Does the M in PMS Stand for Menopause?

If you read any book or article about PMS, you will notice that it is invariably accompanied by a long list of symptoms. In our opinion, creating such a list is futile and could even be counterproductive, because the syndrome is so variable. Some of the symptoms can occur in relation to your monthly cycle, and many of the symptoms can— once having occurred—also change during your cycle. The same symptom can affect other women in very different ways. There is no group of symptoms that uniformly and regularly affects each individ­ual woman.

If you think you might have PMS, the best way to determine how the syndrome affects you is to chart any changes in perception, behav­ior, and feeling that you experience during your monthly cycle using the format described earlier for Claire. Physical symptoms could in­clude breast tenderness and swelling, abdominal bloating, edema, and weight gain. Emotional symptoms often include anxiety, depression, tension, insomnia, anger, and fear. Behavioral changes sometimes have included absenteeism from work, proneness to accidents, and in very rare instances, other phenomena such as criminal tendencies and suicidal impulses.

The variety of symptoms of PMS can make diagnosis difficult. The best way to begin involves giving your physician a very detailed history. You will also probably be asked to chart your symptoms carefully, measure your body weight on a daily basis, and record your entire behavioral pattern over two to three monthly menstrual cycles. Your doctor, then, has a basis for evaluation. (A PMS diagnostic chart has been included to help you chart your symptoms. Take the chart to your physician.)

Since many theories relate PMS to hormonal changes, you may wonder why physicians do not simply measure the amount of estrogen and progesterone in your blood. Unfortunately, this practice does not offer the easy answer it seems to suggest. Your hormonal changes may be so subtle that your hormone measurements fall within accepted normal limits even though your body is reacting strongly to those changes. So these blood tests will merely be expensive for you and will not help to diagnose your problem.

Studies of hormonal levels in premenstrual syndrome have shown a striking lack of consistency. For example, comparisons of hormone levels in both women with and without PMS have failed to show any statistical differences between the two groups. This lack of difference shows that PMS is not caused by abnormal circulating levels of gonadotropins or gonadal hormones.

Other hormones such as prolactin, Cortisol, and thyroid hormone have been thought to be possible causes of PMS. However, no sub­stantiated medical reports exist as yet to confirm this theory. Other investigators have tried to relate symptoms such as irritability, aggres­sion, and paranoia to higher levels of male hormone within the female body. Studies have also failed to confirm this relationship.

Since it seems that we cannot blame PMS on hormone imbalances, we are led to theorize that PMS may be the result of abnormal re­sponses to normal endocrine levels. Research today is directed toward more sophisticated evaluations to learn what actually occurs chemi­cally in the brain.

When large groups of women with premenstrual symptoms were studied, the results suggested that PMS actually may be clusters of problems that can occur separately at different phases in a woman’s life. One of these phases is the premenopausal time. It is likely that women who have few PMS symptoms in their early reproductive years, but who suddenly develop such symptoms in their later repro­ductive years, may be suffering from a variant of PMS that should appropriately be called premenopausal syndrome.

About Menopause and Late Pregnancy

We often need to respond to, “How does my age impact on my chances for a healthy and successful pregnancy?” It is a question asked of obstetri­cians as more and more women are choosing to conceive after the age of thirty-five. It is not always easy to do because fertility rates decrease with age, but it happens with increasing frequency as fertility treat­ment becomes more sophisticated and successful.

You may be interested to know that prior to 1975, the peak years for women to have babies were between their twentieth and twenty-ninth birthdays. Then, at the height of the “baby boom,” in 1975, the birth rate in the United States started downward. The major reason for the decline was the change in contraceptive practices. Many more married women of childbearing age were using contraception in the 1980s than in the 1960s. (Married women between ages thirty-five and forty-four use contraception less often than younger wives. When they do, they tend either to end fertility permanently, through steri­lization, or to rely on nonmedical methods.)

Recently, however, the downward trend ended, as the large group of “baby boomers” began having babies at age thirty-five or older. “Late pregnancies” increased by a whopping 37 percent. This switch is the subject of several studies of women over age thirty-five, de­signed to learn whether there is an increased risk associated with pregnancy, childbirth, or the period of confinement after labor for this growing group of women.

Recently reported results suggest that the risk of some problems in pregnancy may increase in midlife and that hypertension, diabetes, preeclampsia (toxemia of late pregnancy that includes hypertension, albuminuria, and edema), and premature labor may be more common in women who give birth after the age of forty. Much of the time, however, these complications can be taken care of medically and usually do not increase mortality.

The increase in diabetes is understandable. We know that there is an increase in diabetes mellitus with age, and so this problem is more likely to appear in women over thirty-five. Yet, even with this increase in incidence of diabetes and hypertension, modern prenatal care should assure normal results for mother and baby as long as mother is healthy when the pregnancy begins. However, women with medical complications, such as chronic hypertension or diabetes mellitus before pregnancy, may find that these conditions tend to be aggravated. They could affect baby’s health and survival.

