Answering your questions about perimenopause

Separate the myths from the facts about the transitional period from menstruation to menopause. ANNA WAS IN HER 30s when she felt her first hot flash. She’d been thinking a lot about menopause since her recent hysterectomy, which had left her ovaries intact. So when the hot flashes started, she thought they were simply a product of her worrying; she dismissed them as “all in her head.” They lasted for 4 years. Finally, she’d had enough. She visited her gynecologist and told him about the hot flashes. He drew a follicle-stimulating hormone (FSH) level, which is a good indicator of whether a woman is menopausal. As estrogen production from the ovaries decreases, the pituitary gland releases additional FSH to compensate. This stimulates a recruited follicle to grow and produce estrogen. A woman is considered menopausal when her FSH reaches 40. Anna’s level had shot beyond that to 135. Anna’s gynecologist explained that the hot flashes she’d had over the past 4 years were symptoms of perimenopause—the transitional period from normal ovulatory cycles to menopause. As they discussed other symptoms, Anna realized that her uncharacteristic outbursts of anger and rage followed by deep sadness were hormonally related and not signs of clinical depression. At the time, though, Anna had thought she was having a breakdown because she felt far too young for “the change of life.” Anna isn’t alone: Few women know what perimenopause is or that it encompasses many of the changes they experience at midlife. In this article, we’ll separate the myths about perimenopause from the facts and tell you what you need to know. Q: What is perimenopause? A: As mentioned above, perimenopause is a time of transition in a woman’s menstrual cycle. “Literally, perimenopause means around menopause,” says Melinda Dunham Noonan, RN, MS, a visionary leader with more than 20 years of experience in women’s health. Now president of the Chicago-based consulting company M.D. Noonan, Inc., she is the president of the National Association for Women’s Health. The North American Menopause Society defines perimenopause as the entire menopausal transition plus 1 year after the final menstrual period. During perimenopause, changes associated with upcoming menopause are experienced. Perimenopause usually begins in a woman’s mid-to late 40s; the average age at menopause is 51. In general, perimenopause lasts about 4 years, but this varies from as little as 2 years to as long as 10 years (maybe even longer). Such factors as how old your mother was when she entered perimenopause, whether you smoke now or you used to smoke, whether you were ever pregnant, and whether you used birth-control pills play a role in the duration of perimenopause. (Smoking usually means an earlier beginning to perimenopause; pregnancy and the Pill may delay onset.) According to Noonan, most women don’t know when they’re perimenopausal. “They might be having some hot flashes or sleep disturbances,” she says. “If they go to a health care provider with these symptoms—and if that person is listening—an FSH level might be run,” she says. Q: What are the symptoms of perimenopause? A: Perimenopause is associated with erratic fluctuations in reproductive hormone levels. This frequently leads to irregular menstrual cycles, vasomotor symptoms (hot flashes often followed by chills), changes in mood or cognition, and sexual dysfunction. Twenty percent of women are asymptomatic, according to Noonan. Twenty percent have extreme symptoms. And everyone else falls in between. Also, heavier women tend to have less symptomology because estrogen is stored in adipose tissue. “I don’t think there is a way to predict who’s going to fall where,” she says. “Studies on patterning hot flashes and other symptoms showed no strong correlations to one’s family history.” Noonan elaborates on some of the common symptoms: Sleep disturbances. Sleeping may be difficult due to vasomotor changes (too hot, too cold) at night. “You may not fully awaken, but you’re having hot flashes during the night and not getting that good, deep-REM sleep,” Noonan says. Hot flashes and night sweats interrupt sleep patterns and can even cause insomnia. Additionally, any type of chronic pain during restless sleep—arthritis, back pain, fibromyalgia—will further fragment your rest. Psychological and cognitive changes. Sometimes seen in perimenopause are mind-and mood-related symptoms such as depression, mood changes, poor concentration, and impaired memory. These changes are often the result of fluctuations in reproductive hormones. Psychosocial considerations such as having teenage children, illness, aging parents, divorce or widowhood, career change, or retirement may also trigger mood and cognitive changes. One of the biggest myths in perimenopause, Noonan says, is that you’re going crazy. “Everyone has an Aunt So-and-So who ended up in a mental hospital,” she says. “But depression increases in incidence in both men and women as they reach midlife. That’s coincidental, and it’s not necessarily caused by perimenopause.” Menstrual flow. Menstrual irregularity, often the first sign of perimenopause, is caused by erratic ovarian hormone secretion and decreased frequency of ovulation. Changes in menstrual cycle length and flow and worsening premenstrual syndrome may occur. In early perimenopause, periods are usually more frequent and getting shorter. Flow may increase, and premenstrual spotting may occur. Later, missed periods or longer cycles are common. Most irregular bleeding during perimenopause is normal; however, it can also be caused by underlying abnormalities and diseases, such as endometrial hyperplasia or cancer, cervical cancer, or uterine myomas or polyps. These conditions must be ruled out when there’s significant change in menstrual bleeding. Genitourinary symptoms. Estrogen levels decline as perimenopause progresses, causing many women to experience sexual difficulties such as decreased libido, reduced vaginal lubrication, painful intercourse, and vulvovaginal