What Is Perimenopause

Menopause does not happen all at once—it is a transition, and for most women, there is an early stage, called perimenopause, or menopausal transition, which starts before the actual onset of menopause. Perimenopause—peri, Greek for “around” or “near,” + menopause—usually starts between ages 40 and 55, but it can start much earlier. Perimenopause begins with the onset of irregular menstruation and lasts until 1 year after your last period.

During perimenopause, your ovaries slowly stop releasing eggs and producing hormones such as estrogen and progesterone.

This causes the signs and symptoms that people associate with menopause, such as irregular menses, hot flashes and mood swings.

Your periods may be irregular for a while—possibly for years—before menopause. But you can still get pregnant, so you should continue using contraception during this time if you want to avoid an unplanned pregnancy.

During perimenopause, you can have symptoms like menopause, such as hot flashes and mood changes. Your period may go away and come back at unpredictable intervals. Since intermittent ovulation can occur, you can still get pregnant in perimenopause.

For most women, perimenopause lasts two to eight years. You can’t say for sure that menopause has begun until a year has passed since your last period.

In perimenopause and shortly after menopause starts, you may have other changes, such as hot flashes, trouble sleeping, mood swings, and changes to your body, such as vaginal dryness. You may have changes in your sex drive and you may find it hard to focus on what you’re doing or find the right word.

After perimenopause is menopause. Technically, menopause is the specific moment when your periods stop, right after your last period. But of course without the passage of time there is no way for you to know definitively which is your final period. Menopause is confirmed when you have not had a period for a full year.

While these changes are normal and natural, you may feel a bit uncomfortable at times—please seek medical treatment if  symptoms persist and become problematic for you.


What Causes Perimenopause

During perimenopause, your body is preparing for menopause and your estrogen levels may go up and down. All women experience menopause at some point in their lives, typically between the ages of 45 and 55. Occasionally, women can experience premature menopause (onset before age 40). Menopause is a natural stage of the female body brought on by the ovaries’ decreased production of estrogen and progesterone. As estrogen and progesterone levels decrease, the woman no longer ovulates (her ovaries stop making and releasing eggs) and menstruation ceases.

Diagnosing Perimenopause

Perimenopause is often self-diagnosed as it’s a natural occurrence of the female body—women who are approaching the menopausal age are expecting the change to occur and are generally familiar with the symptoms.

Gynecologists or general practitioners can also help to determine whether your symptoms are a result of menopause or another condition. Factors he or she may take into account include:

  • Age. Perimenopause typically begins in your mid-forties, and the median age of menopause is 51.
  • Change in monthly periods.  Changes in menstrual flow and period frequency can be a sign of perimenopause or other conditions. A span of 12 or more months since your last period is typically an indicator of menopause.
  • Symptoms. Symptoms such as hot flashes, vaginal dryness, night sweats, mood swings, and memory lapses can be signs of menopause. Other symptoms, such as fever and abdominal cramping, could point at another cause (i.e. such as an infection)
  • FSH (follicle-stimulating hormone) test. An FSH test is a test that determines if you are nearing menopause based on the level of follicle-stimulating hormone in the blood. This test is not effective if you are taking the birth control pill, which can cause changes in blood FSH levels. Since menopause symptoms are relatively standard and recognizable, FSH tests are not typically administered unless a doctor suspects your symptoms could possibly be caused by another condition and is attempting to definitely identify menopause as the cause.


Symptoms of Perimenopause

Some women may experience only a few symptoms of perimenopause while others experience many. Symptoms of perimenopause are similar to those of menopause, and may include:

  • Night Sweats and Hot Flashes (Vasomotor Symptoms).  For those lucky enough not to know what it is, a hot flash is a feeling of warmth that spreads across your body. Approximately 75% of women experience hot flashes and night sweats at some point during perimenopause.Of the approximately 40 % of women in their forties who experience hot flashes, 80 % will no longer have them at five years. Hot flashes typically last between 30 seconds and five minutes. According to the American College of Obstetricians and Gynecologists (ACOG), about two-thirds of North American postmenopausal women experience hot flashes, and an estimated 10-20% of those women experience severe hot flashes. Night sweats (drenching sweats) might accompany the hot flashes, which can lead to disrupted sleep.
  • Irregular Vaginal Bleeding. Some women experience minimal abnormal bleeding while in perimenopause while others have excessive abnormal bleeding. Menstruation may occur more frequently or get farther apart, and such irregularities can occur for years before menstruation stops entirely. Because irregular vaginal bleeding can be a sign of many of conditions, it is essential to visit your doctor to confirm that the cause is menopause.
  • Vaginal Changes. As the estrogen levels in the body fall, the tissues lining the vagina become thinner and dryer. This can cause itching, irritation, and pain during sexual intercourse, which can begin in perimenopause.
  • Psychological Symptoms.  During perimenopause, many women find themselves experiencing memory problems, irritability, and rapid changes in mood. To be considered a sign of menopause, psychological symptoms must be in combination with other menopausal symptoms, as stress and other factors can cause almost identical symptoms.
  • Other Physical Changes.  The distribution of fat may change with menopause, which can cause weight gain. The texture of your skin may change, leading to wrinkles or adult acne. Given that your body is continuing to produce small levels of the male hormone testosterone, some women experience hair growth on the chin, chest or upper lip.

