If you are confused by the term perimenopause you are definitely not alone!  Even though half of the population will experience perimenopause, a staggering number of people have never even heard the term.   Dr. Heather Hirsch, a menopause expert, helps us answer all of your questions.

What is perimenopause?

Perimenopause is the time leading up to menopause when your body makes the natural transition to menopause.  During perimenopause your ovaries begin to gradually produce less estrogen and systemic levels of estrogen begin to decline.  Eventually your ovaries stop producing estrogen. Menopause is actually a one day event that marks the one year anniversary of being period free and the end of the reproductive years.. 

How long does perimenopause last?

Perimenopause can last from one to ten years which is much longer than most people realize. Menopause on average occurs between the ages of 45-55, with an average age of 51. Since perimenopause can begin up to a decade before, women in their mid-30s may begin noticing changes.  For one percent of women menopause will occur at age 40 or younger, so symptoms for these women can begin even earlier. 

What are the symptoms of perimenopause?

To answer this question properly you need to understand what is behind the symptoms.  Before perimenopause your ovaries are producing estrogen in a cyclical, predictable wave pattern every month.  During perimenopause your ovaries begin to produce estrogen in more erratic patterns.  These surges and crashes in estrogen levels can cause many of the symptoms women experience during perimenopause. Perimenopuse is not a ‘disease” so some people object to the term symptoms.  However, it is useful to know the signs and symptoms that women experience during perimenopause mostly as a result of diminishing estrogen. 

The most common symptoms of perimenopause include:

• hot flashes
• irregular periods (longer or shorter cycles)
• heavier bleeding
• mood changes
• migraines
• vertigo/dizziness
• joint aches and pains
• vaginal dryness
• painful intercourse
• low libido
• breast tenderness
• issues with memory or concentration,
• racing heart
• hair loss/thinning hair
• dry skin
• insomnia
• bone loss
• change in cholesterol levels
• weight gain

There are other symptoms as well, so it is important to keep track of how you are feeling and let your doctor know.   

Oh No! Will I definitely experience these symptoms?

There is no easy answer to this question.  About twenty percent of women will feel no symptoms and easily reach menopause.  But 70-80 percent of women will experience symptoms and for about 25 percent of that group they can be severe. The average length of symptoms is about 5-7 years.  Interestingly, women tend to follow their mother’s pattern so it is a good idea to talk to your mother if you can. Sometimes you may follow an aunt’s or a sister’s pattern as well.    

“one size does not fit all”

Is Hormone Replacement Therapy Safe?

According to Dr. Hirsch when it comes to hormonal replacement therapy, “one size does not fit all.”

There are hormonal and non-hormonal treatments available to help alleviate symptoms of perimenopause and menopause.  Hormone Replacement Therapy (HRT) fell out of favor over safety concerns in 2002.  The media widely reported that HRT led to a significant increase in risks for breast cancer and heart attacks.  However since then, many doctors are feeling more comfortable using HRT.  The study had concentrated on an older population, and focused on one particular form of HRT giving somewhat of a skewed result. 

Today lower doses of HRT are used for shorter periods of time and is safest when given less than ten years after your last period.  For some women that go through menopause prematurely the benefits of HRT may outweigh the risks.  Women with breast cancer or a family history of breast cancer may choose to avoid HRT.  This is a conversation that each woman must have with her doctor, and is dependent on many factors. 

Dr. Hirsch explains that the fear of HRT is still prevalent in many women’s minds today.  Each woman can make the decision with her doctor about whether HRT might be an option to consider.

Should I go on Birth Control Pills?

Birth control pills can help many of the symptoms of perimenopause.  However, since they involve hormones,  many women have concerns about increasing their risks for blood clots, strokes, heart attacks, and cancer.  Additionally, Dr. Hirsch says that many of her patients that had previously had bad experiences on birth control pills over twenty years ago, are surprised to learn that today’s birth control pills are much different.  For example, they offer a lower dose of estrogen which cuts down on blood cot risks, breast tenderness and perceived mood changes. 

Dr. Hirsch recommends considering taking an active pill every day which means not taking the sugar or placebo pills in the birth control pack.  There are also 84 day packs that she recommends followed by seven days of inactive pills.  Taking birth control pills, allows for a steady level of estrogen in your system that may help smooth the transition and ease many perimenopausal symptoms.  Dr. Hirsch also recommends considering an oral natural progesterone at night which may help some women balance estrogen.

