Perimenopause: A Primer

My female patients, especially those over 35, will often qualify any symptom with the phrase “It could just be menopause, but…” 

It could just be menopause, but I am so tired all the time!

It could just be menopause, but I have gained 15 pound this year! 

It could just be menopause, but I wake up every night at 3 am and never get back to sleep!  

Menopause has a near mythical place in our culture.  Women seem to both dread it and yearn for it all in the same breath.  But what is menopause really?  Are all the symptoms attributed to menopause really warranted? And, most importantly, what can be done to safely alleviate those symptoms?

Menopause is a funny thing because it can only be defined retrospectively.  A woman is in menopause when she has not had a menstrual period in the last 12 months.  The average age of menopause in the U.S. is 51.  95 percent of women will have menopause between the ages of 45 and 55*.  

However, what most of us colloquially refer to as menopause is really the time around menopause, and understanding what is normal and abnormal is often the first step in feeling better.  

The first changes that precede menopause are referred to as the Late Reproductive Years.  Women are typically in their 40s during this time.  They will notice that their menstrual cycles (from the first day of one period to the first day of the next) are shorter.  Some women will develop new or more severe symptoms around the time of their periods including hot flushes and irritability.  Periods can become heavier or lighter and while women are typically still ovulating with every cycle, those trying to conceive may struggle to do so as the quality of eggs diminishes.  

For some women premenstrual symptoms are severe and disruptive.  Often the best treatment option for women at this stage are low dose birth control pills.  The stable dose of estrogen and progesterone can improve symptoms and newer studies suggest that low dose birth control pills are safe for most women until menopause.   

When we classically think of menopause and its most common symptoms we are really thinking of perimenopause. Perimenopause is the time before menopause when periods become irregular.  Menstrual cycles can lengthen to as many as 40 or 50 days and women may start to skip periods altogether.  It is during this time that hot flushes, night sweats, sleep disruption, and changes in mood and cognition typically begin.  On average women are about 47 years old when they begin experiencing these symptoms.

The length of perimenopause varies, but the SWAN Study suggests that if you have gone more than 3 months without a period (even if you then started to have periods again) your last period will be in the next 4 years (I know, that’s a BIG window).

So, if you are staring down four or more years of sleep disruption and mood changes what can you do to feel better?

Definitely, book an appointment with your doctor.  80 percent of women experience symptoms of menopause, but only 20-30 percent seek treatment! Your doctor can’t help you if you don’t tell them you are having symptoms.  Your Gynecologist or PCP are reasonable starts.  

The most effective way to treat hot flushes is with estrogen–be it in the form of combination birth control pills, combination hormone replacement therapy (like birth control pills but in lower doses and with no sugar pills at the end of the month), estrogen and combination patches, or bioidentical pellets and creams. Estrogen therapy can also help with sleep disruption, changes in mood and cognition.  

A short course of hormone replacement therapy has generally been shown to be safe in women in their 40s and 50s.  However, many women need or prefer to avoid hormonal treatment.  Estrogen is NOT the only treatment option.   

Don’t hesitate to speak with your doctor about the symptoms you are experiencing even if you know hormonal treatments aren’t a good choice for you.  A wide range of non-hormonal medications have been shown to improve menopausal symptoms, it is important to discuss ALL the symptoms you are experiencing to make the best choice regarding which treatment is best for you.

Some behavioral changes do seem to improve mild symptoms. These include weight loss, cognitive behavioral therapy (a particular method of talk therapy) and mindfulness training.  

As important as what does help with menopausal symptoms, is what does NOT help.  There is not currently evidence that plant estrogens or herbal remedies such as black cohosh are helpful.  Similarly, both exercise and acupuncture have been studied and have not been shown to be beneficial.  

Many women are also helped by knowing that perimenopausal symptoms do end! A portion of women will have symptoms for 10 years or more.  For most women hot flushes and sleep disruption last for just under 5 years. 

Once the perimenopausal years pass many women experience decades of good health.  We will discuss the secrets to aging healthfully after menopause later this week.  

* It is important to note that if you stop getting regular periods before age 40-45 you should always be evaluated by your gynecologist and/or an endocrinologist.