Hot Flash, Revised
New terminology—and new studies—help demystify women's midlife health

By Kristen Laine

Our grandmothers called it the "change of life." Our mothers talked about "going through menopause." But for members of the Woodstock generation, euphemisms won't do. After all, baby boomers redefined adolescence and set groundbreaking terms for their 20s and 30s. So it's in character for women boomers to help usher in a newly defined midlife phase: perimenopause.

It turns out that the long-held belief that menopause is a multiyear process—hence "going through menopause"—is incorrect. Menopause actually refers specifically to a woman's final menstrual cycle and is thus analogous to menarche, or a young woman's first menstrual cycle. But while there has always been a word (puberty) for the hormonally charged years surrounding menarche, there has not been such a term for the analogous years surrounding menopause—until recently.

Perimenopause is now commonly considered to start about four years prior to menopause and to include menopause itself. Some women feel hormone-related symptoms as early as their mid-30s and others as late as their mid-50s, but most U.S. women start perimenopause at about 47. The broad term perimenopause is still being defined by the medical research community; the process of perimenopause is now commonly considered to start about four years prior to menopause and to include menopause itself. (Peri in Latin means around.) Some women will feel fluctuating hormone-related symptoms beginning as early as their mid-30s and others as late as their mid-50s, but since the average age of menopause among U.S. women is 51, most U.S. women start perimenopause at about 47.

Thanks to improved longevity, the huge number of women now nearing menopause is unprecedented: In the United States, nearly 2 million women are expected to turn 50 each year for the next 20 years. Just a century ago, a majority of 50-year-old women died within the year. Most women who celebrated their 50th birthdays in 2000 can expect to live about 30 more years.

Not coincidentally, since the term perimenopause was coined in the mid-'80s, the medical research community has focused increased attention and resources on women's health at midlife. In 1994, the National Institutes of Health and other agencies funded by far the largest of several ongoing projects, the Study of Women Across the Nation (SWAN). A ten-year, multisite survey, SWAN is in its seventh year of collecting data from 3,200 women representing five ethnic groups. By the end of this decade, it's expected that hundreds of research papers based on this data will answer questions both large and small about perimenopause.

The Wild Ride
Researchers have already learned that the process of perimenopause is enormously complex, and that its changes affect virtually every area of a woman's life. "Perimenopause is like puberty in reverse," says John F. Randolph Jr., MD, director of the Division of Reproductive Endocrinology at the University of Michigan and chair of SWAN's ovarian markers committee. During perimenopause, a woman's ovaries mature to the point that estrogen production that started in puberty declines, though not in a straight-line manner. The resulting fluctuations in estrogen and in related female sex hormones, such as progesterone and follicle-stimulating hormone, can make for a wild hormonal ride. The following, rather daunting symptoms may all be attributable to hormone swings or dips: erratic periods, heavy bleeding, hot flashes and night sweats, sleeplessness, stress incontinence, irritability, lack of concentration, forgetfulness and low libido.

Women who eat soy-based, estrogen-emulating foods report that they have fewer hot flashes. But SWAN researchers have discovered enormous variability not only in symptoms, but also in hormone data, as well as in perceptions across individual women and between ethnic groups. For instance, African-American women reported more hot flashes than Caucasian and Asian-American women, but expressed less discomfort than other ethnic groups in the study.

Dozens of other factors are believed to influence the frequency and severity of perimenopause symptoms, including diet, lifestyle, hormonal therapies, and botanical remedies. Studies have found that Asian-American women eat more soy-based, estrogen-emulating foods than other ethnic groups in America, which may help explain why they report fewer hot flashes. Researchers of a study based in Japan found that only 11 percent of perimenopausal Japanese women reported hot flashes, compared with 85 percent in some U.S.-based studies.

Preliminary SWAN findings suggest that overweight women are more likely to suffer a difficult perimenopause, more frequently reporting symptoms such as urine leakage, hot flashes, night sweats, and joint stiffness and soreness. The multiplicity of factors and interrelations will take researchers decades to untangle. "There's a whole lot more going on in perimenopause than we thought at the beginning," says Randolph.

Bounce Back
Thankfully, virtually all these symptoms are temporary, and an estimated 20 percent of women pass through perimenopause with little or no discomfort. Even before all the research is in, you can take simple steps to ease common symptoms.

If you're in your 40s, be sure to see a health care provider regularly. Perimenopause itself is no cause for alarm, but it shares symptoms with serious conditions that can also arise during middle age, such as thyroid disease and certain cancers. Be sure to tell your doctor about any medications and remedies you may be taking.

Nearly 95 percent of all perimenopausal women will have irregular periods. Indeed, an irregular cycle is the classic early sign of perimenopause. Soy foods, which act like weak estrogens on the body, may make periods more regular. Low-dose birth control pills (BCPs) also can stabilize an erratic cycle. However, don't take BCPs if you smoke, have had breast or endometrial cancer, have liver disease or hepatitis, or have a personal or family history of strokes or blood clots.

Irritability and forgetfulness may result from disturbed sleep or fluctuating hormones. Three out of four women will occasionally experience heavier menstrual bleeding during perimenopause. The endometrial lining of the uterus builds up during extended menstrual cycles, creating a heavier flow once a period comes. Some doctors still perform hysterectomies on women whose primary concern is heavy bleeding. "It may be frustrating and frightening at times, but it's a normal part of what's going on," says Randolph. "If we can make heavy bleeding tolerable, we could avoid major interventions like surgery." Hormone replacement therapy (HRT), a common treatment for postmenopausal women, can also be used to treat severe perimenopausal bleeding. However, because an increased risk of various cancers, heart disease, and stroke has been associated with HRT, many doctors and women prefer to use natural alternatives, such as soy and wild yam (Dioscorea villosa).

Hot flashes, which are thought to be caused by rapidly fluctuating levels of estrogen, are experienced by somewhere between 45 percent and 85 percent of American women. Some of this variability, SWAN data suggest, may be attributable to genetic differences, some to diet. (A soy-rich diet is generally associated with fewer hot flashes, though existing studies differ on soy's effectiveness.) Black cohosh (Cimicifuga racemosa), a standard botanical remedy in Germany, is currently under study in the United States as a treatment for hot flashes. And increased physical activity, though researchers still don't understand how it works, also tends to mean fewer hot flashes, especially at night, while a sedentary lifestyle is associated with more severe symptoms.

Then, of course, there's not being able to think. Cognitive issues such as difficulty concentrating were the most distressing set of symptoms for participants in a 2000 study of perimenopausal quality-of-life issues. "Minor decreases in cognitive function seem most severe a year or two before the final menstrual period," Randolph says, citing preliminary SWAN research. "After that, things seem to rebound." Related symptoms of irritability and forgetfulness may result from disturbed sleep patterns or sharply fluctuating hormone levels.

Menopause has traditionally been considered the cause for a waning libido. Yet the quality-of-life study cited above found that today's perimenopausal women are not particularly concerned about sexual dysfunction. Women surveyed worried more about losing their car keys than about problems in bed. (Perhaps this is a benefit of the Woodstock generation's complete exploration of drugs, rock 'n' roll and sex.)

Hear Me Roar
As the first generation to reap the benefits of intensive research into this "new" phase, women baby boomers will be able to understand their midlife issues more clearly and will be empowered to address them more proactively, more so than any previous generation. Now all that's needed is someone to give us the great rock anthem of perimenopause. Who will it be? Bonnie Raitt? Alanis Morrisette? J. Lo? Madonna? Talk about a revolution!

A freelance writer based in Orange, New Hampshire, Kristen Laine writes frequently about women's health issues.