Guesswork of Perimenopause

Everything You Need to Know

When women hit their late thirties or early forties, many begin the process of perimenopause, a highly variable period of time when the reproductive cycle begins to shorten, eventually starts to skip (usually around age forty-seven), and then finally comes to a halt with menopause (average age fifty-one). The term perimenopause is more of a description than it is a true developmental state. It is a time of transition from full fertility into menopause.

The average age of perimenopause onset is within a broad range, between thirty-nine and fifty-one (but it can start anywhere after age 25, the peak age of fertility) and is highly unpredictable with respect to any individual woman. How and when perimenopause appears is an inexact process; its symptoms vary month-to-month and even day-to-day. Often the earliest sign is the shortening of the monthly cycle. You still will have your period, but you may notice that it comes sooner, is heavier and/or shorter. You may skip some months. You may also notice physical changes reflecting changing ratios of hormones.

These changes are the result of the aging and declining number of remaining follicles, or eggs, in the ovary. The ovaries are somewhat like an hourglass of sand, with the follicles (eggs) being represented as the grains of sand. The hourglass is turned over even before we are born, and the follicles begin to slip away. As we age, the “sand” begins to run out and the volume left behind is less, affecting the end mix of the hormones generated by the remaining follicles. Thus, the lessening of hormonal power becomes more evident. Usually this takes place in the early to mid-forties, but even earlier for some women.

When the remaining eggs’ cells can no longer generate the response the brain demands for fertility, the hormones generated by the follicles begin to change in duration of maximum peak and in the ratio of one hormone to another. This is what kicks in the symptoms of perimenopause. Some of the symptoms include:

  • Shorter cycles (shorter and earlier periods)
  • Bleeding amounts changing: heavier or lighter
  • Night sweats, especially before periods
  • Decreasing vaginal lubrication
  • Worsening PMS (more abrupt)
  • Insomnia, worse premenstrually
  • Adult acne
  • Increasing facial hair
  • Thinning head hair
  • Symptoms of anxiety: racing thoughts, air hunger, feelings of unexplained worry
  • Palpitations

Handling some or all of these changes at once can be an incredible challenge when many in their forties are already dealing with parenting demands, spousal needs, aging parents, and professional expectations. What is absolutely clear is that no two women have the same way of experiencing perimenopause or its symptoms. Many women experience hot flashes, sleep disturbances, lessening of libido (sex drive), and vaginal dryness (usually associated with menopause), while some women experience no symptoms at all. Others may experience a short period of hot flashes, but as soon as they hit menopause (the actual cessation of menses), their hormones complete the transition and the symptoms stop.

The duration of symptoms also varies from woman to woman. Occasionally, symptoms that begin in perimenopause, such as hot flashes, may persist into the postmenopausal years indefinitely. Sometimes women suffer typical PMS associated with one cycle day, only to have hot flashes and insomnia the next month. Such is the roller coaster for many in perimenopause.

During perimenopause, estrogen levels may remain normal in your blood and saliva (or even slightly higher than average, in response to the brain’s signal for more) and the peak of estrogen that generally occurs right before ovulation (the midcycle) may remain, but the duration of the estrogen-dominant days is lessened by the aging follicle(s). This can be confusing to patients who are told that their hormone levels are normal when they feel so hormonally different. As the ovary ages, blood levels of estrogen may not reflect the health of your follicles until they (the eggs themselves) have nearly disappeared.

Much has been theorized about the various causes of “ovarian decline”; however, the truth is that it is not a disease, but a natural occurrence. As human women, we are programmed to stop reproducing long before our expected time of death, so that we can be around for an extended time to raise our youngest child. For some, ovarian decline begins somewhat early, but it happens eventually for all women. Again, the ovary is programmed to spend its follicles (beginning before birth), but ovarian decline is not often obvious until about age forty-three, when a woman may develop clear symptoms (such as those listed earlier).

Some physical consequences follow the change from regular ovulation to a sporadic pattern. Ovulation must occur to generate progesterone. In your mid- to late-forties, ovulation is interrupted more easily and time may stretch between ovulation occurrences, causing skipped periods. If significant amounts of estrogen in your body tissues are present, the absence of bleeding can lead to what is known as an unopposed estrogen effect. Without progesterone and the coordinated sloughing of the menstrual uterine lining, the lining can build up, resulting in very heavy, unpredictable vaginal bleeding and even increase the risk of uterine (endometrial) cancer. Endometrial cancer is very rare before menopause, but abnormal bleeding is common in many forty-something women. Often, using cyclic hormones or even the low-dose birth control pill can help these problems. If you are experiencing abnormal bleeding, you may need an ultrasound to check for other causes of bleeding and, possibly, a biopsy of the uterine lining to rule out pre-cancer or cancer, although rare.

The ebb and flow of emotions at this time can also be a source of frustration. Some women in perimenopause feel so depressed the week before their period that they are literally stymied in their lives. Other women experience frustration with low libidos. Still others are actually experience an increase in libido due to the lessening of estrogen’s presence, which can free up more testosterone (estrogen’s effect can suppress testosterone); these women may also experience unpleasant symptoms of testosterone dominance such as adult acne, negative cholesterol changes, scalp hair thinning, and facial hair.

Most women need an individualized approach to their perimenopause. There is no one-size-fits-all, and a careful analysis of physical and emotional issues must be carried out to answer questions and deal with problems.

Your metabolism also changes in perimenopause, and you will become more likely to store fat after eating processed carbohydrates (sugar, starch, etc). Exercise is of utmost importance at this time: at least 150 minutes a week, (22 minutes a day). Exercise will help even out dramatic hormone fluctuations and elevate your mood (besides the fact that it is good for your heart, brain, and sex-life).

Omega 3 fatty acids (fish oils) are also helpful as they stabilize mood and metabolism and are good for the heart, brain, and sex-life. Taking a multivitamin daily is of prime importance to make certain your body has the tools to keep its chemistry optimal. For those who have trouble swallowing or who have stomach upset with a multivitamin, chewables work just as well. Calcium is important as perimenopause marks the time of a loss in bone density due to declining estrogen. Calcium has been shown to help stabilize mood swings with PMS as well. Vitamin D is also important in perimenopause as in other stages. Studies show that most women do not get sufficient Vitamin D, which is imperative for bone health but also for cancer protection. Many health experts feel the current US RDA (recommended daily allowance) of 400 IU is set too low.

  • Multivitamin (preferably women’s formula)
  • Calcium, from your diet or supplements: 1000 to 1200mg a day in divided doses (no more than 500-600 mg at once)
  • Vitamin D: 1000 IU a day
  • Omega-3 fatty acids (fish oils): 1000mg a day
  • Phytoestrogens: 50-70 mg of isoflavones a day to reduce night sweats and stabilize declining estrogen levels

If you are still feeling concerned about your symptoms, and you are seeing no change with the above mentioned over-the-counter solutions, consult with your health care provider to discuss your specific issues.

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