Mapping Menopause: The Agent of Change

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A guide to your changing body and gynecological health during your 40’s, 50’s, 60’s and beyond


A life-changing event like menopause doesn’t just happen overnight. The physical signs of menopause begin many years before the final menstrual period.

First comes perimenopause when you still have periods, but they more erratic.

“We start to see fluctuations of many hormones—estrogen, progesterone, testosterone, DHEA, cortisol—around the ages of 45 through 55, though every woman follows her own biological clock, “says Dr. Vivien Brown, family doctor and menopause expert, certified by the North American Menopause Society. “Gradually, the ovaries are making less estrogen and other hormones that regulate menstruation,” she explains.

“Then comes menopause, when menstruation stops and a woman has missed her periods for twelve consecutive months. The average Canadian woman begins menopause between age of 51 and 52,” says Brown. The last stage called post-menopause is all the years beyond menopause. Brown notes that women “may [may continue] to experience hormonal fluctuations for a few years even after the last menstrual cycle has ceased.”

Click through for some of the common signs of each stage, and a few of the troubling symptoms, during this time of hormonal transition.

45+ Perimenopause

  • Irregular periods mean “lengthened or shortened cycles, heavier or lighter bleeding, and spotting between periods,” according to Brown. “They eventually stop when menopause is reached,” but be mindful she advises. “Irregular bleeding can occasionally be a warning sign of other medical issues, so it is prudent to discuss the issue with your health care provider.”
  • Hot Flashes and/or night sweats. “They often start during perimenopause when estrogen levels are fluctuating. Sometimes they are associated with racing heartbeat and disturbed sleep,” says Dr. Wendy Wolfman, a professor in the Department of Obstetrics and Gynaecology at the University of Toronto and director of the Menopause clinic at Mt. Sinai Hospital. If treatment is required, hot flashes can usually be reduced or eliminated.
  • Unexpected Pregnancy. Though fertility declines, pregnancy is still possible during perimenopause.“Total pregnancies decrease as women age but statistically there are more unwanted pregnancies proportionately after 40,” says Wolfman. “Women do have to continue using contraception into their 40’s until a year after the last menstrual period.”
  • Increased PMS Symptoms “A hormonal imbalance of estrogen dominance and progesterone deficiency can heighten PMS-like symptoms of anxiety, moodiness, water retention, breast pain, food cravings and disturbed sleep,” says Dr. Alvin Pettle, OBS and GYN ( and co-author of A Smart Woman’s Guide to Hormones.


  • Low Dose Birth Control pills provide a steady supply of estrogen to help even out hormone fluctuations, thereby helping reduce or eliminate common perimenopause, symptoms like irregular periods and moodiness, suggests Brown. Plus they offer protection against an unplanned pregnancy, which is still a concern at this time.
  • Progesterone “Some early perimenopausal symptoms are caused not by a decrease in estrogen but by a fall in progesterone,” explains Pettle. “To compensate, I often prescribe using a transdermal bio-identical progesterone cream.”
  • Exercise, diet and lifestyle play a part. A Smart Woman’s Guide to Hormones states that exercise aids menopausal symptoms by enhancing key hormones including estrogen, testosterone, growth hormone, endorphins and thyroid hormone. Pettle also believes a diet of high quality foods, along with nutritional supplements if necessary, can help keep hormones stable by improving your overall health. Try using meditation, spirituality, and good friendships to help reduce stress and anxiety.


  • Heavy Periods, “where you go through lots of super-absorbency pads or Tampons, occurs when the lining of the uterus gets very thick,” says Pettle. “It can also be caused by fibroids, or hormonal imbalance, though some women with heavy periods have no underlying gynecological abnormality. We also have to rule out that the lining isn’t thick because of uterine or cervical cancer,” cautions Pettle. Severe cramps and anemia often accompany heavy periods.
  • Fibroids arebenign, muscle tumors that can be as small as a pea or as large as a cantaloupe. According to Pettle, many women with fibroids develop symptoms that include long or heavy menstrual periods, increased menstrual cramps, pain or pressure in the pelvis or lower back, pain during intercourse, constipation and bloating. Treatment depends on their size and location. “Once a woman gets to menopause, fibroids will shrink by one third,” adds Pettle.


  • Hormone Therapy Transdermal bio-identical progesterone if heavy bleeding is linked to hormonal imbalances. “It will counteract the increase of the womb’s lining, so there is less to shed, which reduces heavy bleeding,” says Pettle.
  • Uterine Artery Embolization is a surgical out patient, minimally-invasive technique that involves injecting particles into the arteries supplying blood to the fibroids to block the blood supply, causing them to shrink in size.
  • Endometrial Ablation is a surgical procedure where the lining of the uterus is reduced to a thin level to decrease the heaviness of menstrual flow. Performed as a day case under anesthetic.
  • Laparoscopic Hysterectomy surgery.“If all else fails, then you’re stuck with the choice of a hysterectomy which involves removing the uterus,” says Pettle. A laparoscope is like a thin telescope with a light that’s inserted into the bellybutton through a small incision. Through two other small incisions above the groin, fine instruments are also passed into the abdomen and used to cut, trim, biopsy, or cauterize inside the abdomen. Recovery from laparoscopic hysterectomy surgery is quicker, less painful and leaves less scarring than a standard abdominal hysterectomy that requires a four to eight inch incision, and approximately six weeks of recovery as compared to a routine abdominal hysterectomy for which you need a longer incision and the recovery is more difficult according to Pettle.

 NEXT: 50’s & 60’s Menopause

50’s: Menopause

  • Vaginal Dryness is by far the most common problem for women in their post-reproductive years. “The vagina is exquisitely sensitive to estrogen,” says Wolfman. “When women become estrogen deficient at menopause, the vaginal lining thins, there’s a tightening of the vaginal opening, and/or narrowing and shortening of the vagina. This is a silent epidemic, and women should not be shy to speak to their doctors because it’s a problem that’s easily fixed,” adds Wolfman.
  • Colon Cancer Risk Wolfman warns that the risk of colon cancer increases in this age group, and recommends that all women after the age of 50 be screened of colon cancer.


  • Vaginal Estrogen products–creams, tablets, rings, available by

prescription–deliver estrogen to the vagina and allows tissues to regain thickness and elasticity.

  • Water-based lubrication

60’s and beyond– POST MENOPAUSE

  • Urinary Control, the loss of urine inadvertentlycan plague post-menopausal women. According to Wolfman, urge incontinence, that feeling when you have to go, occurs more commonly post menopause, and may be linked to reductions in estrogen. Stress incontinence which occurs when a woman coughs or sneezes, tends to affect women in their 40’s (perimenopausal years). Primary causes of weak urinary control include obesity, lax pelvic muscle tone, involuntary bladder contractions (called “overactive bladder”), some medications, infections and hysterectomies.
  • Increased cancer risk “Any woman who has post menopausal bleeding, meaning bleeding one year after the last menstrual period should see their gynecologist to make sure it’s not something ominous.” cautions Wolfman. “Bleeding after menopause can be a sign of uterine cancer. In addition, continue to have PAP test every three years until 70 (or after 70 if a woman has a new sexual partner or has had recent abnormalities) to screen for cervical cancer.”


  • Kegel Pelvic floor exercises that strengthen the muscles around the pelvis may help.
  • Improving abdominal muscles tone also helps.
  • Hormone therapy or permanent surgical interventions are also options.
  • Dr Brown refers her patients to the website of NAMS, for further information and understanding of these complex changes.