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Menopause is something we are taught to dread. The misery of hormonal imbalances. Mood swings. Hot flashes. Night sweats. Insomnia. Even deep feelings of sadness and loss. Menopause lurks in every woman’s future, an inevitable change that provokes anxiety.

Yet in recent years, there is a new understanding of how to approach menopause — the permanent end of a woman’s menstruation and fertility, medically defined as beginning a year after a woman’s last period. According to many experts, taking a proactive approach to menopause can result in a relatively smooth, and even positive, transition.

For Mary Casey, menopause was just that. “I started to wonder when it was going to happen [when I turned 50],” says Casey, now 52. She soon got her answer. During the next year, her periods shortened, and six months after she celebrated her 51st birthday — the average age for menopause in the United States — her periods stopped abruptly. She started suffering night sweats and hot flashes, which came and went sporadically over the next several months. By taking the herbal supplement black cohosh, however, she soon curtailed these.

Now, two years later, menopause has done little to slow Casey down. She still works long hours as a financial consultant in Louisville, Ky., and volunteers for several charities. And she makes her health a priority. She walks every day, practices yoga weekly, and spends weekends cooking and catching up with friends.

“Mary is more balanced and more beautiful today than ever before,” says Joe Perkowski, her husband of 11 years. “She seems to be relaxing and expanding into life in new ways.”

Rose Kumar, MD, would like to see more women approach their changing bodies with Casey’s attitude. Kumar is the author of Becoming Real: Harnessing the Power of Menopause for Health and Success. For years, she says, women have been taught that menopause equals misery — but that is simply because women’s health has been pathologized by the healthcare industry.

“We need to remember that menopause is not a disease,” says Kumar: “It’s an opportunity to transform and connect with our real selves.”

Perimenopause: The Transition to Menopause

Every woman follows a different path to menopause. This transition is called perimenopause, the time during which a woman’s fertility starts to wind down. Typically, women’s ovaries start making less estrogen and progesterone — the hormones that regulate menstruation — in their late 30s. Perimenopause can begin up to 15 years prior to menopause. Other women spend as few as four years in the transition.

Exactly when perimenopause begins and ends is hard to quantify because it’s a retrospective diagnosis, says Mary Jane Minkin, MD, author of A Woman’s Guide to Menopause and Perimenopause. In other words, you can only know how long you’ve been in perimenopause after you’ve spent that year without a period, which signals menopause.

For some women, the journey is much more abrupt — and, potentially, emotional. Surgeries, such as hysterectomy or oophorectomy (removal of one or both ovaries), bring on “surgical menopause” immediately.

“Medical menopause” is brought on by cancer treatment, namely chemotherapy, and can shut down the ovaries in a matter of weeks. Both surgical and medical menopause are precipitous changes that dramatically affect hormonal balance. Women thrust into early menopause should seek out their healthcare practitioner’s advice for picking their way through this rocky physical and emotional landscape.

Regardless of your route to menopause, you can smooth the ride by paying attention to your hormonal health at an early age, says Christiane Northrup, MD, author of The Wisdom of Menopause. Northrup counsels her patients to treat every period as a progress report on their own hormonal balance. Do you have severe premenstrual syndrome, fibroids, or trouble getting pregnant or staying pregnant? If so, your hormones need tending. “A choice point arrives every month,” she says. “You can resolve hormonal issues or sweep them under the rug.”

It’s important to manage your hormonal health effectively. And the sooner you start, the better, advises Sara Gottfried, MD, author of The Hormone Cure. “If hormonal health isn’t on your radar screen,” warns Gottfried, “perimenopause will hit you over the head like a two-by-four.”

The hormones that most affect peri-menopausal and menopausal women are cortisol, thyroid, and estrogen. “These are the three biggest needle movers,” says Gottfried. “If you can get these working for you, you’ll have smooth sailing.”

Here’s a quick description of each hormone and its role in your body:

  • Cortisol is a stress hormone created in the adrenal gland that controls the body’s fight-or-flight response. It alerts the nervous system to threats — real and imaginary. Women who are hypervigilant often find themselves simultaneously feeling wired and tired. Too much cortisol in the blood ratchets up cravings for sugar, fat, and alcohol. (For more on cortisol, see “How to Balance Your Cortisol Levels“.)
  • Thyroid hormones are made in the thyroid gland and determine energy level, weight, and mood. Signs of thyroid glandular trouble include weight gain, constipation, hair loss, fatigue, depression, and mood swings. (See “What You Need to Know About Your Thyroid” for more on this all important gland.)
  • Estrogen mainly comes from your ovaries and keeps tissues pliable, joints flexible, and mood steady. It also balances your body’s cortisol and thyroid-hormone production.

