Christine Koh

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I'm Christine Koh, a music and brain neuroscientist turned multimedia creative. I'm the founder + editor of Boston Mamas, co-author of Minimalist Parenting, co-host of the Edit Your Life podcast, and creative director at Women Online. Drop me a line; I'd love to chat about how we can work together!

12 Things To Know About Menopause

12 Things To Know About Menopause

Earlier this summer on my personal Facebook page, I posted about some aging lady problems I was experiencing, with a candid ask about whether anyone else was suffering the same problems and what they were doing about it. The response was overwhelming (well over 100 comments). There was so much interesting information from the thread that I did a live broadcast on the topic. A friend added me to a private perimenopause support group. It was insanity!

And it’s also clearly normal. I’m only 43 and generally speaking, I take really good care of my body, but clearly there are some factors out of my control that I need to learn more about. So I’m thrilled that today as part of an ongoing editorial partnership with Tufts Medical Center, Margaret Sullivan, MD is here to share information about menopause -- perfectly timed, it turns out because September is Menopause Awareness Month! Let’s get aware together, y’all!

1. When does menopause typically begin?

The average age of menopause in the United States is about 52, with ranges of several years on either side. There is a familial component to age of onset of menopause (we typically ask patients when their mother/sisters went through “the change”).

The period of life between premenopause (when women get regular periods and can get pregnant) and postmenopause (defined as no period for one year) is called perimenopause.

2. So I had never even heard the term perimenopause until someone added me to that private perimenopause support group! Can you describe exactly what this is and what women typically experience?

I see many women struggle with symptoms during this transition, which can last 2-8 years. Common symptoms include: irregular/heavy periods, mood swings, weight changes (weight gain and differing distribution of weight, women who never had “belly fat” may now carry more weight in their mid-section). Hot flashes, vaginal dryness, and difficulty sleeping also occur. 

It’s important to see a physician with expertise in menopause to ensure any symptoms you are experiencing are not due to any other medical conditions, and that any medical conditions that can mimic menopause and/or co-exist are treated appropriately. (For example, thyroid disease/imbalance is common in women and can cause menstrual irregularities.) A full evaluation typically includes a comprehensive history/physical, lab work, Pap smear, possible biopsy of the lining of the uterus, and an ultrasound.

3. What are the most common symptoms of menopause?

Menstrual irregularities, hot flashes, weight gain (and changes in how women carry weight), difficulty sleeping, decrease in libido, vaginal dryness, and sometimes painful intercourse are all common symptoms.

4. Let’s talk about irregular/heavy menstrual bleeding. I feel like in the last year or two my periods have become so much worse! Can you talk about treatment options?

Irregular/heavy menstrual bleeding can be treated in several ways: 1) Hormonal medication (a low dose birth control pill or cyclic progestin); 2) A hormone-containing intrauterine device (the most common one used is the Mirena IUD, which manages bleeding very effectively and is placed during an office visit and lasts for 5 years); 3) Endometrial ablation is a surgery commonly performed as an outpatient procedure; the entire lining of the uterus is cauterized (many women never get a menstrual period after an ablation); 4) Finally, I reserve hysterectomy as the treatment of last resort -- typically only when the above options have not worked for a patient.

5. I’m so interested to hear you talk this way about hysterectomy because I try to be as non-interventionist as possible with treatment. Why do you feel this way?

Years ago, the only treatment was hysterectomy. Anecdotally, I have several patients in their late 70s/early 80s who had hysterectomies and when I ask them why they had the procedure done, they tell me “the doctor said I needed one.” I can’t stress enough that women need to advocate for themselves and make sure they have a physician who listens to them and explains ALL possible options to manage symptoms.

6. AMEN to that. OK, let’s go back to symptoms. Talk to me about everyone’s favorite subject – vaginal dryness! How do you treat it?

Vaginal dryness and pain with intercourse can be treated with over the counter lubricants or prescription vaginal estrogen creams/tablets/rings.

