By Dr. Nicole Sundene
Menopause is a common often frustrating Women's Health condition caused by a woman's permanent cessation of her menstrual period for more than 12 consecutive months. The sudden drop in estrogen, progesterone and testosterone levels from menopause result in hot flashes, night sweats, irritability, insomnia, weight gain, stomach aches, joint pain, hip pain, vaginal dryness, painful intercourse, bladder infections, anxiety, depression, anger, agitation and sadness.
While progesterone and testosterone begin to decline for women around age 35 as seen in Perimenopause, Menopause is primarily associated with the deficiency of the hormone estrogen. Menopause typically occurs between 40 and 50 years of age, with the average age of menopause being 52 years old. As women's estrogen levels drop they notice changes in their body temperature, hair, skin integrity, vision, vaginal dryness, sleep and concentration.
In the United States, studies reported that women at the age of 51 often experience menopause. Further, every year 1.3 million women report menopausal symptoms in the United States. Women with menopause have lost the ability to become pregnant naturally. Early menopause, also known as "Premature Ovarian Failure" occurs when women are in their early 40's or 10 years or more prior to the average age of menopause.
Medical studies report that hormonal disturbances are common in later stages of life. Depletion of estrogen level leads to the high concentration of follicle-stimulating hormone and luteinizing hormone in the body that significantly disrupt the hypothalamic-pituitary-ovarian axis. As a result, endometrial development failures disrupt the regular menstrual cycles and finally develop various menopausal symptoms. Moreover, different surgical procedures such as hysterectomy with bilateral oophorectomy may also cause surgical menopause. Other health conditions such as cancer, cancer treatments such as chemotherapy can cause early menopause and affect a woman's hormone and thyroid. Endometriosis medications such as antiestrogen medication can also lead to the development of premature menopause. [1, 2]
It is important for women not to confuse Perimenopause, Menopause, and Postmenopause. With so many different labels how can the patient even know which one applies to them? Knowing the correct diagnosis when working with your hormone doctor is important as different treatments, herbs and hormones are appropriate for these 3 different stages of a woman's normal life span. Perimenopause generally occurs 10 years prior to menopause or ages 41-51 if we were to predict based upon the average age of menopause and is characterized by irregular periods with heavier or lighter menstrual flow before menopause. Menopause is the complete absence of menstruation and often the most difficult time for women to get adjusted to as their body and brain adjust to their new low hormone levels. This is when women commonly need the most hormonal support as even tapering a patient slowly off BHRT is often more gentle than just the sudden cessation of estrogen. Some of my female patients need bioidentical hormones around menopause for a few years and then discontinue them when no longer needed and some patients will prefer to be on hormones at all times. Once a woman has gone through menopause she then becomes labeled with "Postmenopause."
Signs and Symptoms of Menopause
Menopausal symptoms are divided into the following three main categories. [1, 3]
Vasomotor Symptoms: Studies reported that 75% of menopausal women experience vasomotor symptoms. The vasomotor symptoms include:
Hot flashes are the prominent symptoms of menopause experienced by almost 85% of menopausal women. A menopausal hot flash episode often remains for at least three to four minutes. Moreover, different factors such as alcohol, emotional stress, and diet may aggravate hot flashes. Studies reported that the average age of menopausal hot flashes is around 5.2 years.
Note that the intensity and severity of migraine changes over time. Studies also reported that the migraine without aura commonly occurs during menopause. Remember that although migraine with aura is less common in menopausal women and is highly associated with the risk of stroke. [3, 4]
Urogenital symptoms occur in approximately 60% of menopausal women. These symptoms include:
Vaginal dryness, pruritus, lichen sclerosis and dyspareunia (painful intercourse) results from vaginal atrophy. In contrast, urethral atrophy leads to urgency, frequent urination, dysuria, and stress incontinence. Women have more bladder infections, more kidney infections, more yeast and vaginal infections with menopause as the vaginal flora is impacted by pH changes and lack of hydration from diminished goblet cells producing mucous that can protect bacteria from adhering to the tissues. 
