Perimenopause and menopause. This is the beginning of the chapter for many women leading into the “second journey” of their lives. While the focus is often on hot flashes and irregular menstrual periods, the landscape of hormonal changes is much broader than that. Thus, this guide will help you understand what these changes mean for the female body.
“Perimenopause” is the time when the menstrual cycle is irregular. The word “menopause” marks the end of the last menstrual period. On average, women will be in perimenopause for approximately 4 years during their late 40s to early 50s. Menopause happens at an average age of 51, but many women notice changes in menstruation earlier than that. Some women have their last period as early as their late 30s. “Premature ovarian failure” is a diagnosis that is only made if a woman has her last period before the age of 40. It is often difficult to predict exactly when a woman will have her last period. However, changes in bleeding and in the length of the menstrual cycle are the most important clues that the last menstrual period is approaching. The aim of this guide is to increase awareness of the importance of hormonal changes as women age and to empower women to seek support from healthcare professionals. It will show women how to get to know the changes in their bodies better and how to work with their healthcare professionals to manage any symptoms that might pop up. Just as pregnancy and the “change of life” are natural parts of being a woman, so are the ups and downs of our reproductive cycle.
Perimenopause and Menopause
Perimenopause is a distinct phase in a woman’s reproductive life that signals the transition to less-fertile (and ultimately non-fertile) years. It is referred to as midlife and menopausal because the great majority of women are somewhere between 45 and 55 years old in this period. It actually encompasses 70 percent of most women’s reproductive lives. This initial part of the hormonal shift involves a more rapid drop-off in ovarian hormones, with greater subjective symptoms like flushes, sweats, varying body and joint pain, fatigue, and moodiness. This is why some women actually feel sicker in their 40s than they do in their 50s.
Menopause is defined as being one specific day in a woman’s life: the first day of 12 consecutive months with no menstrual cycle. The subsequent years are referred to as “postmenopause.” Menopause is a life stage that is identifiable and has defining criteria: 12 consecutive months without a period because you don’t have a uterus, your ovaries have stopped working, or because you’re 48 (or some other age). At any one time, women’s menopause or perimenopause experiences vary widely. Some have significant symptoms during the reproductive years, while others have no symptoms. Conversely, some women have virtually no symptoms during the perimenopause/menopause and many develop them postmenopausally. Some women have painful or problematic periods for only a year or two, while others say they have symptoms for six to eight years before or around the last period. Many women have their worst symptoms in year 3 or 4 of hot flashes, moodiness, and the other complaints, and then improve greatly.
Hormonal Fluctuations and Symptoms
Preparing for this “slow and stealthy” menopausal transition is perhaps most difficult because many women do not have the advantage of understanding what is happening to their bodies. The symptoms women experience, and when they experience them, are all connected to changing hormonal levels. As a way to prepare for the inevitable, it is helpful to keep in mind that women in this age group, which is generally 35 and older, do fluctuate in their hormonal levels.
To best address the symptoms of perimenopause and menopause, it is important to understand what is happening. The main hormones that fluctuate, or decline, are estrogen and progesterone, while the ovaries are still functioning for the most part. But these age-related changes in hormone levels vary from woman to woman. Some may experience diminished levels of estrogen and others diminished levels of progesterone. Others may continue to produce a progesterone-estrogen combination or double the amount of estrogen to progesterone. At some point, though, most women will not have the surge of estrogen around days 12 to 14 in the cycle that signals ovulation. This variance can cause a variety of symptoms. To make matters more complicated, these fluctuations do not naturally occur for all women. There are not only physical symptoms, such as the often talked about hot flushes and sleep disturbances, but also emotional symptoms. These emotional symptoms are often challenging for women because of societal and perceptual attitudes towards women who are coping with their mental health, both from the women themselves and others around them. Women experiencing mood shifts or often feeling sad should seek medical care, as there are medical illnesses that can cause mood changes.
