Hot flashes, mood changes, night sweats, insomnia, vaginal dryness…all of this can happen long before our final menstrual period. We used to just talk about menopause–what happens after our periods cease. Perimenopause is the time leading up to the final period and is typically when the most intense symptoms happen. Didn’t know that symptoms are usually worse before your periods end? Most people don’t! Thankfully, people are beginning to talk more about perimenopause. It is as inevitable as puberty and most of us knew what to expect then. So what do we expect now with the perimenopausal transition?
What are symptoms of perimenopause?
Everyone will experience the perimenopausal years differently. Rarely, people have no symptoms at all. But most of us will have at least one of the following symptoms:
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Period changes–they become unpredictable. The periods can be more or less frequent, more or less painful, and more or less heavy.
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Hot flashes–it can feel like a furnace has been ignited inside of you. They typically last for 1-5 minutes. Sometimes they are mild and you just have an awareness that they are there. More severe hot flashes can happen frequently throughout the day, cause flushing or sweating, and can disrupt what you are doing.
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Night sweats–sometimes people just feel a little more sweaty than usual when they wake in the morning. Others can wake multiple times a night drenched in sweat, wetting through their PJs and sheets.
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Insomnia–sleep can be disrupted from the hot flashes and night sweats. Other people can have insomnia not related to hot flashes and night sweats–these people tend to have difficulty staying asleep at night.
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Mood changes–many people start to feel more crabby, more irritable, and like they have a shorter fuse. Some experience outright rage and can get into trouble at work or have difficulty with relationships. Others become more sad or weepy. Mood swings are common. Old issues with anxiety or depression can be reawakened.
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Decreasing fertility–the changing hormone levels disrupt the body’s ability to ovulate.
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Vaginal dryness and painful sex–a loss of vaginal lubrication can cause pain.
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Decrease in libido–your sex drive can drop.
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Worsening incontinence–people can have more leaking with coughing, laughing, and sneezing. They can also have issues with feeling urinary urgency and like they can’t make it to the bathroom in time.
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More UTIs–lower estrogen levels increase the risk of bladder infections.
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Changes in body composition–people often complain of weight
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gain, especially around the belly. This is accompanied by a loss of muscle mass and muscle strength. As that happens, bone mass decreases as well. Cholesterol levels generally increase. Joint pains
What causes perimenopause?
Perimenopause is the ovaries’ transition from synchronized monthly cycling to no hormone production. It is usually not an abrupt process–few people go from monthly periods to no periods again without years of transition. The hormone levels don’t smoothly drop from 100% to 0%–the levels will fluctuate over time. One day you can be at 80%, then 30% for a few months, then back up to 75%. During times of higher hormonal levels, people tend to feel more “themselves” with periods that can be more regular. When hormone levels drop, people can experience temporary loss of periods, hot flashes, and mood changes. And the levels can rise again. This can create a lot of uncertainty and frustration. It can feel like you’ve lost control over your body and what to expect from it.
What are the phases of perimenopause? How does it start?
This transition can be unpredictable but generally progresses in a typical fashion. Very early perimenopause starts in the late 30s to mid 40s when progesterone levels start to drop. Periods are still regular but PMS symptoms, mood irritability, and insomnia become more common. In early menopause, fluctuating hormone levels start to disrupt your periods. When people ovulate, a delicate hormone symphony needs to happen. When the hormone levels are a little bit off, the symphony doesn’t work and we don’t ovulate. When we don’t ovulate, periods tend to get heavier and crampier. That is why we can expect periods to get heavier and more frequent before they start to space out. Then estrogen levels start to drop. When estrogen levels are low we begin to experience the “vasomotor” symptoms of hot flashes and night sweats. As estrogen levels rise again we can resume our periods and the vasomotor symptoms improve. In late menopause, estrogen levels drop to a level where ovulation is rare, periods become lighter, and periods are spaced out by months. Ultimately, estrogen production stops and your periods will end. Late menopause is the 12 months following your last period. And after those 12 months you are considered to be in menopause. In menopause, there is no more production of estrogen or progesterone. The hormone levels are steadily absent, and the way you feel on a daily basis becomes reliable again.
How does perimenopause impact fertility?
As the hormone levels rise and fall, the ability to ovulate can come and go. If you miss your period, don’t assume it is perimenopause–it could be pregnancy! If you are having penis-in-vagina sex and don’t want pregnancy, it is recommended that you continue contraception until you have not had a period for the past 12 months. If you do want to conceive then time can be of the essence. I would recommend seeing a reproductive endocrinologist right away.
How do I know if I’m in perimenopause?
We determine whether or not you are in perimenopause by talking about symptoms. Lab work for estrogen and progesterone is not helpful because the hormone levels fluctuate so much day to day. A helpful analogy–if your menstrual month is a movie, lab work is like taking one still picture from that movie and trying to figure out the whole plot from that one picture. But testosterone and thyroid hormone levels remain more consistent and blood work can be helpful in evaluating those.
How is perimenopause treated?
Perimenopause symptoms can be very disruptive to one’s quality of life. When they are, I recommend treating them in some way. Perimenopause symptoms do not have to be treated–in the past, women were told to “tough it out” and they did. But at what cost? We have discovered that menopause hormone therapy is very safe especially in the perimenopausal phase. I prescribe bioidentical hormones that can be adjusted over time to address symptoms that can change with time. These hormones can be delivered in pill, patch, pellet, and cream forms. The hormones can be obtained from a “regular” pharmacy like Walgreens or “compounded” from a specialty pharmacy like Prescription Alternatives. In general, hormone therapy is the most effective treatment for perimenopause symptoms. People who live a healthy lifestyle are less likely to experience bothersome symptoms. Non-hormonal medical treatments for hot flashes are available. Herbs like black cohosh and chaste tree berry can be helpful. Acupuncture works. Other sources of perimenopause-like symptoms also need to be considered. The thyroid, adrenal, and serotonin pathways can be culprits and need to be treated in different ways.
What is the impact of lifestyle on perimenopause?
Perimenopause is a great time to address your overall health and to prepare your body for wellness and longevity. During perimenopause, the metabolism slows down and the risks of heart disease and bone loss increase. Lifestyle improvements can not only reduce perimenopause symptoms, but they will also lower the risk of cancer and heart disease. People also tend to feel “well” when they are following a healthy lifestyle. This typically includes:
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Exercising at least 3 days per week
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Eating a diet low in sugar and processed foods
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Lowering alcohol consumption
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Avoiding nicotine products
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Managing stress
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Maintaining a normal weight
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Following a healthy sleep routine
How do I find relief from perimenopause?
Perimenopause can be a wild time. I’d be honored to help you through this transition. My treatment style focuses on optimizing your quality of life–helping you to feel your best on a daily basis. It is important your treatment is tailored to your goals, lifestyle, medical history, and preferred treatment modalities. Come and see me for an expert, individualized treatment plan that resonates with you. I have clinics in Frisco, Buena Vista, and Edwards CO and I accept most health insurance.