Smokers and women with high blood pressure should not go on birth control pills.

While we are not discussing birth control pills as contraception here, it is important to know that you can get pregnant during perimenopause so you should consider some form of birth control depending on your situation and if your want to avoid becoming pregnant.

What else can I do about some of these symptoms?

Hot flashes– In addition to considering hormonal options an ultra low dose of anti-depressants can help some women.  

Heavy Periods– Before considering surgery or ablation make sure to ask if birth control pills would be an option for you.  Additionally An IUD with progestin such as Mirena can help with heavy bleeding. 

Migraines– While you should see a migraine specialist if they are frequent, Dr. Hirsch recommends 250-500 mg of magnesium oxide and 50 mg of Riboflavin (B2) at bedtime for some of her patients.  She suggests keeping a diary of migraine symptoms to help identify triggers.  Often migraines come from neck pain, so she recommends physical therapy to help alleviate that as well. 

Vaginal Dryness– Dr. Hirsch recommends considering a local estrogen cream.  These are thought to be safe as estrogen is localized.  New creams without estrogen are currently in trials. Vaginal moisturizers without estrogen can help as well.  A good lube is always a good idea to help with painful intercourse.

Weight Gain– Dr. Hirsch sometimes prescribes Metformin which is actually a diabetes medicine to help with weight loss.  Of course diet and exercise are important factors for weight loss.

The domino effect of symptoms:

Often one symptom can make others worse.  For example, lack of sleep can effect mood or be a trigger for migraines.  So if hot flashes at nights are making you lose even more sleep, treating this symptom can help alleviate other symptoms.

Does acupuncture, meditation, yoga, and other lifestyle changes help?

While there have been no studies showing that acupuncture, exercise, yoga, or meditation help alleviate perimenopausal symptoms, Dr. Hirsch reports that some patients have found relief from these.  There certainly is no harm in trying them, and even if they do not help with these symptoms, they do offer other benefits. 

Biofeedback and behavioral therapy have been shown to help with perimenopausal symptoms so that may be worth pursuing.

CBD oil has become a hot trend that often promises to cure all that ails us.  However, Dr. Hirsch cautions that CBD oils are unregulated and hard to study.

What else can I do?

Dr. Hirsch recommends keeping a diary because so many women in their 40s and 50s are extremely busy and may miss some symptoms.  Women may not even know when their last period was, which is useful information to have, so record the dates of your periods as well.  This diary will help track symptoms and help your medical care provider come up with a plan tailored for you.

Know your health history- Did you suffer from postpartum depression, PMS, or PMDD?  If so these may offer clues that your estrogen levels may effect you more strongly during perimenopause.  As discussed above, often women will follow her mother’s pattern so make sure to find out as much as you can.  Your health history and your family history can be used as predictors for age of onset, duration and severity of perimenopausal symptoms.

Can Lab work help?

While lab work can help, there is currently no test that can accurately predict when perimenopause will begin or end.  It can offer a piece of the puzzle, but a thorough clinical exam including a careful history is most important.

Why does my doctor dismiss my concerns?

Not only are many women not informed enough about perimenopause, but many doctors are not either.  Even OB/GYNs are given minimal training in perimenopause and menopause.  They are often focused on reproductive health.  Dr. Hirsch says there is a troubling black hole when it comes to women’s health and menopause.  It is important to find a provider that understands your issues.  One place to start is NAMS which allows you to search for a provider in your area by zip code. Many women find themselves seeing numerous specialists to find out what is causing their symptoms without any doctor attributing these issues to perimenopause.  Keep looking for a provider that is not dismissive!

YOU ARE NOT ALONE!

Perimenopause and its symptoms can be bothersome to many women, and even debilitating.  You do not need to suffer in silence.  Talk about it with your friends, seek medical care when needed, and stay informed.  While we do a great job of preparing women for puberty and childbirth, we are doing a horrible job of preparing women for perimenopause and menopause.  Let’s change this together!  Make sure to share this article with your friends and family.

 

Resources:

Dr. Heather Hirsch

North American Menopause Society (NAMS)

NAMS – Find a provider

Mayo Clinic

Cleveland Clinic