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 Physiologically, the 40s represent a time of declining ovarian function. At birth you have approximately 500,000 ovarian follicles (eggs). This follicle number declines with age by a process of genetically programmed cell death (atresia) with at first a gradual depletion over time followed by an accelerated decline starting at about age 38. These aging follicles do not produce the same degree of consistency in hormone production as exists in the reproductive years. This leads to greater fluctuations in hormone levels, and less consistency in ovulation. Irregularities of menses or skipped cycles are more likely, particularly after 45 years of age. Known as perimenopause, the symptoms experienced during this stage can include hot flushes, night sweats, mood changes, irritability, insomnia, fatigue, increased premenstrual symptoms, decreased short term memory and difficulty concentrating. Another hormonal change that is common in the 40s is the gradual decline in testosterone levels. This may manifest itself in decreased libido, energy and sense of well being. Body composition changes may also occur in midlife. Body fat is gained during periods of energy imbalance, namely greater intake of energy (food) than expenditure. Total daily energy expenditure includes the following components: (1) resting metabolic rate (RMR) or maintaining the body's physiologic functions, (2) physical activity daily energy expenditure (PAEE) and (3) digestive process with meal ingestion. The most variable part of energy expenditure is physical activity such as traditional exercise. Resting metabolic rate makes up the largest share of energy expenditures at 60-75 percent. Since this is the largest contributor to daily energy expenditure, changes in this parameter have the greatest potential to affect body weight. Resting metabolic rate starts to decline by the late 40s by 4-5 percent per decade. It is no wonder that with the exact same food intake, weight drifts up with age unless there is some compensatory change (i.e. decreased calorie intake, increased energy expenditure through exercise, or change in body composition such as increased muscle mass) Also, lean body mass (muscle mass) declines as well with age by as much as 3 kg (about 6.6 pounds), further decreasing resting metabolic rate and contributing to gain in weight and body fat. It is unclear exactly what role hormones contribute beyond the normal aging process since these metabolic changes occur in men as well as women with the aging process. Nevertheless, it is the belief of most menopause specialists that hormonal changes increase the intensity of the process beyond aging alone. The accumulation of central body fat (greater waist to hip circumference ratio or change in figure) is strongly correlated to metabolic complications such as increased risk for diabetes and heart disease.
 If you are experiencing some of the changes that have been reviewed, discuss it with your doctor. The best way to make a diagnosis of perimenopause is a detailed history and examination to rule out other causes. The first line of therapy is a healthy diet, exercise (aerobic and weight bearing) and adequate sleep to help maximize your intrinsic health and a full understanding and knowledge of these changes in order to optimize your mental state and reduce anxiety. If this proves inadequate there are many additional treatments available.
Dr. Charles Dubin is a specialist in gynecology, menopause and gynecologic minimally invasive surgery. He is in private practice in Santa Monica, Calif. He was among the first 100 physicians in the United States certified in advanced laparoscopy and hysteroscopy by the Accreditation Council for Gynecologic Endoscopy. He was cofounder of the Westside Menopause Center and a member of the North American Menopause Society. He was founder of the Endometriosis Center of Southern California. Dr. Dubin’s practice caters to the needs of perimemopausal and menopausal women employing a customized, holistic approach using hormonal, herbal, dietary and lifestyle approaches. Send your questions to Charles@smartnow.com.
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