Around 45% of menopausal women report psychological symptoms. These symptoms include:
Studies also recommend checking and evaluating weight, blood pressure and overall health at a check up when women become menopausal or begin to notice changes. The Latin rood word for Uterus comes from "Hysteria" and that is how we ended up with the word hysterectomy. Most likely because a doctor made the observation that women go hysterical with menopause. As much as I hate this judgement label, I would agree it is true for some of my patients and have sadly seen many women struggle with menopause and their mood. My great grandmother was "accidentally given a hysterectomy after the birth of her last child" and she suddenly went in to severe depression and hot flashes. Back in 1911 the only cure her doctor was aware of for menopause was to "Drink beer." The church lady was told to illegally brew beer during Prohibition so she had medicine for her menopausal symptoms. She had to shutter her house once a month to make the beer she needed for her hot flashes. Thankfully we have much better treatments for menopause thanks to bioidentical hormones, nutrition and Naturopathy! I do not want any of my patients to feel like they have to break the law to treat their menopause. Brewing beer for menopausal symptoms illegally seems barbaric. I did learn in Naturopathic school at Bastyr University that Hops are a natural phytoestrogen that help with menopausal symptoms. Fortunately we have tinctures and capsules so women do not need to rely on drinking beer!
The key indicator that a woman's depression or anxiety is related to menopause or perimenopause is a sudden onset of anxiety or depression later in life when no previous mental health disorder occurred. Most women with anxiety will have a lifetime pattern that they describe to me as always feeling anxious since childhood, teens or 20's but when women that are 40-50 experience a sudden adverse shift in their mental health we should be extremely concerned about their hormone balance whether we are treating the menopause with hormones or herbs it is vital for it to be addressed and properly diagnosed or women can often feel they are going crazy, "I feel like I am suddenly going crazy!" has been a comment I have heard time and time again as a menopause doctor. I then ask whether they have experienced any mental health disorder previously in their life and when they tell me no, I counsel them that it is their hormones impacting their mental health and they are not crazy.
Nearly every single work day I get a new female patient that is depressed or anxious struggling with their mood and frustrated that they are not getting any results from their anti-depressants or anxiety medications. When we get their hormones properly fine tuned it can help stabilize the patient and oftentimes I have seen patients be able to discontinue the antidepressants whether I taper them off myself, their psychiatrist tapers them off or they just suddenly stop taking it because they tell me they no longer need it. Obviously I do not recommend women suddenly stop their antidepressants but instead gradually taper them down once their treatment is working effectively and they no longer need the anti-depressant or valium, Ritalin, Vyvance, etc. Hormones can impact mood, memory and concentration. It is possible for women to be taken off these common medications once their concentration, peace and sense of joy is restored by addressing the imbalanced endocrine system with Functional Medicine, Bioidentical Hormones and Naturopathy.
Did you know I once had a patient sent to me by a Psychiatrist that was on 5 mental health drugs? She is no longer taking any of those medications thanks to her decision to get her hormones checked and treated. Once we had all her levels adjusted properly she completely returned to normal. All of her symptoms started at 35 and she had never had anxiety or depression before until her hormones began to suddenly shift. The psychiatrist was of course shocked to see how much better she was with the hormones as we worked together to taper her down from everything. It was a very powerful mental health lesson for both of us.
While many Naturopathic Doctors are intimidated by complex patients, my background in prescription family medicine makes me a bit more fearless...especially since I know my treatments are generally harmless compared to the side effects of antidepressants, anti-psychotics and the addiction potential for patients at risk of becoming hooked on benzodiazepines like valium and xanax when really their hormones are just off and not compatible with feeling happy.
Perimenopause which begins as early as 30 for some women that will enter menopause early can be extremely hard on a woman's mental health as they battle estrogen dominance and progesterone deficiency or "Permanent PMS" as I like to call it as my mental health patient nods and says "That is exactly what is wrong with me. It does feel like permanent PMS because I am gaining weight, I am super bloated, I feel agitated, and I am constantly fighting with my husband and crying over nothing!"
