INTERVIEW. “Hormonal treatment is just one piece of this puzzle called life at 45+.” A gynecologist explains what happens in a woman's body during menopause

Raluca Enciu, obstetrics-gynecology specialist, explains what happens in a woman's body during perimenopause and menopause, how hormonal changes can be recognized and why menopause is finally starting to be seen in a new light: not as an end, but as a stage of life that can be understood, managed and lived more balanced.

For many women, menopause does not begin on a specific date on the calendar, but with a series of signs that are difficult to decipher: sleepless nights, persistent fatigue, moments of mental fog or an inexplicable state of irritation. Many times, these changes are attributed to stress, the fast pace of life or everyday responsibilities. In reality, they may be the first signals of a major hormonal transformation that every woman will inevitably go through.

ZYX Books: – As a medical specialist, you are an important ally of the mature woman during menopause. You are helping women through a complicated time. What happens in a woman's body during menopause?
Raluca Enciu: – We must realize that women are a complex and fascinating organism. Perhaps more than men, she is subject to hormonal storms beginning with puberty, then pregnancy, childbirth and breastfeeding, and ending with perimenopause and menopause. When we understand what is happening in our bodies, it is easier to accept the change and look with ease at this natural stage that will inevitably come for all of us.

Menopause begins on the day one year has passed since menstruation stopped coming. When the ovaries decide to retire, because they are no longer capable of producing sex hormones, menopause will set in. In the years leading up to menopause, which can be as long as ten, women often experience perimenopause, that is, that stage when the ovaries are increasingly poor in follicles, having less capacity to produce optimal hormone levels. The more women I see in perimenopause, the more I am convinced that it is a chameleon-like, fluctuating stage. Why am I saying this? Because there are women extremely affected by this period with intense hot flashes, heavy bleeding, insomnia, maybe depression and anxiety, and on the other side there are women who don't complain of symptoms, maybe just mild fatigue or high level of stress. But who isn't tired? Who doesn't have periods of insomnia? Who doesn't lose libido?

Since we do not have a generally valid analysis that tells us that we have entered perimenopause, it is often difficult to diagnose, or rather it is underdiagnosed. There is no dedicated training in college or residency, and the information is obtained through super-specialty courses and a lot of personal study. Thus, the right specialist will correlate the information with the troublesome symptoms, medical history and hormonal analyzes to establish the diagnosis of perimenopause and develop a personalized treatment plan.

– I read somewhere a headline that “in Romania, the average age of onset of menopause is 49 years old”. I was intrigued by the possibility arising from this title, that the age of onset of menopause differs from one country to another, from one region to another. Is it possible?
– When a woman enters menopause is genetically determined and has a lot to do with the lower or higher number of oocytes we were born with. However, there are studies that have shown that women who smoke can enter menopause earlier, because smoking affects the vascularity of the ovaries.

Epidemiological data show that women tend to enter menopause later in countries with a high socioeconomic level, such as Iceland, Norway or Australia, i.e. around the age of 51-52 years, at the opposite pole in India, at 47-49 years. In Romania, statistical data show that the average age of natural menopause is 49 years, compared to the European average of 50-52 years.

The most common symptoms

– What are the 3 most common symptoms of menopause?
– Hot flashes, mental fog and sleep disturbances are the symptoms that affect us most frequently. It's incredible how for years menopause was thought to mean only hot flashes, when in fact the woman experiences an avalanche of symptoms, from “brain to toe”.

Although they are called sex hormones, their role does not stop only at this level. Every organ has receptors for estrogen, and without it, the whole body goes into decline. Various areas in the brain can decrease in volume, as demonstrated by neuroscientist Lisa Mosconi in her books and studies, blood vessels become more aggressively loaded with atheroma plaques, the skin loses its elasticity and shine because the synthesis of collagen and elastin decreases dramatically, bones are prone to osteoporosis, troublesome symptoms such as vaginal dryness, discomfort during sexual contact, vaginal infections or frequent urination or urinary incontinence appear. 79% of women suffer from hot flashes, but most of the time they disappear spontaneously after the first years of menopause and they are rarely the most distressing symptom.

The symptom that most severely alters the quality of life is sleep disturbance. Patients may have consecutive sleepless nights or wake up several times, and even if they do fall asleep, the sleep is not deep and restful. The next day comes mental fog, irritability, difficulty concentrating, memorizing and organizing, and over time, depression and burnout can occur. The good news is that, most of the time, these symptoms improve significantly with hormone treatments.

– Why is hormone replacement therapy so confusing for women? Some consider it a super cure, others consider it dangerous. What is the truth?
– Hormone replacement therapy was popular in the US and Europe from 1970 until 2002, when the results of the WHI (Woman's Health Initiative) study were published. This study, done in America on 160,000 women with an average age of 60 who were given oral synthetic hormones, reported a slight increase in the number of cases of breast cancer – the same risk as smoking, drinking two glasses of wine a day and six times less than the negative impact of obesity on the breast.

