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http://www.nytimes.com/2002/06/23/fashion/23PERI.html

Menopause Forever

By ALEX KUCZYNSKI

n April 15, eight million Americans tuned into "The Oprah Winfrey Show," as they do every weekday as sure as the sun rises.

Ms. Winfrey's voice, authoritative but also soothing, boomed the day's topic: "Today, are you in menopause . . . and don't know it?"

A parade of women flitted across the screen. One complained of cold hands; another asked why she felt out of control. A third said: "I'm 33 years old. This can't be happening to me."

In fact, menopause was not her problem. That day's show focused on perimenopause, the new, attention-grabbing younger sister of menopause.

The World Health Organization says that the symptoms associated with perimenopause begin two to eight years before a woman's final menstrual period and end a year after it. But many doctors define the condition more loosely, with some saying it can begin 15 or even 20 years before the final menstrual cycle and end some time after it.

Still other doctors and researchers define perimenopause as an opportunity by drug companies, book publishers and herbal supplement makers to exploit the concerns and pocketbooks of millions of health-conscious women over the age of 35.

For its first major foray into mass-market awareness on the "Oprah" broadcast, perimenopause could not have had a better platform. So many concerned women sent in e-mail messages afterward that the Oprah.com Web site, accustomed to heavy traffic, crashed temporarily.

Dr. Christiane Northrup, a guest on the show that day and the author of "The Wisdom of Menopause" (Bantam 2001), said she was not surprised at the volume of requests for information. "This is the PMS of the new millennium," she said in a telephone interview from her home in Maine last week. "It is something women have to pay attention to."

Years after menopause became a popular topic of discussion and debate, in part because of books in the 1990's like "The Silent Passage," by Gail Sheehy, and "The Change," by Germaine Greer, perimenopause is following the same path into public consciousness.

But this time some doctors say the universe of symptoms attributed to the condition — cramps, hot flashes, night sweats, memory loss, sleeping problems, mood swings, anxiety, irritability, irregular menstrual periods, heavy periods, light periods, diminished libido, increased libido, vaginal dryness, frequent urination, migraines, bloating and breast tenderness — are so general and arbitrary that almost any woman would have some of them at almost any time in her life. Irregular periods, for example, are common among adolescents, athletes and lactating women.

"Women's health has been phenomenally overmedicalized and commercialized, and to a large extent perimenopause is a manifestation of that overmedicalization," said Dr. Anthony Scialli, a professor of obstetrics and gynecology at the Georgetown University School of Medicine in Washington. "At the same time, there are symptoms that can occur during the years prior to menopause — and I am being purposefully vague about the number — that are normal and are simply what happens as a woman comes closer to menopause. It is not a disease, and it is not an illness."

The term perimenopause came into vogue among doctors in the middle and late 1990's, after it received the definition from the World Health Organization in 1996. (Other terms in general use include premenopause, which also refers to the time before menopause, and premature menopause, a relatively rare condition in which ovulation and menstruation cease abnormally early, as in the 20's or early 30's.)

Despite some doctors' concerns that perimenopause is a phantom syndrome, a cottage industry has grown up around it. Books on the subject include "What Your Doctor May Not Tell You About Premenopause: Balance Your Hormones and Your Life From 30 to 50" (Warner Books, 1999); "Before the Change: Taking Charge of Your Perimenopause" (Harper San Francisco, 1999); "The Change Before the Change: Everything You Need to Know to Stay Healthy in the Decade Before Menopause" (Bantam 2002); and "Could It Be . . . Perimenopause? How Women 35 to 50 Can Overcome Forgetfulness, Mood Swings, Insomnia, Weight Gain, Sexual Dysfunction and Other Telltale Signs of Hormonal Imbalance" (Little Brown, 2000).

BEFORE THE CHANGE," by Ann Louise Gittleman, lists 48 symptoms in all, including acne, allergies, anxiety, leg cramps and weeping, and even one that would seem anachronistic in a contemporary book about women's health: hysteria.

