Menopause: The season of our discontent
By Sylvia Wrobel | Emory Medicine | Dec. 20, 2016
On a sweltering summer evening, a group of six women gather around a candlelit table covered with sparkling glasses, deviled eggs, peach salad, North Carolina trout, and roasted sweet potatoes.
Despite having just met, the women — all in their early 50s — are talking like old friends, sharing stories of night sweats, crying jags, hot flashes, and brain fog. Laughter floats through the humid air, amplified by the instant camaraderie that common frustrations can forge.
"I just can't run as far or fast as I used to," says one woman, an avid runner whose mile speed has rapidly diminished. "It happened so dramatically and quickly."
"Nights are the worst for my hot flashes," she adds. "I have a fan and a space heater next to each other in the bedroom."
"After a few nights of no sleep, I will cry about anything," says another.
No matter the individual symptoms, the women's questions centered on a common theme: How long does this last?
"Well, usually two to five years for the most severe symptoms, but up to 12 years," says Emory obstetrician/gynecologist Mary Dolan, one of a handful of certified menopause practitioners in Georgia. "And technically forever, since what we are talking about is a lack of periods and a diminishing of estrogen."
A lot is happening during this time in a woman's life, says Dolan, from physical changes to emotions surrounding children leaving home and caring for aging parents. Many doctors and even specialists are not trained in how to treat women during this phase. "Other health concerns, such as heart conditions or breast cancer, tend to get more attention," she says. "After all, you don't die from menopause."
But how you deal with issues that arise during this hormonal shift can influence your physical and mental health over the long run, impacting everything from bone density to cardiovascular conditions.
That's why a place where practitioners are well versed in women's health, midlife challenges, and the latest effective therapies for aging well is vital to treating this target demographic, says Dolan, director of the new Emory Midlife and Menopause Center. Located on the seventh floor of the Doctor's Building at Emory Saint Joseph's Hospital, the clinic is a large airy space with one wall overlooking the Atlanta skyline. Clinics specializing in women's health during midlife exist at just a handful of other academic health centers— Harvard, UC San Diego, Mayo.
Ira Horowitz, head of the Emory Women's Center (of which the new clinic is a part), says that historically, women going through menopause have been overlooked by the medical establishment. "Even obstetrician-gynecologists can focus too much on a woman's fertile years, as opposed to her whole lifespan," he says. "Understanding a woman's midlife and menopausal needs will be more and more important as our population ages."
Fifty-one is the average age when women have their final menstrual period. But Dolan, director of the Midlife and Menopause Center, says she and her colleagues are concerned about "menopause, the big picture"—what happens to women in the years before, during, and after that last period.
Not your mother's "change of life"
Dolan, director of the Emory Midlife and Menopause Center, became focused on menopause — especially non-estrogen options for its treatment — during a fellowship as an Epidemic Intelligence Service officer at the CDC, when she saw the effects of surgical or chemotherapy-induced menopause on young women with breast cancer.
Dolan sees 50 to 60 patients a week. The typical patient is in her mid-40s or early 50s, and experiencing problems related to the changes of perimenopause.
For some, menopause happened suddenly, following surgical removal of the ovaries, certain forms of chemotherapy, or other medical conditions affecting estrogen production. Others experienced classic perimenopausal symptoms— abnormal periods, hot flashes, trouble sleeping, mood swings—leading up to their last period. And some thought menopause was behind them, only to find themselves facing recurring urinary tract infections, vaginal pain, or sexual problems.
Many of Dolan's patients are seeking a second opinion and have questions about hormone replacement therapy (HRT), which lost popularity after a major study showed that it increased women's susceptibility to some serious diseases and risks. Other research, however, has shown that if the right hormones are used in the correct way, they can still be of benefit to some women.
Dolan calls the years around menopause "a good time for women to pause, focus on themselves — sometimes for the first time in years — and take stock of what they need to do to maximize their health and well-being. Our job is to help them do that."
The team develops a personalized treatment plan for each woman coming into the center, based on her initial evaluation.
A symptom and health risk assessment
Evaluating and discussing appropriate treatment of menopausal symptoms, from hot flashes to mood changes to sexual problems such as decreased libido, diminished genital sensitivity, vaginal pain, or difficulty achieving orgasm.
Dealing with risks
Gauging aging and menopause-related hormonal changes, primarily through:
- a breast exam, referral for mammograms and other imaging modalities; prevention strategies for women at high risk of breast cancer, and gynecologic care for breast cancer survivors
- osteoporosis and bone density testing
- referrals, as needed, for colon cancer screening
- screening for pelvic organ prolapse, urinary incontinence, overactive bladder, and other problems, which are then treated by a urogynecologist on the Midlife and Menopause team
While the center's core physicians — Dolan, Taniqua Miller, and Penny Castellano — are all gynecologists with special interest and training in menopause, the Midlife and Menopause Center is connected to a range of specialists for comprehensive care who see patients at the center on a regular basis. For example, gynecologic oncologists see women with (or at high risk for) ovarian and uterine cancers. Endocrinologists see women with excessive hair growth or loss or thyroid disorders. Gastroenterologists provide colon cancer screenings and treat irritable bowel or gluten sensitivity. Rheumatologists see patients for autoimmune conditions that can develop. Neurologists help with insomnia or migraines. Psychiatrists evaluate and treat severe mood swings or depression. In turn, they sometimes refer their patients to Dolan.
"Women with depression or bipolar disorder sometimes hit menopause and everything goes haywire. The medicines and the doses they were taking aren't working anymore," she says.
Especially important, says Dolan, is the collaboration with the Emory Women's Heart Center, since cardiovascular disease remains the No. 1 killer of women in the United States, with risk factors increasing after menopause.