Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

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

  • Judith A. Ross March 12, 2012 at 2:49 pm

    Dear Dr. Pat,
    Thank you for the update. I had been wondering.

  • Patricia Yarberry Allen, M.D. March 12, 2012 at 2:23 pm

    Dear Marian,

    Thanks for your personal story and your template for patient self care. No one should be more vigilant about a patient than the patient herself! You have given excellent suggestions for our readers.

    Maggie had surgery that found extensive endometriosis, involving the bowel, ovaries, uterus and fallopian tubes. She had adhesions that were causing some partial bowel obstruction. The surgery was extensive but she was fortunate not to have a neglected malignancy.

    She is now on the mend.


    Dr. Pat

  • Marian March 11, 2012 at 3:34 pm

    Maggie, I am writing to see how you are making out and to tell you I had very similar symptoms as you are describing back in 2004 and 2005 including abdominal pain on lower left side, and random constipation and diarreah. I have no kids, never took birth control pills, and had one miscarriage back in 1997. I have a thyroid disorder (Hashimotos) and I take synthroid. Diagnoses came from the emergency room where I went in 9/05 for severe abdominal pain, lower left quadrant: I was told I had both an ovarian cyst on left side and, a more serious problem, diverticulitis. Sent me to my ob/gyn and to a gastroenterologist. Both helped me through this difficult time. After antibiotic course and colonoscopy, was told I would need surgery for the div at some point in next 10 years. It came sooner rather than later, as I went to emergency room again in 12/05 with severe lower left abdominal pain and a fever. I underwent surgury to remove my sigmoid colon and clean up the infection, woke up with a colostomy, and then underwent another surgery in 5/06 to reverse the colostomy. Diagnostic tools were CAT scans, ultrasounds, blood work. Docs and surgeon did a great job and I have recovered. In 2008, I had lower left abdom pain again; CAT scan showed no colon problems, it was an ovarian cyst. Next I had a CA 125 test and ultrasound by a specialist gyn to look for ovarian cancer. None detected, but I remain watchful for this, as it has no real symptoms. I recommend keeping a daily log with all your symptoms, paying particular attention to where in abdomen it hurts. I felt around till I located the spots and then drew them in pen on my body so both the doctors and I could see exactly where it hurt. If you have pain, there is a reason, and you need to keep focused on getting a clear diagnosis that leads to treatment that works. Sometimes it seems that we don’t take our own symptoms as seriously as we would those of our child or another person we care about. Writing them down faithfuly will help you see that there IS a pattern (or help the doctor(s) figure that out). I also got the hospital to put all my CAT scans and ultrasounds on a cd and I carried that to each doctor’s office and had them download it so they could see all the previous tests as they were reviewing my case. Regarding menopause, after driving myself and my husband crazy trying to figure out hot flashes and trouble sleeping and aches and pains, I subscribed to Menopause Matters Magazine (pub in England) and learned I was not alone with all of these symptoms. These symptoms have dissapated with time, vitamins and Shiff’s Joint Compound, but we did most of the research ourselves to resolve them. I think there needs to be WAY more info given to women to plan for their menopause years. Good luck and I hope you feel better soon! Dr Pat, I appreciate your web site!!! Marian

  • Dr Pat Allen March 11, 2012 at 12:56 pm

    Dear Dana,

    Menopause at 44 is not all that unusual. I am surprised that your doctor was surprised! And you were clearly in the peri-menopausal transition prior to this diagnosis. Medoxy progesterone is not the kind of hormone therapy that women are given to control menopausal symptoms. In fact, this medication is often poorly tolerated by most women. So, you were never on “hormone therapy”. Your doctor gave you this unpleasant medication to perhaps induce vaginal bleeding if your ovaries were producing estrogen but no longer producing progesterone. However, I would like to suggest that you discuss with your doctor changing from the oral birth control pill with its chemical hormones to a transdermal form of estradiol and oral progesterone since you have chosen to manage severe symptoms with hormone therapy. We do suggest the lowest dose possible for the shortest period of time. The New Menopause begins at 40 so that women can be educated, informed and prepared when cyclic irregularity and other routine perimenopausal symptoms occur.

    We appreciate your comment and look forward to hearing comments from you again about any subject that interests you.


    Dr. Pat

  • Dana Vigilante March 10, 2012 at 9:28 am

    I am 44 years old. No pregnancies, never on The Pill. Three years ago, my usually very regular periods became more sporadic. Suddenly, they stopped all together. My ob/gyn put me on Medroxyprogesterone (50mg. for ten days every other month)to bring on my period. After three doses over a course of six months, I still did not have my period. During this time, I also started having awful hot flashes, which I had never had before. At the time, my bloodwork was still indicating that my body was making estrogen. Two weeks ago, I went back to my ob/gyn because I did not want to continue HRT. He did complete bloodwork, including a thyroid panel, CA125, as well as a transvaginal ultrasound (I ask for one yearly, as I know too many women who have died of ovarian cancer). He called me Thursday to tell me my body was no longer making estrogen and I was definitely in menopause. Even he said it was unusual and he was surprised that thats what it is. He started me on a very low dose of The Pill, and I’ve been taking black cohosh and evening primrose oil three times a day. I actually feel better, as I don’t have the hot flashes as much. However, I am definitely eating more. I really had the feeling I was going through menopause before I got the clinical diagnosis, but it’s still strange to actually hear it fron your physician. Dana Vigilante

  • Jennifer December 13, 2011 at 11:48 am

    I, too, would urge you to follow Dr. Pat’s advice. I read your letter and got a shiver, but was absolutely calmed by Dr. Pat’s response. Please follow her advice – women in their 40’s often blame what could be considered pedestrian symptomology on menstruation, when often there is another culprit at hand. This often leads to late diagnosis for other illness. Take heart! You’ve listened to your body, now find a professional who will interpret the signs for you. However be certain to not offer your own diagnosis until the facts have been laid out for your doctor – that’s his/her job. Best of luck!

  • Judith A.Ross December 13, 2011 at 10:50 am

    I would urge you follow Dr. Pat’s advice immediately.This is not meant to alarm you, but I do think you need the correct information about what is going on.

    And don’t let them schedule your appointment in a few months. Make it clear that you need to see someone this week like Dr. Pat says.

    This stuff can be scary, and I’ve dealt with my share of it, but I’ve always found that getting good information as soon as possible is the best and safest route and the surest way to peace of mind.


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