Menopausal symptoms: What are we complaining?

by Etsuko Ueda, Updated Dec. 2013

The most troublesome and most overlooked menopausal symptom

Hot flush is almost synonymous with menopause in the US. According to some research, more than 80% of menopause age women experience it. If you have not actually experienced it, you would wonder what the big deal is. Feeling too warm and getting a little sweaty may be inconvenient in some situations, but it cannot be really that bad. True, if that's all there is. Many non menopausal people experience something similar when they have a bowl of hot soup, for example. But, in most cases that's not all. Actually, hot flushes may not be the dominant, or most troublesome symptom for many people. There are several troublesome aspects to menopausal symptoms with or without hot flushes, which a person may not want to attract too much attention to, due to a fear that she/he may be treated like a nut case, or due to a lack of words that adequately describe it.

My journey

The first hot flushes came when I was on a hormone blocker in my mid 40's in a failed attempt to stop uterine fibroid. It came as a wave of warmth that ran through my body more or less at a regular interval and did not bother me at all, which promptly went away right after the total hysterectomy when my doctor gave me an estradiol patch (0.05mg/day). From there on, I've never had hot flushes or any other so called menopausal symptoms until I started to experiment to quit estrogen, which was a big mistake. "Vasomotorsymptoms usually reappear after cessation of postmenopausal hormone therapy: aSwedish population-based study." (Lotta Lindh-Åstrand, et. al. Menopause. 2009), although "Postmenopausal women withoutprevious or current vasomotor symptoms do not flush after abruptly abandoningestrogen replacement therapy." (M Hammar, et. al., Maturitas. 1999),

Experimenting with estrogen

When I first discovered natural progesterone and learned that my health was deteriorating due to estrogen dominance and progesterone deficiency, I learned many women can do just fine with progesterone alone (less likely if your ovaries are gone, I came to realize later). I called late Dr. John Lee right after I read his book, What Your Doctor May Not Tell You About Menopause (to ask about Japanese translation rights, but it was already in translation). He kindly took my call and gave me some advice to reduce estrogen slowly 3 months at a time, meaning reduce by half each 3 months to see if I can get used to it. But in my eagerness, I thought I was able to quit in 3 months. First, I took short breaks from estrogen and made the breaks gradually longer. After about 3 months of that, when 1 week break did not cause any problem, I stopped estrogen and continued with the 20 to 30 mg/day of progesterone in cream form which I started 3 months earlier. It looks like I had 1 to 2 months worth reserve of stored estrogen in my body at that point, and after that I started to notice unmistakable symptoms.

Looking back, the first sign was a "burned out / I am pushing too hard" reaction. I was getting nervous and sweaty (the oily kind) and felt as if I was pushing too hard in a normal room temperature doing regular work. There was a reason to think I could be actually exhausted. So I did not give it much thought at the time. Although I could not remember the last time I had had that kind of reaction to that level of stress, it did not happen repeatedly after I took a good rest.

Then came a strange "brain strain sensation" that felt like something was gripping and squeezing my brain, which was straining to function freely, but could not. Whatever it was, I had this constant sickly sensation in my head, that interfered with my concentration. More strangely, it was there all day during the day time, but promptly lifted at around 5:00 p.m. (indicating some relation to circadian rhythm of brain metabolism, cortisol or... Does anyone out there have any clue?). I had never experienced anything like that before in my life, and it was far more troublesome than the occasional hot flashes, the weird sensation of pulsation right above my naval, the prickling "electric" sensation of the skin/nerve that felt much like the sensation you would have when alarmed or shocked, the racing heart, or even the early wakening sleep problem. Another thing that scared me was my bones, which seemed bruising too easily. One time I drove for about 45 minutes without quite realizing my tail bone was hitting a crease of a bunched up thick jacket. By the time I noticed the pain the damage was done, and it took months for the pain in my tail bone to go away.

Non estrogen remedies

I eventually resumed estrogen and almost all of the troublesome symptoms went away, including the brain strain sensation and its associated symptom of hard to concentrate. Below is a list of some remedies I tried while I stayed off estrogen. Keep in mind I was on bio-identical progesterone cream all that time.

• Taking licorice root extract significantly reduced "brain strain sensation" almost immediately, but did not eliminate it completely.

