Signs of Change: Perimenopause -- Laura Corio, MD -- 02/20/03

Last Editorial Review: 10/23/2003

By Laura Corio
WebMD Live Events Transcript

Irregular periods, breast tenderness, worsening PMS, and diminished libido can all be signs that you're experiencing perimenopause. If any or all of these symptoms are a part of your life, review our discussion with ob-gyn Laura Corio, MD, author of The Change Before the Change.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD Live. Today our guest is Laura Corio, MD, author of The Change Before The Change: Everything You Need to Know to Stay Healthy in the Decade Before Menopause.

Member: Hello Dr. Corio. Can you please explain whether the symptoms of perimenopause (hot flashes, etc.) are caused by estrogen loss or fluctuations of estrogen/progesterone levels?

Corio: The hot flashes in perimenopause are caused by a fluctuation in estrogen at the brain level and it affects the temperature regulation in our brain. Once our levels of estrogen decline all the way down a lot of women feel relief of their hot flashes.

Member: I am 51 and a half and my lab tests -- two normal ultrasounds (normal ovaries, one small fibroid) -- and still regular periods suggest a later than average menopause. My doctor feels I have several years to go and I take Prometrium, 200 mg daily, 10 days a month to try to regulate somewhat erratic (between 21 and 38 days between) periods. No hot flashes yet. What are the risks and benefits to a late menopause? My mother was older too and had a hysterectomy for heavy bleeding. My second question is if there are any problems associated with Prometrium if taken like this for several years? Thank you.

Corio: It's interesting that progesterone also can affect the brain but we usually think of the hot flashes as related to estrogen. The risks and benefits from a late menopause are the following:

The benefits include better protection of your bones because the longer you have estrogen, progesterone, and testosterone in your body, the more protection to your bones, therefore decreasing your risk of osteoporosis.

The risks include an increased risk of cancer. We're talking breast cancer, uterine cancer, ovarian cancer, and colon cancer because of the long exposure to estrogen.

I always use Prometrium, which is oral micronized progesterone, to regulate women's cycles just as you are being treated. I feel totally comfortable with natural progesterone, which is what you're taking, to use until menopause.

Member: Do hot flashes mainly begin during sleeping hours?

Corio: No. They can begin during waking hours, daytime hours, and they can also be night sweats. My patients have described feeling warm during the day, hot and cold during the day, as well as having night sweats. So it can happen anytime.

Member: I am 41. My periods have been getting progressively heavier and lasting longer during the past six months. I also have terrible cramps and pass several clots while bleeding. Four years ago I had a vaginal ultrasound and the doctor said I had fibroids in my uterus. I recently read an article about menstrual suppression using low-dose estrogen birth control pills. Would this help me?

Corio: It is important for you to go and have another sonogram because you could have fibroids that are inside the cavity, such as sub-mucosal fibroids that are causing very heavy periods, cramps, and clots. Or, you could have dysfunctional bleeding, which means that you may not be making progesterone and you should have a biopsy of your uterus four days before your expected period to make sure that your uterine tissue is normal and that you are ovulating. Then, you could try birth control pills to see if it could regulate your cycles, but I'm am a big believer of making a diagnosis first and treating second.

Member: Is age at menopause purely genetic or is it in any way a reflection of general health?

Corio: Menopause could be both. It could be related to genes (genetics). You could be very similar to your mom and go through menopause around the same age as your mom.

Or, it could be related to environmental factors. Smoking we know will make a woman go through menopause a year to a year and a half earlier. Some women may have a tragedy in their lives and stop menstruating and never menstruate again. Being treated for cancer with chemotherapy can also affect periods.

Member: Are FSH tests a reliable test for diagnosis of menopause?

Corio: FSH is a reliable test for menopause if it comes back elevated. It also has to be realized that if you do have an elevated FSH but you have not gone a full year without a period, you are still considered perimenopausal and that FSH test could still go up and down before you go a full year without a period.

Member: I enjoyed your book very much and could relate to the experiences of the women you treat. At what point do hot flashes start in perimenopause?

Corio: Perimenopause is the four to seven years prior to menopause, so you could have hot flashes as early as 35 if you are to begin menopause in your early 40's. Women have described pre-menstrual hot flashes that are not in perimenopause, women who have absolutely normal cycles can experience night sweats pre-menstrually. But I think you have to look at the change in your cycles as the first sign of perimenopause and then if you start hot flashes they can be any time in your cycle.

Member: Do exercise and nutrition help lessen the symptoms?