Understanding the Menstrual Cycle
Every month, an adult woman’s body navigates through four phases of hormones and change. After bleeding, estrogen begins to rise in preparation for ovulation when the ripest egg in a cohort of follicles is released. After ovulation, the shells of the follicle from which the egg was released become the corpus luteum, which is a small gland that produces a lot of progesterone and a little estrogen to prepare the interior of the uterus for pregnancy. If pregnancy does not occur, the ripening and release of an egg are prevented, and the corpus luteum dies, leading the body to discard the lining of the uterus. After bleeding ends, estrogen begins to rise in the follicular phase. Normally around day 10, estrogen sends the signal to the brain to thicken cervical mucus, “ripen” the endometrium with tailored blood vessels, and prepare the lining of the uterus to receive the egg. Ovulation is triggered when the high levels of estrogen eventually send a signal to the brain to surge with luteinizing hormone. During ovulation, the egg is released and swept into the fallopian tube. The shell that held the egg, called the follicle, seals the entrance to the fallopian tube to prevent another egg from fertilizing on top of the egg. In the luteal phase, the now-empty follicle that once held the egg becomes the corpus luteum. It is a small endocrine gland that will signal the body to keep the lining of the uterus intact if pregnancy should occur. If pregnancy does occur, estrogen and progesterone continue to rise during early pregnancy until the placenta fully forms.
Phases of the Menstrual Cycle
The menstrual cycle can be divided into several main phases. The follicular phase begins on the first day of menstruation and can last anywhere between 12 and 21 days, or even longer. During the follicular phase, the levels of estrogen, a sex hormone primary to female reproduction, start to increase. Estrogen prepares the woman’s body for ovulation. Ultimately, ovulation marks the beginning of the second phase, known as the luteal phase, which typically lasts for 12 to 16 days. In response to the increase of estrogen, the pituitary gland starts to secrete luteinizing hormone and follicle-stimulating hormone.
Follicle-stimulating hormone and luteinizing hormone control the menstrual cycle and act on the ovaries, which release a matured egg to be fertilized by sperm. Around the 14th day of the menstrual cycle is when ovulation usually occurs—although this can differ from woman to woman. The phase leading to ovulation is known as the periovulatory phase. It is marked by a peak in luteinizing hormone and estrogen levels. Due to the roles of these chemicals in mood, some experts argue that periovulatory hormonal changes affect the brain, leading to behavioral changes. Following ovulation, the level of estrogen starts to decrease, while the hormone progesterone rises. Together, estrogen and progesterone prepare the uterus in case of pregnancy. After some time, if the egg does not get fertilized, hormone levels drop, and the woman gets her period. Tracking these menstrual cycle phases is essential because it gives insight into a woman’s general reproductive health and can signal imbalances in sex hormones. When the menstrual cycle is not regular, it can be a sign that female hormones are out of balance. This leads to menstrual imbalances and can result in perimenopausal symptoms.
Physical and Emotional Symptoms of Perimenopause and Menopause
One reason why the perimenopause-to-menopause experience is so challenging for some women is that the range of symptoms runs the gamut from physical malady to emotional despair. At the end of the day, moodiness and night sweats can be equally distressing. One happens to your mind, the other to your body, but they both significantly impact your daily life. These symptoms are often experienced by overweight or obese women in Western countries, although menopausal symptoms can affect a woman of any size.
Some of these symptoms include: physical symptoms (hot flashes, night sweats, vaginal dryness, incontinence, decreased libido, headaches, weight gain, hair loss, dry skin, acne, brittle nails, irregular periods, vaginal odor), emotional distress (problems with short-term memory and focus, anxiety, depression, crying spells, mood swings, irritability, panic attacks), and pain (headaches, arthritic pain or stiffness, hot flashes induced by a drop in estrogen, heavy bleeding, and menstrual pain). It is important to understand that all of these explanations are not to suggest that the emotional and psychological aspects don’t need to be tended to, but they often manifest as physical symptoms. While it’s clear that the mental aspects of going through perimenopause and menopause need to be addressed, women need to be prepared for all aspects of this often-difficult transition, not just the emotional. The more open the discussion is about these topics and explorations of the physical symptoms, the more women can share and understand, the less stigma and silence will envelop them, and the more outside support they’ll seek and receive.
Common Physical Symptoms
The hormonal changes of menopause and the years leading up to it can cause a myriad of symptoms in many women. Probably the best known of the menopausal symptoms, a lot of attention has been given to hot flashes. Hot flashes are brief episodes of feeling very warm, flushing, and sometimes sweating. Night sweats are the nocturnal form of hot flashes, causing awakenings from sleep in up to 60% of menopausal women and contributing to fatigue, mood swings, and often outright depression. Sleep disturbances are reported by up to 8 in 10 women transitioning to menopause even in the absence of hot flashes, and they are a source of great distress for these women. Again, early morning awakenings due to poor sleep quality can contribute to mood disturbances, fatigue, and depressed feelings, and these are very common menopause symptoms. Sleep needs can actually increase during menopause by 25%. Worsening or the onset of snoring can develop either during or shortly after menopause, as the hormonal changes can reconfigure fat deposits in the neck. Pay attention to these findings for possibly sleep apnea-related symptoms: complaining of fatigue and tiredness, needing frequent awakenings to void, loud and disruptive snoring, fits and starts in breathing during sleep, and being overweight. Menopause body aches include low back pain, joint pain, and occasional arthritis stiffness symptoms in some women entering menopause. These occurrences are standard in women diagnosed with fibromyalgia during this time, and fibromyalgia is much more common in women than men overall. People diagnosed with fibromyalgia have body aches throughout many tender points on the body, and the velvet underside of the ear is a particularly tender point to touch.
