In your mid-40s, you begin a transitional phase called perimenopause, a period marked by changing hormone levels and menstrual cycles that generally lasts from age 45 to 55. During this time, the ovaries get smaller and produce less estrogen. Other changes occur, too, though they happen so slowly that you may not notice them. Menopause is defined as the absence of a menstrual period for at least one year. On average, most American women have their last menstrual period at age 51. Although all women go through the same basic changes, no two women experience perimenopause in exactly the same way. Some have mild symptoms, while others symptoms are more severe.
It is important to remember that perimenopause and menopause are natural events that are best experienced fully informed. By knowing what to expect, you can take steps to ease symptoms and prevent health problems later in life.
Your Changing Menstrual Cycle
During your childbearing years, your menstrual cycle is controlled by the production of two hormones made by the ovaries estrogen and progesterone. During the first part of the cycle, the ovaries release estrogen, a hormone that causes the endometrium the lining of the uterus to grow and thicken to prepare the uterus for pregnancy. Ovulation, a process in which one mature egg is released by an ovary each month, occurs in the middle of the cycle. (The ovaries contain thousands of eggs, but only 400 or so are released in a women’s lifetime; the body absorbs the rest.) After ovulation, progesterone levels begin to increase. If the woman doesn’t become pregnant, estrogen and progesterone levels decrease, triggering menstruation, or the shedding of the uterine lining.
During perimenopause, the ovaries begin to make less estrogen. Some months, there may not be enough estrogen to thicken the uterine lining. Ovulation may not occur, and you may skip a menstrual period. During this time, the number of days between periods may increase or decrease, your periods may become shorter or longer, and menstrual bleeding may become heavier or lighter.
Although changes in menstruation are normal as you near menopause, they should be reported to your doctor. Abnormal bleeding can be a sign of other problems. See your doctor if you have any of the following symptoms:
- Bleeding between periods
- Bleeding after sex
- Spotting at anytime in the menstrual cycle
- Bleeding that is heavier or lasts for more days than usual
- Bleeding after menopause
A woman can be sure she has entered menopause when she has not had a menstrual period for one year. However, a woman is not completely without estrogen after menopause. It continues to be made by body fat and other glands, though there is less of it than before menopause.
The stage of life between the ages of 40 and 60 is a period of ongoing transition often marked by increased feelings of physical and emotional well-being. For many women, midlife is a time to establish new goals, plan for the next life stage, switch careers, go back to school, become active in the community or take up new hobbies. It’s also a time of incredible physical change.
As you approach menopause, you may start experiencing hot flashes, one of the most common and uncomfortable symptoms of perimenopause. A hot flash is a sudden feeling of heat that rushes to the upper body and face. The skin may redden and you may break out in a sweat. It can last from a few seconds to several minutes or longer.
Hot flashes can occur a few times a month or several times a day, depending on the woman, and can happen at any time, day or night. Those occurring during sleep, called night sweats, may wake you up and leave you tired and sluggish the next day. Some women will get hot flashes for a few months, some for a few years, and some won’t get them at all. Some will continue to experience them into their 60s and 70s. Although hot flashes are a nuisance and often embarrassing, they are not harmful.
Sleep problems are common among perimenopausal women. You may have insomnia (trouble falling asleep), or you may wake up much earlier than usual. Night sweats may disrupt your sleep. It is unknown whether sleep changes are the result of growing older, hormone changes, or both.
Perimenopausal women may not get enough rapid eye movement (REM) sleep, the stage when dreaming occurs. Without REM sleep, you will not feel rested. When normal sleep rhythms are broken, a woman’s moods, health and ability to cope with the changes she is experiencing may be affected. She may have trouble concentrating or become depressed.
If you are having trouble falling or staying asleep at night, try the following suggestions:
- Stay on a schedule. Go to bed and wake up at the same time every day, including weekends.
- Eat regular meals at regular times. Avoid late meals and filling snacks.
