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Postcards from a perimenopausal vacation

Menopause

Iyar 5779 | May 2019
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It had been three years since their last vacation together and Shuli was euphoric to spend the next 12 days alone with her husband in paradise.  The plane had just taken off and she desperately needed to go to the bathroom.  To her tremendous disappointment, she discovered that she was bleeding though she had just gone to the mikve last week (it had taken her 16 days to get there). After all,  her trip had been planned for a time when she would not be in niddah.  At the age of 48, her periods were erratic, too long and arrived more often than she would like.  Now, she would be forbidden to her husband for the entire vacation. Devastated by this reality, she wondered if all of this bleeding all too often was due to perimenopause.

Menopause is derived from the Greek, meno, moon and pause, cessation. It refers to cessation of monthly bleeding for 12 months.  Yet, a more appropriate phrase to describe this period in a woman’s life is the Hebrew expression, gil ha’ma’avar, the period of transition.  Indeed, perimenopause, the years leading up to the final period can be a confusing journey.  As the ovaries make less estrogen, fluctuations in hormones may cause unpredictable bleeding, hot flashes, sexual dysfunction and difficulties with memory.  Long-term estrogen depletion can lead to bone loss, heart disease, dementia, weight gain and change in body composition, skin changes, wrinkles and loss of balance.  This stage of life with its hormonal changes can create several unique halakhic challenges.  Women may have shorter menstrual cycles and spotting between cycles putting them into niddah more often.  They may experience heavier and more prolonged menstrual bleeding making it more challenging to get out of niddah. Towards the end of the perimenopausal period women experience lengthening of the interval between menstrual cycles which makes calculating onat prisha, the time of separation prior to a period, confusing and complicated.  Eventually, when a woman goes three months without a period she will achieve the halakhic status of zekena, msuleket damim, and no longer need to worry about the time of separation.  Her years of mikve observance cease. Are there steps that one can take to make gil hama’avar, the period of transition, easier? How can one best navigate this challenging stage of life?

Shuli’s recent menstrual complications and niddah frustrations are typical of perimenopause.  Shortened menstrual cycles may mean that a woman goes to the mikve and a few days later stains or bleeds again leaving her with maddeningly few days to be with her husband and no control over when she is a niddah.  Although a flow of blood typical of a period does render a woman a niddah, not all stains qualify as niddah.  The Mishna in niddah recounts a woman’s visit to Rebbi Akiva to ascertain the status of a stain.  He asked if she had a cut.  She answered, “Yes, but it had healed”.  He asked if she rubbed the cut would it yield blood and she replied that it would.  With this, Rabbi Akiva declared her permitted to her husband.  His students who had observed the interaction expressed disbelief that he declared her permitted.  The gemara offers the following for Rebbi Akiva’s ruling: the laws of ketamim are rabbinic and we apply leniencies whenever possible.  Thus, built in to the Laws of ketamim are many exemptions based on size of the stain, material and color of the surface on which the stain is found and attribution of the blood stain to a non-uterine source.  Because the laws of ketamim do not apply to stains that appear on colored surfaces, Rama recommends that women who are not in niddah wear colored underwear “to save them from stains”.  Relying on these exemptions can increase the amount of time a couple are permitted to each other and ease the burden of shortened cycles and intermenstrual staining typical of the perimenopausal period.  In addition, waiting to wipe after urination, not looking when one urinates or at the toilet paper after wiping, averting unnecessary bedikot or insertion of a tampon (unless one is certain that she is a niddah) can help avoid becoming a niddah from stains.  While many women feel like they are cheating the system by taking precautions to avoid becoming niddah from spotting, one must remember that halakha seeks to limit the amount of time that a woman is in niddah.  Indeed, truncated intervals between periods and intermenstrual spotting severely interfere with the Biblical mitzvah of Onah, the husband’s conjugal obligations toward his wife.

If bleeding persists, women should seek medical attention and may also consider consulting their doctor regarding hormonal options or placement of an IUD.  While hormonal treatment can help control the timing of bleeding and increase the interval between cycles, spotting may continue in spite of such therapy, leading some women to opt against hormones, choosing to let the stains take their course.  Although during the first few months after placement of an IUD, most women have irregular bleeding or staining, eventually the amount of bleeding diminishes and some women no longer menstruate.  For those who continue to bleed, the staining may be light enough to avoid becoming niddah.

For women with prolonged perimenopausal bleeding, it may take many days to obtain an adequate hefsek taharah. The Jeruasalem Talmud (Nidah 2:4)  states, “It is forbidden for a woman to remain in niddah,” suggesting that within the halakhic framework every effort must be made to help a woman become tehora.  To this end, the support of a morah L’halakha or yoetzet halakha to navigate the process of tahara may be especially critical during perimenopause. Soaking in a bath prior to the hefsek may help achieve a better hefsek.  It is important to be aware that yellow or light brown colors on a hefsek or bedikha are acceptable. Rather than categorically assuming that a questionable color of a bedikah or stain is prohibited (invalidating the process of tahara and starting all over again), one should consult with a halakhic authority and even bring the questionable hefsek, bedika cloth or stain for evaluation.  If achieving an acceptable bedika is challenging, consulting with a halakhic authority regarding reducing the number of bedikot may also be worthwhile.  Because spotting during the shiva nekiim can invalidate the entire process of tahara, many of the recommendations to prevent stains from becoming niddah in between periods also apply during shiva nekiim, including not looking when one urinates, waiting to wipe after urination and not looking at toilet paper after wiping.