1. These common physical menopausal symptoms can greatly vary in intensity and duration, be very mild or a severe sleep disrupter, and last for a few months or hang on for many years. 2. Becoming informed about possible changes can be empowering and serve to lessen anxiety if the changes occur. 3. Clarity on hormone replacement therapy and other available options to treat complications of menopause with a healthcare provider is appropriate and should be sought if problems arise. However, many women either cannot take estrogen or would rather not. There are many other highly effective treatments to improve and relieve these hot flash and menopause-associated symptoms. Few women are without remedy. Root causes of skin persist, but one therapy is highly effective at relieving hot flash symptoms.
Emotional and Psychological Changes
While many people are familiar with the physical symptoms associated with perimenopause and menopause, the emotional and psychological changes that often go along with them are more complex. Many people experience a variety of mood swings, from intense anger to deep sadness in a short amount of time due to rapidly fluctuating hormone levels. Because declining levels of estrogen can also impact the autonomic nervous system, some people living with this fluctuation in hormones will also report increased feelings of anxiety. Finally, self-esteem can also decrease throughout perimenopause, menopause, and postmenopause due in part to the loss of fertility and cultural attitudes about aging and women’s sexuality. Symptoms of menopausal mood changes can impact quality of life, functioning, mental health, and disrupt already existing mental health conditions.
Knowing what to expect can be very helpful, as those who are aware of the context of perimenopausal mood changes may feel more equipped to cope and be more resilient. Ideally, we would all feel psychologically prepared to expect these changes and also discuss them openly with others. Unfortunately, the highly emotional and psychological origins of these feelings often take women by surprise and can cause feelings of shame, confusion, and distress. Discussing mental and emotional well-being can be seen as a taboo topic during perimenopause and beyond. Emotional symptoms are often as impactful — or even more so — than the physical ones. It is very important to name and normalize these feelings, understand the roots, acknowledge the complex biological, social, and psychological factors, build resilience, and discuss effective coping strategies for emotional changes through the support of health care providers. It is absolutely okay to not feel okay and right to seek support.
Managing Hormonal Changes
So, what can be done about these hormonal changes? More than you might have previously thought. While it requires more than changes in lifestyle, counseling and treatments for the symptoms of hormone changes in menopause can incorporate a range of options that aim to address our diet and nutrition needs, our need for physical activity, and our individual response to stress. In this way, hormonal changes in menopause are just another part of our health that benefits from an integrated approach. There’s no one perfect diet for hormonal changes, and it’s not typically associated with weight gain, despite women’s fears. But lifestyle changes can help you reduce the severity of your complaints to manageable levels. A registered dietitian can help individualize this. Similarly, exercise is important for mental health, energy, and sleep, with benefits that extend to menopause as well. Getting enough sleep is important, as is stress management, including social support and engagement.
Alternative or natural therapies can be very helpful for many women with hormonal symptoms, if that’s your thing. Acupuncture has some good evidence behind it for the treatment of hot flashes. A head-to-head comparison with hormone therapy showed comparable benefits. Yoga and meditation are also good ways to help learn to cope with stress and can help with feeling better about our sexual selves as well. Many of the same supplements that play a role in good health—a good diet, healthy weight, not smoking, and some mix of exercise and good sleep—should be the mainstay of health across menopause. But in addition to this, for people with mood symptoms, hormone replacement therapy has been a controversial but consistently effective treatment. For hot flashes, hormone replacement therapy is the most effective intervention we have—hands down. Hormone replacement therapy is also the best treatment to try first for people experiencing vaginal dryness, itching, and discomfort. But once a woman is more than 10 years postmenopausal, there’s less evidence that hormone replacement makes a difference in these menopausal symptoms. Hormone replacement therapy is also a very individual decision. Some people feel it is right for them and experience a light menstrual flow. Some people feel that it makes their heavy menstrual flow less manageable. With any hormonal changes, weigh things alongside your health history. What are your risks and what are the potential symptoms you have? Then go a step further. If you think hormones might be right for you, then you can potentially go down the route of discussing your blood clot and heart risk with your health care provider. Do you need a medication? HRT is just one of many treatments you might consider and only one of many that we can help guide your choice. There are a multitude of different therapies, from other pharmaceuticals to talk therapy or other non-pharma approaches. But that way forward doesn’t start with the decision about hormones. It starts with a conversation with a knowledgeable provider. Because managing your menopause is about so much more than just your hormone levels. It’s about you.