- Limit caffeine, which is found in coffee, tea, chocolate and colas. Caffeine stays in the bloodstream for up to six hours and can interfere with sleep. Consume as little as possible, and limit it to the morning or early afternoon.
- Avoid nightcaps. Alcohol may make you feel drowsy, but it also affects the pattern of REM and non-REM sleep and may cause you to wake up often during the night.
- Exercise regularly, but not within three hours of bedtime. In general, people who are fit tend to sleep better.
Vaginal and Urinary Changes
As estrogen levels decrease, changes take place in the vagina. Over time, the vaginal lining gets thinner, drier and less elastic. Some women experience vaginal burning and itching. It may take longer for the vagina to become moist during sex. This vaginal dryness may cause pain during intercourse, and vaginal infections may occur more often.
The decrease in estrogen may thin the lining of the urinary tract and weaken supporting tissues. As a result, you may need to urinate more often and the urinary tract may become more prone to infection.
Our bones are always changing. As old bone is broken down and removed by the body, new bone is formed. From childhood until age 30, bone is formed faster than it is broken down, and bones become larger and denser. After age 30, the process begins to reverse: Bone is broken down faster than it is made. A small amount of bone loss after age 35 is normal in all women and men and doesn’t usually cause problems. But in the first 4 to 8 years after menopause, decreased estrogen levels cause rapid bone loss in women. (The estrogen produced before menopause protects bone tissue.)
Too much bone loss can increase the risk of osteoporosis, a condition that causes bones to become thin and weak, and can result in breaks or even disability. Later signs of osteoporosis include back pain or tenderness, slight curving of the upper back, and height loss. When spinal bones weaken and collapse under the weight of the upper body, they can cause a pronounced curve or hump in the back.
To prevent bone loss and reduce the risk of osteoporosis, you should try to build and keep as much bone as you can before menopause. You can do that by getting plenty of calcium and exercise. Women younger than 50 need 1,000 mg of calcium a day; women 50 years and older need 1,200 mg of calcium a day. Milk and other dairy foods are good sources of calcium, or you can take a daily calcium supplement.
Vitamin D helps the body absorb calcium. Your body makes vitamin D on its own if you get 15 minutes of sunlight each day. However, many women do not get enough vitamin D, and the body’s ability to make vitamin D from sunlight decreases with age. Women should get 400 to 800 international units of vitamin D daily. The best sources of vitamin D are fatty fish, such as salmon and tuna.
Just as muscles get stronger with regular exercise, so do bones. Active women have higher bone density than women who do not exercise. Regular weight-bearing exercise, done three to four times a week, can strengthen bones and slow bone loss. Weight-bearing exercises include activities where muscles and tendons put extra pressure or tension on the bones, stimulating them to make new bone tissue. Such activities include brisk walking, hiking, stair stepping, tennis, running and lifting weights. Balance training may help you avoid falls, which also could lead to broken bones.
All postmenopausal women 65 years and older should have a bone mineral density (BMD) test; those younger than 65 should have a BMD test if they have fracture risk factors. The BMD test measures the amount of bone in the spine, hip, wrist or other bones to determine bone density in other parts of the skeleton. Based on these test results and other risk factors, your doctor may recommend that you increase calcium intake, get more exercise, quit smoking or limit alcohol consumption.
Cardiovascular disease is the No. 1 killer of women in the United States, accounting for more than 33 percent of all deaths in women each year. More women die from cardiovascular disease, which includes heart disease and stroke, than from all forms of cancer combined. About 450,000 women die from cardiovascular disease each year, compared with 72,000 from lung cancer and 40,500 from breast cancer.
Women who have not yet reached menopause are at lower risk for cardiovascular disease because the estrogen they produce protects against heart attacks and stroke. However, the risks of heart disease and stroke increase after menopause because less estrogen production means less protection.
Risk factors for heart disease also increase during midlife. These include high cholesterol, high blood pressure, smoking, a high-fat diet, diabetes, physical inactivity and being overweight. Heart disease is almost twice as likely to strike inactive people than people who exercise regularly. The best exercises to strengthen your heart and lungs are brisk walking, running, swimming and other aerobic activities.