Many marriages can be pushed to the brink of marriage counseling when women are struggling with their hormones. In order for men to have more empathy and understanding I would love to perform an experiment where I give someone's husband 6 x 1mg estradiol tablets with no progesterone to oppose it and see how bitchy and evil the husband becomes. So far I have not been able to find any men to participate in my "PMS Experiment" and I won't be holding my breath waiting for someone's husband to volunteer, although I would like to make a a video of a man crying and raging on imbalanced hormones. So that we can have more understanding and support with PMS and PMDD. I believe many marriages could be saved, families could stay together and not be broken with better understanding and more support for women. Many women bring their husbands in to the appointment so they can learn how to keep a period tracker app, know what window in the month is best to be kind, silent, keep things simple, or even better maybe just leave us alone and go on a fishing trip and return when it is all over.
In conclusion, its a massive hormone red flag when women suddenly develop anxiety or depression later in life yet also cite no current stressors such as work stress, death, loss, finance, parenting or relational stress yet cannot figure out why they continue to remain unhappy, moody, agitated, on edge and constantly anxious or stressed. We all know when we are going through a tough time that we can expect not to feel fabulous. But if there is no actual trigger for a woman's mental health condition then I need to put on my Detective cap and look for possible hormone, vitamin and nutritional imbalances that can be the actual underlying cause of the moodiness. "Tolle Causam" means "Treat the Cause" and is my favorite Naturopathic Principle because unless we understand the cause we cannot treat the cause. Until we treat the actual cause whether it be with natural medicine or prescription medicine... the patient will fail to improve because we are not addressing the actual problem and simply trying to mask each symptom of hormone imbalance rather than treat it at its source.
Causes of Hot Flashes during Menopause
Hot flashes are the first thing everyone thinks of when they hear the word menopause. But what actually is causing this hot flash? A hot flash is a feeling of sudden warmth in the upper body parts, experiencing high in the chest, face, and neck region. Sometimes it is accompanied by sweating, followed by chills. Medical research studies are still working to explore the exact mechanism of menopausal hot flashes. Multiple research studies attribute the hot flashes to hormonal changes during menopause. Such as the fluctuations in the estrogen or progesterone level, less estrogen production, and modulation of the thermoregulatory system that results in the development of hot flashes. With less estrogen the hypothalmus that is in charge of setting the body temperature is now telling the body to run hotter. The sudden drop in estrogen triggers the serotonin receptors in the brain to turn the temperature up via vasodilation. As a reflex the woman then becomes too cold and is having hot and cold flashes or hot flashes followed by sudden chills.[3, 5]
Research studies have found a connection between hot flashes estrogen and serotonin and have attributed the hot flashes to the estrogen withdrawal and imbalance between estradiol and follicle-stimulating hormone levels. Recent studies reported the association between hot flashes and a high concentration of serotonin that triggers changes in the set-point temperature. A low estrogen level modulates the activation of serotonin receptors in the hypothalamus that change the set-point temperature sensitivity and results in hot flashes. [3, 5, 6]
Complications of Menopause
Studies reported that women with menopause are at greater risk of developing certain medical conditions. These conditions include heart and blood vessel diseases, urinary incontinence, osteoporosis, sexual problems, and weight gain. [1, 2]
Menopause Diagnosis and Hormone Tests
The diagnosis of menopause involves the evaluation of clinical symptoms and lab tests. Generally, there is no need for lab tests to confirm menopause. However, there is never a more important time for a woman to get her check up and make sure her thyroid, cholesterol and blood chemistry are normal. While not all women require treatment for menopause having the full profile of hormones tested and balanced can help women to feel more optimal. [1, 2]
Menopause Treatment History
Menopausal treatments from opium to acupuncture were used for the management of menopausal symptoms till 1942. Then Wyeth pharmaceutical introduced Premarin containing synthetic estrogen obtained from "Pregnant-Mare urine" for the treatment of menopause. Despite the fact collecting urine from pregnant mares trapped in stalls all day is animal abuse, the sales of Premarin spiked until the 1970s. Reports linking synthetic estrogen with a high risk of breast cancer. During that time, the formulation was modified with the addition of progestin to ensure safety and efficacy. But the 1984 National Institutes of Health assertion backed that estrogen is an effective agent for hot flashes, bone loss prevention, night sweat, and other menopausal symptoms. 
