Sound Solutions To Nine Mid-Age Nasties

Dr. Maria Sophocles Tells Us What to Do When Nothing Seems Normal

Illustration by: Cé Marina

If you have any hesitation talking about intimacy and vaginal issues, it’s likely you’ll shilly-shally no more after only one conversation with straight shooter Dr. Maria Sophocles.

Menopause Master, gynecologist, and sexual medicine specialist, Dr. Sophocles calls herself a "Sexual Equality Emissary, Global Women’s Health Ambassador, Intimate Justice Seeker, and Bedroom Gap Closer."

Listen to her TedWomen talk, "What Happens to Sex in Midlife? A Look at the “Bedroom Gap” —only 14 minutes, worth every second of your time—and you’ll know what we mean.

Smart, experienced, and passionate about all things menopause, Dr. Sophocles advises precisely on what to do if you come up against any of these nine common emotional, physical, and mental issues in midlife.

1. You're in your early 40s and your cycles, which have been regular for 20 years, are suddenly unpredictable.

Ask yourself, did I gain or lose weight? Do I have new and unusual stresses in my life? Am I on new medications? If you can’t come up with a clear reason for why this is happening, you should see a clinician who specializes in menopause. Reasons can be thyroid disease, a polyp in the uterus, or maybe simply the chaotic hormonal milieu of perimenopause.

2. You've always had a relatively strong libido and wanted to have sex. Now, you’d just as soon fall asleep in front of the TV at night.

Again, you can assess what’s going on in your life. Are their relationship issues? Issues with stress from taking care of aging parents or a sick child? Financial or job stress?

If you can’t connect the dots, it’s worth getting in touch with a menopause-certified practitioner or a clinician who has had experience with sexual medicine. The lack of estrogen as we approach menopause can really affect your libido. When you make less estrogen, you also make less testosterone in the ovaries. Both of these link directly or indirectly to the libido.

Pay attention to mindfulness. Have you lost the ability to be in the moment? Sometimes a therapist can help you with this. AASECT-certified therapists can help you determine what’s happening between the ears that’s impacting your libido. And a Menopause Master can help determine if estrogen deficiency is the cause, or if there are other physiological reasons.

3. You used to fall asleep immediately and stay asleep. Now you wake up two or three times a night and go to the bathroom, but you can’t get back to sleep.

Sleep disruption is another classic issue with perimenopause and menopause. We know that the ovaries’ inconsistent estrogen secretion affects the brain, how we sleep, and our ability to stay asleep. Dyssomnia—or interrupted sleep—is super, super common but improvable, usually with hormonal therapy.

If you are truly not a candidate for estrogen, there are other ways to sleep better. Use good sleep hygiene, such as taking magnesium or melatonin; avoiding computer and phone screens before bed; keeping exercise to daytime, not nighttime; eliminating or removing caffeine. It’s all common sense stuff.

There are also prescription sleep medications with excellent safety profiles that can smooth the estrogen chaos.

4. You’ve become short-tempered, start crying easily, and can’t tolerate even the slightest imperfections in a messy house or office assignment.

We know estrogen is needed in at least six distinct parts of the brain to control our mood and our cognitive functions. So, it’s no wonder that in perimenopause - which can be a decade before periods end - women note changes in their mood, anxiety, depression, increased irritability, even panic attacks. These changes can absolutely be a result of the hormonal chaos of perimenopause.

Gynecologists or psychiatrists are comfortable prescribing non-hormonal medications that work on serotonin or norepinephrine uptake to smooth mood issues.

5. You're searching for words, struggling to remember someone’s name or where you put your keys.

Brain fog is the common phrase for symptoms such as these, and they too can be related to declining estrogen. Sleep disturbances from night sweats or urinary incontinence can be other contributing factors, and once these are controlled, sleep and mood improve, as do cognitive issues.

6. You're suffering from multiple menopause symptoms, but you know that your family history of cancer prevents you from taking hormones.

A family history of cancer is not a reason to shun hormone therapy. I have three patients a day—every single day—that come to me and say, “I’m suffering terribly from these eight symptoms, but I know I can’t take estrogen because my great aunt had breast cancer.”

Your great aunt’s breast cancer, while sad and tragic, does not preclude you from taking estrogen. If you’re not sure, ask a clinician. And if the clinician says ‘I’m not sure,’ make sure you’re speaking to one who is truly up to speed on current safety recommendations for estrogen. A family history of breast cancer is not a contraindication for estrogen.

7. You’ve been diagnosed with breast cancer, so you surely can’t take hormones

Certain breast cancers—and all uterine cancers feed off estrogen—but other breast cancers do not have a link to estrogen.

We live in an error of precision medicine. Your specimen will be analyzed very carefully, so your team will know whether your cells are sensitive to estrogen receptors.

8. You’re experiencing heart palpitations that make you think you’re going to have a

heart attack.

Lower estrogen levels can cause heart palpitations—also called arrhythmias—which indicate overstimulation of the heart. The heart might pound, flutter, race, or beat irregularly. Palpitations are often short-lived, lasting from a few seconds to a few minutes.

Many women experience palpitations, and cardiologists often respond that there’s nothing wrong with them. This may sound reassuring, but it can also be dismissive.

Palpitations may seem alarming, but they’re often harmless. You should still contact a doctor, who can recommend lifestyle changes and natural remedies to reduce their frequency.

Low-dose transdermal estradiol will help, but non-hormonal medications can also be effective.

9. You’re noticing that when you jump, cough, or sneeze, you feel an urgency to pee right away, but you don’t always make it to the bathroom in time and have a little bit of urinary leakage.

Called stress urinary incontinence (SUI), this occurs as a result of weakening pelvic floor muscles supporting the bladder and sphincter muscles regulating the release of urine. The urgent need to urinate develops when the weakened muscles are stressed by a movement such as jumping.

You might also experience urge incontinence (UUI) or overactive bladder, which is a strong, sudden need to urinate caused by the bladder involuntarily squeezing.

SUI and UUI are improved with vaginal estrogen. When a patient asks why she’d use something vaginally to help her bladder, I explain that the opening to the bladder is in the vagina. And, the bladder suffers when there’s less estrogen in the vagina as you approach menopause.

Low-dose vaginal estrogen is so darn safe. It’s been on the market for decades and has not been linked to cancer at all.