Sexual Changes in Women
Even though your body is changing, you can enjoy an active sex life well after menopause. When estrogen levels are low, vaginal tissue becomes thinner and dryer, often causing discomfort during intercourse. Water-soluble or silicone-based lubricants can help moisten the vagina. Having regular sex may help, too. In fact, an active sex life increases blood flow to the genitals and may help you prevent some of the vaginal changes associated with aging. If sexual intercourse is not comfortable, it may help to remember that sex can include such activities as kissing, fondling, oral sex and mutual masturbation.
Lack of interest in sex is the most common sexual concern reported by women. Many women may not feel a desire to have sex until they begin to engage in sexual activity and subsequently become aroused. As women age, sexual arousal takes longer. It is important to talk with your partner about what you are feeling and what excites you. You may want to spend more time on foreplay or try new positions. However, if you have no interest in sex at all, and this lack of interest becomes a problem for you and your partner, you may want to seek a solution, either on your own, with your partner or with the advice of your health care provider. Lack of sexual desire also can be a sign of depression.
Although some postmenopausal women enjoy sex less than before, many women say their sex lives improved after menopause. With pregnancy worries behind them, they feel more confident and adventurous. An array of sexual how-to books, videos and devices are available for couples to try together. You may find that sex is now more enjoyable than ever.
Sexual Changes in Men
As men age, they may take longer to get aroused and their erections may become less rigid. These changes are normal and should not affect sexual satisfaction. However, some men may suffer from erectile dysfunction (ED), a condition that prevents them from keeping an erection long enough for intercourse. ED, which affects almost all men at some point during their lives, may be caused by such diseases as diabetes, by certain drugs or by surgery. It can also be related to stress, fear, depression or emotional problems. Many treatments are available for ED, including medications, penile implants and surgery. If your partner is experiencing ED and it is affecting your sex life, see a health care provider.
Constantly changing hormone levels during perimenopause can affect a woman’s emotions. Some women experience mood swings, symptoms of depression, memory lapses and poor concentration during perimenopause. It is not clear whether these problems are caused by changing hormone levels or the natural effects of aging on the brain. Not all women experience these symptoms, but those who do may find it difficult to cope.
Losses, new demands and unsettling changes are common at midlife. If your children are entering those challenging teen years, they may pull away, talk less openly with you or act moody or hostile. If your children are grown and out of the house, you may feel less needed.
About 2.5 percent of all U.S. babies are born to women age 40 and older. Becoming a mom at midlife no matter how joyful an event is a big adjustment, and you may find yourself struggling to juggle a job, child care, household chores and 3 a.m. feedings. If you are a single mother, the challenges are even greater.
Perhaps the roles have reversed and you now find yourself parenting your parents in addition to your other responsibilities. Today, nearly 22 million Americans are caring for aging parents.
Women who never married or had children also face midlife changes, and may become concerned about the future and a lack support in confronting new challenges.
Despite these challenges, midlife can be a rewarding phase of life. You are wiser and better equipped emotionally to handle problems than at any other time. Midlife may reveal strengths you never knew you had.
How to Cope
The best way to get through midlife’s rough spots is to reach out for help. Talking with others can be reassuring. You may find that friends are facing the same fears and stresses. Counseling and support groups exist for everything from grief and divorce to career changes.
If you are bothered by unsteady emotions or mental lapses, talk to your health care provider. You’re likely not going crazy, as many women fear, but instead are dealing with the symptoms of perimenopause. These symptoms often occur when life’s pressures are greatest: raising teenage children, caring for aging parents and managing career responsibilities. Exercising regularly, controlling stress and getting more sleep can help. Antidepressants can help even out moods. Sometimes, just knowing what is wrong can bring relief.
Hormone therapy can be helpful for treating the symptoms of perimenopause. There are risks and benefits of hormone therapy. Many of the risks are related to a woman’s health and family history. If you are thinking about taking hormone therapy, it is important to learn as much as you can and discuss your options with your health care provider.