I don't want to sound pathetic, but the WHI is probably one of the greatest injustices done to women in history. The erroneous statistical interpretation, the wrong structure of the study, the poor communication of the results, the taking over by the press of a partially correct information stated in the study and the perpetuation of these erroneous statements over the years led to a 78% decrease in the number of women who benefit from hormonal treatment. Medical staff were misled and hesitated to prescribe hormone treatments, and ongoing trials using hormone replacement were discontinued.

Twenty years later, the authors of the study reassessed the statistics, and today we know that if we choose the right hormones, identical in structure to those produced by our ovaries, called bioidenticals, and administered transdermally, through the skin, the real risks are extremely small, and the balance is tilted far in favor of the benefits.

Bioidentical hormone treatments are a real help in improving the quality of life of women in puberty and menopause and can reduce the risk of severe conditions such as osteoporosis, type II diabetes, cardiovascular disease, depression. However, hormones do not cure or solve all problems. Lifestyle education is essential from childhood. Regular exercise, healthy eating, optimal weight, giving up alcohol or smoking are those factors in our lives that we can shape to prevent chronic diseases, including breast cancer.

– When is it good for a woman to come to the consultation to find out how menopause should be approached? When does he have certain symptoms, a certain discomfort?
– Ideally, the gynecological consultation should be done once a year and include a simple Pap test, a transvaginal ultrasound and a breast ultrasound, and after the age of 40 and a mammogram once every two years. When you experience menstrual cycle irregularities, perimenopause symptoms such as sleep disturbances, unexplained anxiety, depression, mental fog (and the list goes on, as over 70 perimenopause symptoms are described), then it's time to choose a hormone specialist to have a detailed discussion with. First of all, to see what hormonal stage of life you are in and to establish with the doctor the optimal treatment plan.

Three myths

– What would be a top 3 myths about menopause?
– “Menopause comes after 50 years.” If we did an opinion poll about menopause among young people and men, the answer would invariably be that this stage belongs to the third age, but in reality in the practice I see more and more young women entering menopause. It is estimated that 1% of women under the age of 40 suffer from primary ovarian failure, so they will run out of sex hormones before the age of 40. I am reminded of the case of a 27-year-old lady who wanted a baby and for whom the absence of menstruation was not due to the presence of a pregnancy, but to an extremely premature menopause.

The second myth would be: “HRT is risky.” Yes, but no more risky than smoking, alcohol or paracetamol! Have you ever read the leaflet of paracetamol? How many times have you taken a pill in the last year? There is no risk-free procedure or medication in medicine. Studies have shown that female smokers or those who consume two glasses of wine per day have a slightly higher risk of developing breast cancer, similar to women taking synthetic hormone replacement therapy or oral contraceptives. The hormones currently used are bio or identical bodiesthat is, they have the same structure as the hormones produced by our ovaries. That is why they are better tolerated by the body and involve lower risks.

Also, in terms of the risk of thrombosis (myocardial infarction, stroke), we are on a much safer record these days because we apply estrogen directly to the skin, we no longer take it orally and thus do not increase the risk of developing a blood clot. Hormonal therapies are personalized, each case is carefully analyzed and we will always choose the safest path and preparations for the patient.

“Menopause means I'm getting old” is perhaps the statement I hear most often at my doctor's office or in the women's communities I'm a part of. This stage of life was associated with defeat or futility. Throughout the generations, women have hidden the entry into menopause, including from their husbands, they have looked with shame and fear at such a natural, natural stage that we cannot avoid. But now we are experiencing a turning point: the time has come for this paradigm to be replaced by a new vision of the era, “the new menopause”, which aims at the mature woman, at 45-50 years old, at the peak of her career and who does not want to be abandoned by the invisible engines of her life, namely hormones. Fortunately, there are many ways to help us overcome hormonal changes, to feel better, to look better, to be better people to ourselves and to those around us, to have a better quality of life and to reduce the risk of severe pathologies such as diabetes, osteoporosis, stroke or Alzheimer's disease.

Every day I see women at the clinic who have fallen into the trap of old age – maybe they carried the weight of the whole family on their shoulders, maybe they fought with some disease, maybe they asked for help and didn't get it, no one has the right to judge, but no matter how hard it is, don't stop looking for ways to make your life better. I'm not saying that HRT is a panacea or an elixir of youth, but it is certainly helpful in regaining your restful nights, energy, vitality, well-being, and why not, your libido. Hormone treatment is only one important piece of this puzzle called life at 45+. For the other pieces, it is up to you to gently, steadily and harmoniously bring them into your lives.