Online Health Chat with Lynn Simpson, MD

Tuesday, February 7, 2017


The “change of life” is a normal event in every woman’s life. Menopause is actually a process involving three stages: perimenopause, menopause and postmenopause. The most important thing you can do to understand changes relating to menopause is to arm yourself with the facts. Don’t let any stage of menopause keep you from enjoying a normal life.

Perimenopause is the natural transition that moves a woman from her childbearing years into her post-childbearing years. It can be a confusing time, and many women wonder if they are going through menopause when symptoms start to arise. Menopause is defined as the cessation of normal menstruation for one year, and is experienced by all women as they age. Both stages are treatable, and women should not have to suffer with symptoms during this transition through menopause into the final stage, postmenopause.

There are a variety of treatment options available for women, and successful treatment will depend on a customized plan. Women should know about their health care options during perimenopause and menopause, including hormone replacement therapy, bone density testing, and screening guidelines for mammography and gynecology pelvic examinations. As unique as each woman is, the treatment can be very different for each person.

Going through “the change of life” does not mean you have to just “deal” with all of the symptoms. The best way to come up with a plan that will minimize your symptoms is to discuss all of them with your physician and come up with a plan together to treat them until you are satisfied. With proper care and management, you can minimize the impact of perimenopause and menopause. Some women even find a new freedom during this time in their life and are able to really enjoy it!

About the Speaker

Lynn Simpson, MD, is a staff physician in the ObGyn & Women’s Health Institute at Cleveland Clinic. She practices in the Center for Specialized Women’s Health. Dr. Simpson’s clinical interests are in women's health, osteoporosis, menstrual disorders, perimenopause, menopause, postmenopause and vulvar disorders. She earned her medical degree at The Ohio State University College of Medicine and Public Health, and completed her residency at Grant/Riverside Methodist Hospitals, both in Columbus, Ohio. She was appointed to Cleveland Clinic in 2010.

Let’s Chat About Perimenopause and Menopause

Describing and Defining

Young&Flirty: How is perimenopause different from menopause?

Lynn_Simpson,_MD: Menopause by definition is the cessation of menses for 12 months. The average age for this in the United States is 51.4 years, with a range of 45 to 55 for most people. Perimenopause includes the years leading up to menopause and on average starts about four years before periods actually stop. This is the time when periods become farther apart, and symptoms such as hot flashes may begin.

adhd1: How do I know if I am in perimenopause since I have heard that so many of the symptoms are close to what I already experience with my ADHD?

Lynn_Simpson,_MD: You did not mention your age, but on average menopause (which is cessation of menses for 12 months) happens around 51.4 years old. Perimenopause begins around four years before periods stop. The average age range is 45 to 55 for periods to completely stop, with some people being a little younger and some a little older. It is abnormal to stop periods completely before age 40, although there are women who have irregular cycles. During the perimenopause, along with symptoms experienced after periods completely stop, it is very normal for women to have hot flashes, sleep disturbances and sometimes mood changes. The hallmark of the perimenopause is the lengthening of the interval between periods, with cycles becoming more like 40 to 50 days, instead of the usual range of 24 to 35 days.

Betty_spaghetti: I’m 46 years old and started having hot flashes at night. Have I started menopause? How long will this last?

Lynn_Simpson,_MD: Hot flashes frequently start in a woman’s 40s. If you are not skipping periods or having a lengthening of your cycle, it is not perimenopause yet. However, instead of the more regular cycles women have in the earlier years, the hormone fluctuations in the 40s can be quite pronounced, even when the cycles are still regular. That is why some women who are still having regular cycles will begin to have hot flashes. Hot flashes can occur intermittently during this time and frequently become more pronounced when the cycles start to lengthen. Some women will spontaneously stop hot flashes about a year after their periods stop. Many more will stop by four or five years after menopause. However, about 9 percent can continue indefinitely, even into their older years.

sgol: Does having gone through fertility treatment and having had several children at all affect when perimenopause may start?

