an OBGYN will follow up with you and ask â hey do you get regular mammograms? Have you had a colonoscopy?â This way there is a protective measure in place to make sure youâre indeed receiving the necessary, lifesaving screenings.
Osteoporosis
Weight bearing exercise, diet and exercise are all simple, accessible preventive measures for osteoporosis. The primary concern of osteoporosis is fractures, which are extremely common when bones are brittle.
If youâre in your 60âs and above, be aware of avoiding falls- very simple but important.
Avoid a trip to the ER and a surgery. Calcium, vitamin D and weight bearing lower risk of osteoporosis. There is a test that can be done to determine how brittle your bones are, and based on the results you can adjust your lifestyle accordingly- a simple intervention to avoid other traumas.
Post Menopausal Bleeding
When someone has not bled for over a year and is officially menopausal, any bleeding should prompt an evaluation. Yet, this doesnât always indicate that something is wrong. We must rule out bleeding from the uterus which could be a serious condition- the first step would be an endometrial biopsy. It's a relatively easy, in-office procedure.
Menopause is under-represented medically. If your doctor is not so available or does not give you the time you need in the office, find another doctor that specializes in perimenopause and menopause-age treatment. It is incumbent upon you to advocate for your health. Yes, doctors are there to be in your corner, but you know your own body the best. Be sure to address any concerns with your provider even if something feels embarrassing, bring it up for peace of mind and to see if any further actions are necessary.