Moreover, by the 1990s, the American Heart Association, the American College of Physicians, and the American College of Obstetricians and Gynecologists recommended estrogen for both heart conditions and bone loss. As a result, estrogen use soared up again among menopausal women until the Women’s Health Initiative (WHI) in July 2002. The Women’s Health Initiative (WHI) conducted a study on around 17,000 postmenopausal women. The study revealed that the combination of estrogen and progestin increased death rate in postmenopausal women due to increased risk of blood clotting, heart attack, stroke, breast cancer, and ovarian cancer. This report changed the whole scenario of hormone replacement therapy for more extended periods. Later, multiple research studies confirmed the WHI reports and found a high incidence of heart conditions and cancer with hormone therapy. The risk of these morbidities is prevalent in women older than 60 years. Moreover, women who abruptly stopped the hormone therapy intervention also showed a significant risk of death or comorbidities. Thus, the prescription of hormone therapy depends on the patient medical condition, duration of therapy and previous history. In 2002 we had to call 100's of women to take them off of their Premarin and Prempro without bioidentical hormones as widely available at the time, most patients were transitioned to soy and black cohosh although we have seen advancements in Women's Health since then and have much better natural treatment options for menopause. 
How Long Should Women take BHRT Hormones After Menopause?
Hormone experts generally prescribe BHRT hormone therapy for a 3-5 year window after menopause. Once a woman turns 55 her cancer risk is naturally going up which is when I generally taper the hormones down. An irresponsible hormone doctor leaves patients on the same dose, while a responsible hormone doctor will taper the dose down as is considered biologically normal for the woman's age group. Yes, hormones are effective drugs of choice in the treatment of menopausal symptoms, but treatment goals must be safe and realistic as the patient ages.
Do BHRT Hormones Cause Cancer?
It is important to work with an ethical hormone doctor to determine if BHRT is safe. The doctor should first evaluate the patient's entire family history of blood clots, heart disease, stroke, breast cancer, uterine cancer and ovarian cancer risk when considering any hormone use whether natural or synthetic. Women without a family history of reproductive cancer are excellent candidates for BHRT. A good menopause hormone doctor will provide alternative remedies to BHRT when family history of breast cancer exists. The hormone doctor should case by case weigh the benefit-risk ratio of hormone therapy and recommend a symptomatic approach to treat menopausal symptoms. For safety reasons women should not use hormones without a doctor continuously monitoring and checking hormone levels. Hormones should not be given to patients with cancer. After a reproductive cancer an Oncologist would need to approve if BHRT will be safe or harmful for the patient to use. While some cancers are hormone driven, patients that have had cancer will need to follow their Oncologist's instructions. Naturopathy and herbs can still be used even when hormones cannot be used. While BHRT hormones generally do not cause cancer a woman should always get their mammogram, pap smear and pelvic exam every year as a safety measure. Should a woman naturally develop cancer while taking BHRT these important cancer screenings will help Reproductive cancers are generally very slow to grow and thus the hormones would be removed immediately. 
