What is Perimenopause?
[Disclaimer: I will use woman/women and people with uteruses interchangably in this article in an effort to aknowledge alternative identifications.]
Perimenopause is a natural transition period that marks the beginning of the end of a woman's reproductive years. It typically occurs in the late 30s to early 50s and can last anywhere from a few months to over a decade. During this time, the ovaries gradually and erratically, produce less estrogen and progesterone, leading to changes in menstrual cycles and the onset of various symptoms. Understanding perimenopause is crucial for managing its effects and preparing for the eventual transition into menopause.
Perimenopause Symptoms
Perimenopause can present with a wide range of symptoms, which can vary significantly from one woman to another. Some of the most common symptoms include:
Irregular Menstrual Cycles: Periods may become shorter, longer, lighter, or heavier. Some people with uteruses may also experience skipped periods. One does not need to have erratic cycles to be in perimenopause. This is ONE symptom.
Hot Flashes and Night Sweats: Sudden feelings of intense heat, often accompanied by sweating and flushing, are common. These can occur during the day or at night, disrupting sleep.
Sleep Disturbances: Difficulty falling asleep, staying asleep, or waking up too early is often reported during perimenopause. New onset or worsening insomnia in anyone causes me to question their hormonal status.
Mood Changes: Women may experience increased irritability, anxiety, or depression. Mood swings can also be more pronounced.
Vaginal Dryness and Discomfort: As estrogen levels drop, the vaginal lining can become thinner and drier, leading to discomfort during intercourse or general irritation.
Cognitive Changes: Many women report memory lapses, difficulty concentrating, or feeling mentally foggy during perimenopause.
New or worsening mental health issues: Anxiety, ADHD and depression that are no longer manageable or are common during this transition.
Decreased Libido: A decrease in sexual desire is common, often linked to hormonal changes and physical symptoms.
Blood Sugar Dysregulation: Especially for people who had gestational diabetes or with a family history of diabetes or hypoglycemia, blood sugar issues are very common during perimenopause and if they are treated appropriately as early as possible, they can be kept from getting worse with age.
Fatigue: Persistent tiredness or a lack of energy can be another symptom, even with sufficient sleep. Although, waking frequently and having difficulty falling asleep can also be perimenopause symptoms.
These symptoms can range from mild to severe and fluctuate over time as hormone levels change. The most common thing I hear from my patients during this time is, “I just don’t feel like myself!”
Estrogen in Perimenopause
Estrogen is one of the primary hormones that regulate the menstrual cycle and reproductive system. During perimenopause, estrogen levels become unpredictable. They may fluctuate significantly, sometimes rising to higher levels before dropping again. This inconsistency in estrogen levels is a key driver behind many of the symptoms experienced during perimenopause.
Estrogen is essential for maintaining various bodily functions, including bone density, cardiovascular health, and the regulation of mood. As estrogen levels decline, women may experience symptoms such as hot flashes, night sweats, vaginal dryness, brain fog, word recall difficulties, sleep disruption, mood changes, acne, weight gain, muscle weakness and dry skin. Long-term estrogen deficiency can also contribute to an increased risk of osteoporosis, dementia and cardiovascular disease.
Progesterone in Perimenopause
Progesterone is another crucial hormone in the female reproductive system, primarily responsible for preparing the uterus for pregnancy and regulating the menstrual cycle. People with uteruses and ovaries make, on average, 100 times as much progesterone as estradiol (the most active form of estrogen). During perimenopause, the production of progesterone decreases, often more abruptly than estrogen. This imbalance between estrogen and progesterone can lead to symptoms such as irregular periods, increased PMS symptoms, headaches and migraines, and heavy menstrual bleeding.
Progesterone also plays a role in mood regulation and sleep. A decline in progesterone levels may contribute to mood swings, anxiety, and sleep disturbances that many women experience during perimenopause.
Testosterone in Perimenopause
Testosterone, commonly associated with male health, also plays a significant role in women’s bodies. Although present in much lower levels in women, testosterone is essential for maintaining libido, muscle mass, and energy levels. During perimenopause, testosterone levels can decline, contributing to some of the symptoms experienced during this transition.
