PERIMENOPAUSE IS A time of increasingly variable hormone levels and irregular ovulation which can result in a change in our menstrual cycle. This hormonal chaos happens, on average, from the age of 45 onwards. However, it can start earlier, for some women. When ovulation (and estrogen production) cease, we call this “postmenopause”.
From puberty onwards, ageing causes a decline in the number of follicles in our ovaries. These follicles contain the small oocytes (eggs) which we release once per month, with ovulation.
As the number of follicles declines, our brain releases a hormone (FSH) which stimulates the ovaries, to promote ovulation and drive ovarian function. This stimulation is often imperfect and creates an erratic, unstable hormonal environment. Oestrogen, a hormone produced by our follicles, swings up and down, from too much to too little.
It continues until the ovaries no longer respond to the brain’s stimulus. They stop ovulating and with that, lose their estrogen production.
This is a challenging question to answer. Our ovaries are tricky little buggers who like to keep us on our toes.
In early perimenopause, the small fluctuations in hormone production may not produce much in the way of symptoms. Remember that your brain is used to a bumpy hormonal landscape – other than during pregnancy or if you are taking the contraceptive pill, hormones fluctuate up and down throughout a normal menstrual cycle. Women may women experience this as “PMS” (premenstrual syndrome).
Increasing hormone variability and inconsistent ovulation will typically result in a change in the menstrual pattern – your periods change. For some women, this means shorter cycles, such as less time between your periods or bleeding. For others, their periods become less frequent.
A persistent difference in cycle length of more than seven days, in consecutive months, is typical of perimenopause.
If you have stretches of 60+ days without a bleed, that would be typical of “late perimenopause”, reflecting that you are further through the menopausal transition and closer to the time of your final period.
There are no blood tests we can do that help figure out “how far” someone is through this process. This is because the hormones fluctuate so much that they can’t be relied upon. There are no over-the-counter tests which will guide you here so don’t be fooled by marketing.
We diagnose perimenopause by listening to the patient – their clinical symptoms and signs. A new persistent change in the menstrual cycle, as above, is one useful indicator.
Some women describe more dramatic PMS-type symptoms; tender breasts, irritability, mood swings, more frequent migraines, low libido, poor sleep and difficulty with finding words or short-term memory.
For some, they may start to experience night sweats, hot flushes or vulvovaginal symptoms such as dryness or painful sex.
Frustratingly, these symptoms may be present in some months but not others. This can lead some women to feel as though they are “losing their mind” and explains why women may doubt themselves or not look for help at this time.
Of course, other stressors can also contribute to these symptoms because perimenopause often occurs when women are at their busiest with work or family life or just life in general. That can make it hard for us to distinguish what is “life” from a hormonal symptom.
Interestingly, cognitive symptoms (memory etc.), mood and migraines peak through perimenopause, which is before your periods have stopped. In fact, research suggests that most women experience their worst cognitive symptoms before their final period. Most of the symptoms we develop at this time are due to the brain having to learn to function in a new, unstable, hormonal environment – the brain is trying to adapt to this new stage of hormonal life.
Lots. First of all, try to keep a (simple) diary. Have a look at your bleeding cycle and if your symptoms, such as headaches or mood swings, have a pattern – are your symptoms often worse before your period?
Don’t panic, you are not alone. Life, in general, is tough but if you throw a hormonal storm in the mix, it’s harder again.
Everyone experiences the menopausal transition differently, with different symptoms or challenges so it can be a very lonely time. Know that these symptoms are common, that you won’t feel like this forever and there’s lots of help out there.
Certain interventions can help but will depend on what your own individual symptoms are. Reducing caffeine and alcohol, increasing exercise, paying more attention to “sleep hygiene” and a good sleep routine may be helpful. For some women, cognitive behavioural therapy can be useful for anxiety, low mood, low confidence and sleep.
We can also discuss nonhormonal medications (such as SSRI/SNRI medications, often used for depression or anxiety) which can improve mood, sleep and hot flushes. For some, the oral contraceptive pill or the progestogen-only pill (“mini-pill”) may provide symptom control, menstrual regularity and contraception. The intrauterine device (IUD) is also very effective in reducing menstrual bleeding and for birth control.
Hormone Replacement Therapy (HRT) has a role here too as it can reduce the need for so much stimulation from the brain’s pituitary gland, helping some of the hormonal chaos to settle down to a slightly more stable state. Think of it as having a bucket of water in the car – in our 20s and 30s, the car is on an even road and the bucket of water just has ripples. In perimenopause, it’s as if the car is going over big hills, bumps and potholes (like any typical Irish road trip!) and the water is sloshing violently, spilling over. HRT is like trying to hold the bucket still. It’s not perfect but it helps.
HRT is a medication and as with any medication, there are potential benefits, risks and side effects. We know that HRT can impact the risk of breast cancer and may cause side effects such as unexpected vaginal bleeding, mood changes and headaches. However, the benefits may outweigh the risks for some women, who find their worsening PMS, low mood, migraines and new nighttime sweats resolve. It really depends on the individual.
Take home points if you think you’re in perimenopause:
1. Don’t forget about contraception. If you are still having periods (and have not gone at least one year without a bleed – two years if you are under 50!) then you need to consider your need for birth control. There are lots of options here and it is worth discussing this with your GP or healthcare provider.
2. Remember that you are not alone and reach out for help if you feel you need it.
3. Perimenopause is sneaky. The symptoms can wax and wane, come and go.
4. This is a great time of your life to start health planning – be aware of the risks of heart disease, bone density loss and look at lifestyle interventions that can be beneficial. Start taking vitamin D (over the counter), plenty of calcium in your diet and weight-bearing exercise.
5. It’s not all bad news - perimenopause is a time to take control of your long-term health and feel positive – women are amazing! We need to embrace new stages of life as they happen, educate ourselves and most of all, support each other.
Dr Caoimhe Hartley, clinical lead of the Complex Menopause Clinic in the Rotunda Hospital and founder and clinical lead of Menopause Health in Dalkey County Dublin, is an expert panellist at the upcoming National Menopause Summit Cork supported by M&S which takes place on Friday, 20 October in Cork City Hall. Details can be found at www.
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