A frequently asked question is whether women over thirty-five are more likely to have smaller babies. The answer is “no.” According to various studies, there is an increased birth weight in babies delivered by older women.

Delivery itself is another matter. Generally, there are fewer vaginal deliveries after the age of forty. This increase in cesarean sections is apparent in most of the medical literature.

After the baby is born, there might be an increased risk to the mother of fever due to infection, or of blood clots and possibly pulmo­nary emboli. The incidence of these complications is not dramatic, however, and doctors generally can recognize and treat these prob­lems effectively. As far as the baby is concerned, chromosomal abnor­mality is one of the major worries of women having later pregnancies. A direct correlation between the age of the mother and chromosomal abnormality does exist, particularly in the number of Down’s syn­drome infants that are liveborn. At age twenty-five there is one Down’s syndrome birth in 1,200; this statistic increases to one in 365 at age thirty-five; it jumps to one in 32 at age forty-five.

When all other chromosomal abnormalities are included, the risks are even higher. A review of middle-trimester amniocentesis data reveals that the risk increases from 1.3 percent at age thirty-five to 1.9 percent at age forty, and to almost 10 percent beyond age forty.

The most recent best-controlled hospital-based studies suggest that women of advanced maternal age delivering under optimum condi­tions may be at no higher risk for adverse outcome than pregnancies in younger patients. There once was a term, the elderly prima gravida, which referred to a woman who had never had a child before age thirty-five. The term is obsolete! We believe that in the absence of underlying medical disorders, and assuming modern obstetric care including prenatal diagnosis, advanced age in itself only minimally increases pregnancy risks.

What Younger Women Should Know about Getting Older

Getting older is terrific and very natural! It’s what we all begin to do at the moment of our birth. If you could just keep that same happy anticipation that you felt while waiting to “become a woman” for your final menstrual period, you could quite contentedly look forward to what’s in store for you in the future.

The number of eggs that your ovaries produce will lessen and stop sometime during the climacteric. You cannot see or feel or reverse those universal changes. However, you can alleviate many of the other bodily changes that occur as a result of the cessation of menses. The hot flash is the most prevalent sign and can start early. Almost all women have them at menopause. The hot flash can make you feel as if your personal thermostat has gone awry. Suddenly, you are uncom­fortably hot. While you are removing your jacket or sweater, you realize that no one else in the room is feeling the heat. So it begins. For many women, the hot flash is just a mild discomfort, yet others sweat through intense heat. For some, the hot flash occurs only occa­sionally; for others it returns with almost unbearable regularity.

You may be able to avoid hot flashes or lessen their intensity by avoiding alcohol, especially red wine (the chemicals in it seem to encourage flashes and headaches), and tobacco, caffeine, and stress (whenever possible). Regular exercise helps, too, to stabilize your body. Relaxation and visualization techniques, in which you conjure up cool, comfortable surroundings, may work for you as well.

If you are in your mid-thirties and beginning to show premenopau­sal symptoms, you can begin to work toward having a more comfort­able menopause and by exercising regularly to protect yourself against heart disease and to conserve bone mass to help safeguard you against osteoporosis. We should mention here also that the activities that help the younger women most are weight-bearing pursuits such as racquet sports, walking, cross-country skiing, low-impact aerobic dancing, and bicycling.

Vaginal discomfort can occur early, too, as the vaginal lining gradu­ally thins in response to very subtle shifts in estrogen levels. Some women in their thirties do experience vaginal dryness, itching, and atrophy, causing some discomfort during sexual activity. Frequent sex is the most positive prescription for these problems. If you are at a time in your life when it takes you longer to become sexually aroused and lubricated, then tell your caring partner openly. If extra lubrica­tion is necessary, consider using a vaginal moisturizer like Replens. If more than that seems required, check with your physician to see if a vaginal estrogen cream should be prescribed for you.

Bladder control problems can occur with estrogen decline because the muscles in the pelvic area become slacker or weaker. Certain exercises can help to keep that muscle strong. Kegel exercises, named for the physician who first described them, usually work. There are two varieties: the slow Kegel, during which you contract all the pelvic muscles as if you were trying to squeeze the vaginal opening closed, holding it closed for a count of three, relaxing, and doing it again; and the fast Kegel, in which you alternately contract and relax the muscle as quickly as you can. Twelve of these exercises each time you stop at a traffic signal for a total of fifty Kegels per day will often work wonders with bladder control and may enhance your sex life, too.

We know that aging is more difficult in a youth-oriented society such as ours, and far easier to accept in other cultures where age and wisdom are synonymous and revered. However, change is change, and for some people it is always exciting; for others it is always stressful. Our ability to handle change has to do with matching posi­tive actions to a positive attitude about the change. Thus, the Menopause Management Program can be a valuable asset to your continued good health. It promotes a positive outlook and shows you how to structure your diet, exercise program, health and grooming practices, and vocations, avocations, and preventive medicine pro­grams to get the best out of the best years, which are yet to come.