Effects of Declining Testosterone: A decrease in testosterone can lead to reduced sexual desire, fatigue, and decreased muscle strength. Some women may also notice changes in body composition, with a tendency to gain weight, particularly around the abdomen. Mood changes, including irritability and a lack of motivation, may also be linked to lower testosterone levels.
Testosterone Replacement: While less commonly discussed than estrogen or progesterone, testosterone replacement therapy is sometimes considered for women experiencing significant symptoms related to low testosterone during perimenopause. However, this treatment is typically approached with caution, and it’s important for women to discuss the potential benefits and risks with their healthcare provider.
How to Know if You Are in Perimenopause
Identifying whether you are in perimenopause can be challenging, as symptoms can be subtle and vary widely. However, there are several indicators that you may be entering this transitional phase:
1. Changes in Menstrual Cycle: If you notice that your periods are becoming irregular, shorter, or longer, it may be a sign of perimenopause. Skipped periods or heavier-than-usual bleeding are also common.
2. Onset of Common Symptoms: The appearance of symptoms like hot flashes, night sweats, mood swings, or sleep disturbances may indicate that you are in perimenopause, especially if these symptoms occur in combination.
3. Age: Women typically enter perimenopause in their late 30s to early 50s. If you fall within this age range and are experiencing changes in your cycle or new symptoms, perimenopause may be the cause.
4. Hormone Testing: While symptoms and age are often enough to diagnose perimenopause, hormone testing can provide additional confirmation. Blood, urine, saliva or capillary blood tests measuring levels of estrogen and progesterone can help determine if you are in perimenopause.
5. Family History: Your family history can also offer clues. If your mother or sisters experienced early perimenopause, you might be more likely to experience it earlier as well.
Safety of BHRT as Treatment for Perimenopause
Bioidentical Hormone Replacement Therapy (BHRT) is a treatment option for managing the symptoms of perimenopause. BHRT uses hormones that are chemically identical to those produced by the human body, such as estrogen, progesterone, and sometimes testosterone. These hormones can be delivered through various forms, including pills, patches, creams, or gels.
Safety and Efficacy: BHRT is generally considered safe for most women when prescribed and monitored by a healthcare provider. It can effectively alleviate many perimenopause symptoms, such as hot flashes, night sweats, vaginal dryness, and mood swings. However, like any medical treatment, BHRT is not without risks. Potential side effects can include bloating, breast tenderness, and irritability.
Using synthetic hormone replacement therapy like oral birth control pills and progestins, can have an increased risk of certain conditions, such as blood clots or breast cancer, particularly if used for extended periods. Bioidentical hormone replacement therapy has been shown to reduce the risk of breast cancer, osteoporosis, dementia and blood sugar dysregulation.
Individualized Approach: The safety and effectiveness of BHRT can vary depending on individual factors, including age, health status, family history, and the specific symptoms being treated. It's essential for women considering BHRT to have a thorough discussion with their healthcare provider, weighing the potential benefits and risks based on their personal health profile.
Monitoring and Adjustments: Regular monitoring and follow-up with a healthcare provider are crucial for anyone undergoing BHRT. Hormone levels may need to be adjusted over time, and ongoing evaluation is necessary to ensure the treatment remains effective and safe.
In summary:
Perimenopause is a significant transitional phase in a woman's life, marked by hormonal changes that can lead to various symptoms. Understanding the roles of estrogen, progesterone, and testosterone in this process can help women better manage their health during this time. While Bioidentical Hormone Replacement Therapy offers a potential solution for alleviating perimenopause symptoms, it’s important to consider the safety, risks, and benefits on an individual basis. Consulting with a healthcare provider is essential to developing a personalized approach to managing perimenopause effectively.
Dr. Roz Donovan is a graduate of National University of Natural Medicine, with a doctorate in Naturopathic Medicine. Throughout her doctoral studies, Dr. Donovan received hands-on training from herbalists and a botanist, while also interning in mental health, environmental medicine, pediatrics and general medicine. Her advanced training mentorships focused on traumatic brain injury, mental health disorders and gastrointestinal health. As of this writing, her current research is in hormone therapy and collagen variabilities.
Dr. Donovan’s blog posts are for educational purposes only and are not intended as medical advice. Please consult with your health care practitioner for personalized guidance.
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