Corio: Definitely exercise and good nutrition and vitamins and minerals will all help lessen perimenopausal symptoms. A lot of women release endorphins during exercise when they do cardiovascular exercise; I know for myself, I do pilates and it makes me feel so much better after I've exercised. It releases a lot of the anxiety that women get during perimenopause.

I can honestly say that I wish I had the experience I have now during the time I wrote the book because I should have devoted more attention to the anxiety that women feel during this period of time. So, yes, exercise is very beneficial. It also makes you look and feel better. And, of course, I can't stress the diet enough. We really, really, really try to get rid of the carbs and patients tell me all the time that the vitamins work so well. So, yes, I think that combination is the first combination that should be tried.

Moderator: All carbs or just simple carbs?

Corio: I really try to minimize carbs. I prefer complex carbs to simple carbs, of course, but we try to minimize all carbohydrates.

Member: Could you give some example of the recommended carbohydrates?

Corio: Something that isn't white. Something that is colorful:

  • A sweet potato
  • Brown rice
  • Couscous
  • Multi-grain breads
  • Pasta made of zucchini or artichoke or spinach (but I have a hard time with that, being that I'm Italian)
  • Even oatmeal

Member: Does the anxiety go away when you are through?

Corio: I think so. My patients tell me that when they finally are in those post-menopausal years that they feel much better. It's the calm after the storm.

Member: What vitamins and minerals do you suggest?

Corio: Here's the cocktail:

  • Multi-vitamin
  • B-complex 50
  • Vitamin E
  • Evening primrose oil (Omega-6, an essential fatty acid)
  • Omega-3 (fish oil)
  • Calcium
  • Magnesium

Member: When does a woman's risk of heart disease begin to rise, during perimenopause or after? The men in my family have heart disease in their 40s; am I at risk also?

Corio: During perimenopause, the risk of women's heart disease begins to rise. The research shows that once estrogen starts declining that the arteries and our body and our heart and our brain begin to fill with plaque, and therefore the changes that you see that lead to narrowing of the arteries, heart attacks, strokes begin in our perimenopause. Once one has gone into menopause, the changes have already begun and that's why in my book we spoke about early intervention, having blood tests for your lipids, cholesterols, HDLs, LDLs, triglycerides, homocystines. Those tests should be done in early perimenopause to look at your risk factors.

Member: I am 47 and having a terrible time with perimenopause. The estrogen patches helped immensely but I cannot tolerate the 10 days of Prometrium as it causes feelings of extreme anger and depression. I still have my uterus so my doctor switched me to the combi-patch, which makes me miserable every day. At least I had a few good weeks each month with the estrogen. The hot flashes, 45-day periods of bleeding, and weight gain I've experienced are inconvenient, but without the estrogen I am a totally different person. By this I mean being verbally abusive to family members, friends and co-workers and feeling like I could easily be homicidal. Prior to perimenopause, the only time I have ever experienced such feelings was one or two days before starting my period. Now it is EVERY day. Do you think I would benefit more from a homeopathic treatment such as Remifemin? In the last year I have become as reclusive as possible to prevent people from observing my displays of rage. Help?

Corio: It's difficult to advise you without knowing your dosage of estrogen. I would try to decrease the amount of progesterone and give it to you every day in hope that by lowering the dosage of progesterone and giving it to you every day it would decrease your symptoms. You could go back to your doctor and ask about taking progesterone every day, but at a lower dosage.

Member: Is hair loss a sign of entering perimenopause?

Corio: I see so much hair loss and I can't tell you for sure that it is a relationship to perimenopause. I think there are many, many reasons for hair loss, including:

  • Anemia
  • Thyroid disease
  • Stress
  • Genetic reasons
  • Various medications
  • Various diseases

So it's difficult to say whether it's just a perimenopausal entity.

Member: I think the findings from the recent WHI study have many women concerned about taking combination HRT for perimenopausal hot flashes. Are there any natural remedies that can be effective at easing those symptoms, without putting the heart at risk?

Corio: Hormone replacement therapy is taking estrogen and progestin. In the study that came out in the summer of 2002, the hormone that was researched was Premarin and Provera. Provera is a progestin; a synthetic hormone. And way before the study came out Provera had been shown to negate the benefits of estrogen on the heart. Also, Provera had been shown, years back, to increase the risk of breast cancer.

