Perimenopause

Perimenopause is the name for menstrual symptoms leading up to menopause.

• Menopause is the time during a woman's lifetime when menstrual periods cease. The medical definition of menopause is the time at which a woman has not had a menstrual period for 12 consecutive months.
• The time preceding menopause has been referred to as perimenopause. There is no strict medical definition of perimenopause, but it typically refers to the time approaching menopause during which a woman starts to develop symptoms of declining estrogen levels.
• Some of the symptoms of perimenopause include
  • hot flashes,
  • night sweats,
  • weight gain,
  • mood changes,
  • vaginal dryness,
  • vaginal pain, and
  • pain with sexual intercourse.
• Not all women experience all the symptoms of perimenopause to the same degree, and symptoms vary among women.
• Treatment of perimenopausal symptoms includes hormone therapy and lifestyle changes such as diet, exercise, and smoking cessation.
• Estrogen therapy may decrease the severity of symptoms of perimenopause.

Perimenopause refers to the period that begins when the ovaries begin to decline in function and continues until menopause (defined as the total cessation of menstrual flow for one calendar year) has been reached. Perimenopause has been called the "change of life" or "transition period." It usually begins in the 40s but may start as early as the late 30s. During this time, a woman may exhibit several symptoms largely due to abnormal hormonal fluctuations.

Perimenopause can become a difficult period in a woman's life, as the ovaries begin to become depleted in eggs and produce hormones in reduced amounts. It is essential that each woman attempt to understand the alterations that her body is undergoing in an attempt to proactively manage these physiological changes. Moreover, she should not attempt to hide her feelings and symptoms from others involved in her life, as this may lead to misunderstanding and frustration. Professional help is available, and new products and technologies are constantly being developed to assist with the control of perimenopausal symptoms. With appropriate dialogue between a woman and her health care professional, most women can navigate this potentially difficult period of their lives.

Perimenopause usually begins in the 40s but may start as early as the late 30s. During this time, a woman may exhibit several symptoms largely due to abnormal hormonal fluctuations.

Every woman is endowed at birth with a set number of eggs within each ovary. As she enters adolescence, the higher brain centers that are responsible for the onset of puberty begin to mature and function in a coordinated fashion. Menstrual cycles begin, and once a month, one of the ovaries will release an egg, which may be fertilized if intercourse occurs during the days when the egg is viable. If fertilization does not occur, the egg, which is composed of a single cell, degenerates and dies within the abdominal cavity. Without fertilization of the egg, the uterine lining is shed off approximately two weeks after ovulation (i.e. release of an egg by the ovary). This cycle is repeated monthly unless a pregnancy is conceived. As a woman ages, her ovaries become depleted of eggs. At this point, ovulation may become erratic. This results in irregular bleeding episodes that may be heavy and unpredictable.

Hormones are produced from the ovaries in a rather precise sequence throughout the normal menstrual cycle. This can cause numerous side effects (for example, menstrual cramps,) which may or may not be predictable. As the ovaries become depleted of eggs and bleeding episodes become more erratic, there are alterations in the quantity and frequency of ovarian hormone production, leading to numerous physical manifestations. The period when the depletion of ovarian eggs results in irregular bleeding and other related symptoms has been termed "perimenopause."

1. Irregular vaginal bleeding or menses

The ovaries are responsible for the production of the hormone estrogen in a reproducible pattern. As the ovaries become deficient in eggs (ova), the production of estrogen becomes less precise. Estrogen is the hormone that, when produced in the normal sequence and concentration, results in the orderly shedding of the uterine lining. If the estrogen production is not regular, the uterine lining or endometrium may shed off in small amounts, resulting in irregular vaginal spotting. The time interval between ovulatory events may lengthen. During that long interval, the endometrium continues to grow and may become quite thick. When the ovary finally releases another egg and subsequent shedding of a thickened uterine lining occurs, the menstrual flow may be extremely heavy and associated with severe cramps.