No one single hormone causes all the problems during perimenopause and menopause. Estrogen is often blamed, but it actually holds steady for much of the transition. Think of perimenopause as a combination of changing hormone levels and preexisting brain chemistry, advises Northrup.

This means that if you have been suffering from stress, depression, and anxiety prior to perimenopause, your hormones will likely be affected and you may be in for a bumpy ride. “Hormone imbalance doesn’t happen in a vacuum,” explains Claudia Welch, MSOM, author of Balance Your Hormones, Balance Your Life. “Hormones respond to our environment, our actions, and our perceived stressors.”

Those factors change as you age, as do the strategies for managing them. Here’s a decade-by-decade guide on how you can take charge.

In Your 20s: Gather Data and Examine Your Priorities

The post-teen years are the perfect time for you to tune in to your body’s hormonal signals because they are usually not competing with other age-related aches and pains. Everything from your fertility to your libido to the health of your relationships is telling you something.

Consider the shape you’re in two days before your period. “If those two days are a piece of cake, you’re in good shape,” says Northrup. If not, do some detective work.

Women who rue their period as “a curse” and have problems with bloating during menstruation may be headed for trouble, she says. “If you don’t respond to these signals now, by perimenopause, your body will decide it needs to scream to get your attention.”

Traditional Chinese Medicine (TCM) practitioners treat age 28 as a stepping stone because they believe that’s when women’s hormones start to shift. Your vital life force is known as your “chi,” which can be translated as “breath” or “energy.”

“Before age 28, a woman’s chi is galvanized in the direction of her ovaries,” says Gottfried. “After age 28, her chi begins to shift toward her heart.” So this is a time to examine your priorities in life.

Your 20s are all about creating the foundation of your future, a pursuit that often focuses on education, family, and career. But it’s also a time to develop a lifestyle that values self-care.

“Ignore the voice in your head that says you don’t have time, you can’t afford it, or you need to get one more thing checked off your to-do list,” says Northrup. Do something every day that gets you out of your head and into your body. Go for a bike ride, get a massage, or take a bath. Self-care feeds the body’s parasympathetic nervous system and promotes feelings of rest and well-being.

In Your 30s: Address Stress

Stress is the No. 1 contributor to perimenopausal and menopausal angst, according to every expert we consulted. That’s because stress changes the body’s biochemistry and aggravates hormone imbalance. You feel stressed when your cortisol levels are high, which is controlled by the adrenal glands. Life in industrialized nations, with 24-hour artificial light, nonstop workdays, and shrinking free time, means the adrenals are often working overtime.

An uptick in cortisol throws everything out of whack. Too much stress upsets insulin balance, which affects blood sugar, hunger cues, and weight. The chemical cascade disrupts your thyroid hormone, slowing your metabolism, which can also lead to weight gain and fatigue. Finally, stress amplifies estrogen’s dark side, which can intensify cramps, incite hot flashes, and scramble the brain. Stress can also cause infertility in women under 40, says Gottfried, because high cortisol levels force the ovaries to slow down.

Thanks to the deluge of stress, hormone-related health issues, such as polycystic ovary syndrome and infertility, are showing up in younger women, says Marcelle Pick, MSN, OB/GYN NP, author of Is It Me or My Hormones?. “Twenty years ago, women came to me with hot flashes; now I’m seeing anxiety beyond belief,” she says.

So if you feel stressed out, what should you do? Researchers are now exploring the relationship between heart function and cortisol production, says Gottfried. She raves about a free iPhone app called GPS for the Soul. Using the phone’s camera as a “sensor,” the app monitors your stress levels by tracking your pulse. If your heartbeat is stress-monkey fast, the app offers several options to calm yourself, including soothing music, pictures of loved ones, a slow-breathing pacer, even self-selected poems or meditations. The goal is to dial down cortisol levels.

If you prefer to be device-free, you can get similar results from breathing deeply and envisioning people, pets, and places you adore. Consider meditation or yoga. The body responds to positive emotions by emitting oxytocin, which lowers cortisol. “By slowing down your breath, focusing on feelings of love, and breathing into your heart, you can lower your cortisol level by 20 percent,” says Gottfried.

Finally — and this goes for all ages — enlist the help of a good massage therapist and acupuncturist. Both modes of bodywork can lower cortisol.

In Your 40s: Read the Signposts

Most women feel the inklings of perimenopause by their mid- to late 40s. Common signposts are irregular periods, weight gain (especially around the middle), fatigue, poor-quality sleep, and depression.

What concerns women’s healthcare providers most is adrenal-gland health. By design, the adrenals should accelerate production of hormones to deal with stress. But if the adrenals are overtaxed from years of chronic stress, they become fatigued and can’t do their job. (For more on adrenal fatigue, see “Pick Yourself Up”.)

