Perimenopause
Understanding Perimenopause: A Comprehensive Guide to Symptoms, Causes, and Management
What is perimenopause?
Perimenopause is the term used to describe the transition between our years with a regular menstrual cycle and the onset of menopause (which starts when we have not had a period for 1 year). The perimenopause transition includes changes to our reproductive cycle and the hormones which control it, resulting in a variety of different symptoms and timeline for everyone going through it.
When does perimenopause start?
Perimenopause can start anywhere from late thirties in some women, to sometime in their early 50s. Because the transition is so different for each individual (and therefore also makes it hard to study!) current research has separated individuals into different “stages” of perimenopause (see figure 1.).
Figure 1. Stages spanning the menopausal transition. The average age of most women entering in Stage 2 is 47 years old, exiting stage 2 is 49 years old, and the average age most women have their final menstrual period is 51 years old.
Taken from Santoro, Nanette, et al. ‘The Menopause Transition: Signs, Symptoms, and Management Options’. The Journal of Clinical Endocrinology & Metabolism, vol. 106, no. 1, Jan. 2021, pp. 1–15. DOI.org (Crossref), https://doi.org/10.1210/clinem/dgaa764.
How do my hormones change?
Our menstrual cycle functions on an axis that runs from our hypothalamus (in our brain) to our pituitary gland (in our brain), and finally to our ovaries.
Different hormones send signals at each stage to alert the next part of the axis to continue signalling or reduce their signal message. Our “upstairs” hormones that stimulate our ovaries to grow follicles (which eventually turn into eggs) are Follicle Stimulating Hormone (FSH), and Luteinizing Hormone (LH).
FSH encourages the growth of a single follicle, while a well timed LH surge (rapid increase in LH hormone) signals the ovary to release the egg, resulting in ovulation.
Estrogen rises as the follicle grows (in our follicular phase), and progesterone rises once the follicle is release (in our luteal phase). When “downstream” hormones (estrogen and progesterone) are higher, they impede the “upstairs” hormones (FSH, and LH), which leads to a streamlining of all the hormones into a well-timed orchestra.
In perimenopause, the decline in the quantity of follicles (due to age) means that the feedback loop starts to malfunction.
This actually starts with the hormones Anti-Mullerin Hormone and Inhibin B, which are secreted from growing follicles normally. Since there are less follicles, these two hormones are found in lower concentrations. Normally, AMH and Inhibin B suppress FSH levels, but in smaller quantities, they are unable to suppress FSH as well as they used to.
Elevated FSH is a trademark sign of perimenopause. However, in stage 3 of the perimenopause transition (the start) it may only be elevated occasionally (and therefore hard to see on blood work). Typically in this stage, women may not notice any changes to their cycle, or know at all that they are approaching perimenopause.
By stage 2, most women may have noticed a missed period, or variation in their cycle that exceeds 7 days. By this point, their FSH will be elevated, and measures of follicle count such as inhibin B, AMH and antral follicle count on ultrasound will be low.
Eventually, FSH continues to rise, which results in follicles being stimulated quicker than normal, and are ovulated at a smaller size. Sometimes follicles are growing at the same time as the luteal phase from the cycle before is occurring. This results in cycles that are termed as “Luteal out of phase” or LOOP cycles. Symptomatically, this can look like cycles that are occurring on top of one another, leading to bleeding for weeks on end, or and absence of bleeding. Essentially you may experience long bleeds that occur within quick succession of one another, or no cycle for over 60 days. In these circumstances, because of a lack of ovulation, or lots of ovulation occurring, estrogen may be fluctuating (higher, then lower) which can lead to a variety of different symptoms.
By the time women reach stage 1, the menstrual cycle is typically irregular or absent all together, and we see more of the common symptoms of menopause.
Menopause is finally reached when a woman has not had a menstrual cycle for one year.
Can I still get pregnant?
Yes! Depending on which stage you are in of perimenopause (typically stages 1 or 2), you may still be ovulating (despite some cycle irregularities). This means you do have the potential to fall pregnant. Discussing contraception options with your practitioner can protect you from unwanted pregnancy, and help manage some of the symptoms of perimenopause. Falling pregnant at an older age comes with increased risks, talk to your health care provider about what makes sense for you.
How do I know I’m in perimenopause?
The first sign of perimenopause for most people is a change in their period - either a skipped month altogether, or a cycle that varies by at least 7 days. Hormonal changes may have been occurring before that, but may have only been detectable on blood work (and not always consistently!).
What are the potential symptoms I might experience?
The hormonal changes of perimenopause impact a variety of different body systems which can lead to a variety of symptoms.
These may include:
Vasomotor Symptoms (Hot Flashes)
Anxiety
Low Energy
Genitourinary Symptoms of Menopause
Increased urinary tract infections, vaginal atrophy, irritation of the vagina
Insomnia
Decreased libido
Reduced bone density
Brain Fog
Body composition changes & weight gain
What can I do to help the symptoms?
Lots! Depending on what symptoms you are experiencing we can support you with diet, lifestyle, and supplement options to manage your symptoms and reduce your risk for cardiovascular disease, support brain health, bone health and maintain a healthy weight.
For some patients, hormone replacement therapy may make sense to manage symptoms and reduce risk of cardiovascular disease.
Curious about how we can support your hormonal health while you undergo perimenopause? Book an appointment with one of our naturopathic doctors to learn more!