Symptoms and Signs that You May Be Going through Perimenopause
We’ve heard of menopause, but perimenopause? What is that? For that matter, what exactly is menopause?
Menopause can be marked by a specific day in time, but perimenopause is not a once in a lifetime event. Instead, it is a process that occurs over the course of several years, typically during our 40s. If asked about menopause on the street, most people would likely say, “oh that’s when you have all of those hot flashes and your periods stop.” Yes, that’s partly true, but…
The menopausal experience is a continuum. Perimenopause (“peri” = around, so “around” menopause) is the time of our lives, leading up to the last period, and for a year thereafter. Menopause has occurred once we have been without a period for a full year, regardless of how regular or irregular our periods were before that. During the years following menopause, and for the rest of our lives, we are considered to be postmenopausal.
What is happening during this time? What does it all mean? It’s largely about our ovaries. Throughout the continuum of peri/menopause, our ovaries are gradually reducing the amount of estrogen they are producing. Let’s travel back in time a bit to our Biology 101 classes…for it is worthwhile understanding the basic physiology of this process.
Basic Biology
Hormones are like messengers, carrying information from one part of the body to another. There is a complex interaction of hormones along what is called the hypothalamic-pituitary-ovarian axis, which regulates the processes of reproduction. Having a basic understanding of these processes can enhance our understanding of what is happening during the perimenopausal, menopausal and postmenopausal time periods.
Hypothalamus
The hypothalamus (a small gland in the brain, located near the brain stem) makes several hormones, one of which is gonadotropin releasing hormone (GnRH). At the beginning of the menstrual cycle (defined as the first day of a period) GnRH carries a message from the hypothalamus to the pituitary gland (another small gland in the brain, which is situated just below the hypothalamus). This message tells the pituitary gland to stimulate the release of other hormones. Two pituitary hormones, follicle stimulating hormone (FSH) and lutenizing hormone (LH) carry messages from the pituitary gland to the ovaries, as part of the female reproductive hormonal cycle.
Follicle Stimulating Hormone
Follicle stimulating hormone carries one message to the ovaries – to stimulate the development of an egg follicle in the ovary. Lutenizing hormone carries another message to the ovaries – to release an egg from the ovary, also called ovulation. This hormonal process leading up to ovulation occurs over an average of 14 days (a shorter period of time for those with a shorter menstrual cycle, a longer period of time for others with a longer menstrual cycle). FSH and LH also stimulate the release of a number of hormones from the ovary, one of which, estradiol, is a form of estrogen. Inhibin is another reproductive hormone produced in the ovary and released due to the influence of FSH and LH.
Ovulation
Ovulation occurs during the mid-cycle phase of menstruation. During ovulation, an egg is released from the ovaries and is available for fertilization. Once one egg (rarely two or more) is released, there is no need to release another egg, as we as humans most typically have only one baby at a time. To prevent the release of another egg, high levels of estrogen and inhibin, as well as increasing levels of progesterone being made by the ovarian follicle, send messages back to the hypothalamus and pituitary. These messages signal the hypothalamus and pituitary gland to reduce the production of GnRH, LH and FSH, so as to stop stimulation of the ovaries and prevent the release of another egg. If after several days pregnancy does not occur, the levels of estrogen, inhibin and progesterone fall. New messages are sent back to the hypothalamus to increase the production of gonadotropin releasing hormone, from which point the cycle repeats itself.
Repeating Cycle
The cycle repeats itself until one of two things happens. Either a pregnancy occurs (if the available egg is fertilized by sperm) or perimenopause begins. Perimenopause may begin seven to ten years before menopause happens. During that time, the ovaries are making less and less estrogen. That hormonal messaging system that relied on a certain pattern of estrogen production from the ovaries? The messaging system which may have worked like clockwork before? It becomes glitchy. The hormonal messages may or may not be sent, such that sometimes ovulation happens, and sometimes it doesn’t.
Menstrual Changes
A menstrual period occurs only if ovulation has happened and the egg released during that cycle was not fertilized. If ovulation does not occur, a period will not follow. One of the hallmark signs of perimenopause is a change in menstrual cycles. Periods that previously came every 28 days or so may start a few days earlier (surprise!) or a few days later. For most women in perimenopause, menstrual cycles will get shorter, so periods come earlier and more frequently. Periods might be lighter than usual, though most commonly they become heavier as menopause nears.
In our 40’s, changes in menstrual cycle length or even skipped periods are common and most likely the result of perimenopausal hormonal changes. Irregular bleeding could however, be a symptom of other conditions. Pregnancy, infection, and benign growths or masses such as fibroids, polyps or simple ovarian cysts can cause irregular bleeding. Irregular bleeding can also be a symptom of serious medical conditions such as ovarian, uterine or cervical cancers. Irregular bleeding is most concerning when it happens between periods and when it happens after sex. It is also potentially dangerous if it is so heavy or painful that it causes fatigue, missed work or an inability to tend to personal and professional responsibilities. These types of bleeding warrant evaluation by a health care provider.
While peri/menopause is primarily considered a reproductive life event – the end of our ability to reproduce in the usual fashion – there is so much more happening. Estrogen’s effects reach far and wide, not only to our reproductive organs and reproductive experiences. Perimenopausal changes can also affect, among others things, how we regulate body temperature, the elasticity of our skin and ups and downs in mood. How well we think, how well we sleep and our interest in and enjoyment of sex can also be influenced by hormonal changes happening during perimenopause.
Is It Hot in Here or Is It Just Me?
Temperature regulation, like reproduction, is, in part, governed by the hypothalamus. The cause of vasomotor symptoms (experiences like hot flashes, hot flushes and night sweats) is not entirely understood. However, it stands to reason that reproductive hormonal changes affecting the functioning of the hypothalamus will consequently influence other functions of the hypothalamus, like temperature regulation.
