What is this Roller Coaster called Perimenopause?
Ten years ago, “perimenopause” was not a word you heard much. Now it’s being talked about so much, it’s even got a nickname “peri” or even “perry." Well for some of us baby boomers and Gen Xers, it’s a phase of life that snuck up on us. No-one warned us it was coming. Personally, I just thought that having two pre-teen daughters was making me crazy!
One reason that we didn’t know what to expect is that we were raised by “the silent generation” (born 1928-1945). Many of our mothers didn’t talk much about female bodily functions; it just wasn’t proper. But now we know a lot and we talk (and write) a lot! Women of the next generation to hit perimenopause (the millennials) are going to be a lot more prepared.
Women often ask me:
Where is all this rage coming from?
What happened to my sleep?
Why doesn’t my brain work anymore?
My joints feel like I’m 80!
Why do I suddenly have belly fat?
I used to like sex, but what happened?
I must be broken!
What’s happening? The ovaries are winding down
We have been wisely designed to stop reproducing at a certain point. (Can you even imagine if there was no end in sight?) Gradually our egg supply dwindles and the ovaries slow and then stop production of hormones like estradiol (the main type of estrogen) and progesterone. Other types of estrogens (like estrone) continue to be made in small amounts by the adrenal glands and fat cells, and may continue to add some protection for our brain, our heart, and our bones, though it is a weaker estrogen than estradiol. There are theories about why our capacity to reproduce ends long before our life ends. Some menopause specialists argue that all animals living “in captivity” with better access to a food supply and antibiotics, in the case of humans and the animals we care for, tend to outlive their reproduction. But I still prefer the “grandmother hypothesis,” which proposes that animals that continue to live long after reproduction ceases (like humans and some kinds of whales) have a biological advantage where the grandmothers help to care for their children and grandchildren and community, increasing the chances of survival of the species. In any case, many of us enjoy the late menopause phase, with fewer responsibilities to others and more time to explore passions (old or new), and are grateful to have the option of activities outside of childbearing and childrearing.
How do I know what stage of perimenopause I’m in?
In perimenopause, progesterone starts to decrease, while estrogen may swing wildly before eventually decreasing as well. There are no tests that can definitively tell you that you are in “perimenopause,” but changes in periods can be the most obvious sign. An official definition of the stages of perimenopause was published in 2001 and revised in 2011 (STRAW: Stages of Reproductive Aging Workshop). As you can see from the chart, the menstrual cycle is the principal criteria for identifying what stage a woman is in. Of course, this gets confusing if she doesn’t have regular periods for other reasons (like if she is on hormonal contraception or has a history of PCOS, an endometrial ablation, chemotherapy, or a hysterectomy).
STRAW + 10: Stages of Reproductive Aging Workshop (2001, revised 2011)
What else you might notice
Even before the period starts to change, many women notice other symptoms. PMS may become a little more pronounced, moods may be a little more mercurial and sleep a little less reliable. Excess weight may accumulate in the upper abdomen and be harder to lose. These symptoms are caused by a decrease in progesterone and either a lower estrogen, or an elevated estrogen to progesterone ratio. While these shifts are normal during this transition, it doesn’t always FEEL normal.
You are NOT CRAZY, and there ARE strategies to help
Many patients have told me that at the age of 45, with symptoms severely impacting their quality of life, their medical provider told them that if their periods are still regular, it’s not perimenopause. OR they have done some labs like serum estradiol, progesterone, and follicle stimulating hormone (FSH), and have been pronounced “not in menopause.” OK, perhaps according to the STRAW criteria above, this is technically true (she might be in the “late reproductive stage”) but that doesn’t mean there are no strategies to help! First of all, you are not crazy and you aren’t imagining things. A little validation can be extremely soothing to your frazzled soul. It’s not surprising that this is a common time of life to be prescribed anti-depressants. But while these drugs have an important role for people who truly have depression, they may not be the most appropriate treatment for women whose mood changes are linked to perimenopausal hormone changes.
Strategies: the foundation
There are lots of strategies to help you through the perimenopausal transition. Of course, the foundational elements are the first place to start: good nutrition, consistent exercise, nourishing sleep, and stress management. There are dietary nutrients that are vital for both hormone synthesis and hormone metabolism, like magnesium, zinc, vitamins B, C, E, selenium, and omega 3 fatty acids. Adequate water and fiber are also critical for elimination of excess estrogen. And for women who need more help, supplements, herbs, or hormone therapy may be helpful, depending on the specific symptoms.
Strategies: hormone therapy
Hormone therapy can be a game-changer for women who are struggling in perimenopause. In recent decades, many medical providers have refused to prescribe hormones at all, or they require a woman to go a full year without a period (diagnostic of menopause) before starting hormone therapy. But these days, menopause experts know that this is not necessary. If progesterone is decreasing and the woman is symptomatic, adding progesterone may be just what she needs to help her sleep better and stabilize her mood. Early in perimenopause, she may not need estrogen, as her levels may still be high. Or a little estrogen may help create a buffer when the estrogen swings low. It can be helpful to start with one hormone (like progesterone if the main symptoms are sleep and mood) and wait for several weeks to see how you feel before considering adding another hormone. That way, whether you have tremendous benefit or unexpected side effects, you’ll know which hormone is affecting you.
Strategies: herbs & supplements
There are lots of options for support for common perimenopausal symptoms. Some of the supplements most often used include Vitex for irregular periods, anxiety, and PMS; soy isoflavones, Siberian rhubarb, and pycnogenol for hot flashes; adaptogens (like ashwaghanda, shatavari, and rhodiola) for stress and anxiety; passionflower, lemon balm, California poppy, magnesium glycinate, Relora, ashwagandha, and melatonin for sleep. Talk to someone knowledgeable about herbs and supplements to help you choose the right one(s) for your specific situation. In the next blog, I’m going to profile one plant (Vitex agnus-castus or Chasteberry) that is particularly helpful for the earliest perimenopausal symptoms such as PMS, mood changes, anxiety, sleep, breast tenderness, and hot flashes.
Want to talk more about your specific symptoms and possible strategies to feel your best during this transition?
About The Author: Heidi Biegel, MSN, CNM, MSCP
I’m a Certified Nurse-Midwife with a passion for supporting women through all of life’s major transitions — with a focus now on midlife, perimenopause & menopause. I blend down-to-earth women’s wisdom with evidence-based solutions to common concerns. I’m certified by the Menopause Society and trained in integrative and functional medicine so that I can offer a wide range of information, support, and guidance to women during this critical time in their lives.
Disclaimer: This blog post is for educational purposes only and is not intended as medical advice. Always seek professional medical care when you have questions relating to your specific health concerns.