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Most of the time, it’s easy to hear people around us say, “I’ve been feeling unwell lately, having trouble sleeping,” but what they might be reluctant to say is, “I’ve been experiencing menstrual irregularities, insomnia, and irritability lately, possibly entering menopause.”
When you were young, you might have heard the grandmothers and aunts from the neighborhood quietly complain about “hot flashes” and “insomnia,” never expecting that as time goes by,even your own mother and you in the future will have to face this day.
At some point, the term “menopause” has been completely stigmatized, becoming a synonym for “irritable, angry, and affecting family harmony,” yet turning a blind eye to the suffering that women silently endure behind these negative descriptions.
As a result, “menopause” is increasingly labeled as “embarrassing” and “shameful,” making many women feel embarrassed to face it and seek help,missing the opportunity to make their lives better.
Menopause is not a disease,
nor should it be stigmatized
In 2024, The Lancet published the ‘Menopause series’, advocating for a change in the stereotypes about menopause, viewing menopause as a part of healthy aging, and warning against the over-medicalization of menopause to help women go through menopause smoothly.
Menopause is a popular term. In 1994, the World Health Organization（WHO）recommended replacing the term “menopause” with “perimenopause” to better describe this stage.
The average age of menopause for Chinese women is around 49 years old, but there is still a significant difference in the age at which individuals enter perimenopause. According to data published by The Lancet in 2024:
●2-4% of women experience a decline in ovarian function before the age of 40,8-10% of women have already reached menopause during the stage of 40-44 years old;
●50% of women at the age of 45 begin to enter perimenopause, and around 51 years old,50%of women have already reached menopause, with the rest all being in perimenopause.
The duration of perimenopause varies from person to person,ranging from 3-4 years to as long as 8-10 years.
Because the primordial follicles in a woman’s ovaries are non-renewable. At seven months of fetal development, the number of primordial follicles in a woman’s ovaries reaches its peak(a total of 6 to 7 million), at this stage, the reproductive stem cells in the ovaries begin to stop replicating, and the primordial follicles start physiological consumption(yes, the consumption begins before birth),at the age of 45, there are only about 10,000 left.
The estrogen and progesterone that are very important for women are secreted by the developing follicles. As the follicles are consumed, the ovarian function gradually decreases, and there is a cliff-like decline during the perimenopausal stage, leading to significant changes in hormone levels and a series of corresponding health impacts.
Due to the above reasons, menopause is a necessary natural stage in a woman’s life cycle, not a disease. However,the discomfort and troubles accompanying this stage need attention.
Figure: The change in the number of oocytes
|
Peak before birth at 7 months of pregnancy |
6-7 million |
|
At birth |
2-3 million |
|
At the onset of puberty |
300,000-400,000 |
|
At 45 years old |
Less than 10,000 |
The “discomforts” deserve to be seen
Perimenopause is the transition of women from sexual maturity to old age. Due to the decrease of various sex hormones, especially the decrease of estrogen, combined with psychological, social, cultural and women’s personality characteristics and other factors, each woman’s menopausal experience is unique and significantly different.
There are many types of related symptoms, and the occurrence and duration of various symptoms also vary greatly over time.
We refer to the problems that appear at the beginning of perimenopause as
recent symptoms of hormone deficiency. These symptoms include hot flashes, insomnia, mood swings, irritability, decreased libido, headaches, urinary incontinence, vaginal pain, and depression, etc.are all common.
The incidence of recent symptoms is shown in the figure below:
In addition to recent symptoms, long-term issues related to perimenopause also include:
osteoporosis, cardiovascular and cerebrovascular diseases, urinary genital tract mucosal atrophy symptoms, and cognitive function decline.
These discomforts, to varying degrees and distances, affect women’s health and quality of life. Behind the simple names of symptoms are countless days and nights of silent endurance.
For example: Hot flashes and insomnia
Hot flashes are a unique symptom of perimenopause, usually starting with sudden heat concentration on the upper chest and face, and quickly becoming whole-body heat. The heat usually only lasts for a few seconds to a few minutes, often accompanied by profuse sweating, occasionally accompanied by palpitations, sometimes also occurring chills and shivering and a sense of anxiety.
This short-duration heat process is very similar to tidal waves, hence the name “hot flash.” Hot flashes can occur several times a day, a few times a day at least, and many times regardless of day and night, every hour. Especially common at night and in the afternoon, can also occur at other times.
In the early stage of menopausal transition, about 40% of women will experience hot flashes, and in the late stage and early postmenopause, this proportion will increase to
60%-80%.
The occurrence of hot flashes is because when estrogen levels decrease, the temperature regulation function of women’s hypothalamus becomes overly sensitive. Reproductive-age women only activate the heat dissipation mechanism when the core body temperature rises by 0.4℃ or more(peripheral vasodilation of the skin and increased skin blood flow, profuse sweating leads to rapid heat dissipation, until the core body temperature drops below normal, then chills may occur), while
postmenopausal women activate the heat dissipation mechanism when the body temperature rises below 0.4℃.
