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Things No One Tells You About Menopause

Hair in weird places, “menopause brain” and other wonders of the female body. 

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All too often, menopause is shrouded in mystery and euphemism. To many, it remains a relatively taboo subject, despite its universality among women. Your friends and family may even have avoided detailing their experiences, leaving you curious, confused—and maybe a little worried about your own menopause journey.

“I wish more women knew that what they’re feeling is normal,” says Afua Mintah, MD, an OBGYN at St. Mary Medical Center in Langhorne, Pennsylvania. “Many women just need validation that these experiences aren’t in their head and they’re not being imagined.”

With that in mind, here are 10 things no one tells you about menopause, along with tips to help ease the transition.

Medically reviewed in December 2020.

YOUR VAGINA AND VULVA MAY CHANGE

2 / 11 YOUR VAGINA AND VULVA MAY CHANGE

Estrogen contributes to the development of female sex traits like breasts and uterine lining, along with regulation of certain bodily functions like menstruation and sleep. During menopause, estrogen levels decrease, which can lead to a common condition called genitourinary syndrome of menopause (GSM). Women with GSM experience a range of uncomfortable symptoms in the vulva and vagina, as well as issues with the urethra, bladder and labia.

“Without estrogen, the walls of the vagina become thin and dry,” says Dr. Mintah. This can cause pain during sex by making the vagina more prone to irritation and tiny tears. You may also develop itching, burning and dryness in your vulva and vagina.

“Additionally, decreased collagen reduces the elasticity of vaginal tissues and can make the entire vagina shorter and narrower,” adds Mintah. Prior to menopause, the vagina has more folds, allowing it to stretch easily during intercourse. When the vagina shortens and loses some of those folds, it becomes more difficult for it to accommodate penetration. The vulva can lose elasticity, as well.

You may also experience light bleeding or spotting after sex. While this is normal, it’s important to be vigilant because it could indicate a more serious condition, such as cervical cancer. If you bleed after sex, speak with a healthcare provider (HCP).

VAGINAL ESTROGEN IS AN OPTION

3 / 11 VAGINAL ESTROGEN IS AN OPTION

So, how can you ease GSM symptoms?

Some women take oral pills to address menopause symptoms like hot flashes in addition to GSM. But for GSM only, vaginal estrogen is a first-line treatment—a prescription medication used to address symptoms like burning and dryness. It comes in multiple forms, including extended-release inserts, tablets, liquid-filled capsules, creams and rings. Unlike medication taken orally, these products are inserted into the vagina. The result is a lower amount of estrogen in your bloodstream than you would receive from an oral treatment. Your HCP can help decide which product might work best for you.

To note: Women who use vaginal estrogen do not need to take progestogen, whether or not they still have a uterus.

LUBE HELPS, TOO

4 / 11 LUBE HELPS, TOO

If you experience discomfort during sex, fear not—there are more solutions and treatment options than you might think. “Lubricants, for one thing, are inexpensive and readily available,” says Mintah.

“Applied to the vagina or vulva, lubricants aren’t absorbed into the skin, but rather act on the surface to decrease friction. Use them liberally if dryness is interfering with your ability to stay sexually active,” she says. Not sure which is right for you?

  • Use water-based lubricants like KY Jelly for sex with condoms or masturbation. If you’re prone to vaginal yeast infections, choose a brand that’s glycerin-free.
  • Silicone-based lubricants like Eros may be used with both condoms and latex sex toys (not silicone sex toys since they can ruin the material). But they’re tough to rinse off, may cause vaginal irritation for some and can taste strange.
  • Petroleum oil-based lubricants (baby oil, Vaseline, etc.) and vegetable oils should be used for external masturbation and massage only. Never use them internally or with condoms, as they can wear down latex, causing condoms to break. They also leave behind a residue in which germs can easily grow.

What might also help? If possible, have more sex. It increases healthy blood flow to your vulva and vagina, encouraging natural plumping and lubrication.

AND THEN THERE’S VAGINAL MOISTURIZER

5 / 11 AND THEN THERE’S VAGINAL MOISTURIZER

“I also wish more women knew about vaginal moisturizers, which are different than lubricants,” says Mintah. “Moisturizers are applied the same way, but they do get absorbed into the vaginal and vulvar tissues. They’re meant to be used regularly, not just during sex, and are effective at reducing itching and irritation.”

Vaginal moisturizers can be found in the pharmacy and include brands like Replens and Vagisil. Make sure to read the application directions carefully and consider wearing a pad or panty liner since your vagina will release any product it doesn’t absorb.