Certain symptoms bother women to differing degrees.  One of the main complaints for women in transition is hot flashes—a sudden, temporary sensation of heat experienced by some women during menopause.

The usual treatment for hot flashes and menopause symptoms is hormone replacement therapy, or HRT, though they can also be treated without hormones, using a type of antidepressant known as selective serotonin reuptake inhibitors(SSRIs), such as low-dose paroxetine, or Brisdelle.

Lifestyle changes may also help alleviate hot flashes, depending on your symptoms.

If you suffer from vaginal dryness, you can use a lubricant or moistener, and if symptoms persist, speak with your doctor about a topical estrogen cream.

Some women seek out alternative treatments to manage symptoms.  The most commonly used alternative over-the-counter treatments are red clover, black cohosh, and soy supplements. Most controlled studies with these supplements do not demonstrate consistent improvement.

You can also manage these symptoms with lifestyle changes. Exercise and healthy eating make a big difference.

For instance, eating whole grains, fresh produce, and healthy fats can cut your risk of hot flashes by one-fifth.

Too much sugar and saturated fats can increase your risk by almost a quarter.

Other things you can do for yourself include dressing in layers that you can take off if you have a hot flash, decreasing stress, and making sure you get enough sleep.


Living With Perimenopause

Though perimenopause symptoms may be disruptive and last several years, there are lifestyle changes you can make that add immeasurably to your quality of life during your transition:

  • Exercise regularly. Aim for 20 to 30 minutes 5 days a week, and vary the routines – walking, swimming, etc., so you don’t get bored. Exercise can help regulate moods, rebuild lost muscle and bone tissue, strengthen the muscles responsible for urinary incontinence, and prevent weight gain. Researchers at Pennsylvania State University found that menopausal women who exercise may experience fewer hot flashes in the 24 hours following physical activity.
  • Don’t smoke. Smoking has been found to cause early onset menopause symptoms as well as increase the severity of symptoms. A recent study has found that a genetic variant found mainly in white women places smokers at an even higher risk of early onset menopause – as early as nine years in the heaviest of smokers.
  • Maintain a Healthy Weight. A study done at Kaiser Permanente and published in Menopause found that losing just 10 pounds helped relieve menopausal symptoms, in particular hot flashes.
  • Consider the Advantages: You no longer have to deal with your periods and you don’t have to worry about an unplanned pregnancy. However, be sure to continue using contraception until at least 12 months have passed without a period and always have a new partner use a condom in order to protect you from STDs, including HIV/AIDS.
  • Consider hormone replacement therapy or alternative treatments.


Complementary and Alternative Treatment

There are ways to treat the symptoms of perimenopause without hormone replacement therapy, though these alternative treatments are not FDA approved, and research is not always clear on effectiveness. Some of these treatments include:

Herbal Medicines. Research has shown that several herbal medicines may be useful in treating many perimenopausal and menopausal symptoms.  Before taking natural or herbal products, discuss with your doctor, who will be able to notify you of any health risks and potential interactions with medications. Because natural products can have side effects and can interact with other botanicals or supplements or with medications, research in this area is addressing safety as well as efficacy. Some findings from this research are highlighted below.

