Susan started having night sweats at 47. “I’d wake up in the middle of the night and even though the air conditioner was running on high, I’d be covered in sweat. Some nights I had to change my nightgown and sheets because they got so wet.” In just a few weeks, Susan began noticing other symptoms like hot flashes during the daytime, irritability, and insomnia. “I know it must be menopause coming on. It seems like one day I’m in the prime of my life, next thing I know, I’m worried about getting old. It makes me wonder if it’s time to update my will and plan for retirement!”

With an estimated 2 million American women reaching menopause each year, Susan is not alone in feeling like an unwilling captive to her hormonal roller coaster.¹ Women of previous generations endured the dreaded “change of life” by themselves, only whispering about it behind closed doors. Menopause would never have been discussed in public; it was just deemed too personal, but today’s baby boomer women demand answers, and they’re getting what they want from the Internet, magazines, talk shows, and prime time news.

Even though the average life expectancy has increased significantly over the past century, the age at which menopause occurs has not changed. American women experience menopause between ages 40 and 58, with an average age of 51.² The average woman in North America turning 50 today can expect to live about 32 more years, meaning that she will spend nearly 40% of her life in postmenopause.³ Many women are determined to get the most out of those years.

Menopause is just one day in a woman’s life — the day when she has gone 12 consecutive months without a menstrual period. That day does not come on suddenly or unexpectedly. Most women experience symptoms of varying degrees for five or more years before reaching menopause. Perimenopause stretches from the time those symptoms begin until one year after the last menses.² Typically, perimenopause lasts six to eight years, although it may be longer or shorter in some women.⁴

Life of an ovary

Human females are born with all the eggs they will ever have; however, less than 1% of them mature.⁵ The rest are reabsorbed within the ovary.⁵ By puberty, each ovary contains about 300,000 eggs housed in their own follicles.⁶ Every month, about 20 eggs begin maturation in response to an increased production of estradiol (the most active form of estrogen).⁶ Usually, only one egg matures, ruptures from the follicle, and then journeys down the fallopian tube.⁶ The ruptured follicle begins producing progesterone, preparing the uterus for implantation of a fertilized egg. If fertilization does not occur, the uterus sheds its lining and menstruation results.

As women age, the number of ovarian follicles declines dramatically. From the fetal potential of millions of eggs, only about 25,000 remain during the final 12-15 years of menstrual cycling.⁷ The ovary becomes smaller, dwindling from about 14 g during the reproductive years to approximately 5 g after menopause.⁶ The aging follicles secrete less estrogen and progesterone.

In response to the decreased ovarian hormones, the pituitary gland secretes follicle stimulating hormone (FSH), which stimulates the development of follicles. The pituitary also secretes luteinizing hormone (LH), which stimulates follicular production of estrogen, ovulation, and formation of the corpus luteum, the body in the ruptured follicle that secretes progesterone.

Pituitary hormones temporarily maintain near-normal ovarian function. FSH levels begin to increase about five years before menopause, while LH levels become elevated about a year before menopause. As time passes, increased amounts of FSH and LH no longer stimulate sufficient production of estrogen and progesterone, and the perimenopausal years begin. Even after menopause, however, small amounts of estrogen in the form of estrone continue to be produced in fatty tissue with help from the adrenal glands.

Symptoms of transition

Women tend to reach natural menopause at about the same age as their mothers and sisters, suggesting a possible genetic link.² No clear correlation has been found between menarche and menopause.² Factors that have been suggested but not proven to lead to a later menopause include multiparity and being overweight.² Smoking is the only factor that has been conclusively shown to lead to an earlier than normal menopause: on average, women who smoke reach menopause two years earlier than nonsmokers.² Other factors that may be associated with an earlier menopause include nulliparity, heart disease, and treatment of childhood cancer with pelvic radiation or certain types of chemotherapy.