THE WORLD CAN FEEL TOPSY TURVY

6 / 11 THE WORLD CAN FEEL TOPSY TURVY

From lightheadedness to confusing mood swings, menopause can make your head spin. Dizziness is a common menopause symptom, for example, but the two aren’t always related. Ask your OBGYN about other possible causes like dehydration, low blood sugar, low blood pressure, anxiety or a heart condition if you experience this symptom often.   

And what about mood swings? One moment you’re ordering a cupcake at the local bakery, and the next, you’d like to smash it in a stranger’s face. You’re not insane—your hormones are fluctuating. During the transition to menopause, called perimenopause, your ovaries make a daily attempt to produce estrogen. Sometimes they fall short, and sometimes they overcompensate. Since estrogen helps to regulate brain chemicals like serotonin, which controls mood, your emotions can have a hard time keeping up.

Changes in hormone levels mess with your sleep, as well, which also contributes to mood swings. The good news: Your emotions should eventually level out after you’ve reached menopause.

“MENOPAUSE BRAIN” CAN AFFECT MEMORY, TOO

7 / 11 “MENOPAUSE BRAIN” CAN AFFECT MEMORY, TOO

Don’t panic if you find yourself wandering into rooms for no apparent reason or forgetting your thought mid-sentence. Brain fog is a common side effect of menopause.

“Many women describe problems with mild memory loss and difficulty concentrating,” says Mintah. Tasks involving working memory—the ability to take in new information, process it and use it to make decisions—may feel especially challenging.

“Estrogen is thought to be important to cognitive function and the decrease in estrogen may be associated with these symptoms,” she explains. Difficulty sleeping adds to the fog.

Sound familiar? If so, try this: Repeat new information like names, numbers or instructions out loud as soon as you hear them. Writing the information down may also help it stick in your mind. (A full night’s rest is a proven brain booster, too.)

YOUR DEPRESSION RISK GOES UP

8 / 11 YOUR DEPRESSION RISK GOES UP

“There’s an increased risk of depression in women during the menopausal transition, compared to their younger years,” says Mintah. “But this risk is generally thought to decrease in the early post-menopausal years,” she adds.

In general, women have double the lifetime risk of depression, compared to men. This is due, in part, to dramatic hormone changes that come with life stages like puberty, pregnancy and menopause. When estrogen drops during menopause, specifically, it can interfere with your brain’s ability to regulate mood chemicals like serotonin. 

Social pressures, family responsibilities and gender inequalities also influence depression risk for women. Middle-aged females, for example, often must juggle careers, childcare, eldercare, financial and household responsibilities, making them prone to caregiver burnout and depression. If you experience the warning signs of depression, such as persistent sadness, fatigue or loss of interest in activities you usually enjoy, reach out to a mental health practitioner for help.

HAIR MAY APPEAR IN UNEXPECTED PLACES

9 / 11 HAIR MAY APPEAR IN UNEXPECTED PLACES

During menopause, hair can fade from areas where it belongs and pop up where it’s not supposed to be, like your face and back. Unlike men, who tend to go bald in patches during midlife, women often experience an overall thinning of hair related to decreasing estrogen and progesterone levels.

At the same time, certain types of androgen—the hormone responsible for male sex traits—might rise during perimenopause. This spike may not be dramatic, but since your estrogens are lower at this point any way, it can be enough to encourage male-pattern hair growth. Hormone changes might also result in acne, decreased skin elasticity and thin, brittle nails.

“Collagen is what gives your tissues elasticity and keeps the skin and hair young-looking,” explains Mintah. “The collagen content in your skin decreases when estrogens are low, leading to wrinkles and an aged appearance.”

ABNORMAL UTERINE BLEEDING CAN HAPPEN

10 / 11 ABNORMAL UTERINE BLEEDING CAN HAPPEN

Abnormal uterine bleeding (AUB) can be an early sign of perimenopause, or come on after you’ve gone months without menstruating. Some women may lose up to 80 ml (1/3 cup) of blood in one cycle, bleed for over seven days at once or experience symptoms related to blood loss that interfere with their lives, like weakness. Women who are obese or have uterine fibroids are more likely to experience AUB.

If it happens to you, make an appointment with your OBGYN to confirm that the bleeding’s related to perimenopause and to order lab tests. Your doctor may recommend you take an iron supplement to treat anemia or hormone therapy to reduce the bleeding. Depending on your blood work, symptoms and medical history, they may also have you undergo additional tests to rule out other conditions like uterine fibroids.

 

ASK ABOUT YOUR HEART HEALTH

11 / 11 ASK ABOUT YOUR HEART HEALTH

“Over the long term, estrogen deficiency can lead to an increased risk of heart disease,” says Mintah. “This is thought to be due, in part, to changes in cardiovascular risk factors, such as cholesterol levels, which begin to change during perimenopause.”

