I want to talk here about perimenopause and menopause, which are distinct developmental phases that people who menstruate eventually experience. The knowledge I am going to share should be information we are taught, and we are not. It should be information our family doctors have, and sometimes they do not. Knowledge of our own bodies should be a birthright, but it is not.

With that acknowledged, allow me to clarify some terminology. Menopause is the phase of life when the menstrual cycle has stopped. It begins one year after the last menstrual cycle. It is common to say postmenopause- adding the ‘post’ is redundant, but the term is in common usage. The average age of menopause in Canada is 51.

Perimenopause, in contrast, refers to the years before menopause (and not after) when changes begin to occur. Perimenopause can begin as young as 35 and end as late as 59. It occurs while there is still a menstrual cycle. Frequently it begins when menstrual cycles are still regular. The symptoms of perimenopause are known and should be readily identified as being caused by hormonal changes. The diagnosis, however, is frequently missed.

Common symptoms are worsening PMS, new or worsening migraines, night sweats, sleep trouble, decreased sex drive, anxiety, depression, fatigue, increased aches and pains, brain fog, heart palpitations and breast tenderness or lumpiness. These symptoms can happen even while menstrual cycles are completely regular.

Later on, menstrual cycle changes show up. Just about any changes can occur: irregularity, missed periods, shorter time between periods, and heavy blood flow.

Heavy blood flow deserves some extra attention. You can consider you period heavy if you soak more than 16 pads or tampons, or you have to plan your activities around when you are bleeding. This situation can often be treated with naturopathic or medical interventions without having to resort to ablation or hysterectomy. With such heavy bleeding happening, it is important to have your red blood cell and iron levels monitored so that you can supplement with iron if required.

What is happening in this phase is that more egg cells are stimulated with each cycle, raising estrogen levels in an erratic pattern. At the same time, progesterone levels gradually decline. This means that the proportions of estrogen and progesterone are different relative to earlier reproductive years. Ovulations continue to occur until menopause. One average, the latest that pregnancy can take place without assisted reproduction is ten years before menopause.

The biology of perimenopause has been criminally under-studied. Therefore misinformation is widespread. The common understanding of the causes of perimenopausal symptoms is that estrogen levels are low. This is not accurate. In fact, estrogen levels in perimenopause are as high as or higher than women aged 20-35.

Estrogen levels eventually drop, very shortly before the last menstrual period.

Perimenopause is a natural and expected change, but the symptoms can be alleviated. To do this, I begin with a thorough assessment of my patient’s overall health and health history. Blood work can detect contributing factors such as Vitamin D deficiency. Herbs, supplements and lifestyle changes can help people feel better. Sometimes it is appropriate to supplement with hormones.

For some people, the idea of the end of their fertile years approaching is upsetting. Additionally, these changes often coincide with difficult life events: burnout at work, taking care of both children and elderly parents, and marriage difficulties. It is important to talk about perimenopausal changes in the context of each individual’s life.

I hope and expect that over time, knowledge of perimenopause and effective treatments for the symptoms it can cause we be more widespread.

Dr. Andrea Hilborn, ND is a naturopathic doctor in Kingston, Ontario

References

Symptoms

Inayat K, Danish N, Hassan L. Symptoms Of Menopause In Peri And Postmenopausal Women And Their Attitude Towards Them. J Ayub Med Coll Abbottabad. 2017 Jul-Sep;29(3):477-480. PMID: 29076687.

This stuff has not been studied adequately

Allshouse A, Pavlovic J, Santoro N. Menstrual Cycle Hormone Changes Associated with Reproductive Aging and How They May Relate to Symptoms. Obstet Gynecol Clin North Am. 2018;45(4):613-628. doi:10.1016/j.ogc.2018.07.004

Estradiol levels are increased in perimenopause, until the latest stages

Prior JC. Ovarian aging and the perimenopausal transition: the paradox of endogenous ovarian hyperstimulation. Endocrine. 2005 Apr;26(3):297-300. doi: 10.1385/ENDO:26:3:297. PMID: 16034185.

Harsh V, Meltzer-Brody S, Rubinow DR, Schmidt PJ. Reproductive aging, sex steroids, and mood disorders. Harv Rev Psychiatry. 2009;17(2):87-102. doi: 10.1080/10673220902891877. PMID: 19373618; PMCID: PMC2861986.

Burger H, Woods NF, Dennerstein L, Alexander JL, Kotz K, Richardson G. Nomenclature and endocrinology of menopause and perimenopause. Expert Rev Neurother. 2007 Nov;7(11 Suppl):S35-43. doi: 10.1586/14737175.7.11s.S35. PMID: 18039067.

Progesterone levels are decreased in perimenopause  

Prior JC. Ovarian aging and the perimenopausal transition: the paradox of endogenous ovarian hyperstimulation. Endocrine. 2005 Apr;26(3):297-300. doi: 10.1385/ENDO:26:3:297. PMID: 16034185.

Greater risk of depression

Gordon JL, Girdler SS. Hormone replacement therapy in the treatment of perimenopausal depression. Curr Psychiatry Rep. 2014 Dec;16(12):517. doi: 10.1007/s11920-014-0517-1. PMID: 25308388.

Allshouse A, Pavlovic J, Santoro N. Menstrual Cycle Hormone Changes Associated with Reproductive Aging and How They May Relate to Symptoms. Obstet Gynecol Clin North Am. 2018;45(4):613-628. doi:10.1016/j.ogc.2018.07.004

Migraines are related to the rate of decline of estrogen, not the absolute quantity

Pavlović JM, Allshouse AA, Santoro NF, Crawford SL, Thurston RC, Neal-Perry GS, Lipton RB, Derby CA. Sex hormones in women with and without migraine: Evidence of migraine-specific hormone profiles. Neurology. 2016 Jul 5;87(1):49-56. doi: 10.1212/WNL.0000000000002798. Epub 2016 Jun 1. PMID: 27251885; PMCID: PMC4932235.

The prevailing hypothesis is that fluctuations of estrogen are associated with symptoms

Allshouse A, Pavlovic J, Santoro N. Menstrual Cycle Hormone Changes Associated with Reproductive Aging and How They May Relate to Symptoms. Obstet Gynecol Clin North Am. 2018;45(4):613-628. doi:10.1016/j.ogc.2018.07.004