Lynn_Simpson,_MD: Fertility treatments and having children do not affect when perimenopause starts. The reasons for needing fertility treatments can sometimes affect the timing. The average age for menopause is 51.4 years. The menopause transition or perimenopause starts on average four years earlier. There are factors that can influence when you start this transition, such as heredity and smoking. Sometimes, women who have had a hysterectomy can have an earlier menopause.

LexiKY: Do women in the same family generally go through menopause at the same age, or is it more dependent on other factors? I am 52 and in perimenopause, but have a sister who is 54 and also still having periods. Unfortunately, my mom doesn't remember the age she started menopause.

Lynn_Simpson,_MD: Heredity can affect the timing of menopause, but not always. Other factors such as health issues and smoking can also affect it. Women who have had pelvic surgeries especially hysterectomies can sometimes start earlier than they would if not having had surgery. On average the transition to menopause (meaning 12 months without a period) takes about four years. This transition is when women begin skipping periods and may begin having menopausal symptoms such as hot flashes, vaginal dryness and mood changes. However, that is only an average; it could be shorter or could be longer.

Helpful Hormones

Katypie: I’m perimenopausal and was told I should be taking low-dose birth control pills. Why is this?

Lynn_Simpson,_MD: There are several reasons a low-dose birth control pill may be prescribed. One is for managing menstrual problems; another is to treat perimenopausal symptoms such as hot flashes. Birth control pills can also alleviate both menstrual irregularities and the associated major hormone fluctuations that are common in the perimenopause.

Mindful98: What are the pros and cons of taking hormones with the onset of menopause? I had my mother stop taking Premarin, and she aged 10 years overnight.

Lynn_Simpson,_MD: If you are having issues with hot flashes, insomnia, mood changes and vaginal symptoms such as dryness, there is no better option to alleviate them than hormone replacement therapy. Hormones are safest when you start them right after menopause. Studies have suggested that there is a 30 percent decrease in mortality in women who start hormones right after menopause. This is not true if you start hormones in your 60s after many years of not being on them. There can be an increased risk of cardiac events in this age group. The biggest con of starting hormones right after menopause is that there is a slightly increased risk of clotting events such as deep vein thrombosis. After five years, there is a slight increase in the risk of breast cancer if you are taking an estrogen-progesterone combination (which you have to do if you have a uterus). Women who have had a hysterectomy taking only estrogen actually showed a decreased risk of breast cancer.

iaschoolnurse: I have been taking 1mg estradiol for five years. My doctor assures me this is safe. I have no history of breast cancer in my family. I had a partial hysterectomy 20 years ago. I had a saliva test a few years ago, and my estrogen levels were off the chart. I understand levels would be elevated due to being on estrogen, but that high? I have tried to wean myself off the estrogen, but when I do, I have hot flashes at night. I have tried natural forms of hormones such as Young Living Progessence Plus oil and a supplement in pill form (I can't remember the name or brand), but neither were effective. I am 52 years old. What are your thoughts regarding long-term usage of estrogen?

Lynn_Simpson,_MD: I agree with your doctor on this. The biggest risk of hormone therapy is a slightly increased risk of blood clots. When you are only on an estrogen, there is no increased risk of breast cancer. The safest and best time to start hormones is right after menopause. Estrogen is the best medication to relieve the symptoms of menopause that you still have. Saliva tests are not reliable and cannot be used to monitor therapy with hormones. I do not recommend them. When you use non-regulated options such as lotions and supplements, there is no regulation for purity, content or ingredients. The reality is that even the compounded substances, also not regulated, are all man-made. I recommend you stick with your estrogen. You can always try to see if you need it in a few years. There is no pressure to get off it now. Remember, women who start hormones at the time of menopause have a 30 percent reduction in mortality. This is not true if starting them when you are older and many years beyond your final period.

queenmom: I thought birth control pills could put women over 45 at danger for blood clots and other possible side-effects.

