Neapolitan Perimenopause

The 3 flavors of reaching menopause

Buonasera! Welcome to my ice cream shop, Neapolitan Perimenopause. Just like the three flavors of a Neapolitan ice cream cone, there are three flavors of reaching menopause:

1. Vanilla

2. Strawberry

3. Chocolate

Vanilla

The perimenopause method. The typical experience of entering menopause (or, as I like to call it, the “vanilla experience of menopause”) is referred to as natural or spontaneous by the medical community. However, we all know perimenopause is not at all spontaneous using the non-medical definition we all learned in school. So, I prefer to call it “progressive menopause” because it progresses through a series of phases until menopause is reached.

If you’d like to learn about the phases of perimenopause, I wrote an article about it comparing perimenopause phases to musical dynamics.

Because the vanilla experience is the most common experience, most of the information on the internet refers to this one way to reach menopause. Even the definition of menopause, “going 365 days without a period,” is geared toward this population.

But, there should always be an asterisk after this declaration to indicate this does not include some women who reach menopause in a different way or those with a hormonal IUD, using birth control pills, or have had a uterine ablation. Women with a hysterectomy but kept their ovaries also fall into this category.

🚫 365 days without a period; need not apply

• hormonal IUD

• birth control pills

• uterine ablation

• hysterectomy with retention of ovaries

I always counsel this group of women to work with their doctor to determine menopause status, if it’s important for you to know, since using your period as your guide is not possible.

Outside of perimenopause, there are two other ways to reach menopause.

Strawberry

The strawberry type of menopause comes by way of a full hysterectomy, where the uterus and the ovaries are removed during a surgical procedure, or an oophorectomy, where the ovaries are removed. This causes a sudden menopause that women should be aware of before this type of surgery. The day of surgery is the day you reach menopause, and all the days after are post-menopausal (however, most women say they are menopausal).

If you’d like to read more about sudden menopause, I invited my menosavvy friend, Dianne Williams, to share her story a few weeks ago in a past article.

Women who have gone through sudden menopause report more intense menopause symptoms and longer-lasting hot flashes. In addition, Dianne had her hysterectomy at 39 and believes that her body has ramped up menopause symptoms now that she has reached the average age of menopause. I’ve heard this from other women, too, but it’s just anecdotal at this point. There isn’t science yet to back this up, yet this makes sense to me, and I believe them. The body keeps the score.

The hysterectomy rate in 1980 was 7.1 women per 1,000, and then it started to drop. By 1986, the rate was 6.6. By 1995, the rate was 5.5 per 1,000.¹²The hysterectomy rate continues to drop and is expected to drop to 3.9 per 1,000.¹³

Like everything, there are a number of reasons for this:

• We understand more about the science and the body.

• There are more non-surgical options.

• Doctors now know to prescribe progesterone along with estrogen to prevent uterus lining problems that would cause a hysterectomy to be performed.

• We (both patients and doctors) are more concerned about the risks of the surgery.

I’d love to say that the rate is declining only because we’re getting smarter and more conservative about surgery, but prior authorizations required from insurance companies also have something to do with it (in the U.S.).

Most insurance companies review hysterectomy treatment plans to ensure they are medically necessary before they cover them. The requirements are getting stricter. They are so strict that I don’t even want to include in this article what would now be a covered reason for a hysterectomy. If this is something you’re considering, please work with your doctor and insurance company.

Chocolate

The chocolate way of reaching menopause is through medical intervention, which involves techniques that effectively shut down the ovaries, thereby halting the production of hormones such as estrogen and progesterone. This is called medical menopause (or, in some countries, chemical menopause).

This can be achieved through the use of medications that suppress ovarian function. These approaches are often offered to women who are facing certain types of cancer diagnosis and treatment, as managing hormone levels can be crucial for their treatment to proceed.

Medical menopause can be temporary or permanent. If temporary, this means that a woman will go through menopause twice, once during her medical menopause and once again when she reaches the age of her progressive menopause.

Anyone going through medical menopause should receive an automatic pass to the head of every line, including at Disney. These women are warriors.

Now, for the Cherry on Top

Now for the cherry on top, so to speak, are women with endometriosis, PMDD (Premenstrual Dysphoric Disorder), and PCOS (Polycystic Ovary Syndrome). These medical conditions make perimenopause more complicated and confusing.

Not only that, but Endometriosis¹ and PMDD² may cause women to experience menopause earlier than usual. PCOS may delay menopause (by about 2 years)³. This is significant because some menstrual symptoms improve for women with PCOS once reaching menopause, even though PCOS is a lifelong condition.

We All Scream for Ice Cream

It's crucial to recognize that each individual's path to menopause can vary greatly. It can be frustrating to try to fit your specific challenges and needs into a one-size-fits-all narrative. During this process, it becomes abundantly clear that we are unique and everyone’s story is different.

If you fall outside of the vanilla experience of perimenopause, I empathize with your frustration in not being able to square peg, round hole your way into getting applicable health information.

Whenever I can, I mention you and let others know there is more than one way to reach menopause. I know you feel forgotten as the middle children of menopause.

This 💗 is for you.

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1. Thombre Kulkarni M, Shafrir A, Farland LV, et al. Association Between Laparoscopically Confirmed Endometriosis and Risk of Early Natural Menopause. JAMA Netw Open. 2022;5(1):e2144391. doi:10.1001/jamanetworkopen.2021.44391

2. Yang Y, Valdimarsdóttir UA, Manson JE, et al. Premenstrual Disorders, Timing of Menopause, and Severity of Vasomotor Symptoms. JAMA Netw Open. 2023;6(9):e2334545. doi:10.1001/jamanetworkopen.2023.34545

3. Sharma S, Mahajan N. Polycystic Ovarian Syndrome and Menopause in Forty Plus Women. J Midlife Health. 2021 Jan-Mar;12(1):3-7. doi: 10.4103/jmh.jmh_8_21. Epub 2021 Apr 17. PMID: 34188419; PMCID: PMC8189332.