What is perimenopause?
Perimenopause is defined as the 10 years leading up to your final menstrual period. It usually begins in your early forties but can start sooner or later. You might have few or no symptoms at the beginning, but as perimenopause progresses you may notice changes to your menstrual cycle and periods. You may get your period more often or less often. Your periods may become heavier or lighter. Sometimes you might skip a period completely. All of this is normal, and worth discussing with your healthcare provider.
You can still become pregnant during perimenopause, so if you are using contraception, you should continue to use it during this time.
How and why does perimenopause begin?
Perimenopause begins due to natural changes in hormone levels, particularly estrogen and progesterone. During peak reproductive years, estrogen levels rise and fall in consistent ways, which results in regular ovulation and menstrual periods. During perimenopause, your ovaries begin to make less estrogen, which changes the levels of progesterone, a second hormone produced by the ovaries. Fluctuating levels of these two hormones during perimenopause leads to changes in the menstrual cycle and other symptoms.
How do I know I have entered perimenopause? What changes might I notice?
- Changes to your menstrual cycle: This is usually one of the first signs of perimenopause. Your periods may get shorter, lighter, and less frequent. While irregularity is common during perimenopause, if your periods become heavier or last longer, you should discuss this with your healthcare provider.
- Hot flashes and/or night sweats: Hot flashes or night sweats can happen anytime during perimenopause, even while your period is still regular. However, they usually happen more often in late perimenopause. Hot flashes typically last six months to two years, but in some cases, they can last longer, and for a small proportion of women, they may never go away completely.
- Sleep disruption/insomnia/fatigue/brain fog: Sleep disruptions are often caused by hot flashes or night sweats. These disruptions can result in fatigue and brain fog and forgetfulness.
- Mood swings/anxiety/depression: Up to 40 percent of women will experience anxiety and depression during perimenopause. Changes in estrogen and progesterone influence serotonin — the brain chemical that promotes happiness. When these hormone levels drop, serotonin levels also fall. This contributes to mood swings, anxiety, and depression.
- Weight gain: While you may be eating and exercising the same amount, weight gain can still occur during perimenopause and after. This is normal, and some studies have demonstrated that, in leaner women, moderate weight gain can be protective for long-term health. Weight gain becomes problematic when it is concentrated around the mid-section. This is because it can increase risk factors for diabetes, cardiovascular disease, and hypertension.
- Vaginal/sexual/urinary changes: Because of hormone shifts during perimenopause, you may experience a decreased sex drive and vaginal dryness. Changes in hormonal levels can also cause structures around the pelvis to weaken. This can cause sudden or frequent urges to urinate.
It is important to remember that some of these changes can be interconnected — for example, night sweats can disrupt sleep, and sleep disruptions can contribute to weight gain.
When should I talk with my healthcare provider?
It is important to let your healthcare provider know when you are concerned about physical changes, especially if any are affecting your quality of life. Your healthcare provider may want to rule out other health concerns before suggesting treatment options.
I have been hearing a lot about perimenopause hormone testing, should I consider getting my hormone levels checked?
Hormone testing is typically expensive and inaccurate. Inconsistencies result due to hormone levels changing throughout the menstrual cycle. In some cases, your provider may want to test for other causes of symptoms that can mimic perimenopause, such as thyroid disease.
I am perimenopausal, but I still want to have children. Is that possible?
Yes, while ovulation is inconsistent, it is still possible to get pregnant during perimenopause. However, the odds of getting pregnant naturally are lower. Here is what you need to know:
- Perimenopausal pregnancies are associated with a higher risk of complications including pregnancy loss, preeclampsia, congenital abnormalities, and maternal health problems. The risk is even higher if you have a health condition such as diabetes.
- Reproductive technologies like IVF can increase pregnancy odds during perimenopause, and provide genetic testing for congenital abnormalities.
If you are concerned about perimenopause but also want to grow your family, schedule a pre-conception visit with your clinician.
How do I know when perimenopause is over, and menopause begins?
51 is the average age when menopause begins, but it is different for everyone. You will know you have reached menopause when you have gone 12 consecutive months without a menstrual period.
If you have any type of vaginal bleeding during or after menopause, contact your clinician to rule out more serious health Issues.
Are there long-term health concerns related to menopause?
Yes. The most common long-term health concerns are:
- Coronary heart disease/stroke: Estrogen helps keep blood vessels flexible to accommodate blood flow. Once estrogen diminishes, arteries can narrow. Rising blood pressure can also thicken artery walls.
- Bone loss/osteoporosis: Without the right amounts of hormones, nutrients and exercise your bones can weaken and become prone to breakage.
How can I reduce long-term health concerns related to menopause?
Maintaining a balanced diet is a critical step in the years leading up to and throughout menopause. This will help reduce the risk of cardiovascular disease. Focus on eating a diet packed with fruits, vegetables, and calcium, low in red meat and sugar, and exercising for 150 minutes each week.
Weight-bearing exercises like weightlifting, and body weight exercises including yoga can help prevent osteoporosis. These exercises force your bones to work against gravity, helping them to get stronger.
Also, it is important not to smoke. Smoking has been linked to an increased risk of bone fractures and osteoporosis.
Estrogen therapies can help protect against bone loss early in menopause, preventing osteoporosis. However, it is unclear if estrogen therapies offer cardioprotective benefits.
What Menopause Hormone Therapy (MHT) or non-hormonal treatment options are there?
Here are some options to help start the conversation with your healthcare provider:
- Systemic Estrogen Therapy: This is considered the most effective treatment option for easing hot flashes and night sweats. It can come in the following formats: pill, skin patch, ring, gel, cream, or spray.
- Low-dose Vaginal Products: This approach is specifically used to treat vaginal dryness, discomfort with intercourse, and some urinary symptoms. Minimal amounts of estrogen are administered directly to the vagina using a tablet, ring, or cream.
There are risks associated with using hormone therapy such as heart disease, stroke, blood clots, and breast cancer. These risks depend on the type of hormone therapy, the dose, how long the medication is taken, and your individual health risks.
Estrogen therapy or antidepressants (non-hormonal) are the first line of treatment for symptoms related to perimenopause and menopause. However, not everyone can take hormone therapies, due to other health concerns. There are alternative options:
- Antidepressants: Antidepressants (SSRIs and SNRIs) may reduce menopausal hot flashes and mood disorders.
- Veozah: This is a vasomotor medication and is used to reduce hot flashes and night sweats.
- Gabapentin: While this medication is typically used to treat seizures, it has also been shown to help reduce hot flashes.
I am going to have a procedure that will cause medically induced menopause (such as a hysterectomy or chemotherapy). Is induced menopause experienced differently?
Yes. Medically induced menopause begins more rapidly, but with the same symptoms. In fact, the sudden onset of symptoms can make this type of menopause feel overwhelming. MHT (Menopause Hormone Therapies) can ease symptoms related to this rapid shift.
I am in my mid to late 30’s, and I have already reached menopause. What specific information do I need?
If you think you have reached menopause, talk to your healthcare provider. Premature menopause can increase risks for health problems later in life, such as osteoporosis and heart disease. Your healthcare provider can help you evaluate the need for MHT (Menopause Hormone Therapies).