Perimenopause: Surviving the Transition to Menopause 

by Barbara Tunick

Ann Louise Gittleman thought she was going crazy. The 47-year-old certified nutrition specialist and author had always been able to maintain a hectic work schedule, fly across time zones, and still show up fresh and focused for lectures she was presenting. But over the past few years, something had changed.

“I would stand in front of a room full of people and couldn’t remember my speech,” she recalls. “My ‘brain fog’ was so bad that things would go in and out of my head faster than I could follow them. And for the first time in my life, I couldn’t sleep, no matter how tired I was. To top it off, I was moody and anxious. I had always prided myself on knowing what was going on with me from the inside out, and now I didn’t have a clue.”

Ann Louise’s doctor examined her and ran a battery of blood tests, including tests that measured her menstrual cycle hormone levels. The results of the exam and tests shed light on just what was causing her symptoms: she had entered perimenopause—the 4- to 10-year transition preceding menopause (the end of menstruation).

Like many of the 40 million American women currently experiencing perimenopause, Ann Louise hadn’t considered that her symptoms were related to this transitional period. Her periods were regular, even though her hormones were fluctuating wildly. “Although more women realize there is a transition period before menstruation stops, many are still surprised when it happens to them,” says Steven R. Goldstein, MD, professor of obstetrics/gynecology at New York University School of Medicine and coauthor of Could It Be...Perimenopause? (1998, Little Brown). “They think they’re too young to be perimenopausal, or they’re worried that they’ve started menopause early,” Dr. Goldstein says. But given the average age for menopause in the United States—51 years—most women are likely to become perimenopausal around age 47.

“Many women dismiss their irritability or memory lapses as the result of stress, aging, or even a case of premenstrual syndrome (PMS) from hell,” says Nancy Lee Teaff, MD, coauthor of Perimenopause: Preparing for the Change (1996, Prima) and a reproductive endocrinologist in Charlotte, North Carolina.

What’s Happening?
During perimenopause, the ovaries begin running out of follicles—the saclike structures that each contain an egg. Each month, the follicles respond to the body’s release of the hormone FSH (follicle-stimulating hormone) by preparing for ovulation (release of the egg). If there isn’t a follicle healthy enough to respond to FSH, ovulation doesn’t occur, and estrogen isn’t produced. Without estrogen, the uterine lining doesn’t thicken, and there is nothing to slough off as a menstrual period. During perimenopause, your body is also producing less of the post ovulation hormone progesterone, which can contribute to other perimenopausal symptoms, such as heavier periods.

And, although estrogen levels can drop sharply during this period, they can also become higher than normal. These ups and downs in estrogen levels also contribute to perimenopausal symptoms.

Symptoms of Perimenopause
As your body begins to produce less estrogen and progesterone, you’ll notice a change in your menstrual cycle. Even if you’ve always been regular, you might skip a period here or there, or go from a 28-day cycle to a 25- or 26-day cycle. In fact, an estimated 70% of women in their 40s experience irregular bleeding, making it the most common sign of perimenopause (see “Symptoms of Perimenopause”). 

“Some women are going to have hot flashes (waves of body heat, flushing, sweating), migraine headaches, and severe PMS, and others will breeze through practically symptomless,” says Dr. Teaff. “The one consistent thing about perimenopause is its inconsistency.” Some women experience heavier periods, others lighter. PMS can worsen, or, if you’ve never had cramps, you may suddenly get them. In addition, fibroids—benign tumors of the uterine wall—can grow larger during perimenopause.

The biggest complaints women often have during perimenopause are a lack of libido or sexual dysfunction, sleep deprivation, memory loss, and moodiness, says Veronica Ravnikar, MD, director of reproductive endocrinology at the University of Massachusetts Memorial Hospital. Other symptoms include vaginal dryness, weight gain, frequent urination, and stress incontinence caused by the drop in estrogen, which weakens the bladder’s supporting tissues.

