MENSTRUATION MATTERS

Guest Post by Jerilynn Prior, M.D. — Centre for Menstrual Cycle and Ovulation Research

By “midlife muddle” I don’t mean the trouble concentrating or remembering names that sometimes occurs for all of us (but more frequently if we’ve wakened with night sweats and not gotten back to sleep). I mean the condoned and official confusion about naming of women’s reproductive aging. Let me show you why I am upset.

 

STRAW+10 staging system for reproductive aging in women

Stages of Reproductive Aging Workshop (STRAW) held a 10-year anniversary last summer. (As someone frustrated by not being “heard” at the original conference, I still think that the “W” in STRAW should stand for Women!) Despite that, STRAW+10 has made progress because at least some of the classification is now supported by population-based prospective data rather than based on what experts believe. The names that are now politically correct are summarized in the STRAW+10 Executive Summary1 and the diagram1 at right.

 

We in the Society for Menstrual Cycle Research have also had our say about nomenclature: “Naming Women’s Midlife Reproductive Transition”.  I wrote this (with revision and refinement by collective effort of SMCR members) because women keep getting left out of this naming business. For example:

  • a regularly menstruating woman with night sweats, heavy flow, and increased cramps could learn to call herself perimenopausal2 (not STRAW+10 Late Reproductive Phase -3b?!).
  • a woman who just finished her period can say, I’m in late perimenopause and have at least a year without further flow before I’ll be menopausal. Based on STRAW+10 she could be told that specific menstruation was her final menstrual period (nickname “FMP”) and the next day, according to STRAW+10 be told that she is now “postmenopausal”!!
  • a woman with sore breasts, irregular periods, and heavy flow could say, I’m in perimenopause. However, she may instead be told she is in the “Early Menopausal Transition.” Because she has heavy flow she is also likely to be prescribed the birth control pill (as is currently and commonly recommended). Usually she will not be told that The Pill will make her perimenopausal irregular flow worse—she may well start spotting in the middle of her cycle.3

This new and improved STRAW+10 still centers all of women’s reproduction on that mythical FMP. But to call the FMP “menopause”, as many women’s health experts do, is just unscientific. It takes at least a year without another menstruation in those of us over age 45 before nine out of ten of us will not get another period4. But one (out of ten) of us will get a further, normal period even though we’ve been that whole year without any4. We can tell that new flow is normal (in other words, does not need investigation for endometrial cancer) if we had cramps or bloating or sore breasts or moodiness—or all of these—that told us our period was coming.

 

So our new Naming position statement says don’t call it “menopause” until you’ve not had a period for a year. And do call it “perimenopause” if things are variable and changing even if you are still having regular flow2.  Three of nine changes can confirm for you that you are perimenopausal even if your flow is still regular:2

  1. Shorter cycles (25 days or less);
  2. Increased cramps;
  3. Heavier flow;
  4. Increased trouble sleeping—especially waking up in the middle of sleep;
  5. New or increased migraine headaches;
  6. Night sweats—especially if they tend to occur before or during flow;
  7. An increase in or new premenstrual mood swings;
  8. New sore, enlarging or nodular breasts; and
  9. Weight gain without changes in what you eat or the exercise you do.

If women can learn to call themselves perimenopausal, they will be saying they know that perimenopause is not the same as menopause—perimenopause is a midlife transition with higher and erratic estrogen levels. Menopause is a fairly stable life phase with normally low estrogen and progesterone levels that begins one year after their last menstrual flow.

 

Furthermore, by naming themselves accurately they will be able to tell whether a medication that is proposed for them has been tested and proven effective in perimenopausal women. Usually symptomatic women are treated with oral contraceptives (that are proven reasonably safe and useful for premenopausal contraception), or offered hormone therapy that has only been tested and shown effective for hot flushes/flashes in menopausal women.

 

So. . . I like the word, perimenopause and think if women understand and own it they will be on their way out of a midlife muddle.

 

References

  1. Harlow, S. Executive Summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging [pdf]. Fertility Sterility, 2012   doi: 10.1016/j.fertnstert.20012.01.128
  2. Prior JC. Clearing confusion about perimenopause. BC Med J 2005; 47(10):534-538.
  3. Casper RF, Dodin S, Reid RL, Study Investigators. The effect of 20 ug ethinyl estradiol/1 mg norethindrone acetate (MinestrinTM), a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause 1997; 4:139-147.
  4. Wallace RB, Sherman BM, Bean JA, Treloar AE, Schlabaugh L. Probability of menopause with increasing duration of amenorrhea in middle-aged women. Am J Obstet Gynecol 1979; 135(8):1021-1024.
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