7. What about hot flashes? I feel like this is the thing you hear about most in reference to menopause symptoms.

Hot flashes can be more difficult to treat. Over the counter remedies include anything containing soy and black cohosh. Dietary increase in soy, yams, tofu, and other estrogen-containing foods can alleviate mild symptoms. Hormone replacement therapy remains the mainstay for treatment of hot flashes. We recommend using the lowest dose for the shortest amount of time (typically 2-5 years) to ease the menopausal transition. Some women may not be candidates for HRT so it is important to discuss risks/benefits with your doctor.

There are also non-hormonal ways to treat hot flashes -- the most common is with SSRI (selective serotonin reuptake inhibitors) medications. These medications help to stabilize the vascular system to prevent the flushing/sweating many women experience. SSRIs are antidepressant medications; however, we often use them in much lower doses to alleviate these symptoms

8. As I mentioned earlier, I tend to be non-interventionist when possible. What are your top recommended lifestyle changes? For example, top recommended physical activities?

It’s important to maintain a healthy lifestyle as you approach menopause. Eating a well balanced diet and regular exercise at least 3 times per week are really important. Also, in order to ensure optimal bone health, weight bearing exercise is crucial -- basically the only thing that does not "count" is swimming (even though it is great exercise otherwise!). I also recommend limiting alcohol intake (red wine often causes flushing in women) and no smoking. Smoking has been shown to have a deleterious effect on bones and increases the risk of fracture in menopausal women. Yoga and meditation can also help with trouble sleeping. These are all things your health care provider should discuss with you.

9. Are there other health issues you have to think about as you go through menopause?

Cardiac disease is more common in postmenopausal women. “Typical” symptoms of heart disease can include chest pain, shortness of breath, arm/jaw pain, sweaty feeling. It is important to note that women often present with atypical symptoms -- a vague sense of “feeling unwell,” nausea, and anxiety. Women need to advocate for themselves when seeking medical care given they may not experience the same symptoms that men do when suffering from cardiac disease.

10. When will menopause end?

The menopausal transition can last 2-8 years. I do have patients who continue to experience hot flashes well beyond 8 years. After careful consideration of pros/cons, many choose to continue with hormone replacement therapy. There are risks of prolonged use (slight increase in breast cancer and heart disease) so it is important to follow these patients closely and reevaluate on an annual basis.

11. Can you talk about osteoporosis recommendations? This is something my Mom continually gets on me about!

Osteoporosis is another concern after menopause. Women reach their maximum bone density in their early 20s so it is important to maintain a healthy lifestyle entering menopause to optimize bone health. Calcium intake of 1200 mg/day is recommended (dietary or supplemental form). Weight bearing exercise for at least 20 minutes three times per week is recommended. Screening for bone density is typically done at age 65, or sooner if risk factors exist (smoker, thyroid disease, chronic steroid use),

12. In the past I have talked about medical visits as a form of self-care (not as fun as the spa, I know). What pattern do you see with women in your practice?

Many women regularly see their OB/GYN throughout their reproductive years as they are having their babies, annual GYN exam/pap smears, and contraceptive visits. We often perform annual screening for other medical conditions (thyroid, cholesterol, depression, etc.) but it is extremely important that women get plugged into a primary care MD at this time. I can’t tell you how many times patients ask me, “Can’t you be my PCP?” OB/GYNs are considered specialists and it is important for women to have an internal medicine/family practice physician to manage existing and/or developing medical conditions, and ensure you are up to date with immunizations and any other screening tests (e.g., screening colonoscopies are recommended at age 50 in the low risk population).

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Disclosure: This post reflects a compensated editorial partnership with Tufts Medical Center. All personal commentary about workplace wellness (or, er, unwellness) are, of course, my own.

Disclaimer: The content provided in this post is intended solely for the information of the reader. This information is not medical advice and should not replace a consultation with a medical professional

Featured photo by Jake Melara on Unsplash


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