Menopause is a time of physical and emotional change

Dr. Lisa Lipschitz is an OBGYN affiliated with Sharp Grossmont Hospital. A version of this essay was originally published in The San Diego Union-Tribune.

Due to patient confidentiality, real names generally can't be used when doctors write about their patients. So, for this essay, I will call one of my patients Maggy. She's 53 and has been my patient since she gave birth to her son 17 years ago.

During a recent visit, Maggy sat across from me looking defeated and exhausted, tears rolling down her face. She described waking up in the middle of the night drenched in sweat and experiencing hot flashes during the day that felt “like a fire from the inside out.” She also felt irritable and tired and wished she could be more patient with her teenage son, husband and her ailing 84-year-old father.

Maggy is in midlife, a time of significant transition. Midlife falls between the ages of 40 and 65, when many women are faced with a larger social and financial burden. Frequently, they are part of the “sandwich generation,” trying to launch their children while experiencing more responsibility and stress caring for their aging parents.

Additionally, as women approach menopause, the end of their reproductive years, they undergo profound hormonal and physical changes that can result in many symptoms, including sleep disturbances, night sweats, hot flashes, brain fog, mood changes, painful intercourse and recurrent urinary tract infections.

As women age, they may also develop new health issues that mimic menopause symptoms. For example, sleep disturbance may be a sign of menopause but also could indicate sleep apnea, thyroid problems or depression. After a thorough evaluation, we confirmed that Maggy did not have any underlying health issues.

Additionally, Maggy met the medical criteria for menopause: no menstrual cycles for a year, indicating a cessation of reproductive hormones. She was also experiencing severe vasomotor symptoms, commonly known as hot flashes and night sweats.

Fortunately, we live in a time when there are many safe and effective options to alleviate hot flashes and night sweats. A simple nonmedical strategy is wearing layered clothing and keeping a fan close by. Hot flashes can also be treated by clinical hypnosis, a mind-body therapy, and cognitive behavioral therapy, a form of biofeedback.

The first-line medical therapy for hot flashes, which is often highly effective, and FDA-approved, is systemic estrogen. For women who choose this therapy and still have a uterus, estrogen must be paired with progestogen, a reproductive hormone that the body produces. This protects the uterus from uterine lining proliferation and eventually precancer or cancer of the uterus.

Hormone therapy is generally safe for most women if started within 10 years of menopause or before age 60. However, it is not suitable for everyone. Contraindications that would prohibit their use include unexplained vaginal bleeding, active liver disease, personal history of heart attack, stroke, blood clot or inherited risk of blood clots, and a personal history of breast cancer.

For women who can’t or choose not to use hormonal therapies, several nonhormonal medications are available. Traditionally, specific medications used for depression (paroxetine), overactive bladder (oxybutynin) or pain (gabapentin) have moderate success for vasomotor symptoms.

In 2023, the FDA approved a promising new nonhormonal medication called fezolinetant (brand name Vezoah), which acts on the thermoregulatory center of the brain and decreases severity and frequency of hot flashes and night sweats. The only contraindications are active liver disease or end-stage renal disease.

Maggy chose hormone therapy and decided to find a therapist to help manage her stress. She opted for an estradiol patch and oral micronized progesterone which are identical to the hormones produced by our bodies.

Four weeks later, her life had significantly improved. She was sleeping soundly through the night, and with the combination of hormones, therapy and improved sleep, she felt better equipped to deal with her father and to be more present for her teenage son and husband. Although she still experienced some hot flashes during the day, they no longer bothered her significantly. Maggy happily reported, “I have my life back.”

Menopause is a time of great physical and emotional change for women. Many share similar experiences. While not all women may recognize themselves in Maggy, it’s likely many will. The hope is that they realize they’re not alone and seek help.

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