As you enter midlife, many changes occur that you should know about in order to find the health maintenance program that is best for you. PMS, when it arrives late in your reproductive life, may be a premenopausal signal that it is time to spend some time on yourself. The following questionnaire was designed to help you figure out just where you fit into the midlife cycle. Once you know, you can make optimal use of the Menopause Management Program. Your responses may also serve as a foundation for your next meeting with your physician.

What You Should Know About Midlife And Menopause?

Since the first step in prevention is understanding, let’s start with a brief overview of the most important points to remember about the fascinating systems that operate in women’s lives.

The human body is an exquisite mechanism constructed so that each system works in a delicate balance with other processes within the body. This idea of balance and interrelationship is especially important in understanding what occurs at midlife.

Your monthly cycle is controlled by certain centers in your brain. They signal appropriate body parts and systems, “telling” them when and how to operate.

Often women ask me whether they have a glandular problem. It is important to understand just how the glands work within your cycle. There are two types of glands in the body: exocrine and endocfifu. The exocrine glands release chemical substances directly to the area where they are heeded. A good example is the sweat glands, which aid in the cooling of the skin, and the sebaceous glands, which secrete oils that keep the skin pliable. When meno­pause arrives, these glands may not work as effectively because of the changes in their “programming.” The sweat glands may not “cool” as efficiently and the sebaceous glands may not keep the skin as soft and smooth as before. Endocrine glands, in contrast, produce and release their substances directly into the blood­stream. These substances are chemical messengers called hormones.

Before menopause, your monthly cycle is under the control of certain centers in the brain. The brain is our ultimate computer, handling billions of messages, signals, and functions, all operating simultaneously with remarkable order and purpose. Neurotransmit­ters are the “messengers” that activate the appropriate brain areas and systems, “telling” them when to go into operation, or when to alter their function.

Brain activity is controlled by messages from both inside and outside of the body. It is within the cerebral cortex, or higher brain areas, that we are made aware of ourselves, our surroundings, and our sense of well-being. When signals go awry in this area of the brain, the results are changed emotions, feelings, and perceptions.

Tucked in the base of the brain in the middle of the skull lies the funnel-shaped hypothalamus, one of our most important endo­crine glands. It is to the human body what mission control is to space flight. Messages or impulses from our senses, such as sight, smell, hearing, taste, and touch, are eventually directed to the hypothalamus, which is strategically connected to all other areas of the brain.

The hypothalamus produces several hormones, but the one that is of importance in understanding the female monthly cycle is called the gonadotropin releasing hormone (GRH). GRH dictates action in another important gland, the pituitary, a pea-sized struc­ture lying directly beneath the hypothalamus in a bony cave at the base of the skull. The pituitary, in turn, produces the hormones that control, amongst other glands, the all-powerful ovary. The pituitary secretes two hormones called the gonadotropins: individu­ally called the follicle stimulating hormone (FSH) and the luteinizing hormone (LH). These are the hormones that directly affect the growth and development of the ovarian follicle. The FSH stimu­lates the follicle to ripen and the LH matures the egg and causes its release.

The ovary is the most powerful gland in a woman’s body, pro­ducing those two sex hormones, estrogen and progesterone, that make the differences between men and women. Women have two ovar­ies that have two directly interrelated functions: to produce those sex hormones and to produce eggs.

Before a female child is born, there are probably several million eggs in her ovaries, but for unknown reasons, this number reduces to about 500,000 eggs at her birth. Unlike the male, who is able to produce new spermatozoa for the rest of his life, the female ovary can only lose eggs until the supply is depleted at menopause. The supply of eggs is actually programed for exhaustion. The ovary raises hundreds of follicles each month, each containing an egg, but only one egg is expelled in the menstrual cycle (except in the rare case of multiple fraternal births). The others are lost.

Almost every part of your body is changed somewhat by the levels of estrogen and progesterone your ovary is producing. All of the sex organs, both inside and outside of the body, need estrogen in order to work properly.

Notice the reduced size of the clitoris and outer labia and the loss of pubic hair. Changes also occur inside the body as the walls of the vagina and the uterus gradually become thinner without estro­gen. The bladder lies just in front of the uterus. The tube through which the bladder empties, the urethra, lies in front of the vagina. The bowel is behind the uterus, and the rectum and the opening of the bowel, the anus, are behind the vagina. This diagram will be useful for reference as we review other changes. The relationship of all these organs to the vagina is of importance when we consider the problem of prolapse, or drop, of the pelvic organs, a condition that often becomes a problem in the early postmenopausal years.

The female breast has been idolized and romanticized in poetry and prose throughout history. Although this organ has miraculous capabilities, it is important to remember that the func­tions of the breast are not related to their size or shape. Breasts are comprised of glandular tissue surrounded by fat, which serves as a kind of packing tissue. The ducts from the glands end in the nipple. Another important fact to remember about the breast is that these glands react to the presence or absence of hormones and also that the glands are the site for cancer when it develops in the breast.

Many patients ask why breasts droop with age. Fibrous bands known as Cooper’s ligaments run throughout the breast and are attached to firm tissue that lies like a sheet covering the chest wall. The stretching of these bands caused by weight, gravity, and aging accounts for breast sag.