Learning August 16, 2019

Perimenopause.

One of the challenges in understanding menopause is that we don’t have great data. One of the most broad-based studies while good is from 1998. And when we accept the reality that every woman will experience menopause differently, it makes it even harder. So, when we talk about menopause, we have to accept that we speak in general terms.

In this piece, we laid out the phases of menopause. To reiterate menopause is both a point in time (technically once a woman has gone 12 months without a period) and a multi-year transition. For menopause as a multi-year transition, we can break them down into distinct phases: perimenopause, early-post menopause and later-post menopause.

Let’s talk perimenopause.

In colloquial terms perimenopause things start to go haywire - estrogen levels rise but are unpredictable and volatile and progesterone production wanes throwing everything off balance, which can cause symptoms. Symptoms can be further exacerbated not only because individual levels are important but the ratio of estrogen to progesterone is also an important factor to hormonal balance.

It is imperative to highlight that in perimenopause estrogen levels are on average higher than during the reproductive years. Yes, higher. Common understanding is that menopause (and all its variations) equates to diminishing and/or very low estrogen. That is the case for early post- and later-post menopause. But not with perimenopause. And it’s worth repeating. In perimenopause, estrogen levels are high - not low. So we have to keep this in mind when assessing symptoms.

Perimenopause is often identified once symptoms arise. The most easily identified one are changes to the menstrual cycle. Commonly, the cycle will get heavier because estrogen (specifically estradiol) levels are increasing (and fluctuating) and cycles will get shorter because progesterone levels are falling. Remembering that estrogen triggers the building of the endometrium during the first half of the cycle, more estrogen means more building of the endometrium which means heavier flow. Progesterone is produced during the second half of the cycle and helps regulate the cycle. Waning progesterone shortens the cycle.

Other common physical symptoms are hot flashes and vaginal changes. For hot flashes, currently, all we know is that estrogen is involved in triggering hot flashes (though no one knows exactly how or why yet). In some research, 35-50% of women experience hot flashes during perimenopause. Estrogen is also essential to vaginal tissues and changes (i.e., fluctuations) can cause changes in the tissues of the vaginal walls. For some women, the changes cause a bit of discomfort (itching or dryness) and for some it can cause really painful intercourse.

From the emotional side, estrogen influences feelings of anxiety. And, research studies that looked at anxiety and estrogen levels (and estrogen treatment) are conflicting and point to quite a complex relationship between estrogen and anxiety because some mechanisms (i.e., certain receptors) increase anxiety and some decrease anxiety. Sometimes high-levels of estrogen helped, sometimes low levels help. It’s pretty safe to say, it is the fluctuation of estrogen that causes problems. In perimenopause, estrogen levels are volatile so pay attention to increasing levels of anxiety.

And in terms of timing, changes to a woman’s reproductive status (i.e., hormonal profile) generally start to change in her 40s with perimenopause symptoms commonly starting in her mid-40s. And while research and surveys differ, they point to a range of 2-5 years of transition and symptoms.

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