Perimenopause

Definition

By Mayo Clinic staff

Perimenopause, also called the menopausal transition, is the interval in which a woman’s body makes a natural shift from more-or-less regular cycles of ovulation and menstruation toward permanent infertility, or menopause.

Women start perimenopause at different ages. In your 40s, or even as early as your 30s, your may start noticing the signs. Your periods may become irregular — longer, shorter, heavier or lighter, sometimes more and sometimes less than 28 days apart. You may also experience menopause-like symptoms, such as hot flashes, sleep problems and vaginal dryness. Treatments are available to help ease these symptoms.

Once you’ve gone through 12 consecutive months without a menstrual period, you’ve officially reached menopause, and the perimenopause period is over.

Symptoms

By Mayo Clinic staff

During the perimenopausal period some subtle — and some not-so-subtle — changes in your body may occur. Some things you might experience include:

  • Menstrual irregularity. As ovulation becomes more erratic, the intervals between periods may be longer or shorter, your flow may be scanty to profuse, and you may skip some periods. Early perimenopause is defined as a change in your menstrual cycle length of more than seven days. Late perimenopause is characterized by two or more missed periods and an interval of 60 days or more between periods.
  • Hot flashes and sleep problems. About 65 to 75 percent of women experience hot flashes, most commonly during late perimenopause. The intensity, duration and frequency vary. Sleep problems are often due to hot flashes or night sweats, but sometimes sleep becomes erratic even without them.
  • Mood changes. Some women experience mood swings, irritability or increased risk of depression during perimenopause, but the cause of these symptoms may be sleep disruption caused by hot flashes. Mood changes may also be caused by factors not related to the hormonal changes of perimenopause.
  • Vaginal and bladder problems. When estrogen levels diminish, your vaginal tissues may lose lubrication and elasticity, making intercourse painful. Low estrogen levels may also leave you more vulnerable to urinary or vaginal infections. Loss of tissue tone may contribute to urinary incontinence.
  • Decreasing fertility. As ovulation becomes irregular, your ability to conceive decreases. However, as long as you’re having periods, pregnancy remains a possibility. If you wish to avoid pregnancy, use birth control until you’ve had no periods for 12 months.
  • Changes in sexual function. During perimenopause, sexual arousal and desire may change. But for most women who had satisfactory sexual intimacy before menopause, this will continue through perimenopause and beyond.
  • Loss of bone. With declining estrogen levels, you start to lose bone more quickly than you replace it, increasing your risk of osteoporosis.
  • Changing cholesterol levels. Declining estrogen levels may lead to unfavorable changes in your blood cholesterol levels, including an increase in low-density lipoprotein (LDL) cholesterol — the “bad” cholesterol — which contributes to an increased risk of heart disease. At the same time, high-density lipoprotein (HDL) cholesterol — the “good” cholesterol — decreases in many women as they age, which also increases the risk of heart disease.

When to see a doctor
Some women seek medical attention for their perimenopausal symptoms. But others either tolerate the changes or simply don’t experience symptoms severe enough to warrant attention. Because subtle symptoms may come on gradually, you may not realize at first that they’re all connected to the same thing — fluctuating levels of estrogen and progesterone, another key female hormone.

If you do experience symptoms that interfere with your life or well-being, such as hot flashes, mood swings or changes in sexual function that concern you, see your doctor.

Causes

By Mayo Clinic staff

As you go through the menopausal transition, your body’s production of estrogen and progesterone fluctuates. These hormonal fluctuations are at the root of the changes your body goes through during perimenopause.

Risk factors

By Mayo Clinic staff

Menopause is a normal phase in a woman’s life. But in some women, it may occur earlier than in others. Although not always conclusive, some evidence suggests that certain factors may predispose you to entering perimenopause at an earlier age, including:

  • Smoking. The onset of menopause occurs one to two years earlier in women who smoke, compared with women who don’t smoke.
  • Family history. Women tend to experience menopause around the same age as their mothers and sisters, although the link between family history and age at menopause is still inconclusive.
  • Never having delivered a baby. Some studies show that never having had a baby may contribute to early menopause.
  • Childhood cancer treatment. Treatment for childhood cancer with chemotherapy or pelvic radiation therapy has been linked to early menopause.
  • Hysterectomy. A hysterectomy that removes your uterus, but not your ovaries, usually doesn’t cause menopause. Although you no longer have periods, your ovaries still produce estrogen. But such an operation may cause menopause to occur earlier than average.