Induced menopause is that caused by medical or surgical treatment. Surgical removal of both ovaries causes immediate menopause. A hysterectomy with ovaries left intact may result in menopause occurring within two to three years, probably because of disruption of ovarian blood supply.² Chemotherapy or pelvic radiation may cause an immediate menopause or one that occurs over several months, depending on the treatment.² Women with induced menopause may experience a sudden and severe onset of menopausal symptoms compared with women who have a natural menopause.

About 90% of women have symptoms during the years prior to menopause.² The symptoms women experience, typically starting in their 40s, are due to fluctuations in estrogen and progesterone levels. The variation in circulating estrogen during perimenopause is substantial. Average estrogen levels in perimenopausal women are higher and more significantly variable than in women at any other stage, including puberty.⁸ Coupled with lower progesterone levels, it’s not surprising that the majority of perimenopausal women feel like they’re caught up in a hormonal storm.

While perimenopausal symptoms are normal, they should not be taken for granted. It should not be assumed that unusual symptoms and changes in the menstrual cycle are solely due to perimenopause. Women with new symptoms should have a thorough evaluation by their health care provider to ensure that the symptoms are not indicative of pathology.

Young women may mistakenly believe that menopause begins with a decline in the frequency of menstruation until it stops entirely. Other women think mostly about hot flashes when they think about menopause. One study showed that despite the increase in consumer information about menopause in recent years, many women remain unfamiliar with the symptoms of perimenopause.⁹ The most commonly experienced symptoms are described below.

Menstrual irregularities: The most common early sign may be changes in the menstrual cycle. Cycles may become longer or shorter than average, or occasionally, completely skipped. Flow may be scanty to profuse. As ovulation becomes increasingly erratic, a decrease in progesterone levels may lead to longer and heavier periods.

Hot flashes and night sweats: About 85% of American women experience hot flashes during perimenopause.¹⁰ The pattern varies in each woman. Some report only minor hot flashes for a few months, while other women experience them for a longer period of time. Fifty percent of women who have hot flashes have them for at least five years.¹¹

Associated with a drop in estrogen levels, hot flashes are the result of the hypothalamus mistakenly sensing that a woman is too warm. It sets off a series of events to cool her down, including peripheral vasodilation in an attempt to radiate body heat. It may also utilize perspiration to help cool the body. A chill may follow the hot flash. These are known as vasomotor symptoms.

Night sweats are hot flashes that occur during sleep. Some women wake up so drenched with sweat they must change their nightgowns and sheets. The heavy sweating can lead to shivering and a need to bundle up, only to experience another hot flash a few moments later.

Insomnia: Night sweats can lead to serious disruption of normal sleep patterns. In one study of women with severe hot flashes or night sweats, 81.3% had symptoms of chronic insomnia.¹⁰ Sleeping problems include difficulty falling asleep, waking in the middle of the night with inability to fall back to sleep, and early morning awakening. Insomnia is common during perimenopause, even in the absence of night sweats. Some women report insomnia as their only perimenopausal symptom.

Genitourinary changes: Estrogen depletion can cause changes in the vagina and urinary tract that may affect a woman’s quality of life, especially during the years following menopause. Tissues of the vulva and vagina become thinner, drier, and less elastic as collagen and fat content is lost, leading to greater risk of infection and injury. Allergic reactions to soap and feminine hygiene products are common and may lead to genitourinary irritations and infections.

The lining of the urethra thins and pelvic muscles may weaken, leading to possible urinary problems such as increased frequency, urgency, infections, and stress incontinence. Normal vaginal secretions decrease so intercourse may be painful, which may lead to decreased pleasure for either partner. Over-the-counter vaginal lubricants may alleviate some of the discomfort.

Mood changes: Many women report depression, poor concentration, irritability, memory loss, and anxiety during perimenopause. Women who easily managed normal life stresses in the past may find it more difficult to cope. Most of these problems are due to normal hormonal fluctuations but may be due to insomnia. Hot flashes can aggravate mood changes as well. The decrease in endogenous estrogen sets off a cascade of chemical changes that can affect body and mind: norepinephrine increases (inducing hot flashes); serotonin decreases (causing insomnia, depression, and fatigue); dopamine and acetylcholine decrease (leading to memory changes, insomnia, depression, and fatigue).⁸ These changes may have a negative impact on the real and perceived quality of life, and in some instances may have a greater negative impact than symptoms alone.

