We hear a lot about hot flashes and the end of regular periods, but there are plenty of other changes that happen during perimenopause and menopause that aren't quite so well-known.
The hormonal changes of menopause spark concerns about a woman’s heart, bones, and mental health, too. And that’s in addition to health risks like weight gain and increased odds of developing cancer, which aren’t so much the result of menopause as they are a consequence of aging.
Here are some of the health changes that can come with perimenopause and menopause that every woman should know.
One of estrogen’s roles is to inhibit the breakdown of bone, a process called bone resorption. The decline in estrogen production during perimenopause and menopause means that bone loss starts outpacing new bone building.
“Women can lose up to 20% of their bone density after menopause,” says JoAnn V. Pinkerton, MD, executive director of the North American Menopause Society.
This doesn’t mean you’ll end up with osteoporosis, when the bones are so weak they break easily. Rates of bone loss vary among women, and there are plenty of things you can do to keep your skeleton strong.
For starters, make sure you’re getting enough bone-supporting vitamin D and calcium. Dr. Pinkerton suggests aiming for 1,200 mg a day of the latter from your diet and supplements if needed.
Weight-bearing and balance exercises, along with maintaining good posture, can also help. If your risk for fracture is high, your doctor may recommend certain medications to prevent further bone loss or decrease fracture risk, Dr. Pinkerton adds, including hormone therapy for some women.
Some women say they have brain fog, including memory lapses and difficulty finding the right word, during and after menopause. But the evidence linking this specifically to hormonal changes is weak.
“There’s not a lot of data supporting the fact that cognitive function and dementia is related to natural menopause,” says Karen Carlson, MD, assistant professor of obstetrics and gynecology at the University of Nebraska Medical Center. “The women who do have noticeable cognitive impairment, it’s probably more related to other menopausal symptoms such as sleep deprivation.” (More on sleep issues later.)
Researchers have linked early menopause–age 40 or younger; the average age at menopause is 51–with lasting negative effects in cognitive function. There also may be a link between menopause and Alzheimer’s disease: More women than men develop Alzheimer’s as they age, and early research suggests the decline in estrogen at menopause may leave women’s brains more vulnerable to the disease.
Fluctuating from happy to sad (or angry) and back again is common in perimenopause. This is probably because of hormone levels that keep dipping and rising before they finally settle down after menopause.
Mood swings before menopause may also be more pronounced in women who had bad PMS earlier in their lives, or who have a history of depression. Lack of sleep (often due to night sweats) also doesn’t help.
Exercise and meditation are good remedies for the blues whether they happen in midlife or not, but consult a health care professional if the lows last for extended periods of time or are severe.
Problems sleeping are common among perimenopausal and menopausal women, affecting as many as half or more of women aged 40 to 64. Specific issues include poor sleep quality and insomnia due to hot flashes and night sweats.
Lifestyle changes can help, says Dr. Pinkerton, who is also division director of Midlife Health and professor of obstetrics and gynecology at the University of Virginia Health System. Lower the temperature in your bedroom and use fans to circulate air, she suggests. It’s also probably smart to avoid spicy food, alcohol, cigarettes, and hot drinks. Some women find hypnosis and cognitive behavioral therapy also help with night sweats and sleep problems, she adds.
Of course, in today’s 24/7 world of blinking and beeping screens, sleep problems are common in many age groups. The same advice that might help a younger person can also help a woman going through menopause: Try hitting the hay and waking up at the same time each day, avoiding afternoon naps, and powering down your electronics before bed. Regular exercise can promote sleep too, although maybe not right before bed.
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In addition to vulvar atrophy and vaginal dryness, some women notice bladder changes at menopause. Experts refer to the range of bladder and genital changes and symptoms that come with menopause as genitourinary syndrome of menopause or GSM.
“We know that there are estrogen receptors on the bladder and urethra, which help with bladder and urethral functions,” Dr. Carlson explains. “With the decrease in estrogen, a lot of women do see changes in bladder function, as well as definitely the vaginal dryness and vulvar atrophy.”
Bladder problems often consist of stress incontinence–bladder leakage when you cough or sneeze. This may be more noticeable if you’ve given birth vaginally several times, says Dr. Carlson.
Strengthening exercises can help, as can hormonal treatments. Talk to your doctor about what’s best for you. Because the lack of estrogen makes your vagina dryer and less pliable or stretchy, sex can also be painful, so take advantage of a good lube.
Women’s risk of heart disease increases after menopause, and the decline in estrogen likely plays a role. The hormone usually helps keep blood vessels flexible, improving circulation.
However, as the American Heart Association states, menopause does not “cause” heart disease. Other contributing factors also change at this time in life: LDL or “bad” cholesterol and blood pressure rise, HDL or “good” cholesterol declines, and unhealthy habits (a high-fat diet, smoking, a lack of exercise) practiced throughout a lifetime may finally catch up with you.
Aim for the well-known and simple (though not always easy) solutions: a nutritious diet, 150 minutes of physical activity every week, and no smoking. Try to avoid weight gain and keep track of your numbers–cholesterol and blood pressure in particular, says Dr. Pinkerton.