Complications

By Mayo Clinic staff

Irregular periods are a hallmark of perimenopause. Most of the time, this is normal and nothing to be concerned about. However, see your doctor if:

  • Bleeding is extremely heavy — you’re changing tampons or pads every hour
  • Bleeding lasts longer than eight days
  • Bleeding occurs between periods
  • Periods regularly occur less than 21 days apart

Signs such as these may indicate the presence of an underlying gynecologic problem that requires diagnosis and treatment.

Preparing for your appointment

By Mayo Clinic staff

You’ll probably start by discussing your symptoms with your primary care provider. If you aren’t already seeing a gynecologist, your doctor may refer you to one.

What you can do
By monitoring your menstrual cycles and recording your signs and symptoms for several months, you’ll gain a better understanding of the changes occurring during perimenopause. You’ll also have valuable information to share with your doctor.

Appointments can be brief. To make the best use of the limited time, plan ahead and make lists of important information, including:

  • A journal of your menstrual cycles for the past few months, including first and last date of bleeding for each cycle, and whether the flow was light, moderate or heavy
  • Detailed descriptions of all your symptoms, including premenstrual symptoms
  • Names and dosages of all medications you take, including nonprescription drugs and supplements
  • Questions for your doctor, such as what treatment options are available

Questions your doctor may ask
To facilitate a discussion about your perimenopausal experience, your doctor may ask questions such as:

  • Do you continue to have menstrual periods? If so, what are they like?
  • What symptoms are you experiencing?
  • How long have you experienced these symptoms?
  • How much distress do your symptoms cause you?
  • What medications or vitamin supplements do you take?

Tests and diagnosis

By Mayo Clinic staff

Perimenopause is a process — a gradual transition. No one test or sign is enough to determine if you’ve entered perimenopause. Your doctor takes many things into consideration, including your age, menstrual history, and what symptoms or body changes you’re experiencing. Some doctors may order tests to check your hormone levels. But other than checking thyroid function, which can affect hormone levels, hormone testing is rarely necessary or useful to evaluate perimenopause.

Treatments and drugs

By Mayo Clinic staff

Possible therapies to treat perimenopausal symptoms include:

  • Oral contraceptives. These are often the most effective treatment to relieve perimenopausal symptoms — even if you don’t need them for birth control. Low-dose pills can regulate periods and reduce hot flashes and vaginal dryness.
  • Progestin therapy. If you have irregular periods, but you can’t — or choose not to — use oral contraceptives, cyclic progestin therapy may regulate your periods. Some women with heavy bleeding during perimenopause may find relief from a progestin-containing intrauterine device (IUD).
  • Endometrial ablation. Endometrial ablation may provide relief from the heavy bleeding some women experience during perimenopause. During the procedure, the lining of the uterus (endometrium) is destroyed using a laser, electrical energy or heat, which effectively reduces menstrual flow or ends menstruation. This procedure isn’t the right choice for everyone, so talk with your doctor about what is best for you.

Lifestyle and home remedies

By Mayo Clinic staff

Making healthy lifestyle choices may help ease some of the symptoms of perimenopause as well as promote good health as you age. These choices include:

  • Good nutrition. Because your risk of osteoporosis and heart disease increases at this time, a healthy diet is more important than ever. Adopt a low-fat, high-fiber diet that’s rich in fruits, vegetables and whole grains. Add calcium-rich foods or take a calcium supplement that also supplies vitamin D, which helps your body absorb calcium and helps protect against bone loss. Avoid alcohol and caffeine, which can trigger hot flashes.
  • Regular exercise. Regular physical activity helps prevent weight gain, improves your sleep, strengthens your bones and elevates your mood. Try to exercise for 30 minutes or more on most days of the week. Combining walking with strength training, for example, has been shown to help prevent bone loss and fractures in women who have gone through menopause.
  • Stress reduction. Practiced regularly, stress-reduction techniques, such as meditation or yoga, can promote relaxation and good health throughout your lifetime, but they may be particularly helpful during the menopausal transition.

