Am I in perimenopause?

What is perimenopause? … and am I in it??

You may have heard about perimenopause recently but are you familiar with the signs and symptoms? We are loving that perimenopause is finally receiving the attention it deserves. So many women are either misdiagnosed or ignored when it comes to their long list of symptoms. There are 96+ symptoms that can be attributed to perimenopause and symptoms are frequently being added. So what is perimenopause? 

Simply put, perimenopause is the transition timeframe to menopause. This transition period causes erratic hormone fluctuations in estrogen and progesterone. Testosterone is another hormone that is important for women however studies show that testosterone steadily declines during this time but generally is not erratic during a woman's cycle. As we near the end of ovulatory cycles, our bodies try to produce enough hormones to make an ovulation happen. The brain sends the signal to the ovaries to make hormones (estrogen) in order to produce an egg for ovulation. When our egg count is low the signal is sent but the ovaries may not produce enough estrogen to make an ovulation occur. There are also some times where the signal is sent by the brain to produce the hormones for ovulation and too much estrogen is produced. Then boom! you get an egg, sometimes two in ovulation. It’s this erratic cycle that wreaks havoc on our bodies. This timeframe can start 7-10 years before the bleeding cycles actually stop. 

There are estrogen receptors all over our body so it’s so important for us to have enough estrogen readily available. Estrogen receptors receive signals that are used to produce physiological responses such as a change in the electrical activity of the cell. For example, the estrogen receptors in the ovaries, receive the signal by the brain to produce the hormone estrogen and this is what starts the electrical activity in the cells which starts the process of ovulation. Estrogen receptors have been found in the brain, the bones, all the organs including the heart. When we begin depletion of estrogen, we may start noticing symptoms that most providers do not recognize as hormonal changes. 

Symptoms of perimenopause can include:

• changes in the menstrual cycle (shorter or longer bleeding times, shorter or longer time frame between cycles)

• unexplained weight gain

• anxiety and/or depression

• mood changes or swings

• issues with sleep

• heart palpitations 

• headaches 

• changes in libido 

• muscle or joint pain

• hot flashes and night sweats (some of the later stage symptoms)

• dryness (hair, skin, nails and vaginal)

• urinary changes (urge to urinate more often)

• brain fog

• trouble concentrating

• issues with memory / cognition

• lack of resiliency

• worsening PMS symptoms like bloating, irritability, etc

• dry eye

• frozen shoulder

The list continues to grow. 

So many women unfortunately will see several specialists before they get put on anti-depressants. While this can be helpful in certain situations, hormone replacement therapy has been proven to help the various symptoms associated with perimenopause where as anti depressants may only help treat anxiety and depression. Many women who experience headaches will see a neurologist. They may also see a cardiologist if they also have palpitations. A psychiatrist for mood changes. A primary care physician for weight gain and generalized symptoms. A gynecologist for changes in their menstrual cycle. This can be very costly for the patient and many providers, including gynecologists, do not know how to treat perimenopause symptoms. Replacing the declining hormones can help restore the body’s balance however providers do not think this is the answer if a patient is still having regular menstrual cycles. Giving the body a regular dose of estrogen, progesterone and testosterone can keep our bodies from reacting erratically to the wavering levels of hormones therefore minimizing or eliminating the various symptoms. 

There are various ways to replace estrogen, progesterone and testosterone for a woman who is still cycling as well as for a woman who has stopped having cycles. I prefer pellets because they are bio-identical and natural to the body. They are about the size of a grain of rice and are implanted in the fatty tissue of the buttock. They slowly release hormones every day and last about 3-4 months. The downside is that there is a 3 day, easy recovery where you can’t work out your lower body or submerge in water. Showers are okay. 

There are creams available as well which you apply to your forearms or abdomen or thighs on a nightly basis. The creams are less desirable in my opinion because absorption can vary from person to person and the patient must be very careful to wash hands afterwards to prevent transfer to others in the household. The patient must be careful with touching family members and pets after the cream has been applied. These are generally bio-identical as well. 

Pills are another option but are only available for estrogen and progesterone replacement and not testosterone. A pill is easy to take every day however it is metabolized through the liver and can increase clotting factors therefore has a slightly increased risk of clots. The pills are synthetic. 

Troches are another great option. They are lozenges that are placed between the cheek and gum line and allowed to melt over 30 seconds. These are bio-identical and because they are absorbed in the mucosa of the mouth, they bypass the liver therefore decreasing the risk of blood clots. 

The final method currently available is an estrogen and progesterone patch combo. The patch gives a slow release of synthetic hormones and it is changed every 3-4 days. Again testosterone is unavailable in patch form. 

There are other ways to help manage symptoms of perimenopause and this includes a whole food diet and cutting out all processed foods. Performing regular exercise can also be a big help and this can include weighted exercises, walking, running, hiking, etc. Improve sleep hygiene by minimizing screens at night and doing relaxing activities before bed can also help with sleep disruptions. Meditation can helpful to reduce stress. Also, minimizing or eliminating tobacco and alcohol can also be very helpful. 

So, where should you begin if you are experiencing some symptoms of perimenopause?

Finding a provider that you trust and will listen to your concerns and symptoms is the first step. I am in the process of becoming certified through The Menopause Society so I think this website is a great resource to find providers in your area. If you see a provider who attempts to scare you out of hormone replacement therapy (HRT), find another provider. There are so many studies that have been published since the WHI study decades ago that have proven that HRT is safe and effective at treating the debilitating symptoms of perimenopause and menopause. Your provider may or may not recommend lab work. Hormone levels fluctuate sometimes by the hour so they are not a great tool to use to diagnose perimenopause. I prefer to draw labs just to obtain a baseline level and know where we are starting from. I then discuss the options with the patient and allow them to decide if this is for them.