TCM practitioners see adrenal fatigue as a “yin” deficiency, meaning the body lacks the nourishment it needs to stay grounded, cool, calm, and lubricated. This overabundance of “yang,” which creates heat in our bodies, can result in hot flashes, mood swings, and even heart disease. The 40s are about nurturing yin and defusing yang.

Start by eating more plants; veggies that grow above ground are especially high in yin. Physician Kumar suggests cutting back on red meat, sugar, and alcohol. Pick recommends green tea, pomegranates, and artichokes — all three help rid the body of estrogen, which is key to reducing the risk of estrogen-related cancers.

Get close to your ideal body weight. It’s not unusual to gain 5 pounds as your metabolism downshifts, but don’t let a few additional pounds gradually become a few larger dress sizes. Sticking close to your ideal body weight has many health benefits, says OB/GYN Minkin, including hot-flash relief. About 80 percent of women will experience hot flashes during perimenopause. For 10 percent of women, hot flashes stick around for 10 or more years. With extra insulation on board, the body can’t dissipate heat as quickly.

Exercise accordingly. Not everyone needs to break a sweat to benefit from different forms of physical activity. Indeed, women who lead fast-paced, stressful lives often benefit more from a restorative yoga class or a gentle walk in nature.

Lastly, it’s important to note that surprise pregnancies can (and do!) occur during perimenopause. Your menstruation can be erratic — one month you have a period, the next month you don’t — and you might think you’ve passed into menopause. You may, however, still be ovulating without knowing it.

In Your 50s: Make the Transition

If your perimenopause was a breeze, as with Mary Casey, this is the time you may start to feel some of the classic symptoms, like hot flashes, night sweats, insomnia, vaginal dryness, and trouble multitasking. Your body needs your attention.

Start by getting sound sleep. Along with melatonin and other hormones, estrogen tells the brain it’s bedtime. So when your ovaries stop making estrogen after menopause, it’s no surprise that insomnia is a common complaint. A poor night’s rest can affect mood, concentration, and even immunity.

Consider cutting back on your alcohol consumption. Many of Minkin’s patients confess to using wine as a sleep aid. And while it’s true that alcohol will put you to sleep faster, it also increases middle-of-the-night wakefulness and exacerbates hot flashes, which disrupt sleep. “Drinking alcohol is like pouring gasoline on hot flashes,” says Kumar. Try substituting a mug of chamomile or valerian tea for your after-dinner glass of wine.

Revisit some basic good-sleep practices like curbing caffeine in the afternoon, exercising vigorously, and banning technology from the bedroom, such as reading a book instead of
an e-book.

Get your cholesterol checked. Because cholesterol makes the body’s hormones, your lipid profile will also change. “Postmenopausal lipids can get a little wacky,” says Minkin. During your early decades, estrogen protects the heart by inflating levels of good cholesterol (HDL). But as estrogen dips, particularly after 50, a woman’s risk of heart attack and stroke are more like a man’s.

Think about your bones. If you have a strong family history of osteoporosis or suffer from estrogen depletion as a result of breast cancer hormone therapy or other causes, you may want to take a bone-density test. Regardless, a diet high in calcium-rich foods, such as almonds, figs, seaweed, collard greens, and kale, is essential for keeping bones strong. Aim for four or more servings of high-calcium foods a day.

And if perimenopause and menopause make you miserable, seek remedies. Over-the-counter options for hot flashes (e.g., Remifemin) and vaginal dryness (e.g., Replens) have solid safety records and are nonestrogenic.

Also consider hormone supplements. Many women’s health-care providers are nervous about estrogen. Their reluctance stems from a 2002 Women’s Health Initiative (WHI) trial showing hormone replacement therapy increased risks of heart disease and breast cancer. But what people forget, says Minkin, is that the WHI test had two sample groups — estrogen only and estrogen and progestin. Though the estrogen-only study was halted in 2004 due to increased stroke risk, it showed promise. In 2007 more WHI data showed that women who took estrogen early and for a limited time saw heart benefits, and a review of the data last year revealed a drop in breast cancer risk among those women. Since heart disease is the No. 1 killer of U.S. women, that’s no small thing.

For her part, Minkin  stands by supplemental estrogen as a legitimate choice for low-risk women who have had limited success with lifestyle changes and over-the-counter options. She defines “low risk” as no family history of estrogen-fueled cancers. If you have questions about estrogen, consult your health-care practitioner.

No longer do we need to dread menopause. The secret is to be proactive at an early age: Get to know your body. Women are fully equipped to handle menopause, but they must take charge.

“If we balance our lives, our hormones will follow,” says Welch. “It’s nothing short of a call to personal revolution.”

Illustrations by: Mark Allen Miller

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