Alternative medicine

By Mayo Clinic staff

In addition to conventional therapies, many women transitioning toward menopause want to know more about complementary and alternative approaches to treating their symptoms. Researchers are looking into these therapies, hoping to determine their safety and effectiveness, but evidence is still often lacking. Be sure to tell your doctor about any complementary or alternative therapy you are using or considering. Here are a few options that show some potential for treating menopausal symptoms while still being fairly safe:

  • Black cohosh. This herb extract is used to treat hot flashes and other menopausal symptoms. While various studies show that it does reduce menopause-related symptoms such as hot flashes, design flaws in these studies and variations in the product itself make it difficult to arrive at definite conclusions. Overall, black cohosh appears relatively safe, but avoid it if you have a liver disorder. If you’d like to try it, discuss it with your doctor first.
  • Phytoestrogens. These are plant-derived compounds that have estrogen-like properties. There are two main types of phytoestrogens — isoflavones and lignans. Isoflavone supplements are generally extracted from soy or red clover. They may be helpful for mild hot flashes and have a protective effect on your bone density. They may also help decrease blood pressure and low-density lipoprotein (LDL or “bad”) cholesterol. Lignans are derived mainly from flaxseed. Fewer studies support their use in treating menopausal symptoms, although they also may help improve cholesterol. Be careful using phyotestrogen supplements if you have an increased risk of a disease or condition that’s affected by hormones, such as uterine fibroids, endometriosis, or breast, uterine or ovarian cancer. Also, be cautious if you’re already taking a medication that increases your level of estrogen, such as birth control pills, hormone therapy or tamoxifen.
  • Dehydroepiandrosterone (DHEA). This is a natural steroid that’s produced by your adrenal gland. Some studies show that DHEA supplements help minimize menopausal symptoms such as hot flashes, vaginal atrophy, sexual dysfunction and bone loss. But other studies have found no such evidence, and several studies have reported harmful effects from high doses of DHEA, so more research is needed.

Although study results have been mixed, other complementary therapies with low-risk profiles such as acupuncture, yoga and paced breathing have shown some benefit in improving menopausal symptoms. These therapies may help reduce stress and improve psychological well-being, as well. Talk to your doctor about what complementary and alternative therapies may be helpful to you.

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Phytomedicine. 2003 May;10(4):348-57.

Chaste tree (Vitex agnus-castus)–pharmacology and clinical indications.

Source

Department of Clinical and Experimental Endocrinology, University of Göttingen, Germany. ufkendo@med.uni-goettingen.de

Abstract

Extracts of the fruits of chaste tree (Vitex agnus castus = AC) are widely used to treat premenstrual symptoms. Double-blind placebo-controlled studies indicate that one of the most common premenstrual symptoms, i.e. premenstrual mastodynia (mastalgia) is beneficially influenced by an AC extract. In addition, numerous less rigidly controlled studies indicate that AC extracts have also beneficial effects on other psychic and somatic symptoms of the PMS. Premenstrual mastodynia is most likely due to a latent hyperprolactinemia, i.e. patients release more than physiologic amounts of prolactin in response to stressful situations and during deep sleep phases which appear to stimulate the mammary gland. Premenstrually this unphysiological prolactin release is so high that the serum prolactin levels often approach heights which are misinterpreted as prolactinomas. Since AC extracts were shown to have beneficial effects on premenstrual mastodynia serum prolactin levels in such patients were also studied in one double-blind, placebo-controlled clinical study. Serum prolactin levels were indeed reduced in the patients treated with the extract. The search for the prolactin-suppressive principle(s) yielded a number of compounds with dopaminergic properties: they bound to recombinant DA2-receptor protein and suppressed prolactin release from cultivated lactotrophs as well as in animal experiments. The search for the chemical identity of the dopaminergic compounds resulted in isolation of a number of diterpenes of which some clerodadienols were most important for the prolactin-suppressive effects. They were almost identical in their prolactin-suppressive properties than dopamine itself. Hence, it is concluded that dopaminergic compounds present in Vitex agnus castus are clinically the important compounds which improve premenstrual mastodynia and possibly also other symptoms of the premenstrual syndrome.

  1. Hi I am 41 and started getting symptoms of racing heart, dizziness and anxiety last September. I was checked by a cardiologist and he put me on metoprolol as he thought I may have had SVT even though he couldn’t pick it up on any results. Also, as I had some shortness of breath so he sent me for a lung scan and a nodule (6cms) was found on my thyroid. My GP said my thyroid levels were fine at the time. I then saw a surgeon and had the left side of my thyroid removed in November. I felt ok for about 8 weeks and then had a very bad episode of the above symptoms and went to hospital but apart from my tsh level being 6.2 everything else was apparently fine. I saw an endocrinologist after this and he ended up putting me in hospital for 5 days as I had really bad anxiety and depression and some palpitations. This whole episode was during my period and for the next week after. The endocrinologist ran a lot of tests and even did a brain scan but apparently everything was fine and he diagnosed me with GAD. I was taken off metoprolol as well and prescribed a sleeping tablet and Ativan if I needed it. I didn’t take these meds as I really don’t think that anxiety is the cause but more like a symptom of what is going on. I felt fine last month but this month at the same time in my cycle I have started getting the anxiety and heart palpitations again. They aren’t as bad as in January though. I did have my final blood test to check that the other half of my thyroid had adjusted and it was down to 2.2 in mid March. I am also having unusual periods (a bit heavy but blood only comes out when I go to the toilet or use a tampon) and I had an ultrasound and I have a small fibroid and some cysts. My GP has said there is nothing wrong with me but I really am starting to wonder if I could be going through perimenopause or have some type of hormonal imbalance? I would really appreciate your advice on this. Thank you

