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The Big Change: Understanding (and Surviving) Menopause

"The decreases in estrogen and progesterone come with a variety of side effects, some of which are just annoying and some of which can be quite serious."

Dr. Keller Wortham, MD, will be exploring some issues specific to women's health and men's health over the next few weeks, starting with the one that affects all women as they age — menopause. In today's part one of his two-part menopause series, we'll discuss what this condition is, what causes it, what its symptoms are, and some ways the symptoms can be managed. Stay tuned for Part 2 next weekend, when we'll discuss the pros and cons of hormone replacement therapy.

Video Highlights

  • 00:58: What is Menopause?
  • 02:29: How do you know if you're experiencing menopause? 
  • 03:54: Symptoms of Menopause
  • 15:28: Lesser Known Symptoms
  • 16:53: Management Tips
  • 26:28: Wrap-Up

Today we’re talking about the big change. But gentlemen, don't go away because this is for you too. So hopefully you can understand this topic better and be a more supportive spouse, friend, boss, or employee to women undergoing this significant change.

What is Menopause?  

Menopause is a naturally occurring phenomenon that happens to a woman, usually in her 40s or early 50s, where levels of certain hormones start to decrease, and eventually she stops having her menstrual cycle.  In fact, that's what menopause means: it literally means the pausing of the menstrual cycle.

So, why does that happen? Well, just to get into that let's talk a little bit about the female hormone cycle. The menstrual cycle is regulated by two very important hormones — estrogen and progesterone — and those hormones are made in the ovaries. As a woman ages, the ovaries start to have a reduction in the number of eggs there, and the eggs that remain are less healthy. Eventually the levels of estrogen and progesterone decline to a point where a woman stops having her menstrual cycle. This might be considered a welcome occurrence to many women out there who are tired of the monthly visit from Aunt Flow, but unfortunately the decreases in estrogen and progesterone also come with a variety of side effects and symptoms, some of which are just annoying and some of which can be quite serious for a woman's health.  So that's what we're going to talk about it today.

How do you know if you're experiencing menopause? 

The most obvious symptom, of course, is that your period stops. Most of the time, if your period stops and you're a woman in your 40s or early 50s, you can assume that you're going through menopause. Usually menopause is defined as your not having had your period for a year. If you have any doubt about whether or not you're experiencing menopause, talk to your doctor and you can have some hormone levels drawn, which can help confirm it.  

If you stop having your period earlier than that, then you should probably talk with your doctor about something calledpremature menopause. There can be some conditions that cause that, but it’s a topic for another time. But for the most part, you're a woman in your 40s early 50s, your period stop, it's menopause.

So that brings us now to the crux of the lecture here. What happens next? A lot of women out there know once you get into menopause you start having a lot of symptoms. It’s important to  mention that this is a natural process. It happens to all women at some point, but that doesn't mean that it isn’t quite disruptive to a woman's life. Actually, there are sometimes even some dangerous aspects to menopause symptoms. So, we're going to talk about the symptoms of menopause. 

Symptoms of Menopause

We asked 100 women what was the worst thing about menopause, and recorded the top seven answers:

Hot Flashes

The number one thing women complain about at menopause is hot flashes. Two out of three women will experience hot flashes. Men, or women who have yet to experience this, may think it just means you feel a little hot, but actually women say they experience a sudden flushing, increased heart rate, and heavy sweating, not just feeling hot. It's really distracting, it's disruptive. If you’re at the office, you could even need to change your clothes, you could have trouble focusing... It's really uncomfortable. It's easy to write it off as just something that is what it is, but these symptoms can be really annoying and interfere with your life.

So why do women get hot flashes with menopause? The culprit is a hormone called estrogen.  When estrogen levels go down, it's thought to be not anabsence of estrogen but rather a suddendecrease in estrogen. There is a part of the brain called the hypothalamus that senses that the body temperature somehow just got too high. It’s sort of like your brain makes an  incorrect assumption, which then causes the heart rate to go up, and causes vasodilation or opening of the blood vessels in the skin, and that creates a flushing, and all this is designed to trigger the body's natural cooling mechanism, which is sweating. So, the estrogen plummets, the hypothalamus thinks the body is overheating, sends blood into the body, and triggers sweating. If you were in a sauna, or exercising, these would all be great things, but when you're just sitting there trying to work, it could be really disruptive. 