2. Hot flashes or flushes

Hot flashes are episodic sensations of heat rising over the neck and facial areas of a woman's body, followed by profuse sweating. They can be extremely disturbing and may result in difficulties with concentration. Hot flashes are thought to be due to transient dilation of the blood vessels near the surface of the body due to estrogen deficiency. They frequently persist for years after menstruation has ceased (i.e. a woman has experienced menopause).

3. Breast tenderness

With normal menstrual cycles, the female breasts tend to retain fluid as the next period approaches. This is in response to ongoing estrogen production, which continues throughout the cycle, but tends to diminish with approaching menstruation. As a woman nears perimenopause ovarian estrogen production becomes erratic. The breasts may become tender due to estrogen-induced fluid retention. The fact that the interval between ovulation tends to increase means that estrogen continues to be produced in large amounts between periods, and fluid retention continues until the next menstrual flow begins.

4. Nausea

Many studies have shown that during perimenopause, the overall estrogen production by the ovaries increases, but day-to-day production may be unpredictable. On some days when estrogen production is high, a woman may experience nausea. This can be sufficiently severe in some individuals to require treatment with medication.

5. Night sweats

The term night sweats refer to hot flushes that occur at night. They may occur as frequently as once an hour, and they tend to awaken women from sleep. Insomnia is a frequent accompaniment of night sweats that can, in turn, lead to irritability and depression. Difficulty carrying out normal daily tasks may occur due to the fatigue incurred because of night sweat-induced insomnia.

6. Weight gain

As previously mentioned, estrogen produced erratically and in large concentrations tends to cause fluid retention. This may lead to overall swelling of the body swelling due to fluid accumulation. This fluid may contribute to transient weight gain, which may be transient. In addition, estrogen production can affect the higher brain centers, which control appetite, to increase hunger. It is not uncommon for women in perimenopause to gain a significant amount of body fat.

7. Decreased fertility

As a woman ages and her ovaries begin to run out of eggs, pregnancy will become more difficult to achieve. In addition, the quality of the remaining eggs diminishes as they age. If a pregnancy is achieved, the chance of miscarriage is increased because a higher percentage of the remaining eggs is chromosomally abnormal, leading the body to reject what would otherwise be a defective embryo.

Many women feel that when their menstrual cycles become erratic they cannot conceive. Thus they do not practice contraception. As a result, these women may find that they are pregnant at a time in their life when they are not prepared to begin the odyssey of child-rearing. Many studies have shown that the elective abortion rate is highest in women who are over forty years of age, and who are faced with an unwanted pregnancy.

8. Loss of bone density

Estrogen is intimately involved in the metabolism of bone. Normally, calcium in the bones is in a state of equilibrium, in which the calcium leaving the bone at any given time is being replaced by calcium entering the bone. As estrogen production diminishes and becomes more erratic, this equilibrium is altered to result in a net outflow of calcium from bone. Over time, the bone calcium may become severely depleted, leading to the common condition known as osteoporosis or decreased bone density. Osteoporosis in elderly patients is a national epidemic, with billions of dollars being spent each year on the diagnosis and treatment of this disease.

9. Mood changes

Mood swings, depression, anxiety, and irritability occur frequently during perimenopause. A common denominator for these issues is undoubtedly night sweats, which can cause insomnia, and disrupt the body's intrinsic diurnal rhythm. Many women find that day-to-day activities previously could have been accomplished without difficulty become major challenges. Interpersonal relationships may suffer, particularly if the woman is unable to understand what she is experiencing and verbalize her concerns to those around her. Transient memory loss is also common.

10. Alterations in blood cholesterol levels

Low estrogen levels tend to favor an elevation of so-called low-density lipoprotein (LDL) levels. These are commonly referred to as "bad cholesterol". In addition, declining estrogen tends to also favor a decrease in high-density (HDL) lipoprotein, so-called "good cholesterol". These lipid changes may predispose a woman to heart disease.

11. Low sex drive (decreased libido)

As menopause approaches, many women find that they experience a diminished desire for sexual intimacy. Undoubtedly, chronic fatigue and altered sleep patterns play major roles in causing this problem. In addition to estrogen, the ovary normally produces testosterone, which is largely responsible for sex drive. As the woman ages, the amount of testosterone that the ovary produces diminishes, thus contributing to a decreased libido.