    • It is possible that the hormone changes of the perimenopause are contributing to your symptoms. Confirmation can be obtained by checking your serum progesterone and oestrogen a week before your period. Progesterone is the first hormone to drop in peri menopause, causing mood swings, anxiety and depression. Declining oestrogen levels can cause palpitations and depression. Check your levels with the laboratory normals to see if they are low.

  2. Hi, I am a 44 year old woman who has been diagnosed with early menopause after quite a few years of issues with period pain etc. I also have an under active thyroid and take thyroxine and have this under control with regular check ups. For a year I was taking trisequin as my gyno recommended hrt due to my age and concern about osteoparosis told me this was the best cause of action- it made me feel 100 percent. I started having regular periods and no longer had hot flushes, didn’t feel exhausted or have fuzzy thinking episodes. At the beginning of this year my gyno recommended I change my hrt regime to having a mirena and using Premarin- as he told me this would lessen the chance of getting breast cancer. I feel worse than I ever have- I constantly have brain freeze- where I cannot recall words or people’s names, I have episodes of crashing fatigue, have mood swings and in general feel miserable and that isn’t even taking into account the fact that 5 months on I still am having spotting and unexpected episodes of bleeding. any advice would be greatly appreciated. I went yo my GP on Friday and he gave me a B12 injection and told me that I need to take Vitamin D tablets as my levels are extremely low. I have also been told that I have osteopenia.
    Thanks in advance,
    Debra

    • I think that your hormone balance may not be right. Perhaps a blood test to check your hormone levels would be a good idea, and maybe aske your GP to put you back on trisequens, as you felt so good on it.

      The above is not to be construed as giving medical advise, nor meant to be acted on, or against your own doctors advice. This is added for abvious legal reasons.

  3. Charleine O'Loughlin

    Hi, I am 45 years old and in late 2013 became ill and was found to be anaemic, and iron deficient, referred to gynae undertook hysteroscopy and had Mirena coil inserted, I think fibroids were found and also possible signs of endometriosis, enlarged uterus (10 weeks pregnant size) borderline for insertion of coil. This was performed early 2014, since then it has taken me quite a while to adapt to the coil, however I have and now feel fine, lost weight and healthy again, only issue is spotting 90% of the month, is there something I can do about this. Been to GP today and they have given me ponstan to take for a week, which I don’t think I will take. Would like to come and see you, but also interested in your comments. Thanks for your advice in advance.

  4. Charleine O'Loughlin

    Do you think there is any more that could be done for me and that the mirena was the best option in the first instance?

  5. Marian Chamberlain

    Hello, don’t know if you can help me as I live in Auckland New Zealand.
    If I lived a tad closer I would make a consultation appointment.
    Basically, I am 60, for 2 years I have been taking bio identical estrogen (troche) and oral progesterone for very disturbing “anxiety” like symptoms in my stomach area 24/7.
    This is in all probability hormone related. The dosage has been frequently changed and I am now taking max dosage (I understand) of estrogen and similar in progesterone. I need a second opinion and sadly bio identical treatment is not readily available in NZ. Do you have any suggestions?
    Regards Marian

  6. I have just come across this amazing blog! Thank you Dr Holloway for so generously sharing your expertise and wisdom with regards to hormonal health and wellbeing.

    For Marian (post above) looking for treatment in NZ, this link below might be helpful.

    How to find a cooperative doctor:
    http://www.custommedicine.com.au/health-articles/how-to-find-a-cooperative-doctor/

    I noticed several of the links provided include NZ integrative doctors.
    Hope that helps.

    Jo

  7. Thank you Jo for thinking of me. I will certainly be doing some research on the link you provided, much appreciated 🙂🙂Marian NZ

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