Are You in Perimenopause?
There isn’t any one test that can confirm you’re in perimenopause, so doctors usually consider several factors, including age, symptoms like irregular menstrual cycles and hot flashes, and blood tests of your levels of thyroid hormones, FSH and estradiol (the primary type of estrogen produced by the ovaries). The FSH test isn’t a perfect test for perimenopause because levels of the hormone fluctuate greatly during perimenopause, and the test can reflect only the FSH levels at a particular moment in time.

Perimenopause and Fertility
Another common problem during perimenopause is pregnancy—or the lack of it. As more women are postponing marriage and pregnancy until their late 30s and 40s, perimenopause may interfere with some couples’ baby-making plans. On the other hand, says Dr. Teaff, women in their 40s have the second highest rate of unplanned pregnancies of any age group. Many women mistakenly believe that because they’re skipping periods, they’ve also stopped ovulating, she explains. “What they don’t realize is that, just because they produce a nonviable egg one month, it doesn’t mean they won’t produce a viable egg in their next cycle. Basically, they’re fluctuating between infertility and fertility,” Dr. Teaff notes. That’s why most doctors suggest that women continue using contraception throughout perimenopause and even for an entire year after the last menstrual cycle.

As for women trying to get pregnant later in life, that may be difficult during perimenopause. Ovulation may not occur every month, so there are fewer chances to become pregnant. Perimenopausal women also have fewer eggs, and their quality isn’t as good as that of eggs from younger women, says obstetrician/gynecologist Craig Winkel, MD, chair of obstetrics/gynecology at Georgetown University Medical School in Washington, DC. Older women may also have inadequate levels of progesterone, making it impossible for a fertilized egg to implant in the uterus.

Although infertility is defined as the inability to conceive after one year of unprotected sex, Dr. Teaff advises women over 35 not to wait a full year before seeking a doctor’s help.

Treatments
Low-Dose Birth Control Pills
“Since perimenopause isn’t a disease or illness, many women feel it’s something they just have to live through. But if you’re in your 40s and are having symptoms, there’s no need to suffer,” says Dr. Winkel. “Low-dose birth control pills are usually the treatment of choice for women who don’t smoke or have a history of breast cancer. They not only regulate your periods and provide contraception, they alleviate many perimenopausal symptoms such as hot flashes and mood swings.” (These low-dose pills contain 35 micrograms or less of estrogen.)

Dr. Goldstein tells his perimenopausal patients to think of low-dose birth control pills as “cycle regulators.” “The low-dose Pill works by turning off the ovaries’ natural estrogen production and replacing it with a measured amount of estrogen and progesterone all month long,” he explains. “Since fluctuating hormone levels cause most of the symptoms in perimenopause, the Pill eliminates them.”

ERT/HRT
Another option for treatment of perimenopausal symptoms is estrogen replacement therapy (ERT) or hormone replacement therapy (HRT), which is a combination of estrogen and a progesterone. (If you’ve had a hysterectomy, estrogen can be taken alone; if you still have a uterus, you’ll need to take progesterone along with estrogen to help protect against endometrial cancer.)

Although ERT and HRT are approved by the Food and Drug Administration for use after menopause (a full year without a period), many doctors will not wait until after menopause to treat a woman with severe perimenopausal symptoms, says Dr. Winkel.

Many women like estrogen skin patches or the new estrogen/progesterone skin patch because once put on, you forget about it until it’s time to change it—every three or four days or weekly, says Dr. Teaff. “The gradual absorption of the estrogen into the bloodstream helps quell symptoms, with few side effects,” she says. And, because the estrogen patch doesn’t elevate the level of triglycerides (fats that travel in the bloodstream with cholesterol) as some oral forms of estrogen do, it’s a better choice for women at risk for certain cardiovascular problems, she says. Some women, however, do not absorb enough estrogen through the patch to relieve perimenopausal symptoms.