Lifestyle Changes
Reducing starchy and sugary foods, packaged meals, fried foods, and added sugars, while factoring in sources of healthy fat and protein, can help alleviate perimenopausal symptoms. Weight-bearing exercises and strength training may contribute to the prevention or reversal of osteopenia and osteoporosis. While hot flashes might be exacerbated or triggered by exercise, it is recommended that exercise is paired with lots of water and during times of the day when the outside temperature is more moderate. Exercise has also been demonstrated to alleviate symptoms of anxiety, depression, hot flashes, irritability, and night sweats. Stress reduction techniques such as nature outings, massage, yoga, tai chi, or deep breathing relaxation exercises, and association with those who are willing to listen, be it friends, family, or a counseling professional, can be incredibly helpful.
It is suggested to hear about the benefits received from stress reduction activities from friends or relatives. Additionally, meditation and mindfulness-based stress reduction techniques can help regulate the emotional symptoms associated with perimenopause or menopause. Lifestyle changes in perimenopause and menopause, as in most good management strategies, are about empowering you to make positive changes. None of us is very enthusiastic about it, but it will make a big difference in how we feel. Some women may be sacrificing silence and sleep to take care of the family. But it is never too late to start taking better care of yourself. Even some occasional adjustments to your lifestyle will make a significant difference. Strive to create changes and habits that you are comfortable and happy with. Community engagement can involve consulting your local parks and recreation page or press for classes and programming to learn more.
Medical Treatments
There are a variety of medical treatments that can help manage perimenopausal and menopausal symptoms, but the biggest medical research has been in the area of Hormone Replacement Therapy. Most of the research has shown that it is very effective for preventing and treating symptoms such as hot flashes, mood changes, and vaginal dryness. Hormone Replacement Therapy can also be a treatment for more difficult symptoms, such as sleep disturbances and reducing the risk of bone loss and fractures. There also seems to be a general trend toward better health in women who use Hormone Replacement Therapy, but there are potential increased risks of diseases such as heart disease and an increase in breast cancer. It is important to see a healthcare provider who can consider your health history and priorities and weigh the benefits of Hormone Replacement Therapy, which on the whole far exceed the risks, on a personally tailored basis.
There are also many non-hormonal medications that may be helpful in managing symptoms that are more common during perimenopause and menopause. For example, medications such as SSRIs and SNRIs are often used effectively to treat mood changes. Some women may also benefit from these compounds for advanced treatments of bothersome and mood-related hot flashes accompanied by anxiety. There are also a variety of non-hormonal medications such as low-dose gabapentin that can help prevent or eliminate hot flashes for some women. Overall, it is important to talk to a trusted healthcare provider to weigh the risks and benefits before starting any medical treatment to reduce or eliminate menopause symptoms. Most of these medications require continual rather than as-needed use to see any benefit. The effectiveness of any of these treatments varies by person, so it may take some time and patience to find what works best for you. Ideally, a consultation with a trained healthcare provider who focuses on individualized care and also has expertise in menopause and perimenopause management is ideal to help guide your way.
In this guide, we’ve walked through some of the hormonal changes that happen in women’s lives, with a concentration on perimenopause and menopause. As you move through these different sections, we talked about how understanding what’s happening can give you more control over what’s happening. It’s important to understand, as well, that hormonal events can be quite different from woman to woman.
We also know starting a conversation with a healthcare provider – one who understands these specific issues – can make a huge difference for you. Knowing the important role that our hormones play in our lives lets us be more involved in taking charge of how we want to address the signs of this important life stage. Over and over again, it’s clear that understanding the issues and talking with others about them makes a difference. You are not alone.
Looking ahead, the more we learn about the hormones that are active in our bodies, the more we will know how to promote healthy body systems. There is a great deal of research going on, and a lot more to be done. Growing our dialogue will lead to even more information, with women everywhere working together, exchanging ideas and sharing information on what has worked for them. If we are informed and empowered, perimenopause and menopause can be an exciting time to explore new pathways of health and lifestyle. It is a time when we can finally have the freedom and power to focus on ourselves.