• I increased fermented soy products in my diet (3 servings a week at least), which took the edge off my hot flushes, and increased the vaginal discharge. But it was not quite satisfactory. Especially in the morning, I woke up after 4 to 5 hours of sleep and laying down feeling tired and trying to go back to sleep tossing and turning, while my heart rate stayed elevated and breathing shallow, getting too warm to the point I had to kick off the cover until I felt too cold.
• I also tried adrenal hormone called DHEA (30mg/day oral) soon after I started have the symptoms, but it did not seems to make any difference and I discontinued after one month (I did not know it would take 3 months to kick in). Several years later long after I resumed estrogen, I decided to try it again, thinking it may improve my overall hormone profile, and decided to stay on it regardless. After about 3 months, however, I noticed some changes. The most noticeable changes were oilier hair and skin, vaginal discharge, and libido. My sleep problem seemed also improved. I was still waking up after 4 to 5 hours, but going back to sleep was getting easier. Since then I reduced DHEA to 30mg every other day, which reduced all the changes proportionally.

How Everyday Language Shapes the Recognition of Menopausal Symptoms

When I decided to look into the "Brain Strain sensation", I could not remember the common expression for it, although I have read a fair number of books and articles on menopause. No problem, I thought, I can look up Internet and any list of menopausal symptoms would list some version of it for sure. Well, it was not that simple. The associated symptoms, such as difficulty in concentrating and fatigue are commonly mentioned, but the head/brain sensation itself is not. That was until I looked up The Greene Climacteric Scale, which has been commonly used in menopause research (http://www.menopausematters.co.uk/greenscore.php). It includes among other things "Pressure or tightness in head or body" and "Difficulty in concentrating". However, unlike hot flushes, I've not found any study focusing on this symptom.

I also combed through some forum discussions by menopausal women as well as some non-conventional healthcare information websites. There I have found, "heavy and congested head", "contracting squeezing scalp, temples and forehead". I have also found "weird head pressure" and more broadly "funny head feeling". More commonly used are "foggy brain" and "brain fog", but it is not clear whether everyone is using it to mean the specific head sensation, just the difficulty in concentrating, or both. In any case, there are many websites that offer nutritional, hormonal, and life style remedies for "brain fog", menopausal or otherwise. Even a major news media (ABC news) picked up "brain fog" in "Menopause: Hormones Can Help Memory and Lift Brain Fog " to explain the cognitive aspects. However, the writer seems totally oblivious to the brain strain sensation aspect of it.

Japanese words for menopausal symptoms

My native language is Japanese, but no word was popping up in my head that exactly fits the sensation I was experiencing, either. A general expression for such sickly feeling in Japanese can be すっきりしない, which is similar to the English expression of "not refreshed" feeling, an expression one might also use when constipated (which can also happen with too low estradiol). But I did not feel it was accurately describing the sickly sensation I was experiencing in my head. Then I remembered the expression my mother often used in her menopause years to describe some sickly head sensation; モンモン(MON-MON). At that time I was at an impression that it was associated with high blood pressure she had, but looking back, it was most likely menopause related.

MON-MON (which I took to mean uncomfortable sickly head sensation with some kind of temperature build-up) is an onomatopoetic word, a class of words (similar to twinkle, sizzle, buzz, etc.) the Japanese language allows endless variations to capture otherwise difficult to describe sounds, moods, motions, sensations, etc.

I also combed Internet in Japanese. In the conventional western medicine community in Japan, the cluster of menopausal symptoms are referred to as不定愁訴. It roughly translates as non-specific or unidentifiable complaints, by which they mean a cluster of complaints that indicate generalized sickly feelings that have no corresponding measurable or detectable abnormality according to the standard western medical textbook. This label is by no means confined to menopausal complaints, and used widely to any such complaint often considered to be a result of dysfunctional autonomic nerve system, if not psycho-somatic. (I can almost hear the echo of "It's all in her head".)