The most direct impact of hot flashes on women is an increase in the incidence of insomnia. Just imagine, being woken up in the middle of the night, drenched in sweat, who can still sleep? According to some studies on overnight polysomnography in perimenopausal women, when hot flash symptoms occur,69% of women will wake up, and nocturnal hot flashes are more common in the first 4 hours of sleep.
For women,
hot flash issues are more like a signal of entering perimenopause, prompting us to start paying attention to related issues.
For example: Depression
Symptoms of perimenopause are not just about estrogen deficiency. When a woman reaches middle age, she often has to take care of the elderly and children at home, as well as face the pressure of work. Long-term stress and responsibility can easily lead to various psychological problems. The risk of depressive symptoms varies greatly among different women.
Women with a history of depression,60-70% will experience an exacerbation of depressive symptoms during perimenopause, which is 1.5 to 3 times higher compared to other periods. The reasons include significant fluctuations in estrogen levels, insufficient social support, and the multiple impacts of stressful life events, which can make symptoms more severe.
Women without a history of depression have a relatively lower incidence, but also 20-30%
.
Source: The Lancet, 2024
Therefore,it is not appropriate to attribute anxiety, depression, paranoia, schizophrenia, or even suicidal tendencies during this stage solely to estrogen deficiency during perimenopause. This simplistic and stereotypical impression can easily lead to a misunderstanding: “It’s just a lack of estrogen, just endure it for a few years and it will pass.” This can result in a delay in the diagnosis and effective psychiatric treatment of depressive symptoms and major depressive disorders, causing potential harm to women.
For emotional issues during this stage,due to stigmatization, embarrassment, and poor communication, many women choose to bear it silently rather than actively seek help and support.
So, if you have obvious insomnia, anxiety, or depression issues, it is necessary to actively assess and intervene.
Those silent nights,
actually do not have to be borne alone
When these symptoms seriously affect your quality of life, it is time for treatment.
Mild hot flashes(not interfering with daily activities)women usually do not need drug treatment, but when there are more severe hot flash symptoms, they usually need supplemental estrogen and progesterone or other drug treatments.
According to the impact of hot flashes on daily life, they can be divided into asymptomatic, mild, moderate, and severe, which is very subjective. If they occur 7 times or more a day, they may affect sleep, attention, mood, and libido.
So, no matter if you encounter one or several of the above symptoms, when you feel it is a problem, it is the right time for treatment.
What else can we do?
When you don’t want to use hormone drugs yet
50-75% of women will first try various non-hormonal therapies when perimenopausal symptoms occur. The North American Menopause Society（NAMS）has conducted many comparative studies on a variety of alternative treatments.
Good news first:
The placebo effect can reduce the number of hot flashes by 20%-50%. The saying that comfort is also a treatment seems incredibly powerful at this moment. It is worth noting that compared with no treatment, placebo treatment can also reduce the psychological impact of hot flashes and night sweats and improve sleep.
After comparison, alternative treatment methods that are similar in effect to placebos include:
Deep slow abdominal breathing, various nutritional supplements/ herbs, cooling techniques, avoiding irritants(for example, spicy food), physical exercise, yoga, mindfulness intervention, various plant estrogens(for example, isoflavones, coumestans, or lignans, red clover), cannabis substances, acupuncture therapy, and clonidine.
The above methods are not recommended, and the conclusion is: the therapeutic effect is no better than that of a placebo.
Using drug treatment
So far,estrogen replacement therapy is still the most effective method for treating menopausal symptoms, suitable for most women with moderate to severe hot flashes and no contraindications.
However, due to the historical ups and downs of hormone therapy (for details, see the popular science article “Improving the plight of women’s suffering, starting with the discovery of suffering”), it is necessary to fully assess the risks of cardiovascular diseases, breast tumors, and thrombotic diseases based on the patient’s personal situation and medical history before treatment.
Women with the following diseases may not be suitable for hormone replacement therapy:
●History of breast cancer;
●Cardiovascular diseases;
●History of thrombotic diseases or stroke;
●Active liver disease;
●Unexplained vaginal bleeding;
●High risk of endometrial cancer or transient ischemic attack.
These patients need to choose non-hormonal drug treatment plans.
Before using medication, it is necessary to discuss the risks and benefits with a doctor based on individual circumstances, choose the appropriate medication plan, and carry out regular monitoring and evaluation.
Perimenopause is a natural stage in a woman’s life journey, which requires our respect and understanding, and provides appropriate social and medical support, allowing them to embrace the next stage of life more healthily and happily.
Further Reading
Peer-review expert
Mou Tian
Obstetrician and gynecologist at Distinct, Ph.D. from Peking University Health Science Center, visiting scholar at the University of Kansas Medical Center
