Perimenopause

Overview

Perimenopause means "around menopause" and refers to the time during which your body makes the natural transition to menopause, marking the end of the reproductive years. Perimenopause is also called the menopausal transition.

Women start perimenopause at different ages. You may notice signs of progression toward menopause, such as menstrual irregularity, sometime in your 40s. But some women notice changes as early as their mid-30s.

The level of estrogen — the main female hormone — in your body rises and falls unevenly during perimenopause. Your menstrual cycles may lengthen or shorten, and you may begin having menstrual cycles in which your ovaries don't release an egg (ovulate). 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

Throughout the menopausal transition, some subtle — and some not-so-subtle — changes in your body may take place. You might experience:

• Irregular periods. As ovulation becomes more unpredictable, the length of time between periods may be longer or shorter, your flow may be light to heavy, and you may skip some periods. If you have a persistent change of seven days or more in the length of your menstrual cycle, you may be in early perimenopause. If you have a space of 60 days or more between periods, you're likely in late perimenopause.
• Hot flashes and sleep problems. Hot flashes are common during perimenopause. The intensity, length and frequency vary. Sleep problems are often due to hot flashes or night sweats, but sometimes sleep becomes unpredictable even without them.
• Mood changes. Mood swings, irritability or increased risk of depression may happen during perimenopause. The cause of these symptoms may be sleep disruption associated with 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 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 is still possible. 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 if you had satisfactory sexual intimacy before menopause, this will likely 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 — a disease that causes fragile bones.
• 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 need attention. Because symptoms may be subtle and come on gradually, you may not realize at first that they're all connected to the same thing — hormone fluctuations of the menopausal transition.

If you have 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

As you go through perimenopause, your body's production of estrogen and progesterone, key female hormones, rises and falls. Many of the changes you experience during perimenopause are a result of decreasing estrogen.

Risk factors

Menopause is a normal phase in life. But it may occur earlier in some women than in others. Although not always conclusive, some evidence suggests that certain factors may make it more likely that you start perimenopause at an earlier age, including:

• Smoking. The onset of menopause occurs 1 to 2 years earlier in women who smoke than in women who don't smoke.
• Family history. Women with a family history of early menopause may experience early menopause themselves.
• Cancer treatment. Treatment for 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 surgery may cause menopause to occur earlier than average. Also, if you have one ovary removed, the remaining ovary might stop working sooner than expected.

Complications

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 or two for two or more hours
• Bleeding lasts longer than seven days
• Bleeding occurs between periods
• Periods regularly occur less than 21 days apart

Signs such as these may mean there's a problem with your reproductive system that requires diagnosis and treatment.

Diagnosis

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.

Treatment

Medications are often used to treat perimenopausal symptoms.

• Hormone therapy. Systemic estrogen therapy — which comes in pill, skin patch, spray, gel or cream form — remains the most effective treatment option for relieving perimenopausal and menopausal hot flashes and night sweats. Depending on your personal and family medical history, your doctor may recommend estrogen in the lowest dose needed to provide symptom relief for you. If you still have your uterus, you'll need progestin in addition to estrogen. Systemic estrogen can help prevent bone loss.
• Vaginal estrogen. Estrogen can be administered directly to the vagina using a vaginal tablet, ring or cream. This treatment releases just a small amount of estrogen, which is absorbed by the vaginal tissue. It can help relieve vaginal dryness, discomfort with intercourse and some urinary symptoms.
• Antidepressants. Certain antidepressants related to the class of drugs called selective serotonin reuptake inhibitors (SSRIs) may reduce menopausal hot flashes. An antidepressant for management of hot flashes may be useful for women who can't take estrogen for health reasons or for women who need an antidepressant for a mood disorder.
• Gabapentin (Neurontin). Gabapentin is approved to treat seizures, but it has also been shown to help reduce hot flashes. This drug is useful for women who can't use estrogen therapy for health reasons and for those who also have migraines.
• Fezolinetant (Veozah). This medicine is a hormone-free option for treating menopause hot flashes. It works by blocking a pathway in the brain that helps regulate body temperature.

Before deciding on any form of treatment, talk with your doctor about your options and the risks and benefits involved with each. Review your options yearly, as your needs and treatment options may change.

