Perimenopause is like puberty in reverse; easy for some and difficult for others. But why the difference? A reproductive endocrinologist explains.
While menopause gets all the fanfare, it's the time before it known as perimenopause that prompts the most questions to obstetrician gynecologists. Yet, still, it's a less familiar term, says John F. Randolph, M.D., a reproductive endocrinologist with the University of Michigan Health Von Voigtlander Women's Hospital, who has had a career-long research interest in ovarian aging and infertility.
"There was a time when whenever I went out with my wife, I would get cornered by her friends who had questions about their perimenopause symptoms," he said.
Below, Randolph explains some of the main things you should know about this period in your life.
1. Perimenopause is different from menopause
"It's a little bit of a tricky concept," Randolph said. That's because menopause refers to a single episode in a woman's life, her "last" period. Menopause is confirmed when a woman has gone one full year without having a period. The day after that one-year mark, she's now postmenopausal yet people refer to it as menopause. About 6,000 United States women reach menopause each day. Typically, this occurs around age 52 but the age range runs 40–60, with many who experience it earlier or later.
Although perimenopause is defined as the time before "the change," its starting point isn't so definitive.
"It's a nebulous concept and you enter into it gradually and come out of it gradually. So, there is no easy, identifying place of how or when it starts," he said.
Perimenopause is a result of a woman's aging ovaries, specifically when the coordinated patterns of the hormones estrogen and progesterone begin to vary, throwing the delicate system out of balance.
Perimenopause can start when a woman is in her 30s or 40s, but the 40s are more common. It typically lasts 6–10 years.
"What's hard for people to wrap their heads around is that the experience really varies dramatically," Randolph said. And that's why his wife's friends had so many questions.
2. You may expect symptoms during perimenopause
Some women have no symptoms, Randolph said, while others notice them in hindsight rather than in real time. And for others they can be so severe that a doctor's visit is in order. Randolph said to watch for the following:
Irregular menstrual cycle. It may be longer or shorter than you typically have. Bleeding may be lighter or heavier. You might skip periods or the time between them is farther apart. It's all courtesy of the fluctuating hormones.
Hot flashes. Sometimes they're true to their name and, other times, they last several minutes or longer. It's the brain at work responding to the decreased estrogen and trying to dissipate heat, Randolph says. When the body is too hot, the brain summons sweat, a trick to cool you down.
Night sweats. These are hot flashes that occur during sleep and disturb you from getting good rest. Night sweats are associated with irritability, most likely from fatigue due to lack of sleep.
Insomnia. Women wake up after night sweats and can't return to blissful sleep.
Vaginal issues. A low sex drive due to vaginal dryness and pain during sex are common symptoms.
Bathroom breaks. An urgent need to urinate may arise. So can urinary tract infections. They often increase because the urethra becomes dry and irritated. Urinary incontinence may develop as well, and bowel movements may change too.
Emotional issues. The irritability, depression and mood swings that often accompany premenstrual syndrome, or PMS, may appear during perimenopause.
Weight gain. Women tend to gain weight, often around the waist, during perimenopause.
Faltering focus and forgetfulness. "The good news is that we've documented that it happens," Randolph said. "We've also documented that it gets better. So, for women who are experiencing this during perimenopause, it's going to go back to normal."
Appearance changes. Hair loss or thinning hair is frequent, as is hair growth in unexpected places like the neck and chin. Acne, dry skin, dry eyes and a dry mouth have also been reported.
Decreased fertility. Pregnancy is still a possibility, but it is decreasingly likely once perimenopause begins.
3. There are treatments to help perimenopause
Not every woman needs to be treated, but if perimenopause symptoms are bothering you excessively, visit your OB-GYN, Randolph says. Your physician may recommend:
Oral contraceptives: Heavy or irregular periods and hot flashes may benefit from this medicine that evens out hormonal fluctuations.
Menopausal hormonal therapy: Like oral contraceptives, this is a low dose of hormones to supplement estrogen levels. It helps with hot flashes, night sweats, insomnia, emotional issues and vaginal dryness. Randolph says controversy has surrounded hormonal therapy for decades, so he urges women to research its pros and cons.
Low-dose antidepressants: Selective serotonin reuptake inhibitors (SSRIs) like Prozac may relieve hot flashes, mood swings and irritability by modifying the brain signals. "These work well for women who've had breast cancer or other health issues that preclude them from taking estrogen," Randolph said.
Clotting medicine: If heavy bleeding keeps you homebound, tranexamic acid may reduce bleeding. "The brain is trying to keep the ovaries going as long as possible," said Randolph. As a result, the ovaries are making more estrogen, which causes a thicker lining in the uterus, so there is more blood. "That's a really common reason for a woman to need to see her gynecologist at that time because of the heavy bleeding."
Lifestyle changes: A healthy diet, exercise, meditation, yoga, and a consistent sleep schedule may relieve some of the symptoms, including weight gain, irritability and insomnia. For vaginal irritations, use water-based vaginal lubricants.
Some describe perimenopause like being a teen in puberty when you feel out of sorts and have difficulty pinpointing what is irritating you about the changes you're experiencing.John F. Randolph, M.D.
4. There isn't a way to postpone or put off perimenopause
"It seems to be programmed, probably from before birth," Randolph said. "We can accelerate it. There are things you can do to knock out eggs, but nobody's figured out a way to try to slow down perimenopause."
5. Acupuncture could help perimenopause, or it could not?
"A lot of adjunctive medical options, like acupuncture, work for some people," Randolph said. "When women have severe vasomotor symptoms—that's the official term for hot flashes—the holistic or behavioral kinds of treatments frequently aren't enough to make much of a difference," he said.
6. You may grow hair in new places on your body during perimenopause
Blame the hormones again. Peach fuzz, technically the vellus hair, has always been there but it becomes thicker and more abundant during perimenopause. It favors the face, chest, back and abdomen.
7. During perimenopause you may not feel like yourself, and that's normal
"Yes," Randolph said. "What you feel is normal and the process is normal. Some describe perimenopause like being a teen in puberty when you feel out of sorts and have difficulty pinpointing what is irritating you about the changes you're experiencing. And all these symptoms may last for years."
But remember that is exactly what is supposed to happen, said Randolph. And soon the reward will reveal itself: no more periods for good.
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