There is a lot of confusion both among women and their health care practitioners regarding perimenopause. Literally, perimenopause is “around menopause”; menopause being defined as the spontaneous, permanent ending of menstruation, literally one day, typically the day that is one year after the last menstrual period, usually around age 50, but can be anywhere between age 40-60. Clinically then, perimenopausal symptoms can be described as any symptom that happens around a woman’s last menstrual period. Unfortunately, menopause is not like a light switch, where one moment you are pre-menopausal and the next you are post-menopausal. It is in fact quite the opposite: erratic hormone production fluctuates from day to day and month to month causing changeable and varied symptoms.
Several studies have documented that symptoms may begin up to 17 years before cessation of menses and may last for several years after. As such, if the average age of menopause is 50, some women may start to experience these symptoms as early as 33. Many factors may impact this transition, from genetics, to thyroid function to lifestyle habits and some women enter into menopause through surgery or medication and, for the latter population of women, the symptoms may be more severe and dramatic.
There are estrogen receptors throughout a woman’s body which helps to explain the varied symptoms a woman may have as estrogen levels start to decline as evidenced by this graphic:
Since hormone fluctuations can start in the 30’s for many women and others may experience unintended pregnancy in their 40’s, special consideration should be given to issues related to fertility. Some women may have difficulty achieving or maintaining pregnancy in the absence of these symptoms at any age, but age-related hormonal changes are a common cause. As such, contraception and/or fertility-preserving strategies should be a part of every woman’s assessment and plan during the perimenopausal transition. Regardless of the cause, be it endometriosis, irregular menses or hormonal issues, acupuncture and select supplements and herbs may be helpful in improving fertility outcomes, either when used alone or in combination with conventional reproductive medicine.
When a woman suspects she is having perimenopausal-related symptoms, it is an excellent time to have a complete medical examination by a qualified health professional. The diagnosis of perimenopause can usually be made by reviewing a woman’s medical and menstrual history in addition to her specific set of symptoms and treatment recommendations can be made accordingly. Unfortunately for most women, hormone tests are usually not helpful in giving definitive information as to whether symptoms are related to perimenopause because levels change throughout the menstrual cycle. A single hormone level can be misleading since production does not fall at a steady rate, but varies greatly and therefore cannot predict or confirm menopause. Furthermore, normal hormone levels in the presence of hormone-related symptoms does not eliminate the likelihood that the women is perimenopausal. Some testing may be helpful with complaints of sexual dysfunction, fertility problems or when periods stop at an early age and some lab tests can identify other causes of symptoms that mimic or worsen the symptoms of perimenopause, such as thyroid disease or vitamin deficiencies, and diseases that can increase during perimenopause, such as cardiovascular disease and diabetes. Treatments should never be prescribed to “treat” hormone levels, but solely to alleviate symptoms and therefore hormone levels are unnecessary to determine or adjust dosing.
There are several treatment options available to women and there is no “one-size-fits-all” plan that will take care of all of the symptoms that may be associated with hormonal fluctuations. It is also important to remember that not all women will require treatment; perimenopause is not a disease and as such therapies should be directed at controlling symptoms. Therapies with less associated risk, like diet and lifestyle, should be tried first. There are several studies confirming the positive impact of diet, exercise, acupuncture, stress management and lifestyle changes for women with mild perimenopausal symptoms and should be first-line therapy. Vitamin and herbal supplements may be helpful in some women, but research is mixed and appropriate dosing and use of high-quality products is necessary to know if these may be effective. Finally, there are non-hormonal prescription medications that may do double-duty in decreasing perimenopausal symptoms while treating other conditions, such as depression and anxiety. The goal should be to help patient’s manage menopausal symptoms without needing a grocery bag full of medications or supplements by utilizing targeted therapies that are supported by research.
If hormones are being considered, a thorough assessment of a woman’s potential benefits vs. risks should be conducted. While risks are possible with any use of hormones, symptoms can negatively impact a woman’s day-to-day quality of life, affecting relationships with family and friends and performance at work and the degree to which this happens may outweigh these potential risks. Medical organizations devoted to the care of women agree that there is no question that hormone therapy has an important role in managing symptoms for many healthy women during the transition. There are several benefits to using hormones including decreasing the typical symptoms such as hot flashes, night sweats, insomnia, mood issues, “brain fog”, urinary symptoms, vaginal dryness and painful intercourse, preventing bone fractures later in life and lowering the risk of heart disease & diabetes if hormones are started early. However, despite some claims, there is no such thing as “risk-free” hormone treatment for menopause when used systemically to achieve these benefits. The potential risks include stroke, blood clots, and uterine and breast cancer. What we’ve learned so far about the benefits and risks comes from large groups of women, but each woman is unique. New studies are frequently published, so this topic is constantly in flux.
The question is whether it is the right choice for you. These decisions are nuanced and only after you and your doctor have a thorough discussion about your individual risks, benefits, and preferences can you make a decision that’s right for you.
The North American Menopause Society is an excellent resource for high quality information: http://www.menopause.org/for-women.