itching and irritation. Because estrogen receptors in the urethra, bladder, and pelvic floor aren’t being stimulated during perimenopause, urinary tract infections and incontinence may occur. Cells change and lubrication decreases in the urethral membrane and vaginal mucosa when estrogen levels plummet; that’s when susceptibility to vaginal and urinary tract infections increases. Skin changes. Skin changes associated with estrogen deprivation lead to decreased skin elasticity and blood supply. Age spots, itching, and wrinkles may occur. Estrogen loss also adds to sagging skin. Other symptoms. In the gut, food is processed more slowly, causing gas, bloating, and constipation. You may also experience palpitations and menstrual migraines, resulting from declining estrogen levels. Dental problems may also occur as estrogen levels fall and your mouth’s epithelium undergoes atrophy, resulting in decreased saliva and sensation, a bad taste in your mouth, and increased cavities and tooth loss. Perimenopause also leads to dry eyes and nasal passages. Q: How is perimenopause diagnosed? A: Medical history and physical examination are necessary, but many health care providers also order blood tests to measure FSH and estradiol levels. FSH levels are generally higher in perimenopausal women. Because estrogen decline causes most symptoms in both perimenopause and menopause, an estradiol test may shed some light on a woman’s symptoms. During perimenopause, levels of FSH and estradiol can vacillate unpredictably, so these measurements aren’t considered conclusive. Noonan says, “You can’t titrate your estrogen level, and since it varies among individuals, we don’t know what a normal level is. We do know, however, that if your FSH is over 40, you’re already postmenopausal. The only practical way to regulate estrogen levels is by symptomology—how you’re feeling.” Q: How is perimenopause managed? A: Treatment should first include a one-on-one discussion with your health care provider, Noonan says. Get recommendations for pharmacologic and nonpharmacologic options that take into account your personal and family history and your goals for treatment. In a consensus statement on perimenopausal treatment, the North American Menopause Society recommends a management approach that focuses on optimizing your health. This includes a comprehensive screening for physical and psychological problems and lifestyle counseling to reduce the increasing risk of chronic diseases such as loss of bone mass, adverse lipid profiles, osteoporosis, atherosclerotic heart disease, hypertension, diabetes, and hypothyroidism—all more prevalent during perimenopause. The use of hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) is controversial. Recent study results are on the fence as to whether women should or shouldn’t start it. Research has demonstrated a slightly increased risk of breast cancer associated with taking estrogen. Women who recently started ERT have also been shown to be at increased risk for heart disease and stroke. After they’ve been on ERT for several years, the risk of heart disease decreases but the risk of stroke remains. The decision to start ERT or HRT, however, must be carefully weighed against your history and risk factors. Estrogen taken as ERT can cause tenderness and pain in the breasts; however, the amount of estrogen is much lower than the estrogen contained in birthcontrol pills. An estrogen/progesterone combination (HRT) may be prescribed if you haven’t had a hysterectomy. Testosterone may be added if you’re having libido problems or if you’re taking higher and higher dosages of estrogen but not getting relief. Finding the right combination could take time, Noonan says. “There are many different ways of taking estrogen and many mixtures. You have to find the ones that work for you.” For women who don’t want to take hormones or who can’t take them because of personal or family history, there are alternative remedies such as phytoestrogens and herbal medications. Phytoestrogens, compounds similar to estradiol, are found in yams, flax seeds, sesame seeds, tofu, and other soy products. Studies show that phytoestrogens, ingested over a lifetime, lower your risk of cardiovascular disease, breast and uterine cancer, menopausal symptoms, and bone loss. Other herbal remedies some women take to relieve perimenopause symptoms include black cohosh, dong quai, evening primrose oil, valerian, chasteberry, ginseng, and St. John’s wort. You shouldn’t use these products on a long-term basis, however, because no conclusive evidence exists that they reduce the risk of osteoporosis or cardiovascular disease when compared with HRT. Other alternative treatments some women use include nutrition, exercise, relaxation techniques, homeopathic remedies, acupuncture, mind awareness, and support groups. Q: When a woman first suspects she may be near menopause, what should she do? A: Noonan recommends that you keep a diary of your feelings to find a pattern to your symptoms. “Take that information to your health care provider,” she says, “and together decide whether to have an FSH level drawn. Then discuss the FSH level at which he or she is willing to prescribe treatment.” Also, keep in mind that hypothyroidism and tuberculosis (TB) have symptoms similar to those of perimenopause. Noonan recommends that you get a TB skin test and have your thyroid hormone levels checked if you’re just starting to have menopausal symptoms. Q: Any concluding thoughts? A: “Perimenopause has its challenges, but your body eventually accommodates to it,” Noonan says. “The event should be a call for action to take care of yourself, and there is so much you can do to increase the quality of your life. “PMZ is what Margaret Mead called postmenopausal zest. Women beyond menopause have an increase in energy and excitement about life because it’s their time. Their families are raised, and it’s time to take care of themselves. “Some women find this the most freeing, most exciting time of life. It’s not the end of life. It’s the beginning.”