Dear Dr. Pat,

I am 44 years old and need to know how to manage the symptoms I am having.

I found your website on Google and read all the articles about menopause mangement but I didn’t find an answer to my question. How should a woman in her early 40s be treated for menopausal symptoms if she can’t take birth control pills?

I’ve had a change in my periods for the last 18 months, along with other symptoms that are interfering with my life. My periods became very irregular suddenly, sometimes coming only every three or four months and sometimes spotting every ten days. I recently had a very heavy period that lasted a week. (For the record, I’ve never been pregnant.)

I saw my GP in my town here nine months ago, and he tested my thyroid and checked me for anemia. Those tests were normal. He then prescribed birth control pills. He said that women my age were too young to take hormones, because they would just cause problems with bleeding. He said that birth control pills would prevent the heavy and unpredictable bleeding that I had experienced and smooth out my hormone swings.

I took three different kinds of birth control pills and hated the side effects. I felt moodier, bloated, and gained weight. I haven’t seen my GP in six months because he made it clear that he would not give me hormones as long as I’m having my period.

Lately, I’ve noticed that I don’t have much interest in food and don’t eat as much as I used to. I have this bloating I used to get before my period, but now it’s there pretty much all the time. I feel like I’m going to have my period every day, with that heavy feeling in my uterus. I guess it’s my age, but I’m also having some constipation problems that I never had before. I don’t sleep well, even though I don’t have many hot flashes, and I wake up as tired as when I went to bed. Just like women I’ve read about who have menopausal problems, I have this terrible fatigue, I don’t think clearly, and I get anxious about little things. I was recently given a warning about job performance and I am terrified that I might lose my job. I don’t have the energy to exercise or go out with my friends. It all seems to be getting worse.

I’ve tried every non prescription treatment I found on the Internet—black cohash, soy, oil of primrose, you name it. Nothing helped.

Should I insist that my GP start me on hormone therapy so I can see if this treatment will improve my symptoms?


Dear Maggie,

Your story is not a classic story of menopausal syndrome—which women in their 40s do have—even though you have some of the symptoms: your irregular cycles for the last 18 months, an occasional hot flash, a change in your sleep pattern, fatigue, and a loss of your usual ability to function well at work.

Menopausal syndrome in the setting of unpredictable and infrequent menstrual cycles is described as frequent hot flashes and sweats at night that wake women up many times during the night, leaving them exhausted during the day. Hot flashes do occur during the day as well, often accompanied by sweating, facial flushing, anxiety and heart palpitations. As this situation continues without treatment, many women have trouble with clear thinking and mood change. Often these symptoms in women in their 40s will show up for two or three months, then disappear as the ovarian hormones right themselves again. These symptoms may not show up again for a year or longer.

Your GP is right that it is sometimes a bit more difficult to manage hormone treatment for women in their 40s who are still having menstrual cycles. It is not uncommon for women in their 40s to be placed on oral contraceptives to control abnormal bleeding patterns and to manage disabling menopausal syndrome. A prescription for the birth control pill is often comforting for a woman in her 40s, since she can tell herself that the birth control pill is not hormone therapy for menopausal symptoms.

Maggie, you need a careful evaluation for your troubling symptoms: fatigue, loss of appetite and a change in how much you eat at each meal, constant abdominal bloating and menstrual-like discomfort all the time, accompanied by new and persistent constipation. And you need evaluation of the abnormal menstrual bleeding.

Here’s what I suggest.

  1. Find a gynecologist and schedule a visit as soon as possible.
  2. Do not tell the gynecologist that you are having bad menopause symptoms. Patients can confuse health care providers when they give their own diagnosis, instead of just sticking to a careful report of the symptoms. A patient should come in with the “what, when, where, how.” Finding out the “why” is the doctor’s job—finding the diagnosis.
  3. Write down all of the symptoms that you’ve described in your letter to me. Make two copies. Give one to the doctor and keep one in your hands during this consultation, so you can be certain that you cover everything. Time is often limited in doctors’ visits these days, so prepare your history in advance. Tell the gynecologist that you took the birth control pill for only three months in your life, and that it was prescribed by your GP to make you feel better, since your periods were infrequent. Tell the gynecologist that it made you feel worse. Also, tell him or her that you were never pregnant. No history of birth control pill use and never having had a child may increase a woman’s risk of developing ovarian cancer as she grows older.
  4. The gynecologist should do a thorough pelvic and physical exam and a pap smear, and order tests for evaluation of the fatigue as well as a pelvic ultrasound. The ultrasound (or sonogram) will describe the lining of the uterus—the thickness, the presence or absence of a growth—and will also describe the ovaries: size, presence or absence of a growth in the ovaries (or sometimes in the fallopian tubes). It will also show the presence or absence of free fluid in the pelvic area.
  5.  The pelvic sonogram may find a tumor of the ovary or the uterus, since your symptoms are consistent with those that women may have with these tumors. Tumors are benign or malignant, solid or cystic. The doctor should let you know immediately what the results of these tests are. If there is any ambiguity in the test results (ovarian cyst, perhaps as a result of disordered ovarian function), then insist on another pelvic sonogram with a radiologist at a facility where there is a specialist in female sonography. Give the technician the list of your symptoms and ask to see the radiologist personally. Ovarian cancer is often diagnosed at a late stage because symptoms are ignored or misinterpreted by the patient, or misunderstood by the doctor.
  6. If the ovaries, uterus, and endometrium are clearly normal, then a consultation with a gastroenterologist is in order to see if you have any growth in the GI system, such as the colon or pancreas.

Maggie, I am so glad that you wrote to us. The Internet is becoming a wonderful place for people to go to for information. But it’s hard for patients to get an accurate diagnosis from Dr. Google—who, after all, does not have a medical degree. Some patients become more anxious than they need to be, and others are falsely reassured.

Maggie, you do not have menopausal syndrome, and hormone therapy is not the treatment for your symptoms. I know that you will take this information and find a gynecologist this week to start the process of diagnosis. Earlier detection of any problem always improves the outcome.

Dr. Pat