Lifestyle and home remedies

Making these healthy lifestyle choices may help ease some symptoms of perimenopause and promote good health as you age:

• Ease vaginal discomfort. Use over-the-counter, water-based vaginal lubricants (Astroglide, K-Y Liquid, others) or moisturizers (Replens, Vagisil Prohydrate, others). Choose products that don't contain glycerin, which can cause burning or irritation in women who are sensitive to that chemical. Staying sexually active also helps by increasing blood flow to the vagina.
• Eat healthy. 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. Avoid alcohol and caffeine if they seem to trigger hot flashes. Ask your doctor if you should also take a calcium supplement and if so, what type and how much — also ask if you need more vitamin D, which helps your body absorb calcium.
• Be active. Regular exercise and physical activity helps prevent weight gain, improves your sleep and elevates your mood. Try to exercise for 30 minutes or more on most days of the week, although not right before bedtime. Regular exercise has been shown to reduce hip fracture risk in older women and to strengthen bone density.
• Get enough sleep. Try to keep a consistent sleep schedule. Avoid caffeine, which can make it hard to get to sleep, and avoid drinking too much alcohol, which can interrupt sleep.
• Practice stress-reduction techniques. 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

In addition to conventional therapies, many women transitioning toward menopause want to know more about complementary and alternative approaches to treating symptoms. Researchers are looking into these therapies to determine their safety and effectiveness, but evidence is still often lacking.

Some of the options studied include:

• Black cohosh. This herb extract is used by some women to treat hot flashes and other menopausal symptoms. There's not enough evidence to support its use. Experts also are unsure of what risks taking black cohosh poses. Some studies have suggested that black cohosh was harmful to the liver, but other studies found no evidence that this is true. Researchers also question whether the herb extract is safe for women with or at risk of breast cancer.

• Phytoestrogens. These estrogens occur naturally in certain foods. Two main type of phytoestrogens are isoflavones and lignans. Isoflavones are found in soybeans and other legumes and red clover. Lignans occur in flaxseed, whole grains, and some fruits and vegetables. There are also plant-derived compounds that have estrogen-like properties.

  Studies on phytoestrogens — whether from food or supplements — conflict on whether they help reduce menopausal symptoms. Studies also conflict on what beneficial impact, if any, phytoestrogens may have on breast cancer risk.

• Bioidentical hormones. The term "bioidentical" implies that the hormones in the product are chemically identical to those your body produces. However, compounded bioidentical hormones aren't regulated by the U.S. Food and Drug Administration (FDA), so quality and risks could vary. There's also no evidence that compounded bioidentical hormones are safer or more effective than conventional hormone therapy.
• Dehydroepiandrosterone (DHEA). This natural steroid produced by your adrenal gland is available as a dietary supplement and has been used by some to reduce pain during intercourse due to vaginal atrophy. But evidence on its effectiveness is mixed, and there are some concerns about possible harmful effects.

Talk with your doctor before taking any herbal or dietary supplements for perimenopausal or menopausal symptoms. The FDA does not regulate herbal products, and some can be dangerous or interact with other medications you take, putting your health at risk.

Low-risk complementary therapies that may help reduce stress and improve psychological well-being include:

• Acupuncture. Research on acupuncture for decreasing hot flashes is inconclusive, but promising.
• Relaxation techniques. Yoga and meditation, for example, can help reduce stress, which may in turn help improve menopausal symptoms.

Preparing for an appointment

You'll probably start by discussing your symptoms with your primary care provider. If you aren't already seeing a doctor who specializes in the female reproductive system (gynecologist), your primary care provider may refer you to one.

Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who goes with you may remember something that you missed or forgot.

What you can do

To prepare for your appointment:

• Take along a record of your menstrual cycles. Keep 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.
• Make a list of any signs and symptoms you're experiencing. Include detailed descriptions. Include any symptoms that may seem unrelated.
• Make a note of key personal information. Include any major stresses or recent life changes.
• Make a list of all medications and the doses. Include prescription and nonprescription drugs, herbs, vitamins and supplements that you're taking.
• Prepare questions. Your time with your doctor may be limited, so prepare a list of questions to help you make the most of your time together.

Some basic questions to ask include:

• What is likely causing my symptoms?
• What are other possible causes for my symptoms?
• What kinds of tests do I need?
• Is my condition likely temporary or chronic?
• What is the best course of action?
• What are the alternatives to the primary approach that you're suggesting?
• I have some other health conditions. How can I best manage them together?
• Are there any restrictions that I need to follow?
• Should I see a specialist?
• Are there brochures or other printed materials that I can have? What websites do you recommend?
• What will determine whether I should plan for a follow-up visit?

Questions your doctor may ask

To start 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, herbs, vitamins or other supplements do you take?