Fertility and contraception

Because of aging eggs, fertility begins to decline among women age 35-38, about 10 to 15 years before menopause.² Older reproductive-aged women experience higher rates of miscarriage and genetic abnormalities. In addition, they have a greater risk of complications of pregnancy such as gestational diabetes and are likely to require cesarean sections more frequently than younger women. Women wishing to become pregnant in their later reproductive years may require assistance through advanced reproductive technologies.

Despite the decreased fertility in perimenopausal women, they are not protected from pregnancy until 12 months after their last period. Women wishing to avoid pregnancy must use contraceptive measures throughout the perimenopausal years. An array of choices is available, including sterilization (tubal ligation for women and vasectomy for their partners), barrier methods such as condoms, diaphragms, spermicides, and cervical caps, and intrauterine devices. Effective hormonal contraceptives include oral preparations, injections, patches, and vaginal rings.

Today’s low-dose oral contraceptives may combine estrogen and progestin or may contain only progestin. Such hormonal contraception has been considered safe for most midlife women.^12,13 Contraindications include a history of blood clots, heart disease, breast cancer, uncontrolled hypertension, and cigarette smoking. Use of oral contraceptives may mask perimenopausal symptoms and pose a dilemma as to when a woman should stop taking them. Women should work with their health care providers to ensure that they are protected from unwanted pregnancies.

Women should remember that they still are susceptible to sexually transmitted diseases during and after the perimenopausal years. Up to 15% of people diagnosed with AIDS in the United States are 50 and older.¹ Vaginal, oral, and anal intercourse must include use of condoms to prevent the spread of potentially deadly diseases such as HIV and hepatitis. Condom use should not be discontinued unless both partners have been proven free of STDs and are committed to a monogamous relationship.

Alleviating the symptoms

Some women sail through perimenopause without distressing symptoms. Many will experience only mild to moderate symptoms. A few women will suffer from symptoms severe enough to disrupt their daily lives. Every woman owes it to herself to become knowledgeable regarding her options so she can make an informed decision about available treatment that may improve her quality of life.

Hormone therapy: Until 2002, millions of women routinely took hormone therapy, usually as a combination of estrogen and progesterone. Health care providers promoted hormone therapy as a means to alleviate perimenopausal symptoms and benefit cardiovascular health. As a result of the Women’s Health Initiative, a 15-year research program to explore quality of life in postmenopausal women, women learned the disturbing news that hormone therapy actually increased the risk of stroke, heart attack, breast cancer, and venous thromboembolism. Yet estrogen is remarkably effective in relieving hot flashes, preventing vaginal dryness, decreasing urinary incontinence, and slowing or preventing osteoporosis.

Today, women and their health care providers have a difficult decision to make regarding hormone therapy. While this is a complex issue, the general trend is to prescribe the lowest possible dose of hormones for the shortest period of time needed to control symptoms in perimenopausal women. If not contraindicated, low-dose oral contraceptives may be used for symptom relief, even in the absence of a need for contraception.¹⁴ A physician panel sponsored by The North American Menopause Society includes these recommendations in its position statement on the subject:¹⁵

• Estrogen therapy (ET) or estrogen/progesterone therapy (EPT) is acceptable in younger women on a short-term basis.
• The primary indication for ET or EPT is to treat moderate to severe symptoms and sleep disturbances.
• Local ET is recommended for treating moderate to severe vulvar and vaginal atrophy, dyspareunia, and atrophic vaginitis. However, systemic ET can be appropriate for this purpose.
• The decision to use ET or EPT on a long-term basis for disease prevention (such as osteoporosis) or quality of life improvement must be carefully considered in terms of risk versus benefit of the therapy.