Lynn_Simpson,_MD: Birth control pills can safely be used by women up until the time of menopause, on average 51.4 years, as long as there is no contraindication to them such as high blood pressure. I also do not recommend them in women who have a BMI over 40, as this greatly increases the risk of blood clots. All women, no matter how old they are, have an increased risk of blood clots on the estrogen/progesterone birth control pill. This is not true of the progesterone-only pill. But remember, a pregnant woman has a far greater risk of having a blood clot. Birth control pills can be very useful in managing some of the menstrual issues that woman have in their 40s, as well as a good contraceptive option. In a woman without contraindications, including a strong family history of blood clots, they are a good option. Also, birth control pills decrease the risk of both ovarian and uterine cancer.

Sugarcheryl: When should a woman stop taking hormones post-menopause?

Lynn_Simpson,_MD: That is a good question and a hard one to answer. It is a completely individual thing; there is not one answer for this. It also depends on why you are taking them. Other health issues that you may be having can also influence the decision. This is a question that has to be discussed with your doctor, taking into account the goals of treatment and current health issues. Therapy can be just a few years for some women and indefinitely for others.

Talking Alternatives

LadyJ: Are there alternative treatment options for menopause?

Lynn_Simpson,_MD: It depends on what specific symptoms you are having. Treatment options will vary from none needed to hormonal and non-hormonal options. These options are individualized depending on the person, as there is much variation.

searching?: I’ve been having hormone pellets implanted quarterly for a year. Can estrogen and testosterone pellets make blood pressure increase? If so, what does one do if they need to keep having the pellets?

Lynn_Simpson,_MD: Administration of hormones this way is unapproved and unregulated, and is not a method I would recommend. Testosterone is sometimes associated with elevations with blood pressure. When pellets are administered, the initial exposure is large, followed by a decline. Women will sometimes show the effects of excessive androgen with these. Also, if you have a uterus, you should also be taking progesterone. There are many other, safer, well-regulated methods to deliver hormones including tablets, patches, cream and gels. Methods chosen are individualized to the patient depending on their specific concerns.

LexiKY: What are your thoughts about using a natural progesterone cream during perimenopause rather than taking hormones? Also, I see some creams recommend using them after menopause as well. Is that necessary? What are the pros and cons of doing this?

Lynn_Simpson,_MD: It is important to be aware that all of these products are man-made. They are usually derived from yams. However, they are not regulated; there is no regulation of purity, actual ingredients and levels of medication. Progesterone creams cannot provide a high enough level of protection of the lining of the uterus, so they are unsafe when used to balance out a "natural" estrogen. There are regulated forms of bio-identical estrogen and progesterone that are regulated. These include Prometrium (the progesterone) and Estrace® (an estrogen). I think of progesterone creams as very expensive body lotion.

lindabar: I have been taking Prempro® for two years and decided to stop, as it is too expensive and I would prefer more natural options. What are your thoughts and research on natural remedies, teas, roots, herbs, oils? I am open to anything at this point. My worst symptoms are insomnia, brain fog and mood swings. Thank you, Linda

Lynn_Simpson,_MD: I think there are both hormonal and non-hormonal options for menopausal symptoms. These options have to be individualized, as not all women experience exactly the same symptoms. Most of the research on supplements, including herbs and oils, has not been encouraging. Also, there is no regulation of these substances so the purity, ingredients and efficacy are not assured. There are also bio-identical regulated hormone options such as Estrace and Prometrium. Remember, all of these products are ultimately man-made. Also, some of these substances can cause side effects and may interact with other medications you are taking. I would recommend a visit to a women's health specialist to discuss what options would be best for you to deal with the symptoms you are having. It is a safer way to go than experimenting with unknown quantities.

Symptoms and Solutions

Lonilynn: My question: Is it normal for the period to stop for seven months and then start up again? Is that a part of the body preparing for menopause?

Lynn_Simpson,_MD: You did not mention your age, which is very important to know when answering this question. In general, if this happens under age 40, it is not normal. Between 40 and 45, it can be normal but would need to be evaluated. For those 45 and older, it can be normal during the perimenopause. Heavy or intermittent on-and-off bleeding is not normal for this time. After you have gone 12 months without a period, any bleeding is considered abnormal and needs evaluated. It does not mean something bad is happening, but it needs to be checked out.

Need help: Sex has become painful since menopause. What can I do?

