Before we take a deep dive to understand the biology and symptoms to be aware of, I think it’s helpful to consider some definitions. Menopause is defined as the point at which a woman has not had a period for 12 consecutive months. This is ultimately a singular point in time and often something we only recognise when looking back.
Any time after this is referred to as menopause or post-menopause. Perimenopause is the often ill-defined, debilitating, frustrating and unpredictable phase that leads up to the point of menopause. It can be insidious in onset: creeping up without a big fanfare and without realising we can be putting up with feeling pretty awful. It does not need to be this way!
On average, perimenopause lasts approximately 4-8 years, but it can start up to 10 or even 15 years in advance of menopause. “Average” age of menopause is around 48-52, so symptoms of perimenopause can start in our 30s or 40s. Premature Ovarian Insufficiency (POI) is a specific menopausal syndrome causes by early “failure” of the ovaries and this can happen at any age.
There is no such thing as “too young”.
Back to the beginning
To understand what happens during perimenopause it can help to rewind a little. During our reproductive years our menstrual cycles are governed by a carefully orchestrated symphony of hormonal signals between the brain and the ovaries. The first day of our “period” marks the onset of menstruation. At this point, the body sets about maturing a gang of ovarian follicles in preparation for ovulation. This triggers the cumulative rise in oestrogen we normally see during the follicular phase (first half) of the cycle.
This oestrogen causes the lining of the womb (endometrium) to thicken ready for a fertilised egg to implant. Oestrogen levels peaks mid-cycle and the dominant follicle releases its egg from the ovary at ovulation. Oestrogen subsequently declines. Increasing levels of progesterone act to maintain the endometrium for successful implantation and pregnancy. If this does not happen, progesterone levels also start to fall. In the absence of progesterone, the womb lining is shed again, and the entire process repeats.
During perimenopausal menstrual cycles as our finite ovarian reserve is drained, the amount of oestrogen produced as the follicles mature becomes less predictable. Levels may be low in some cycles, normal or raised in others precipitating the often profound and chaotic variability in symptoms. Throughout the perimenopause transition levels progressively diminish to reach the persistently low levels we see at menopause and beyond.
We have oestrogen receptors in most cells of the body as this magnificent hormone is not only crucial for reproduction but has a key role in heart, brain, gut, bladder and immune function and well as maintenance of normal bone, muscle, joint, skin and hair health. As such these oscillations provoke a diverse range of symptoms. There are 34 “officially defined” symptoms but many more are emerging as the conversation expands and we gather more information from women and their experiences.
Symptoms can include:
Symptoms can include: menstrual changes (lighter, heavier, shorter, more painful); temperature regulation symptoms (hot flushes, night sweats, cold shivers); sleep disturbances (difficult getting to sleep and maintaining sleep); mood changes; anxiety; tension or worry; panic attacks; fear of familiar things (like driving or socialising); brain fog; memory problems; loss of clarity of thought and executive function (decision making and forward planning); loss of confidence, self-esteem and imposter syndrome; dizziness, vertigo, tinnitus, tingling sensations; dry eyes; burning mouth; gum disease; bad breath; new onset allergies (hayfever) or food intolerances (gluten, wheat, dairy and wine!); palpitations, chest tightness, difficulty breathing; body odour; skin irritation, itching (like insects beneath the skin), skin dryness and laxity; scalp hair loss and facial hair gain!; joint aches and pains, prolonged recovery from sport or injury; weight gain or difficulty maintaining weight; bloating and constipation; bladder overactivity, peeing frequently, urgently and at night; urinary leakage such as “latchkey incontinence”; vulval and vaginal dryness; recurrent thrush, cystitis and UTI (often after sex); loss of sexual desire, reduced arousal or inability to climax; fatigue and loss of motivation.
Many women simply do not recognise who they have become or how they have got there. Many have rationalised symptoms away as due to stress or other problems.
Alongside dwindling oestrogen, perimenopause sees progressive decline in the other important sex hormones. Low progesterone may manifest with heavy prolonged periods, breast pain symptoms, anxiety, irritability, insomnia, and restlessness.
Testosterone is important for sexual desire, arousal, and sexual pleasure but also for growth, development, metabolism, cognitive function, mood regulation and maintenance of healthy bones, muscles. Testosterone levels decline from our mid 30s and can often dip sharply in perimenopause and be non-existent post-menopause. Deficiency gives rise to low mood, anxiety, brain fog, loss of confidence, low energy and motivation, sexual dysfunction, weight gain, muscle loss and joint pains.
After menopause, once ovarian reserve has been exhausted there are no more follicles to mature for ovulation. The ovaries effectively stop. Oestrogen, progesterone, and testosterone levels are persistently low, so symptoms tend to be persistent, long-standing and progressive over time.
Making a plan
Each of us will experience any combination of symptoms during perimenopause and the array may vary from day to day, cycle to cycle. Duration and severity of symptoms can also vary considerably. Although we may share similar features, no two women will have exactly the same experience, so assessments and management strategies need to reflect this. It is important to note that many of these symptoms should be investigated to rule out other causes before attributing them to hormonal changes alone.
So, if you have read this nodding your head in recognition, please arrange to speak to a doctor. Consider keeping a record or “diary” of symptoms, using a tracking app or symptom checklist. There are lots of non-medical things we can do to help with symptoms in addition to medications such as hormone replacement therapy with oestrogen, progesterone and testosterone or other non-hormonal medications.
Please do not struggle or suffer in silence. Trust your instincts, share your story and feel empowered to reclaim control over your health and wellbeing to thrive into midlife not simply survive.
Dr Fionnuala Barton
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