There was a study that was out of The Journal of the American Medical Association in 2000 that showed that women who took estrogen alone or a placebo had a much lower risk of breast cancer than those who took estrogen and Provera for more than five years. The risk of breast cancer was significantly higher in women who took progestin Provera. In perimenopause, when women are having hot flashes and night sweats and changes in their heart they would clearly benefit from estrogen at this point in their lives.

My philosophy is to give women hormones during these perimenopausal years at a low dose (one-sixth of a birth control pill is the dosage) with estrogen and progesterone which are bio-identical hormones, not synthetic, to protect the heart and decrease menopausal symptoms. It has been shown that progesterone will potentiate the benefits of estrogen on the heart.

Member: I am 42 and have had irregular periods for the last three and a half years. I have always been a full seven-day cycle individual who started menstruation very early in life. I now am seven weeks past my due date and am wondering if I may be experiencing the change?

Corio: I usually wait 60 days from your last period, and then I test with hormone levels.

We'd like to rule out pregnancy; then we would like to test your FSH, LH, estradiol, and progesterone to see whether you're getting a period, to see whether you're perimenopausal with estrogen still present, or are you close to menopause with a high FSH and low estrogen and progesterone.

Member: I stopped having a period for almost a year. But in January I had a deep tissue massage (which they said would stimulate my glands and relax my muscles) and got my period. Could the massage have stimulated something that made my period come back? I haven't had another one since then.

Corio: I have heard that before, where a deep muscle massage brought on a period. If it was an absolutely normal routine period, I would not be concerned. However, if you have gone a full year without a period and then this period came, I would call your gynecologist because that's not normal. If this period was normal, not heavier, not longer, and like I said, a full year did not go by, then I would not be concerned.

Member: I feel as though I am the only woman facing this problem and I hope you can help me. I have gone to my doctor and she told me that basically all I had to do was talk about it and I would be fine. I am a 34-year-old African American woman, I work full time and I have two children, ages 9 and 4. Before the birth of my children my sex drive matched and at times exceeded my husband's (whose libido is through the After the birth of my daughter (the 9-year-old) my libido slowed but not noticeably. After my son was born the bottom practically dropped out. My drive has almost vanished; I still get turned on by erotic things, but my sex drive has diminished and it has caused a large rift in my marriage. I love my husband and I wish that I had an answer for him. I often do not WANT sex and the few times that we have had it, he has had to initiate it. I could go weeks, months without it and he on the other hand -- his sex drive has done anything but diminished. Am I totally crazy? Is there a pill I can take? I am desperate and don't want to lose my husband but I need to do something.

Corio: No, you're not crazy. It seems that a lot of women, after they give birth to their children, their testosterone drops. I would refer you to the Berman Sisterss book, For Women Only, where they talk about the essence of what I find in my practice: That women, after they've given birth, find their libido in the toilet. You should have your testosterone levels tested mid-cycle, mid-morning. So if you're having a 28-day cycle, around the 13th, 14th, 15th of the cycle mid-morning (maybe around 10 a.m.) you should have your blood drawn for:

1. Testosterone
2. Free testosterone.

And see if your testosterone levels are low. You could take Viagra. Just as a man takes Viagra, you can take Viagra. We also have one pharmacy in the country now making testosterone patches and there's also testosterone cream that can be applied to clitoris and vulva to enhance orgasms. So you are not crazy.

Member: Does being overweight increase a woman's chances in experiencing perimenopause and menopause early?

Corio: No, not at all. Because of their increased weight they have more estrogen in their system and, therefore, could menstruate longer.

Member: Do women need to speak with their physician when they feel they are experiencing perimenopause and menopause?

Corio: I think they should definitely speak to their doctors about how to find out what it is they can do to get through it. It's not an illness. They can prepare and be proactive in taking care of their health because this is a period in their lives where changes are going on and they want to promote long-term health.

Member: Should perimenopausal women have a bone density test? At what age would be best to do this?

Corio: Of course. I do them between 45 and 50, or at the first sign of a hot flash.

Moderator: Dr. Corio, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Corio: I know there's a lot of confusion out there about hormone replacement therapy.

I still believe hormone therapy has a place and can be taken under a wise doctor's supervision. Women do not need to suffer. Women do not need to feel psychotic. There's enough stress in the world right now and they shouldn't stop until they have the answers.

Moderator: Our thanks to Laura Corio, MD. For more information, please read The Change Before The Change: Everything You Need to Know to Stay Healthy in the Decade Before Menopause by Laura Corio, MD. And be sure to check out the information about perimenopause and menopause here on WebMD, including our archived Live Events and on our message boards, which can be found at Member Central.

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