Lynn_Simpson,_MD: There are many things that can help with pain with intercourse after menopause. Lubricants can be very helpful. Unlike before menopause, when estrogen is still present, silicone-based lubricants work better for many women than the traditional water-based lubricants. An example of a good silicone-based lubricant is Astroglide Silicone. This can be obtained at any regular drug store. Better lubricants are not enough for everyone, however. Almost always, a very small amount of vaginal estrogen will improve the problem greatly. Estrogen is administered vaginally either by a ring that stays in the vagina for three months and is then replaced, a cream or a vaginal tablet that is inserted. For women who have contraindications to any form of estrogen, there are vaginal suppositories made from DHEA that can be helpful. Systemic administration of estrogen with or without progesterone (without only if you don’t have a uterus), and a non-estrogen oral tablet called Osphena® are also used for dryness with intercourse.

dhyse123: Hello. I am 50 years old. Is it "the norm" to experience "brain fog" and be disorganized with perimenopause when your mind was once fresh, and organization skills were your forte? Also, is there something not hormone related one can do for those types of perimenopausal symptoms?

Lynn_Simpson,_MD: Brain fog is common at midlife for a variety of reasons. One can be the wild hormone fluctuations that are occurring during this time. Many women after having a baby experience the same fog. Also, if you are having hot flashes or sleep disturbances, it can greatly affect your thinking. Another reason is that frequently you are busy and distracted, and that can affect concentration. I would recommend a visit to your doctor to discuss the symptoms you are having and possible solutions for them, both hormonal and non-hormonal. Therapies recommended have to be individualized always.

Lonilynn: Is it normal for periods to become irregular by missing total months at a time?

Lynn_Simpson,_MD: It depends on how old you are. If you are between the ages of 45 and 55 (the time of transition to menopause), it can be normal. Between the ages of 40 and 45, it can be a sign of an early perimenopause, but other conditions need to be ruled out. Under age 40, it is not normal and needs to be evaluated by your doctor.

Lonilynn: Is it common to still get the typical menstrual cramps, etc., during perimenopause and menopause?

Lynn_Simpson,_MD: If you are still having periods, you can still get cramping. The advent of new, non-characteristic pelvic pain or cramping is not normal. If this is occurring, an evaluation with your doctor is in order. After menopause, pelvic cramping not related to bleeding can have several causes. If that is the case, I would again recommend an evaluation with your doctor.

MariaC: What can I do about facial hair I’ve developed due to menopause?

Lynn_Simpson,_MD: Facial hair is common as we age. There are several reasons for this. One is genetic factors. Also, after menopause, although the ovaries are no longer making estrogen, they do still make testosterone. This imbalance of hormones can make certain women susceptible to unwanted hair growth. There are several options for treating this. There are creams that are applied. Some women tweeze. Laser hair removal works for others. The sudden appearance of hair is different than the gradual appearance. This should be investigated. A dermatologist can give you advice on some of the medical options as well.

Specific Situations

susan13: I have been suffering from menopause for 20½ years. It started when I was 44; I'm now 65. My doctor has been baffled that nothing works to alleviate any of my symptoms (hot flashes, being permanently hot, memory loss and insomnia). I have tried all over-the-counter and prescription medicines available and nothing works. We both have given up thinking there is a solution for me out there somewhere. Would you have any suggestions?

Lynn_Simpson,_MD: That has to be very frustrating for you. My recommendation would be to list every treatment you have had, along with the symptoms that are bothering you, and make an appointment with a doctor who specializes in women’s health and treats especially difficult situations such as yours. That is the best way to individualize the best options for you.

pmpop: I had a D&C back in 2014, and the doctor at that time thought I'd start menopause in about a year or so. Given that medical science is not an exact science, here I am now, almost three years out from the surgery, and my periods are appearing farther and farther apart. Could I finally be starting to make that transition to menopause?