How many ladies out there have started experiencing insomnia if they're going through menopause? Apparently, about 61% of women will say they used to sleep great and now that menopause has started, they can't fall asleep or can't stay asleep and it is ruining their lives, and making them tired, and cranky. 

So, what's going on there? In this case we're talking about another hormone involved in menopause — progesterone. This is the other main hormone in the female cycle and its levels also decrease during menopause. Progesterone has a soporific, or a sleep-inducing, effect on the brain. So, as those levels go down and your brain's not getting that calming relaxing signal from progesterone, it can actually make you feel wide awake and make it more difficult to go to sleep. So that's the second thing women complain about. But there's more!

Mood Swings

Very likely, a lot of you women have experienced this. A lot of you men out there with women in your lives have experienced it as well. It may feel like menopause has transformed your loved one into someone much more volatile. And ladies, it may feel like, “I don't know what it is but now I get so moody and angry, and then I'm sad, and things are going on with me.” So, first of all, physiology aside, menopause in itself can be a very emotional milestone.  Big changes in life can always be emotional, but in this case, menopause marks the end of a woman's childbearing years. It can be associated with aging, with weight gain, with a lot of other changes that can make a woman think about mortality, about aging, about maybe not feeling as attractive... all these things can be wrapped up in this fundamental change. But those are just the psychological reasons for the mood swings.

As if that weren't enough, there are also physiological reasons, like changes in hormones.  And here again the culprit is estrogen. Estrogen has a profound effect on the brain and the production of a couple of very important neurotransmitters. So, as estrogen levels decrease, the brain makes less of these neurotransmitters: serotonin and norepinephrine. 

Serotonin is the feel-good neurotransmitter. It helps us feel balanced and optimistic. Plummeting estrogen means that not as much serotonin is being made. Norepinephrine is the other hormone and that helps people feel alert and focused. So women might complain about feeling things like brain fog. And again, as estrogen levels go down, norepinephrine levels in the brain also decrease. So, you've got these two very important neurotransmitters for helping you feel happy and alert and they just the bottom out.

There are also higher levels of a hormone, or an enzyme, called monoamine oxidase A.  This is basically an enzyme that breaks down serotonin. So you're making less serotonin in the brain and you're also breaking it down faster — it's a recipe for disaster which is why so many women experience depression. Something like one in five women can experience depression, and if they're not experiencing outright depression, they just still feel more sad and more tearful and more emotional in general. Again, that's due to decreasing estrogen levels in the brain. The good thing is that with time, your brain will begin to re-regulate to these lower levels of estrogen. This period of like emotional moodiness is probably temporary, as your brain readjusts to these lower levels. 


This is kind of the other side the moodiness. You may feel more cranky, things may bother you that didn't bother you before, and now you feel irritated all the time. Seventy percent of women experience this irritability, and the culprit is once again, estrogen. As estrogen goes down, those important neurotransmitters (serotonin especially) plummet in the brain. Remember, serotonin is a feel-good hormone. So, if you're not getting enough of that, your brain will start to feel anxious and irritated… ready to pounce on different things. Don't worry, this particular aspect of menopause won't last forever. That irritability will subside as your brain starts to readjust to the lower levels of estrogen.

Decreased libido and vaginal dryness

This can be very disruptive, not only to the woman but her relationship with the romantic partner. Women often complain that their sex drive has just gone away during menopause. and that if they do have sex it's uncomfortable. It's painful or it's not as pleasurable. There are some hormonal reasons for this. Once again, it comes down to estrogen but also to a hormone called testosterone. You might know testosterone is the male hormone, but women have it as well. As testosterone levels and estrogen levels decrease, the libido goes down and that sex drive can decrease, but it also fundamentally changes blood flow to the vaginal area. It decreases blood flow to the vaginal canal, which means that there's less lubrication of the area and then the tissues there they don't get the nutrients that they need. They can get thinner, and drier. These factors can really disrupt the sex drive and also make sex more uncomfortable. 