Perimenopausal women can also use a prescription estrogen vaginal cream if vaginal dryness is a major complaint. These creams are inserted directly into the vagina. Estrogen creams can also be used as a supplement to the Pill or patch, according to Dr. Teaff. Another way to treat vaginal dryness is with a small, diaphragm-like estradiol ring called Estring®, which is placed near the cervix and delivers a steady dose of estrogen for three months at a time.

Women can also use non-prescription products to combat vaginal dryness. Vaginal moisturizers (Replens® is one) can be used several times a week. Vaginal lubricants (for example, K-Y® jelly, Silk-E®, and Astroglide®) can be used just before each intercourse. Use natural, pH-balanced products that have been designed specifically for vaginal use (don’t use petroleum jelly or baby oil, which can interfere with condom effectiveness and cause irritation).

Alternative Treatments
Some women prefer to treat their perimenopausal symptoms with nutritional remedies and non-pharmacologic methods. “Surprisingly, symptoms like depression, mood swings, and weight gain may have just as much to do with your diet as with perimenopause itself,” says Ann Louise Gittleman, who’s written a book about the topic based on her own experience (Before the Change, Taking Care of Your Perimenopause, 1998, HarperCollins).

Nutrition. “Avoiding low blood sugar is critical, because sugar is the body’s main fuel source. When blood sugar levels drop, the sugar cravings begin, as do mood swings and irritability,” Ann Louise says. To avoid plummeting blood sugar levels, eat a healthy combination of protein, slow-acting carbohydrates, and “quality” fats no later than one hour after waking up, and every three to four hours throughout the day. This means, for instance, natural peanut butter on whole grain bread, or natural yogurt with fresh blueberries and a tablespoon of flaxseed oil. Other foods with quality fats include walnuts and pumpkin seeds. Ann Louise also suggests limiting spicy foods, chocolate, caffeine, and alcohol, which may also trigger hot flashes.

Black cohosh. One of the most popular herbal remedies for perimenopausal symptoms is black cohosh. Clinically tested and widely used in Germany, black cohosh seems to reduce many symptoms, including hot flashes, insomnia, and depression, says Dr. Teaff. Because the long-term safety of black cohosh is unknown, it shouldn’t be used for longer than six months. And it shouldn’t be used at all if there’s any chance you might become pregnant, have a blood disorder, or are taking blood thinner medication, Dr. Goldstein warns.

Exercise. Perhaps the one tried-and-true natural perimenopause remedy that everyone agrees on is getting enough exercise. “Exercise, such as walking briskly for 30 minutes five or six days a week, will help you feel better, sleep better, keep your bones strong and healthy, as well as keep your weight under control,” says Deborah Haynes, MD, a family physician in Wichita, Kansas. What’s more, exercise alleviates hot flashes and stress, and reduces the risk of cancer, diabetes, and heart disease.

A Time to Take Stock
Indeed, perimenopause is a time to take stock of your overall health and well-being. “Women in their 40s need to start taking their health more seriously,” advises Dr. Haynes. “There are long-term health risks associated with aging and decreased estrogen production, so this is the time to begin thinking of preventive care if you haven’t already,” she says. That means having regular screenings for illnesses that can plague us as we age—such as osteoporosis, cardiovascular disease, breast cancer, colon cancer, and Alzheimer’s disease.

“Ask yourself, where do I want to be when I’m in my 60s or 70s,” says Dr. Teaff, “on a cruise ship or in a nursing home?” Perimenopause can serve as the wake-up call that impels us to make the changes we’ve been talking about for years. And while we may not be thrilled when the alarm goes off, we’re lucky to have a built-in hormonal impetus to get us moving.”

Barbara Tunick is a freelance writer living in Teaneck, NJ.

Originally published in The Female Patient -- November, 2000
© Copyright, 2000 Quadrant Publishing, All Rights Reserved. Reprints are not allowed without the expressed written consent of Quadrant Publishing.

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courtesy of OBGYN.net