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Menopause & perimenopause

Dr. Mary James, ND

Perimenopause — what to expect and how to feel more comfortable

Reviewed by Dr. Mary James, ND

During an email exchange between sisters, a 43-year-old client of Women’s Health Network told her sister that she had been discussing perimenopause with her healthcare provider. Just seconds later, her (slightly) younger sister shot back a response — “Isn’t it too early to be thinking about this?!”

But after months of exhaustion, crazy mood swings, trouble concentrating, and just not feeling like herself, she was relieved to learn that for her, these actually were symptoms of perimenopause.

Whether you call it pre-menopause or perimenopause, the lead-up to the midlife transition can be a time of confusion and discomfort, one that varies from woman to woman. Some women sail into menopause without noticing any changes other than their periods stopping, while others are not so fortunate. Your changing hormones can set off any number of symptoms, which often vary wildly in severity and frequency. This unpredictability can be unsettling, especially if you think you’re too young for perimenopause.

Understanding what’s happening in your body is a critically important step that will ultimately lead you to the right solutions for feeling your best in perimenopause — and the years beyond.

What is perimenopause and when does it start?

Perimenopause is defined as the natural transition period between healthy, reproductive function and the onset of ‘official’ menopause (defined by 12 consecutive months without a menstrual period). Perimenopause, which is really more of a progression than a series of specific events, is often symptomatic of hormonal imbalance and fluctuations. In many ways it’s the flip side of puberty, when our hormones can be all over the map. The median age of onset of perimenopause is 47.5 years, though for some women it can begin as early as in their mid-30s, and for others, as late as their 50s. The median age of onset of menopause itself is 51.3 years.

When women ask me how they can be sure they’re in perimenopause, I suggest they look to their symptoms for clues. Are your symptoms new? Are some of them familiar, but now suddenly worse than before? Are your symptoms erratic, with no clear pattern to them? Any of these may indicate that you’re in perimenopause and that your hormones are on a roller coaster.

Why does hormonal imbalance in perimenopause cause symptoms?

As with other parts of our endocrine system, levels of sex hormones and the menstrual cycle are regulated via constant feedback between the hypothalamus, pituitary and ovaries. For this ‘hypothalamic-pituitary-ovarian axis’ to function properly, each part must be sensitive and responsive to incoming signals from the other parts.

The number of follicles in the ovary decline as we age, causing them to become less responsive than before. As a result, the hypothalamus steps up its signals for awhile, including follicle-stimulating hormone (FSH) and luteinizing hormone (LH), also called ‘gonadotropins.’ In a sense, they’re now yelling louder to be heard. During perimenopause, the ovaries may be non-responsive or hyper-responsive. In the latter case, the loud FSH signal may cause estrogen levels to spike.

A common misconception is that menopause (and the period leading up to it) means a gradual but steady decline in estrogen. In fact, estrogen levels during the perimenopausal period can sometimes climb higher than they’ve been for years — one reason for sometimes dramatic changes in your menstrual periods. Another misconception is that all symptoms result from diminishing estrogen. In reality, many different symptoms can be associated with a wide range of factors, not just low or changing estrogen levels. Hormone fluctuations have a much bigger impact on symptoms than the actual levels of the hormones, and when these fluctuations are too wide or occur too quickly, our bodies have trouble managing them (See chart below). Besides fluctuations in estrogen, FSH and LH, there are also changes in levels of progesterone, testosterone and DHEA.

With hormone imbalance, you may experience symptoms, such as irritability, anxiety, depressed mood, irregular periods, muscle aches and joint pains, menstrual migraines, poor memory, disrupted sleep, hot flashes, vaginal dryness, or changes in sex drive. I’d also like to point out that these symptoms might appear before you notice any change in your periods, though the problems are certainly compounded when they coincide with erratic periods.

It’s normal to change

normal variation in sex hormones

This diagram illustrates normal variation in sex hormones across a woman’s lifespan.

Our bodies are remarkably effective at managing changing levels of hormones throughout our lifetime. However, the cumulative effects of poor diet, chronic stress, lack of sleep, too little exercise, and environmental toxins often undermine our body’s ability to compensate, causing our sex hormones to get pushed out-of-sync. During the most dramatic changes — such as pregnancy and perimenopause — these changes can feel especially uncomfortable. Now is the time to offer your body the kind of support it needs to restore hormonal balance and ensure a smooth transition into menopause.