  • Black cohosh (Actaea racemosa, Cimicifuga racemosa). This herb is one of the best-studied traditional herbs for relief of perimenopuase and menopause symtoms. It seems to work by supporting and maintaining hormone levels, and for many women lessens the severity of hot flashes.
  • Dong quai (Angelica sinensis) can help maintain the natural balance of female hormones and does not have estrogenic activity. It is well known in China and the West and one of the most common herbs used to treat bothersome perimenopause and menopause symptoms. However, Dong quai should not be taken if a woman is experiencing heavy bleeding.
  • Ginseng (Panax ginseng or Panax quinquefolius). The 2005 NIH panel concluded that ginseng may help with some perimenopausal and menopausal symptoms, such as mood symptoms and sleep disturbances, and with one’s overall sense of well-being. However, ginseng has not been found helpful for hot flashes.
  • Kava (Piper methysticum). According to the 2005 NIH panel, kava has been found to decrease anxiety, thought there is no evidence that kava decreases hot flashes. If one has any liver disease, please beware that the U.S. Food and Drug Administration (FDA) has issued a warning to patients and providers about kava because of its potential to damage the liver.
  • Whole Soy foods. The scientific literature includes mixed results on soy extracts for hot flashes—it is the isoflavones in soy foods that are thought to help balance hormone levels, and have some effect on estrogen levels. Some studies find benefits, but others do not.  Eating natural foods for whole soy beans is seen as more healthy than taking supplements—some foods that fit this description include: tofu, tempeh, soy milk, and edamame among other. Although information on adverse effects is limited, soy extracts appear to be generally safe when taken for short periods of time.
  • Evening primrose oil or black currant oil. The essential fatty acids in these oils can help with moderate symptoms of perimenopause and menopause.

Dietary supplements. Certain dietary supplements can help to restore deficiencies that may occur as a result of decreased estrogen and progesterone production. These include:

  • DHEA. DHEA is a naturally occurring substance that is changed in the body to the hormones estrogen and testosterone. DHEA is manufactured and sold as a dietary supplement. A few small studies have suggested that DHEA might possibly have some benefit for hot flashes and decreased sexual arousal, although small randomized controlled trials have shown no benefit. Because levels of natural DHEA in the body decline with age, some people believe that taking a DHEA supplement can help treat or prevent conditions related to aging; however, there is no scientific evidence to support this notion.
  • Calcium. Calcium helps protect against osteoporosis and bone loss. Women 51 and older need 1,200 mg of calcium per day. Calcium can be found in milk, fortified cereals and soy milks, dairy products, green leafy vegetables, and tofu—and a calcium supplement may help you keep your levels where they need to be if you are not getting sufficient calcium from your diet.
  • Vitamin D. Vitamin D helps your body absorb calcium, so it is just as important as calcium when it comes to bone health. Sunlight is the best source of vitamin D. While it protects you from harmful rays that can cause skin cancer, sunblock can also block out the rays needed for vitamin D production. Only a couple of minutes of exposed sun exposure are needed to absorb the right amount of sunlight for normal vitamin D levels. Make sure that for time longer than that you protect yourself with sunblock. Vitamin D can also be found in food (fortified milks, cheese, tuna) and can be taken in pill form.
  • Vitamin E. A daily dose of 400 IU of natural vitamin E—derived from natural ingredients–(can help alleviate symptoms of hot flashes in some perimenopausal and menopausal women

Bioidentical Hormone Replacement Therapy. Bioidentical hormone replacement therapy,” or BHRT, is a marketing term that is not recognized by the FDA. It is a term used to describe medications that are prepared in specialized pharmacies. BHRT may contain any variation of hormones including estrone, estradiol, estriol, progesterone, and testosterone. Compounded bioidentical hormones are often marketed as natural and safe alternatives to conventional hormone therapy prescription medications. However, compounded formulas are often inconsistent and can vary depending on the batch or the pharmacist. While FDA-approved hormone preparations have been tested for efficacy, purity, safety, and potency, there is a lack of scientific evidence surrounding BHRT and the safety and efficacy of these compounds. As a result, compounded bioidentical hormones are not approved by the FDA. For additional information, see the FDA publication Bio-Identicals: Sorting Myths from Facts.

Acupuncture. Studies have shown that acupuncture, which aims to restore the bodily flow of energy through the insertion of needles into acupuncture points around the body, can help to reduce the severity of hot flashes and night sweats.


Questions For A Doctor

As you go through perimenopause, you may want to talk to your health care provider about what is going on. Here are some questions that might be good for you ask:

  • Should I have an examination to rule out other causes for my symptoms?
  • What can I expect as I go through menopause?
  •  Where can I get more information about menopause?
  • What is my risk of developing diseases related to the loss of estrogen such as heart disease, osteoporosis, and hypertension? What can I do to decrease my risk?
  • Can you explain the potential benefits and risks of hormone therapy?


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