Infertility/Fertility/peri-menopause & other

Advertisement


Question
QUESTION: Hi, I am 42 going on 43 and have been having a lot of ob gyn issues recently (fibroid, ovarian cysts).

But what I was wondering about was that according to blood work done, I am peri-menopausal.

How is this different from being menopausal?

Should I continue to use contraception or can I stop now?

How long does the peri-menopausal phase last, usually?

Thanks!

ANSWER: Hello Teresa from Australia,

"Perimenopause" is the period of time just before the ovaries stop completely (menopause).  In the perimenopausal stage, the ovaries are starting to dysfunction, like an engine sputtering before it stops.  Perimenopause and menopause are due to the ovaries stopping their normal function, and that is ovulation and producing the female hormones estrogen and progesterone.  Estrogen is the key hormone and without it a woman's body will start to deteriorate (some ways that are obvious like osteoporosis, dry skin, hair loss and others more subtle like heart disease, insomnia, emotional changes).  As a result, I am a strong advocate for hormone replacement therapy (there are doctors that will argue against it).  In the U.S., recent studies over the past 10 years have shown great benefit to HRT in preserving a woman's health, especially heart disease, the number one cause of death in women after menopause.

In a young woman, I usually will use a low dose birth control pill because her metabolism is still high and she requires higher doses of estrogen.  After 55 years old, I reduce this to menopausal hormone replacement doses and stay at that level forever.

How long the symptoms of perimenopause or menopause will last is not predictable.  Part of it is probably genetic.  It can be 1 year to 10 years.

If you are asking about contraception for the prevention of pregnancy, you can probably stop it at your age, although, in the perimenopause you are still ovulating from time to time so can get pregnant.  The likelihood that you will get pregnant, however, is very low.  However, as mentioned previously, I would recommend staying on them for hormone replacement.  Contraceptives do not cause problems like fibroids or ovarian cysts.  In fact, contraceptive will prevent physiologic cysts so the only cysts that are left are usually tumors and have to be addressed.  Estrogen can make the fibroids grow but you have to weigh that risk over the risk of dying from heart disease.  I would choose preventing the heart disease.  If the fibroids cause a lot of problems, I would recommend surgery to remove then and/or the entire uterus.  

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
info@montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.





---------- FOLLOW-UP ----------

QUESTION: Hi, thanks for answer. It was helpful.

I have a couple of follow up questions relating to my wider gynaecological issues, hope that is ok.

The blood work that came back as 'perimenopausal' was not done during my regular cycle. What happened was that I went to the doctor because I had been bleeding quite heavily for 3 weeks. This had never happened to me before. I had noticed though that recently my periods had been heavier and lasted longer.

Anyway, aside from this last period that lasted 3 weeks, my periods were still occurring regularly every month. I have no other menopausal symptoms. So I am not sure I can trust the perimenopausal diagnosis because I imagine that after 3 weeks of bleeding my oestrogen would have been as low as it could be (based on fact that oestrogen drops just before/during menstruation, is that right?)

Should I get re-tested while not menstruating, to make sure?

The other thing is that I still have a small amount of breast milk in my breasts even though I haven't breastfed for eleven years! This   
isn't a sudden development, by the way. The milk has just never altogether gone away for some reason. Is that a thing I should worry about?

Thanks for your time!

ANSWER: Hello Again,

You are correct that estrogen levels can fluctuate depending on where you are in your cycle, but you reasoning that you've given is not correct.  Estrogen levels are dependent on ovarian output.  The period (bleeding) is dependent on other factors.

If your estrogen was not done on the 2nd or 3rd day of a normal cycle, then it could be erroneous so I would recommend repeating it to be sure.  However, keep in mind that there is not "diagnosis" of perimenopause that can be made by blood testing as this period is when the ovaries function and dysfunction periodically.  Until the ovary shuts down completely, you can have months where the ovaries work correctly so the blood testing would be normal.

In terms of the breast milk, this could be contributing to the problem and may even be the cause of this abnormal bleeding.  There is a hormone that is produced in the pituitary called prolactin and this hormone is responsible for causing the breasts to make milk.  If it is elevated, it affects the other pituitary hormones including the ones that drive the ovary.  So you should have a fasting prolactin level checked.

A competent gynecologist or reproductive endocrinologist will know this and have ordered the proper testing.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
info@montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.


---------- FOLLOW-UP ----------

QUESTION: Thanks doctor! When I see the gyn I'll remember to ask about all this.

Just one thing, fyou said I could 'probably stop using' contraception, but now, from what you are saying about the perimenopausal period (that ovaries can function normally, then not normally, then maybe go normal again for a bit) it sounds like contraception ought to be maintained.

I realise that it's unlikely a woman of my age could get pregnant readily, but from what you are saying, it doesn't sound impossible!
Perhaps for your own sake you should advise women in my position to keep up contraception til they are sure, or you might end up having to deal with a surprised pregnant lady in her mid 40s one day!

By the way, I am not being rude here, just giving you some friendly advice! I am not a lawyer, but I did study law in my youth and I remember at least one case where an ob-gyn got into trouble over such things! :)

Answer
Hello Again,

Thank you for the friendly advice, but let me point out that I think you may have missed and/or misunderstood my replies.

If you look at my initial response to you, in the 2nd and 4th paragraphs, I wrote: "In a young woman, I usually will use a low dose birth control pill because her metabolism is still high and she requires higher doses of estrogen." and "If you are asking about contraception for the prevention of pregnancy, you can probably stop it at your age, although, in the perimenopause you are still ovulating from time to time so can get pregnant.  The likelihood that you will get pregnant, however, is very low.  However, as mentioned previously, I would recommend staying on them for hormone replacement."  Does this not say oral contraceptives and for contraception? I also said, that you could get pregnant (theoretically) and as such, you can assume that you would be protected from pregnancy if on the contraceptive.

When I said "Until the ovary shuts down completely, you can have months where the ovaries work correctly so the blood testing would be normal." that means the formation of the necessary hormones and NOT necessarily ovulation of a viable egg.  The problem with age is NOT the lack of ovulation in 40 year olds, but the lack of good eggs.  That is why the fertility/pregnancy rate is so low.  Yes, you could be ovulating but in fact, you are probably unlikely to have any good eggs to lead to a pregnancy.  Of course, there are always exceptions to the rule.

I hope that clarifies things.  This forum is strickly for asking and answering questions and is not a blog, so please do not feel compelled to reply.  I hope I've given you the information that you were originally asking about.  I don't think I've given any misleading information.


Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
info@montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.

Infertility/Fertility

All Answers


Answers by Expert:


Ask Experts

Volunteer


Edward Joseph Ramirez, MD, FACOG

Expertise

I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.

Experience

I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 19 years.

Organizations
American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society

Publications
American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

©2016 About.com. All rights reserved.