The herbal supplement industry has heeded the call. Trade journals like Food Technology and Grocery Headquarters encourage manufacturers and retailers to market perimenopause-related products like women-only nutrition bars and cereals fortified with vitamins for women. The shelves of General Nutrition Center and Vitamin Shoppe stores are packed with menopause-related supplements that also promote their benefits for perimenopausal women.

These include Estroven, a soy-based dietary supplement for the treatment of hot flashes, cramps and insomnia, whose slogan is "Don't wait for menopause to get Estroven"; EstroSoy; Dong Quai Formula; GNC Soy Isoflavones; Promensil; and Femgest, a topical cream that promises to deliver progesterone to the body "for women of childbearing years, perimenopausal and menopausal-aged women and postmenopausal-aged women" — in short, anyone with two x chromosomes over age 15.

In 1999, grocery and drugstore sales of soy isoflavone supplements, a source of phytoestrogen often recommended in the perimenopause books, rose to $21 million, more than three times the previous year's figures, according to the market research firms Spins and A. C. Nielsen. Sales of general menopausal formulas were also up, to $36.2 million in 1999.

Some doctors argue that gathering a collection of symptoms of aging under the perimenopause rubric is an example of using women's menstrual cycles to show that they are somehow abnormal.

As Dr. Adriane Fugh-Berman, an assistant clinical professor at the George Washington University Medical School in Washington, put it: " `I'm feverish. I am anxious. I have a headache. I forgot something.' Who doesn't experience those things?" In some cases, she said, women as young as 30 are being told they may be perimenopausal. On the Winfrey segment, the first four women interviewed said they first experienced perimenopausal symptoms at 31, 37, 38 and in the mid-30's. The 38-year-old said she had hot flashes and had been hospitalized three times for "supposed heart attacks."

Packaging products for so-called women's maladies is not new. One recent example was Eli Lilly's response last year when it lost its patent on Prozac, which had sales of more than $2 billion a year. Lilly repackaged Prozac as Sarafem, for women suffering from premenstrual dysphoric disorder. It gained the sole right to market Sarafem for seven years as a fix-all for the blahs many women experience before their periods.

Dr. Fugh-Berman, who is on the board of the National Women's Health Network, a nonprofit research group, likened the marketing of perimenopause to that of Sarafem. "They're both a way of abusing a term in order to sell products," she said.

The debate over perimenopause comes down, in many ways, to a question about the consequences of labeling. Dr. Scialli said he considers it normal to treat symptoms of aging, but objects to lumping those symptoms into what he calls a catchall women's syndrome.

"People who do not feel well can be offered treatment," he said. "However, to a large extent some of the normal things that occur with aging are being attributed to hormonal changes in women, whereas the same symptoms in men are not."

Dr. Northrup, the guest on Ms. Winfrey's show, said that many of the e-mail messages were from women who clearly were not menopausal.

"On the one hand, we help by naming the nameless suffering," she said. "But on the other hand, we take all the women who are doing fine and wave this thing in front of them, saying, `You better watch out because you could be getting perimenopausal,' when it's really the last thing in the world healthy young women need to worry about."

Even so, Dr. Northrup said she did see a benefit: the perimenopausal time in a woman's life can be used to treat symptoms that may lead to serious problems like osteoporosis and cardiovascular disease later. "The good news is that this will help women start to notice something about their changing health and correct it long before there is any real problem," she said.

But the popularity of the term leaves a lingering question for some researchers: will women's lives soon be divided into micropassages like prepuberty, periadolescence, peripostadolescence and postperimenopause, each with its own nutritional supplements, self-help books and pharmaceutical cures?

Dr. Cynthia A. Stuenkel, a clinical professor of medicine in endocrinology and metabolism at the University of California at San Diego, said that women should be wary of over-classifying their lives.

"A friend reminded me of an article we read years ago," she said. "In it, the writer said: `When you start puberty we'll put you on contraceptives. Then we'll put you on hormones so we can harvest your eggs. And then we'll take you off of them, and everything will be chemically controlled.' I don't know if that is a good thing, or a desirable thing. I don't think we need to get too carried away with making it more complicated or creative than we need to."

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