Nonhormonal prescription medications: Women with severe vasomotor symptoms who cannot or who don’t want to take hormonal preparations have other options available to them. Newer antidepressants result in an increase in serotonin and other neurotransmitters and have been shown to be effective in reducing vasomotor symptoms. Fluoxetine (Prozac), venlafaxine (Effexor), sertraline (Zoloft), and paroxetine (Paxil), are typically given in lower doses for vasomotor symptoms than when prescribed for depression.^4,14 The anticonvulsant gabapentin (Neurontin) and the antihypertensive clonidine (Catapres) are also being used for this purpose.^4,14 These medications all carry the risk of significant side effects, and patients should be monitored closely during their administration.

Alternative therapies: Some women turn to alternative medicine, or botanicals, for help with their symptoms. Women considering the use of alternative medicines should check with their health care providers to be certain the proposed therapy is safe. Women should become familiar with the potential benefits and risks of any alternative medicine, because many products are not approved by the Food and Drug Administration. The amount of active ingredients in the products can vary significantly, and there have been few controlled studies proving their effectiveness. In some cases, placebo achieved the same effect as botanical medication. Also, some products can interact in unexpected ways with prescription medications.

The National Institutes of Health’s Center for Complementary and Alternative Medicine offers this information on several commonly used products:¹⁶

• Soy: The scientific literature includes both positive and negative results for the use of soy products for hot flashes. When taken for short periods of time, soy appears to be safe with few side effects. (As these compounds may interact with estrogen, women with estrogen-dependent cancers should ask their health care providers about them.)
• Black cohosh: This herb has received more scientific attention for its possible effects on menopausal symptoms. Studies of its effectiveness in reducing hot flashes have had mixed results, but it has a good safety record.
• Red clover: Five controlled studies found no consistent or conclusive evidence that extract of red clover reduces hot flashes, although it appears to be safe.
• Ginseng: May help with mood symptoms, sleep disturbances, and overall sense of well-being, but it has not been helpful for hot flashes.
• Dong quai: Only one randomized clinical study has been reported, and the product was not helpful in reducing hot flashes

Nursing implications

Today’s midlife women are often busy with careers and family that may extend not only to their nuclear family but also include their aging parents. The hormonal changes, menstrual irregularity, and worries about aging and mortality add up to make some women feel out of control. The level of distress a woman experiences during the perimenopausal/menopausal period often is based on her expectations. New coping skills may be required to weather these turbulent years. Women who readily accept the changes of perimenopause are more likely to embrace the onset of the second half of their lives.

Emotional health may be achieved by striking a balance between self-nurturing and the obligations of work and caring for others. Women can learn to identify their stressors and minimize them as much as possible through activities such as exercising, meditating, finding creative outlets, spending time with family and friends, and maintaining optimum physical health.

The perimenopausal years present an ideal opportunity for nurses to educate patients about beneficial lifestyle changes and health maintenance activities. Often women may not be getting the information they need about available treatments that can help them manage their perimenopausal years. One report showed that less than 30% of women going through menopause have had an individualized discussion with their health care provider regarding menopausal symptoms, risk for chronic disease, or the use of hormones.⁴ Some authorities believe education and anticipatory guidance for perimenopausal women should begin with women in their 30s.⁹

Nurses can work with women to evaluate their health status and encourage them to begin or reinforce a health program that will ensure the best possible health for the coming years. While a woman’s age and genetics cannot be altered, other risk factors for heart disease — the leading killer of American women — can be lessened. Smoking cessation is the most important thing a woman can do to improve her health. Control of cholesterol, diabetes, and hypertension are also crucial.

Nurses are aging as rapidly as the rest of the population, meaning that hundreds of thousands of nurses are presently in their perimenopausal years. Armed with the knowledge of what to expect, nurses can serve as role models for their patients and for other women as well. Nurses can convey the belief that menopause and the transitional years that precede it are a normal stage of life and not an illness requiring a cure. Many women reaching menopause today will find those years to be happy, productive, and rewarding.