Lynn_Simpson,_MD: The timing of the final period is very hard to determine. The best indicator is the frequency of your periods. Once you have gone three months without a period, the final period is expected usually within four years. The time of fluctuating periods (perimenopause) can go on for four years on average. Once you have gone 12 months without a period, by definition this is menopause. If you go six months without a period and then have bleeding, you should see your doctor for an evaluation. While not usually a serious problem, some gynecological problems can present themselves by bleeding like this. It sounds like you are making the transition to menopause.

dajones814: I'm 55 and haven't had a period in two years, but had one out of the blue in November. Is that normal?

Lynn_Simpson,_MD: It is not normal. It does not mean something bad is happening; rarely, women will have a "period" after all that time. However, it absolutely needs to be checked out. There are many causes of this type of bleeding including both benign reasons and non-benign reasons such as uterine cancer. This is a very important symptom and one that requires medical evaluation and advice.

pmpop: Thank you. One other question: I have fibroids and one particularly large one that the doctor did not want to remove since he felt I was close to menopause. At one time, about three years ago, I had heavy bleeding, which led to the D&C. However, within the last year, the pain of cramping is almost non-existent. During this time of transition, is it to be expected that the fibroids would not give me as much trouble as they did previously? (Note: I was 49 at the time of the surgery and am 52 now.)

Lynn_Simpson,_MD: I don't know the size of the fibroids you have, but in general, especially after menopause, fibroids will shrink as time goes on. They rarely cause problems after periods stop. However, large fibroids will only shrink, at most, 30 percent, but will still be present. If you’re not having symptoms such as pressure, pain and bleeding, nothing needs to be done with them. Fibroids are stimulated by hormones, and as estrogen levels decline and progesterone is no longer produced, most women have far fewer problems with their fibroids.

Life After Menopause

melow12: Now that I’ve gone through menopause, am I at risk for other diseases?

Lynn_Simpson,_MD: One of the major risks is to your bones. Bone loss begins even before periods stop. It is important to take 1200mg of calcium per day in divided doses with meals. Don’t ever take more than 500mg, as the body won’t absorb it. Also needed is 1000 to 2000 IU of Vitamin D. Bone density testing should begin as directed by your doctor depending on your risk factors. You begin to lose some of the protection estrogen has provided to your heart as well. Factors such as family history of cardiac disease, weight, cholesterol, especially in association with other diseases such as diabetes, are all important. Many diseases such as colon cancer and breast cancer increase as we age. Prevention strategies are very important, including colonoscopy and mammogram. Lifestyle factors such as exercise, weight control, healthy diet and regular sleep become even more important as we age.

gatorfrog: Hello, and thank you for being here. I am 59 and still having hot flashes. It's more like an all over heating up, a little different than the hot flashes I had when I first started menopause. I didn't even know there was a postmenopause. Can you tell me how long these might last? Thank you.

Lynn_Simpson,_MD: There is a difference between a feeling of warmth and a hot flash. Hot flashes are usually confined to the chest and travel to the face with an extreme feeling of warmth, flushing of the face and possibly resulting perspiration. They usually last from one to five minutes. There are many things that can cause an overall feeling of warmth, including certain medications, stress, anxiety and room temperature. Weight can also be a huge factor, as it acts like an insulator. If you are still having feelings of warmth, I would recommend a physical exam with your doctor. Keep track of when this is occurring, and take the information to the appointment. A women's health specialist can help you figure out if this is related to menopausal hot flashes. There are some women who have actual hot flashes indefinitely, even into their 70s and beyond.


That is all the time we have for questions today. Thank you, Dr. Simpson, for taking time to educate us about perimenopause and menopause.

Lynn_Simpson,_MD: Thank you so much for participating with our health chat. The questions were great, and I enjoyed them very much.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at

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Women can access specialized health care at the Center for Specialized Women's Health as well as referral to other areas of the Clinic if needed. In addition to routine wellness exams and health care screenings by our nurse practitioner, we offer CustomFit Physicals for women, perimenopause/menopause consults, and evaluation and treatment of numerous medical problems of special concern to women including osteoporosis, hormone disorders, urinary leakage, sexual dysfunction, menstrual disorders, chronic pelvic pain, vulvar problems and weight concerns.

Center professionals are happy to accommodate patients who are seeking second opinions, as well as patients who prefer female providers.

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