Who will have more severe hormonal imbalance in perimenopause?

A 2004 study showed that women who suffered from PMS during their reproductive years are twice as likely to also have symptoms in perimenopause. Peri- and postmenopausal women experiencing feelings of depression are also more likely to have a depressed mood during PMS, after childbirth, or while using oral contraceptives. Because all of these scenarios involve dramatic fluctuations in hormones, a woman who is generally sensitive to such fluctuations will likely be sensitive to hormonal changes in perimenopause as well. That being said, symptoms like depressed mood can also show up for the first time in a perimenopausal woman! The good news is that many symptoms, especially mood swings, improve as our bodies gradually adjust to menopause. There is also much we can do to smooth out the fluctuations causing the symptoms.

Women carrying extra burdens in life tend to have more extreme hormonal imbalance. And in my experience, the greatest burdens to your health relate to chronic stress and emotional issues. If we describe our life as a journey, you might consider that perimenopause is like standing at the baggage claim. Chronic stress and unresolved emotions are like baggage that we need to handle right now, or it just keeps on circling around. Compounding perimenopausal symptoms in many women are concerns that can often accompany general aging, such as parenting strain, caring for aging parents, economic stress, poor sleep, concurrent health conditions, and even uncertainty, in general, about the aging process.

Chronic stress can amplify the effects of changing sex hormone and neurotransmitter levels in perimenopause and menopause, as well as the ratios between these hormones, resulting in more dramatic symptoms. It’s helpful to remember that the basic building blocks for hormones can either head toward the production of stress hormone (cortisol) or sex hormones. With chronic stress, continual production of cortisol causes sex hormone production to take a back seat. As a result, both stress management and adrenal support are critical in turning this around.

Also high on the list of burdens are spotty nutrition, inadequate sleep, and sedentary lifestyle. These factors can escalate symptoms in perimenopause because they reduce your body’s natural ability to detoxify and maintain balance. In today’s fast-paced, disconnected, eat-and-run world, it’s not a surprise that younger and younger women are experiencing perimenopausal-type symptoms of hormonal imbalance.

How can I relieve my symptoms?

Perimenopause and menopause share many of the most common symptoms. I’ve found that the most effective approach to relief covers the foundation of women’s health: a healthy and balanced diet, enjoyable exercise, rest and relaxation, herbs and nutrients targeted to hormonal balance, and solid emotional support. This combination can make all the difference for women who are looking to relieve their symptoms.

At Women's Health Network, we start with a pharmaceutical-grade multivitamin-mineral complex like our Essential Nutrients, to provide the key levels of micronutrients your body requires, but which are often lacking. Such targeted nutritional support may be enough to begin healing your hormonal pathways. If not, we recommend gentle phytotherapy (medicinal herbs) as your second step. (Our Herbal Equilibrium is specially formulated for women transitioning through perimenopause.) Phytotherapy supports the body’s ability to restore hormonal balance by mimicking hormonal actions at a molecular level — the result is a balancing-out of the highs and lows. These herbs also interact with your body’s tissues to facilitate natural hormone regulation.

Most women find that adding high-quality nutrients and phytotherapy is enough. Others need more support to reach ideal symptom relief. This can mean adding more essential fatty acids, or amino acids like 5-HTP, or complementary therapies like acupuncture or chiropractic, just to name a few possibilities. Different women have different needs, so you may want to work with a healthcare practitioner to decide which specific therapies can best help you.

From denial to transformation

Perimenopause can be difficult for women at first, especially if they don’t know what’s happening in their bodies. Some women wonder if they’ve waited too long to have children. Others see it as the “beginning of the end” in our youth-obsessed culture. But you don’t have to accept anything short of optimal health and balance for yourself! One woman shared that she was “in denial” for years before finding relief for her physical issues — and, ultimately, peace of mind about her place in the world.

Wherever you may be on your journey through perimenopause, the symptoms you feel will ultimately influence your actions and reactions. I encourage you to choose not to let your symptoms define you during this stage of your life.

Know that you do have the power to help yourself during this time. And we are always here to help. For many women, it is a wonderful time of growth and transformation!

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Last Modified Date: 06/23/2014