12. Vaginal pain during intercourse

The vagina is an organ that responds to estrogen. Normally, the vagina is lined by cells that contain water, which allows it to expand properly. This contributes to pliability that facilitates vaginal expansion during intercourse. If a woman is estrogen-deficient, the cells lining the vagina lose their hydration and become dried out. The vagina begins to shrink in diameter and length, which can result in painful intercourse. As the walls of the vagina become thinner and underlying blood vessels ultimately become exposed, vaginal bleeding may occur when intercourse is attempted.

The presence or absence of estrogen also alters blood flow to the vagina. If the estrogen levels are decreased, normal lubrication of the vagina may also be inadequate, and sexual arousal may become difficult.

13. Bladder problems

The bladder and the urethra (the tube that conducts urine outward from the bladder) are responsive to the presence of estrogen. Women with low systemic estrogen levels

• are more likely to be susceptible to urinary tract infections (UTIs);
• may feel the need to urinate more frequently (urinary urgency); and
• may have a loss of the ability to hold back the flow of urine with increased intra-abdominal pressure, such as occurs with sneezing, coughing, and heavy lifting This is due, in part, to a decrease in pressure within the urethra caused by local estrogen deficiency.

Both primary care practitioners such as internal medicine specialists and family practitioners as well as gynecologists may provide treatment for perimenopausal symptoms. A urologist may be consulted for some cases where the bladder and urethra are involved.

Management of perimenopause is mainly dependent on the severity of symptoms. However, certain risk factors may indicate that a woman is prone to more serious problems. If she is in one of these high-risk groups, she should seek care as soon as any of the symptoms of perimenopause begin.

1. Cigarette smoking: Carbon monoxide from cigarette smoke is found in the bloodstream in high concentrations during the act of smoking. This compound causes a net loss of bone calcium. If a woman smokes and is perimenopausal, she should seek professional care from a healthcare professional who can assist her with efforts at smoking cessation.
2. Steroid usage: Many patients use steroids chronically to treat many diseases (for example, asthma). Steroids affect the bones by depleting calcium. Such individuals are at high risk of osteoporosis if their overall estrogen production is erratic or low.
3. Family history: If there is a family history of early menopause, it may be prudent for a woman to seek medical care shortly after experiencing the onset of perimenopausal symptoms.
4. Small body frame: If a woman is thin with small bones, her bone mass is, for practical purposes, deficient in calcium. She should see her doctor to formulate a plan to prevent further skeletal deterioration proactively.

In addition to the high-risk groups listed above, a woman should consult a healthcare professional if she experiences extremely heavy or irregular vaginal bleeding. Occasionally uterine cancer is found in a woman whose ovaries are not working optimally.

Once a woman has decided to seek treatment to manage perimenopausal symptomatology, she should choose a doctor with whom she is comfortable. Her doctor should perform a complete history with specific reference to any current diseases for which she is being treated. Such a history should include

• a listing of all current medications;
• any pertinent family history; and
• a chronology of tobacco; alcohol; and recreational drug usage.

A general physical exam should be done, including measurements such as

• blood pressure,
• height,
• weight,
• body mass index determination, and
• the normalcy of thyroid, breast, and pelvic examinations.

In addition, the health care professional should review any symptoms that the woman is experiencing, including psychiatric symptoms.

Tests and exams

Laboratory tests should be individualized for each woman and may include the following:

• Complete blood count
• Lipid profile
• General chemistry panel
• Thyroid function testing
• Pap smear
• Mammogram

Measuring the blood and saliva estrogen levels in a woman are, in general, not helpful in diagnosing perimenopause.

Other tests that may be performed include the following:

• A bone density exam (depending on the woman's risk factors)
• An endometrial biopsy (sampling of the tissue lining the interior of the uterus) to rule out uterine cancer if the woman has any irregular bleeding (to rule out uterine cancer or pre-malignant changes).