Bladder Issues 

A lot of women complain about this one. You may have never had issues in the past, but now find that if you cough or sneeze, your bladder releases. What is going on here? As levels of estrogen go down and the blood flow to the vaginal area decreases, the tissue around the urethra, which is the tube where urine comes out of the bladder, starts to get thinner. The muscles there that are responsible for allowing you to constrict and control bladder get weaker because they're not getting the blood supply that they need. So, you get these weaker muscles and the tissues are thinner, and it means that you can't quite really clamp down and hold things in.  


This is a cosmetic one, but it can still be really disruptive. Wrinkles don’t just occur because you're getting older. The hormone changes also speed up the appearance and the worsening of wrinkles. That is (surprise!) because lower estrogen levels mean that there are some fundamental hormone changes in the skin, that reduce the effectiveness of collagen in the skin, and collagen is a very important thing for keeping the skin supple. As estrogen levels go down, the stimulation of the growth and repair of collagen decreases. Some other hormonal changes can also mean that the hydration of the skin and of the collagen molecules is also decreasing. So, you've got less hydrated and weakening collagen molecules, so the collagen can’t do its job and that's why your skin starts to sag and lose its fullness.

Less Noticeable Symptoms

Unfortunately, that's not all. Those are just the things that women mightnotice. On top of that, there are a couple of things that are more serious health risks that might go under the radar. One possible issue is osteoporosis, because as your estrogen levels go down, it's harder for bones to hold onto calcium. That can mean a gradual decline in the calcium content of the bones and a weakening of the bones that can eventually lead to osteoporosis. 

Another thing might be an increased risk of cardiovascular diseases. Basically, it's thought that as estrogen levels decrease, you're losing the protective effect of that hormone. Estrogen tends to make the endothelial, which is the lining of the blood vessels, more supple and more flexible. That's great for the heart and the blood vessels and it also tends to lead to better ratios of cholesterol. So you have higher good cholesterol, and lower bad cholesterol, but as estrogen plummets, you lose those protective effects and your risk for heart disease, heart attack, and stroke starts to go up. It really starts to go up about 10 years after menopause. 

Management Tips

So, there you go. That’s a long list of some very challenging and problematic things for women, which range from just annoying to quite serious. So, gentlemen, you should sympathize with women as they're going through this, because it sounds terrible. But don’t worry, ladies. There are some things you can do.  

Dealing with Hot Flashes

  • If you're trying to manage hot flashes, one of the things that you can do is just try to avoid the triggers, which can include caffeine, alcohol, or even just heat exposure. So, try to avoid those things.  
  • Take an estrogen mimicker. These are natural products that can be found, that actually act like pseudo-estrogens in the body, and therefore can give you some benefit. One of them and you may have heard of is edamame. That’s a soybean, and soy has a molecule in it that acts a lot like estrogen, and can therefore offset some of the things that are caused by declines in estrogen levels. 
  • There's another product calledblack cohosh that has been shown to help reduce hot flashes. 
  • There's something called maca root, which you can add to your diet, which can help offset some of those issues.
  • Certain medications, such as low levels of antidepressants, or even some even blood pressure medications can help. We always recommend natural remedies first, but medications is certainly available to you.  
  • Then also there's the broad category of hormone replacement therapy, which we’ll discuss in part 2.  

Dealing with Insomnia

  • If your progesterone level has gone down, you may be having more trouble sleeping. In this case, you want to improve your sleeping habits, and that can include darkening your room, reducing noise, and keeping the room cooler, especially if you're having hot flashes —  65° degrees could be ideal.
  • There are also products that can help induce sleep. Dr. Keller recommends Cal Mag to his patients, which can have a soothing effect.  
  • Melatonin products can also help. Smarter Sleep, for example, has 3 mg of melatonin in it, which is thought to be the sweet spot for helping induce sleep but not letting people feel too groggy. It also contains bioactive milk peptides, which can help promote healthy sleep.  
  • Tart cherry, and passion flower, are other natural products you can add to your diet to really help you get a good night's rest.
  • Again, there's hormone replacement therapy.