Treatment of Menopause
Various treatment interventions help the management of menopausal symptoms and prevent the risk of severe medical conditions. These treatment options include:
Hormone Replacement Therapy
Hormone Replacement Therapy (HRT) encompasses both natural and synthetic hormone therapy for menopause and is considered the most effective approach to treat menopausal symptoms. It helps prevent both vasomotor symptoms, urogenital symptoms, improves lipoproteins level, and reduces the risk of osteoporosis. The hormonal agents include systemic estrogen, estrogen-progestin combination, progestin alone, estrogen-bazedoxifene combination, or progestin combined with oral contraceptives. Although many hormone formulations are currently available, I only prescribe BHRT from a compounding pharmacy or natural estrogen and progesterone from a regular pharmacy. Synthetic preparations are associated with worse side effects than a woman's own natural hormones or "bioidentical."[1-3]
Hormonal replacement therapy helps treat hot flashes, improves sleep disturbance, prevents bone loss, and helps urogenital atrophy. It is important to know that estrogen alone is not recommended in women with a uterus as it can cause uterine hyperplasia and cancer in such women. It is usually recommended for menopausal women with hysterectomy. The combination of estrogen and progesterone were mainly prescribed to menopausal women with an intact uterus. Now with the latest research we know women without a uterus still need progesterone for their mental health, sleep, vaginal lubrication, vision, weight and overall wellness. [1-3]
Whether natural or synthetic, hormones should be used for a short-term duration at their lowest therapeutic doses. Because the long-term use of hormone replacement therapy is associated with a high risk of coronary heart diseases, thromboembolism, breast cancer, stroke, and ovarian cancer. Side effects of hormones involve bleeding between periods, gastrointestinal symptoms, and breast tenderness. [1-3]
Alternative to Oral estrogen
Medical research studies reported the following alternative to oral estrogen formulations. [3, 7]
Localized Estrogen Therapy
Estrogen intended for vaginal administration helps urogenital symptoms, including vaginal dryness, vaginal atrophy, painful intercourse, and other urinary symptoms. Different dosage forms such as creams, rings, and suppositories deliver estrogen to the vaginal tissues. The localized estrogen therapy is associated with a bit of risk of venous thromboembolism. Alternative to vaginal estrogen, hormone-free remedies, including plant oils and lubricant, are also helpful in managing vaginal dryness. [1-3]
Non-hormonal treatment involves using antidepressants, anti-seizure, and antihypertensive agents for a short duration, usually up to a few months. The antidepressant, including both serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) in low doses, helps the management of both vasomotor (hot flashes) and psychological symptoms (poor mood). Paroxetine is the only FDA-approved SSRI for the treatment of hot flashes. Besides, Gabapentin, an anti-seizure agent, also helps reduction of menopausal hot flashes. Clonidine is an antihypertensive agent that might help both high blood pressure and hot flashes during menopause. [1-3]
Selective Estrogen Receptor Modulators (SERMs)
Selective estrogen receptor agents modulate the estrogen action without interfering with the endometrial growth. These agents include raloxifene, ospemifene, and bazedoxifene that help prevention of osteoporosis and improve lipoprotein level. Also, estrogen combined with these modulators significantly helps vasomotor symptoms and prevent hot flashes. Among these modulators, the ospemifene is highly effective in the management of vaginal dryness. [1-3]
Osteoporosis-specific treatment in menopausal women involves the intervention of the administration of denosumab, bisphosphonates, and supplementation of calcium and vitamin D. Both denosumab and bisphosphonates inhibit the activity of osteoclasts and resorption of bones that increase bone density and prevent the risk of fractures. The supplementation of Vit D and calcium strengthen the bones and improve bone mineralization. [1-3]
Complementary and alternative treatments include phytoestrogens, vitamin E, and omega-3 fatty acids. Vitamin E and omega-3 fatty acids have been used to treat the vasomotor symptoms of menopause. They are generally safe; however, studies have shown that they are no better than placebo. [1-3]
Certain plants contain a high concentration of plant-based estrogen, known as a phytoestrogen. These plants include soybeans, whole grains, lentils, legumes, flaxseed, chickpeas, and various fruits and vegetables. They are rich sources of the main types of phytoestrogens, including Isoflavones and Lignans. [1-3]
Role of Bioidentical hormones in the management of menopausal symptoms
Bioidentical hormones are referred to the manmade hormones obtained from plant sources that share a similar chemical structure with the human testosterone, progesterone, and estrogen hormones. Examples of bioidentical hormones include 17 beta-estradiol, estrone, progesterone, and estriol. They are available in different dosage forms, including patches, oral pills, topical gels, vaginal capsules, and topical creams. Bioidentical hormones are either made by pharmaceutical companies or by pharmacies according to a physician's order. They help treat various menopausal symptoms, including hot flashes, mood disturbances, night sweats, sleep problems, low libido, and weight gain.The bioidentical hormones made in a pharmacy, known as compounded bioidentical hormones, are not approved by FDA. They are marketed as safe and effective bioidentical hormones, but they may possess serious health risks. The side effects of bioidentical hormones include fatigue, excessive facial hair growth, bloating, mood swings, and acne. It is important to mention that FDA recommends low doses of hormone replacement therapy for short-term use.