Once these test results have been received, her doctor will be prepared to outline a treatment plan for perimenopause and the prevention of its consequences. Treatment of any medical problems (for example, anemia and thyroid disease) should be addressed before the treatment of any perimenopausal symptoms.

1. Diet

It is important to consume a healthy diet. This should include foods such as fresh vegetables and whole-grain products. Lower calorie dairy products that are rich in calcium, (e.g. milk, cheese, cottage cheese, and low-fat ice cream) should also be included.

2. Weight control

It is very important to determine the optimal weight for each individual's height and body type. Body mass index charts should be used, and women should work to maintain their ideal weight.

3. Exercise

Regular moderate physical activity for at least thirty minutes three times per week is ideal. If time is limited, aerobic exercise such as jogging or fast walking is preferred. However, if time is not an issue, muscle building or maintenance should be attempted using light weights or other forms of progressive resistance.

4. Smoking cessation!

This is very important in the management of perimenopause. In smokers, the level of carbon monoxide in the bloodstream increases each time a cigarette is consumed. Carbon monoxide has been shown to increase the rate of breakdown of estrogen in the body. This can lead to worsening hot flushes. In addition, smokers tend to lose bone at a higher rate than non-smokers, and this can contribute to worsening osteoporosis at an accelerated rate.

5. Dietary supplements

Women should consider taking vitamin and calcium supplements during perimenopause. Vitamin D is recommended because it's necessary to ensure the integrity of normal bone, and many people are deficient in vitamin D (vitamin D is frequently derived from sun exposure and eating foods rich in vitamin D). Foods containing significant amounts of vitamin D include:

• Fatty fish (salmon, tuna)
• Beef liver
• Cheese
• Yogurt
• Egg yolks
• Selected mushrooms
• Fortified milk
• Some ready-to-eat breakfast cereals

However, please note that huge doses of calcium and vitamin D can be harmful.

6. Stress management

As a matter of general health, attempts to diminish stress help control the symptoms of perimenopause. Yoga and deep-breathing exercises during a quiet time tend to diminish stress, which can contribute to hot flushes, insomnia, and problematic interpersonal relationships. Other stress management techniques include:

• Plan your time.
• Be prepared.
• Relax with meditation, deep breathing exercises, Yoga, or Tai Chi.
• Relax the muscles by taking a hot shower or stretching.
• Try to exercise at least 10 minutes at a time 2 hours and 30 minutes a week. Pick an activity you enjoy like cycling, walking, swimming, aerobics, or running.
• Eat healthier foods.
• Drink alcohol in moderation.
• Talk to friends or family about issues that are causing you stress.
• Seek professional help if you need it.

7. Get more sleep

Attempts to maintain a consistent sleep pattern are advisable. Try to avoid drinking caffeine late in the day, which can contribute to insomnia. Insomnia, in turn, may intensify depression and anxiety, which are frequently seen in perimenopausal women.

8. Talk to your doctor

Talk to a healthcare professional if there are problems with painful intercourse due to vaginal dryness.

There are a variety of medications that may ease perimenopausal symptoms in women. These include

• birth control pills,
• hormonal products,
• vaginal estrogen,
• antidepressants,
• testosterone, and
• gabapentin (Neurontin).

There is no "cure" for perimenopause.

Oral contraceptives

One of the most effective and infrequently mentioned methods of treating the spectrum of problems encountered during perimenopause is the combination birth control pill. These pills contain synthetic forms of estrogen and progesterone, the two primary hormones produced by a normally functioning ovary. They act by preventing the ovary from releasing its estrogen and progesterone. They also work to inhibit ovulation, thus preventing pregnancy.

While on birth control pills, a woman's body responds directly to the hormones in the pill, and her endogenous ovarian hormone production is suppressed. Thus, the irregular, frequently heavy, menstrual periods, which are common during perimenopause, can be eliminated. She will bleed in response to the hormones in the pills. The birth control pills also prevent ovarian cyst formation, which is common during perimenopause and is directly tied to irregular ovulation due to erratic ovarian hormone production. Birth control pills are also known to decrease breast cyst formation, and they may also decrease the frequency and intensity of headaches.