Managing Mood Issues

  • Depression, moodiness, and irritability are related to the decreasing levels of estrogen.  So, taking some estrogen-mimicking things like edamame, and maca root, may help.
  • Then there are the other things that you can do to help boost your serotonin levels naturally, like exercise. This is great because it releases endorphins, and helps produce serotonin and dopamine. You can socialize more. We are social beings as human beings and so if you're socializing with friends that actually can legitimately increase serotonin levels in the brain. Spend more time in nature. Nature has a very calming effect on the body, and has been proven to reduce stress, reduce cortisol levels, and boost mood. If you're in a really urban environment, or don't get out a lot, get in your garden, go for a hike in the woods. These have been proven to improve mood. So if you're really feeling bummed out or even depressed, then try those to boost your serotonin levels naturally. Just a caveat though: if you're feeling really depressed and you're feeling concerned, or your family members are concerned, then you absolutely should be talking to your doctor and it might be that you need to be on a medication temporarily until things start to level out.

As we’ve discussed a lot of these changes are not just because of a low estrogen level but because of a sudden drop in it. So, as your brain learns to rewire, some of these symptoms will go away with time.

Dealing with Libido Issues

  • One great thing to do is always to do whatever you can to feel great about yourself. That's different for everyone — it can be exercise, body image work, counselling, or talking with your spouse and just going over communication — good old fashioned communication and openness about the changes that you're going through that can really help a couple kind of rediscover their passion. 
  • Although you have some hormones working against you, there are things that you can do naturally to increase your testosterone, and get precursors to hormones which are some of the amino acids. Exercise itself can increase testosterone production from the muscles, for example.

Vaginal Dryness and Incontinence

  • In addition to some of the things that we've already mentioned, you can try what are called Kegel exercises. These are often laughed at, but they actually do work. A Kegel exercise is basically clenching down the muscles that control the urethra and the pelvic floor. If you've ever tried to stop peeing midstream, that squeezing that you have to do is involving those pelvic floor muscles, and that is what a Kegel squeeze is.  Doctors often recommend doing a series of them — squeeze, release, squeeze, release — 10 times in a row. Do that several times a day and you can actually strengthen those muscles ,which will help with preventing incontinence and will also help with pleasure during sex.

Addressing Skin Sagging and Wrinkles

  • Again, this happens due to the lower estrogen levels. You can improve your skin health by staying hydrated, and wearing sunscreen with SPF, as well as taking antioxidants. Blueberries are great antioxidants that really can help boost the repair of the collagen fibers in the skin and damage due to sun. 
  • Avoid things that dry out your skin. That could include caffeine or alcohol.
  • Exercise. Exercise helps promote blood flow to the skin, and that helps keep the skin radiant and get the nutrients there that help repair the skin. 

Preventing Osteoporosis

  • As estrogen levels go down, calcium starts to leach out of the bones. So, it's very important to stimulate the bones to stay strong. Again, exercise plays a huge role in that because the pounding on the bones and the resistance that muscles put on the bones — those stimulate the bones and trigger them to stay strong. So do your exercises, especially resistance exercises. That's very helpful for maintaining good bone health.  
  • The other things you need do is make sure that you're getting adequate calcium and vitamin D. Smarter Nutrition’s Vitamin D supplement includes 5,000 IUs of vitamin D3, the most active form of the vitamin, which is helpful for replacing vitamin D if you're deficient (and a lot of people are).
  • Also, you might want to take theSmarter Women's Multivitamin. It includes adequate levels of some of the other minerals that you're going to need to keep your bones healthy. So, take those steps and avoid things that can help reduce bone density, especially smoking, which is terrible for bone density and some medications that can really take calcium out of the bones. This includes things like antacids, and acid blockers that we prescribe for stomach acid, which can reduce calcium absorption into the body.


So that’s a lot of information but it’s really important to lay the groundwork for what menopause is, what women go through when they feel that change, and how men can sympathize with it and be supportive. Hopefully some of you fellows read this and are better able to understand what is happening. And for ladies, hopefully now you can take some steps to do something about it or at least to know what to expect. Knowledge can often go a long way. Stay tuned for part 2, where we’ll discuss the pro’s and con’s of hormone replacement therapy.

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