Most of us are surprised to start having hot flashes, hot flushes and/or night sweats even years before our periods stop (and surprised when they continue long past menopause itself). When a hot flash or hot flush starts, there is an initial increase in body temperature. Like when exercising or being in a warm environment, the body’s temperature will then increase.
- A rise in body temperature will increase blood flow to skin so that heat will dissipate.
- During a hot flash, our faces and chests become flushed due to this increased blood flow, we feel hot, and we sweat.
- Our heart rates increase.
- Then, just as suddenly as it started, it stops, and we may even feel chilly.
Some of us experience hot flashes, some of us don’t. For some of us, hot flashes may be severe and happen several times a day. For others of us, they may be mild and happen once or twice a week.
Am I Mad or Am I Menopausal? Perimenopausal That Is…
The unpredictability of hot flashes rivals the emotional lability that many of us experience during perimenopause. Remember the hormonal roller coaster ride of adolescence? The ups and downs of mood, the irritability? Perimenopause, with its fluctuating hormones, can be like the adolescence of middle age, only this time around we are more experienced and have easier access to reliable information and resources.
Is It Estrogen or Is It Everything Else?
Perimenopause usually coincides with a dynamic period in a woman’s life, entirely unrelated to hormonal changes. It is a time that many women are concurrently raising young children or coping with the trials of adolescent children. It is not uncommon also to be supporting aging parents, financially and otherwise. In our 40s and 50s we are typically at the peak earning potential of our careers. Yet, there is financial strain from multiple financial obligations and responsibilities, such as paying for college for our kids as we try to save enough to be comfortable during retirement. Even though we may want it all, we may not necessarily have chosen to have it this way – all at once.
These stressors can cause both psychological and physical symptoms that overlap with some of the symptoms of perimenopause. High levels of stress can cause menstrual irregularities and headaches. Stress can cause some people to experience problems falling asleep. We rest in bed having difficulty quieting the chatter in our heads – the chatter about how to prioritize the obligations of children, parents, partners and work. Some of us awaken during the night, only to be kept awake by those same internal conversations. Poor sleep hygiene affects cognitive function, making concentration difficult Not getting enough sleep will adversely affect memory problems, attention span and reaction time.
I Don’t Feel Sexy When I’m Sleep Deprived
Changes in our thoughts and feelings towards sex may change during perimenopause. The estrogen in our bodies helps keep blood flowing to the genitals, which helps the vagina stay lubricated and the tissue of the vagina and vulva maintain its elasticity. Perimenopause, a lower estrogen state, can cause vaginal dryness, vulvar irritation and soreness that may limit our enjoyment of sex. On one hand, maintaining an active sex life can prevent these physical changes from happening. On the other hand, if stress or circumstances are getting in the way of sex, it can be challenging to maintain an active sex life.
Pears to Apples
An overall, gradual weight gain is a normal part of aging – one we can’t blame on hormones. But the change in fat distribution? That is due to menopause. Women typically carry most of their fat tissue in their hips, bottom and thighs. This has often been referred to as having a “pear” shaped body. A pear-shaped body is associated with better overall health than an “apple” shaped body, which is more common in men, who more typically carry most of their weight in their stomachs. The changes of perimenopause redistribute this weight, and distribute most weight gain, from the hips, bottom and thighs to the stomach.
Hormones and Hair (and Skin)
Hair and skin changes may happen compliments of the hormonal changes during perimenopause.
Anyone who has been pregnant knows that hormones can affect hair growth. Remember the thick, luxurious hair that grew during pregnancy? The hair that then fell out in small clumps in the shower in the weeks and even months postpartum? Hormones. When rouge hairs suddenly appear on your chin, seemingly out of nowhere, or the hair on the top of your head starts thinning? Hormones. Again.
Estrogen has an important role in the maintenance of healthy and younger looking skin. As estrogen level fall, skin may become dryer, less taut, more wrinkly and heal more slowly.
Making a Diagnosis
Research is underway using hormonal testing to approximate when perimenopause and menopause will happen. For now, there is no predicting when perimenopause will start or how long it will last. Perimenopause is more of an assumption based on age, menstrual cycle changes and other symptoms.
During perimenopause there are very real changes that are happening in our bodies as indicators of approaching menopause. The perimenopausal experience will be different for each of us. Some of us with have no symptoms at all, until one day, periods will stop, never to be seen again. Others will experience hot flashes several times a day that will continue even after menopause. Some women will have less and less desire for sexual activity, whereas other women, having more privacy because children have grown up and are no longer in the house, experience a resurgence in sexual desire and activity.
The signs and symptoms of perimenopause are not specific to perimenopause. Some of the same symptoms may be related to thyroid dysfunction, diabetes or other medical conditions. Any symptom that is disruptive to personal, family or professional life, or negatively impacts relationships, needs evaluation by a health care provider. Even if it is determined that the symptoms are attributable to perimenopause, there are ways to attenuate the symptoms so as to improve quality of life.
Yet, it is not all doom and gloom. We have a lot to look forward to. Most of us will live over one-third of our lives as postmenopausal women. In many respects, we have choices as to how we will live during those years. Right now, our bodies are saying, “look, pay attention, there are changes ahead.”
I encourage every woman to approach perimenopause as a time not only of physical change, but also as a time of potential life transformation. Consider this a good time to pause and think carefully about what you want those years to look like. What are your values? Are you living your values? Are you living your most authentic life? What do you want your quality of life to be and how can you optimize your ability to maintain that? Consider this an opportunity to make the most of the rest of your life.