They have also developed several lists of such menopausal complaints based on commonly used English menopause scales (e.g. The Greene Climacteric Scale, Kupperman Index, etc.), adapted specifically to the complaints seen among the Japanese women (so they claim). The length ranges from 10 to 21 items, however, I could not find anything that suggests the "brain strain sensation" nor the difficulty in concentrating, only a reference to "heavy head" paired with headache. Interestingly, however, some of them include tired eyes, which is similar to brain strain sensation, only you feel it mainly in the back of your eyes. Also included is stiff neck and shoulders, which can be similar or related to brain strain sensation, only you feel it mainly in shoulders close to neck, and back of the neck, while brain strain is mainly in front and sides of your head. Interestingly, both "tired eyes" and "stiff shoulders" have well established words in Japanese (眼精疲労and肩こり), while the brain strain sensation does not. According to a survey of Japanese women aged 49.5+/-3.0 (Factoranalysis of climacteric symptoms in Japan, MK Melby, 2005 Maturitas), three most prevalent symptoms were shoulder stiffness, memory loss (I assume it is memorization capacity loss. Something must have been lost in translation), and stress.

More traditional and/or non-conventional healthcare websites and personal blogs in Japan portray a slightly different picture as do the English counter parts. They often mention some pressure like sensation around the head as well as some sickly head feelings they call MOYA-MOYA (an onomatopoetic expression of foggy: To me, it sounds like milder version of the brain strain sensation).

Then I came across a list of symptoms used to check andropause (the male version of menopause) status used at a Urology clinic of the St. Marianna University School of Medicine in Japan. Interestingly, it includes this MOYA-MOYA head (21.1% responded Yes) as well as heavy head (20.1%), along with difficulty in concentrating (44%) and low energy (43.8%). Is it more prevalent among men? Or does it matter more to men? Or the target population of the clinic uses brain more?

Another interesting aspect of the above list of andropause symptoms, when compared to those of menopause, is the absence of "Depression", which is included in every list of women's menopause symptoms I have seen. It is also frequently mentioned in andropause symptom lists, for that matter. Instead, it includes sleep problem (37.6%), anxiety (30.9%), lower sexual vitality (21.6%), irritable (19.6%), sweaty (18%), impotence (18%). Apparently, the researchers and doctors at the St. Marianna University School of Medicine have determined the head sensations were more relevant symptoms than depressive mood in identifying testosterone deficiency. Does it reflect the real difference between Japanese men and women in terms of the actual symptoms? Probably not. Their list of andropause symptoms looks more relevant to what I have experienced than any menopause symptom list I have seen so far.

Does anyone know what's really going on?

The more I dug the more murky it became. I had no idea menopausal symptoms were surrounded by this much  "fog". Apparently, there is an increasing awareness that many menopausal symptom surveys had been poorly prepared to capture the real picture, partly because they did not have adequate input from the women themselves. In other words, researchers often don't bother to ask the women if the questionnaires contain all the relevant symptoms. See "A feminist Approach to Research on Menopausal Symptom Experience." Eun-Ok Im, Fam Community Health 2007 about how a study can fail to capture the real picture.

The difficulty is understandable. Even if you are free of all the preconceptions and prejudices, you need to separate reproductive hormone specific aging from general aging, for one. There is an increasing evidence that sleep problem may not be menopause specific (in my case, estradiol and progesterone did resolved most of the problems except the sleep problem). For a review, see Hot flashes: behavioral treatments, mechanisms, and relation to sleep (Robert R. Freedman, The American Journal of Medicine 2005). You also need to separate primary symptoms from secondary symptoms. Anxiety, depression and irritability may be secondary to a constant discomfort, or related to coincidental life events such as awareness of aging, changes in their social roles and relationships, etc. (Lynnette Sievert, et. al., Symptom groupings at midlife: cross-cultural variation and associationwith job, home, and life change. Menopause. 2007). Then there is a problem of accurately recognizing and describing the symptom. There may not be a well establish words for some of the symptoms and/or it may not be socially acceptable complaints and suppressed.

A good example of the language effect was demonstrated by surveys of hot flushes among Japanese women. For English speaking populations, hot flush is a well recognized symptom. However, researchers who used translated menopause symptom questionnaires to survey Japanese women found lower occurrences of hot flushes, and learned that there is no specific word for hot flushes in Japanese vocabulary. (How Japanese Women Talk about HotFlushes: Implications for Menopause Research. Jan Morgan Zeserson, Medical Anthropology Quarterly, New Series, 2001). Moreover, hot flush prevalence varied depending on which one of the common expressions of body heat sensation was used; (Vasomotor symptom prevalence andlanguage of menopause in Japan. Melby, MK, 2005, Menopause ).