While menopause doesn’t cause heart disease, blood pressure and cholesterol levels tend to increase during this time (even if you’re following the same healthy diet you always have and are getting regular exercise). These factors raise your risk, so it’s important to have a conversation about screenings and prevention with your HCP. (Remember, heart disease is the number one killer of women in the U.S.)

You can start by discussing blood pressure and cholesterol checks with your HCP, as well as dietary changes, exercise and stress management.

Sources:

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The North American Menopause Society. “Changes in the Vagina and Vulva.” 2020. Accessed December 8, 2020.
 Centers for Disease Control and Prevention. “HIV Risk Reduction Tool.” 2020. Accessed November 9, 2020.
Bonnie Rothman Morris. “Two Years After; Fighting Dryness, With Pills, Gels and Rings.” The New York Times. June 6, 2004.
Vagifem. “How Vagifem works in your body.” 2020. Accessed November 9, 2020.
Johns Hopkins Medicine. “Introduction to Menopause.” 2020. Accessed November 9, 2020.
Cleveland Clinic. “Can Menopause Cause Anxiety, Depression or Panic Attacks?” November 25, 2019. Accessed November 9, 2020.
University of Rochester Medical Center. “‘Brain Fog’ of Menopause Confirmed.” March 13, 2012. Accessed November 9, 2020.
Women’s Health Research Institute. “Effect of Perimenopause on Cognition.” 2014. Accessed November 9, 2020.
Harvard Gazette. “Changes in memory tied to menopausal status.” September 27, 2016.
BL Lasley, S Crawford, & DS McConnell. “Adrenal androgens and the menopausal transition.” Obstetrics and Gynecology Clinics of North America. September 1, 2012. 38(3), 467–475.
T Yasui, S Matsui, et al. “Androgen in postmenopausal women.” The Journal of Medical Investigation. 2012. 59(1-2):12-27.
HealthyWomen.org. “Androgen.” 2020. Accessed November 9, 2020.
UpToDate.com. “Clinical manifestations and diagnosis of menopause.” October 2020. Accessed November 9, 2020.
Johns Hopkins Medicine. “Menorrhagia.” 2020. Accessed November 9, 2020.
BS Agpar, AH Kaufman, et al. “Treatment of Menorrhagia.” American Family Physician. June 15, 2007. 75(12):1813-1819.
UpToDate.com. “Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics).” October 2020. Accessed November 9, 2020.
Centre for Menstrual Cycle and Ovulation Research. “For Healthcare Providers: Managing Menorrhagia Without Surgery.” October 4, 2017. Accessed November 9, 2020.
Andrew M. Kaunitz. “Menorrhagia During Perimenopause.” Medscape. March 1, 2006.
JC Prior. “Progesterone for Symptomatic Perimenopause Treatment - Progesterone politics, physiology and potential for perimenopause.” Facts, Views & Vision in ObGyn. 2011, 3(2), 109–120.
American Heart Association. “Menopause and Heart Disease.” July 31, 2015. Accessed November 9, 2020.
University Health News Daily. “Cholesterol Levels for Women May Increase After Menopause.” April 20, 2020. Accessed November 9, 2020.
RA Lobo, SR Davis, et al. “Prevention of diseases after menopause.” Climacteric. June 4, 2014. Pages 540-556.
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MB Mac Bride, DJ Rhodes, & LT Shuster. “Vulvovaginal atrophy.” Mayo Clinic Proceedings. January 2010. 85(1), 87–94.
Cleveland Clinic. “Do You Bleed After Sex? When to See a Doctor.” September 1, 2017. Accessed December 7, 2020.
R Kagan, S Kellogg-Spadt, & SJ Parish. “Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause.” Drugs & Aging, 36(10), 897–908.
Mayo Clinic. “Estrogen (Vaginal route).” October 1, 2020. Accessed December 7, 2020.
Medline Plus. “Estrogen Vaginal.” August 15, 2018. Accessed December 7, 2020.
J Patterson, L Millheiser, & ML Krychman. “Moisturizers, Lubricants, and Vulvar Hygiene Products: Issues, Answers, and Clinical Implications.” Female Sexual Dysfunction and Disorders. November 3, 2016. 8, pages213–221(2016).
Cleveland Clinic. “Uterine Bleeding: Abnormal Uterine Bleeding.” August 30, 2019. Accessed December 7, 2020.
Medscape. “Abnormal (Dysfunctional) Uterine Bleeding Workup.” December 7, 2018. Accessed December 7, 2020.
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