Towards the end of the perimenopausal period, the interval between periods may become longer and women may wonder, “Am I pregnant or is this just menopause?!” a legitimate concern given that some older women may still be able to become pregnant. With unpredictable and erratic cycles, calculating onat prisha, the time of separation, in anticipation of a period can be confusing but may be simplified by consulting with a halakhic authority or using an app such as mikvahcalendar.  Once 90 days have elapsed without a period,  a woman is considered mesuleket damim and if she is at the age of menopause (defined by some rabbinic authorities as 53) then she achieves the halakhic status of zekena, allowing her to  cease to observe onot perishah (unless she resumes menstruating three times or menstruates on the date of a prior veset kavua).

Just as the beginning of menstruation marks a new phase in a young girl’s life with confusing and sometimes conflicting emotions, the end of menstruation elicits a spectrum of feelings.  Women’s reactions to the realization that they will no longer visit the mikveh every month range from relief to sadness.  To mark the milestone of mikveh completion, the Eden Center is compiling an educational booklet with recommendations for tekes ha’preida, a separation ceremony for the final mikveh visit.  The absence of a monthly period with its concomitant time of separation alters the tenor of a marriage.  Now a couple is always permitted to each other.  There are no off times.  For women who welcomed niddah as a break from sexual relations being permitted all the time may be stressful.  Others may embrace the possibility. Finally, the end of childbearing leaves many women in an existential crisis wondering about their purpose in life.  The Akedat Yitzchak’s description of the duality of Chava as both a mother and Isha, a woman of valor, with all the qualities to be a prophetess, reminds menopausal women that while they may no longer be able to bear children, they still retain their more compelling role as Isha capable of performing good deeds and profoundly impacting the world, independent of procreation.

Does the loss of fertility- the ability to become pregnant and fulfill the mitzvah of pru u’revu diminish mitzvat onah, the husband’s Biblical obligation to sexually gratify his wife?  Does halakha value marital intimacy in the absence of procreation?  The answer is resoundingly yes. In his book, Rav Paalim, Rav Yosef Chaim of Bagdhad was asked whether a man who unknowingly married a woman no longer capable of having children was permitted to remain married to her.  Quoting Avodah Zara 5b which interprets G-d’s command to the Jewish people to resume marital relations after receiving the Torah as an obligation to enjoy conjugal rights and not just engage in them for procreation, Rav Yosef Chaim answers that the husband is clearly still obligated to perform mitzvat onah.  He also cites the Ari Z”L  who believed that marriage had a higher calling or purpose and chastised “pious” men who separate from their wives when they are no longer able to bear children. Thus, mitzvat onah prevails even when procreation is not possible, when a woman is pregnant, nursing, barren or menopausal.   Though the mitzvah persists in menopause, fulfilling this mitzvah may be challenging as couples age and develop sexual dysfunction.  For women after menopause, lack of estrogen can cause vaginal dryness, pain with intercourse, decreased libido or arousal, cervical atrophy and decreased elasticity of the vaginal wall. However, continuing sexual activity may prevent some of these changes.  The colloquial expression is, “use it or lose it”.  Erectile dysfunction common in older men can also interfere with mitzvat onah.  It is important to bear in mind that mitzvat onah is not limited to the act of sexual intercourse and includes any form of intimacy which brings pleasure to the woman.   A broad definition of how one may fulfill mitzvat onah is reflected in the decision of poskim to permit a virgin bride to immerse in the mikveh on Friday night even though it was customary (in some places) to defer intercourse for the first time until after shabbat.  “All other forms of physical contact are a mitzvah,” writes the Shach.

Upon her husband’s suggestion and prompting, Shuli contacted a morah l’halakha when she landed and described the circumstances of her bleeding.  The morah l’halakha reassured her that she in fact was not in niddah as she did not experience a flow, and the blood was only seen on colored underwear but that some halachic authorities recommend abstaining from intercourse for 24 hours to determine if the blood stain represented the beginning of a period.  Luckily, there was no further bleeding, and the couple enjoyed a well-deserved vacation together.  Since then, Shuli consults with her morah l’halakha regularly to when possible obtain an acceptable earlier hefsek tahara and prevent spotting from invalidating her shiva nekiim or sending her back into niddah shortly after she visits the mikvah.

Dr. Sharon Galper Grossman

a radiation oncologist and former faculty member of Harvard Medical School where she also obtained a Masters in Public Health. Her current interests are in Women’s Health and Halakha, specifically issues related to preventing women’s cancers. She has recently published “The Angelina Jolie Effect in Jewish Law: Prophylactic Mastectomy and Oophorectomy in BRCA Carriers” in the Rambam Medical Journal. “Resolving the Debate Over Human Papilloma Virus (HPV) Vaccination for Cancer Prevention in the Religious World” has been accepted for publication in Tradition.