In conclusion

1.    Any description of menopause/andropause symptoms that does not include some version of this brain strain sensation along with the difficulty to concentrate is probably created by people who have not really experienced or understood the full range of hormone related menopausal symptoms.
In a low socio-economic Ecuadorian population (385 women, mean age of 47.6 +/- 5.5 years), the most frequently and intensive presenting symptoms of the 21 symptoms composing the Greene Climacteric Scale were: difficulty in concentrating (87%), feeling unhappy or distressed (82%), headaches (83.9%), and hot flashes (82%) (BresildaSierra, et.al. 2005, Maturitas). As I reviewed in Menopause: Underlying Mechanism, Bone: Destructive Power of Stress Hormones, and Hormone overdose: How can you tell? , menopausal transition is a complex event where not only hormones fluctuate wildly before they settle at low levels, but also the stress hormones shoot up so much that your bones quickly erode if you do nothing, not to mention the anxiety and distress levels it raises through sympathetic - parasympathetic autonomic nerve system imbalance, and constricted blood circulation patterns.  

2.    We need to be very careful when we talk about depression in relation to menopause. There is depression and then there is depression.

A)   Recent studies show depression decreases in post menopause years (Freeman E.W, et. al. 2004, Arch Gen Psychiatry, P E Bebbington, et. at. Psychol Med. 1998). So do Irritability and mood swings in correlation with the drop of hormone levels. (Freeman E.W, et. al. 2008,Obstetrics and gynecology). A study in England has found that "only vasomotor and atrophic symptoms vary with menopausal status. Other somatic and psychological symptoms experienced by middle-aged women cannot be regarded as part of the same 'menopausal syndrome'." (M Porter, et.al. 1996, British journal of obstetrics and gynaecology). This is true only if you consider menopause as a steady hormonal decline process. As I mentioned above, the transition period is different from the post transition period. The perimenopause = transition period is the most turbulent period, and your brain becomes physicaly unstable, which can mimic depression (Clayton AH, Ninan PT, 2010. Prim Care Companion J Clin Psychiatry), as well as anxiety disorders (Juan Enrique M Blümel,at. al. 2004, Maturitas). The first thing to consider is not antidepressants, but a proper hormonal supplementation to stabilize the fluctuation (see Hormones: Dos and Don'ts, Safe Use of Hormones: the Hard Evidence, Hormone overdose: How can you tell?, Safe Effective Natural HRT).

Although the physical symptoms are uncomfortable, worrisome, debilitating, and they definitely make anyone feel miserable, and in that sense they are depressing and anxiety provoking, but it should not be confused with clinical mood disorders (e.g., constant sadness and negative thoughts).

B)   Physiological depression on the other hand, can result from low hormones (estrogen, progesterone, testosterone, DHEA, Vitamin D (sunlight), etc.), unstable autonomic nerve system,  as well as from a chronic lack of sleep and insulin resistance. I would include Loss of vigor and libido, Feeling tired or lacking in energy, Slow digestion, Slow mental processes, Difficulty in concentrating, Muscle weakness, etc. into this category.

3.   We need to be very careful when trying to understand conditions that is hard to describe and there are no well established labels, not to mention objective measures. Unlike hot flashes in which temperature, hart rate, sweating, and various blood hormone levels can be objectively monitored, moods, feelings, and sensations are subjective. In absence of objective measures, there is a plenty of room for misunderstanding, distortion, and dismissal. Simple wordings in a questioner can be misunderstood or inadequate in representing individual's subjective experiences. "Pressure or tightness in head or body" may not sound close enough to brain strain sensation or foggy brain, for example. If it is translated into, let's say Japanese in a certain way, Japanese women may not relate it to stiff neck and shoulders nor to head pressures and MOYA-MOYA head.

4.   Researchers should listen to their subjects more carefully. We know what we are talking about. When we say it is difficulty in concentrating, that's what it is, which was clearly indicated in recent studies "Subjectivecognitive complaints at menopause associated with declines in performance ofverbal memory and attentional processes." (M Schaafsma, et. al. Climacteric. 2009), and [Cognitive function in menopausalwomen evaluated with the Mini-Mental State Examination and Word-List MemoryTest] (Rita de Cássia Leite Fernandes, et. al., Cad Saude Publica. 2009). A loss of brain power in any form is not an easy to admit condition for many of us, but denial will not solve the problem.