My hormone philosophy is to use the least amount of bioidentical hormones needed to keep women in a normal physiological range for their age group as some women will continue to make hormones from their adrenal glands and body fat while other women will have zero hormones in their tank and need a little bit of a hormone cream, troche or lozenge containing natural estrogen, progesterone and testosterone to restore skin integrity and aging, improve vaginal dryness, aid with mood, decrease hot flashes and improve sleep at night. It is important to work with a skilled hormone doctor that understands how to properly test bioidentical hormones via blood work (not saliva) and adjust them while also ensuring their safety. Women undergoing treatments for menopause, perimenopause and PMS will need to have their hormones checked and adjusted 1-2 times per year at minimum to ensure they are functioning optimally and that their hormones are at optimal levels. I have seen a lot of careless prescribing of hormones over the years and it is dangerous to not have these levels monitored and adjusted. Women should always be given progesterone with their estrogen regardless of if they have a uterurs because progesterone is also needed for vaginal hydration, mood, sleep and vision. Women will generally feel better on a low dose of combined hormones.
My practice style is to continuously test the hormone levels to ensure they are safe and being metabolized properly as genetics such as COMT mutation can cause estrogen pooling and increased risk of side effects and adverse outcome in women that are not having their hormones regularly checked.
The recommended schedule for hormone testing in menopausal patients is every 3 months the first year that bioidentical hormones are started and then every 6-12 months after that. Hormone testing is covered per the patient's insurance plan and it is imperative the patient goes to the correct lab either Labcorp or Sonora Quest whichever is contracted with the insurance plan is where the blood is drawn for testing. Whether a prescription product from the pharmacy is being used and states no testing is required or whether a compounded pharmacy is being used to make the BHRT the levels should tested as women metabolize hormones very uniquely and high levels of estrogen that women cannot eliminate can cause sudden weight gain.
Natural treatment of menopause
Medical research studies reported a significant positive impact of the following herb on menopausal symptoms.
Various lifestyle interventions can also ease the menopausal signs and symptoms.  These include:
Dr. Nicole Sundene, NMD
Dr. Sundene is a Naturopathic Doctor in Scottsdale, Arizona, and is considered a Female Hormone Expert in Women's Health and Bioidentical Hormones. She specializes in Holistic Women's Health for Menopause, Thyroid, Hashimotos, PMS, Perimenopause, Autoimmune, Postpartum, Chronic Fatigue, Depression, Anxiety, Food Allergies, Digestion, Dermatology , Acne, Psoriasis, Eczema and Adrenal Hormonal Conditions. In 1999 she began working for a Hormone Doctor prior to starting Naturopathic Medical School. With over 22 years of experience in both Prescription and Natural women's health and hormones she presents to women the best integrated health solutions for their Chronic Disease. She has been an Herbalist for over 27 years and enjoys teaching women how to use herbs to balance their hormones, nutrition and optimize their health. Dr. Sundene relies on blood testing for her hormone metrics. The hormone testing is covered per the patient's insurance plan and conducted at certain points in the woman's menstrual cycle. To learn more about Hormone Testing for Women Visit: Bioidentical Hormones. Follow Dr. Sundene on Instagram, Twitter and Facebook for more tips on Women's Health, Female Hormones and Naturopathy!