Who should not use oral contraceptives for perimenopausal symptoms?

While oral contraceptives can be used in most patients, women who smoke cannot use these products after the age of 35 because of an increased risk of strokes and heart attacks. Additionally, they cannot be used in patients with a history of blood clot formation, breast or uterine cancer, severe migraine headaches, or active liver disease.

Systemic hormonal products (medications)

Systemic hormonal products are products that reach concentrations in the bloodstream that can affect the entire body. Both estrogen and progesterone formulations are available in special situations when treating a perimenopausal woman. If a woman has continued ongoing bleeding, she may be treated with these products to temporarily control the blood loss. In lower doses, they do not suppress ovarian hormone production, resulting in more problematic symptomatology due to hormonal imbalance. Estrogen and progesterone may be taken in pill form or they may be administered transdermally (through the skin) in patches or creams.

Topical vaginal estrogen

These are products that can be inserted into the vagina to relieve the symptoms of vaginal dryness, painful intercourse, and urinary tract dysfunction. These are most appropriate for women who are primarily bothered by these local issues and have no other problems such as irregular vaginal bleeding or hot flushes. Studies have shown that these products are not absorbed into the bloodstream in significant concentrations, so they may be used in women who are unable to use hormone pills or patches in which higher blood estrogen levels are achieved.

Gabapentin (Neurontin)

Gabapentin is a drug that modifies impulse transmission along the course of nerves. It is used primarily in people who have seizures or chronic pain conditions. However, it has some limited efficacy in treating perimenopausal women who cannot use hormone pills or patches because of specific medical conditions (for example, a prior history of blood clot formation or breast cancer).

Antidepressant medications

Antidepressants, primarily of the class of drugs referred to as selective serotonin reuptake inhibitors (SSRIs) have been shown to decrease hot flashes in some patients. This group of medications includes sertraline (Zoloft), fluoxetine (Prozac), and paroxetine (Paxil). They are particularly helpful in patients who have depression and/or anxiety as a part of their perimenopausal symptom complex. They are also particularly helpful in women who cannot take systemic hormones because of medical issues.

Testosterone

When decreased libido is a particular problem in a perimenopausal woman, she may be given supplemental testosterone. This can be given in the form of pills, injections, oral or a subcutaneous pellet. The use of testosterone in peri- and postmenopausal women is controversial, largely because of the side effects some women have while on this therapy. These may include hair loss, acne, oily skin, weight gain, and deepening of the voice.

Black cohosh

This product is a commonly used herbal extract that is touted as a treatment for hot flashes. Multiple studies have shown that it is ineffective. It has numerous side effects, and there have been issues with liver toxicity.

Phytoestrogens

These are naturally occurring estrogens in two forms: 1) lignans, and 2) isoflavones.

Lignans are found in:

• flaxseed,
• Flaxseed oil,
• Whole grains,
• A variety of fruits, for example:
  • Oranges
  • Dried prunes
  • Dried dates
  • Peaches
  • Dried apricots
• A variety of vegetables, for example:
  • Green beans
  • Olive oil
  • Olives
  • Garlic
  • Collards
  • Winter squash
  • Alfalfa sprouts

Isoflavones are primarily found mainly in certain types of legumes, for example:

• Soy products
• Soybeans
• Chickpeas
• Black beans
• Dark miso
• Peanuts
• Pecans
• Red kidney beans
• Refried beans

These chemicals are weak plant-based estrogens that may be helpful in some women who have mild hot flashes. However, they have not been standardized in terms of content and dosage, and they may increase the risk of estrogen-related medical problems, such as breast cancer.

Bioidentical hormones

These are compounded products that are generally prepared by a specialty pharmacy. They are identical in composition to those that are produced in the body and are generally applied to the skin. However, they are not under the regulatory control of the United States Food and Drug Administration (FDA). Their absorption tends to vary among individuals, and therapeutic responses can vary widely from one individual to another. These products are frequently touted as having advantages over commercially available products, but there is no evidence to support this claim. They also tend to be more expensive than branded products.