The Perimenopause Explained
perimenopause is a confusing time for women. The perimenopause
is a distinct transition between the reproductive years and
cessation of menses. This article will hopefully help to explain
and offer treatment options for this often frustrating transition.
The World Health Organization defines the onset of the perimenopause
as the beginning of menstrual cycle changes. Early perimenopause
changes include the first break in regular cycling of menses.
Late perimenopause is classified after missing 3 to 11 months
of menses, while menopause is reached after 12 months of no
menstrual flow. Women usually notice the onset of perimenopause
symptoms during their 40's and irregularities usually persist
for approximately 5 years.
The range of perimenopause symptom duration may be quite variable,
from 2 to 8 years, or even longer(1). In general, the later
in life that perimenopause symptoms begin, the shorter the
transition to menopause. The hormonal changes taking place
probably represent the major cause of symptoms experienced.
These changes can produce many symptoms that are traditionally
thought to only occur after menopause. Changes of the perimenopause
probably results from a decrease in the number of ovarian
follicles (eggs) remaining and the hormonal fluctuations from
one cycle to another. This hormonal fluctuation is best described
as a 'roller coaster' of hormone production and invariable
plays a role in symptom production.
Contrary to popular belief, the perimenopause may be associated
with elevations of estrogen levels. However, these elevations
are generally followed by abrupt falls in estrogen levels.
The constantly changing hormone levels of the perimenopause
can precipitate significant hot flashes and night sweats.
The 'peaks and valleys' of estrogen production during the
hormonal 'roller coaster' invariably contribute to these symptoms.
Other medical conditions commonly seen during the perimenopause
years that can mimic these symptoms are thyroid irregularities
Other commonly described changes during this transition
are related to changes in estrogen production. Vaginal thinning
can lead to discomfort, itching and dryness, and pain with
sexual relations. Urinary complaints include burning, urgency
and frequent urination. Mood changes are very common during
this transition and include irritability, anxiety, depression,
fatigue, and frustration. Hormonal fluctuations may contribute
to these symptoms, although many other reasons can be identified
as a contributor to these symptoms. In numerous instances,
balancing a career, marriage, elderly parents and adolescent
children contribute to these hormonal fluctuations.
The most common early menstrual irregularity noticed
in the perimenopause is a shortening of cycle length. Women
with prior 28 day cycles will commonly describe 24 to 26 day
cycles during the early perimenopause. Eventually, the cycle
length widens and skipping menses typically occurs. These
changes in cycle may lead to heavier flow in the early perimenopause,
followed by a lighter flow and occasional spotting in the
The average age of menopause in the United States
is 51 to 52 years of age, therefore the perimenopause may
start as early as 40 to 45 years of age. Clinically, many
practitioners note a continuum in certain patients. Patients
with significant premenstrual symptoms at 30 to 40 years of
age often proceed to perimenopausal symptoms. Therefore, many
of the treatments for premenstrual syndrome (PMS) are effective
for the perimenopause. According to the Study of Women Across
the Nation, irritability and fatigue are common features of
the perimenopause. Diminished libido and hot flashes also
occur with relative frequency. These hot flashes may be the
classic, intense ones that leave women drenched afterwards.....or
they may be milder with a sensation of warmth and minor sleep
The diagnosis of the perimenopause is based upon
a careful menstrual cycle history and symptom review. Maintaining
a 'menstrual calendar' for 4-6 months will detect a pattern
of changing cycle lengths and flow patterns. Evaluating for
other conditions that are common during the perimenopause
and may mimic symptoms of the perimenopause is also important.
Therefore, thyroid and diabetes testing is prudent. Due to
the rapid fluctuations of estrogen in the perimenopause, the
measurement of gynecologic hormones can be difficult to interpret
and may lead to inappropriate treatment. A commonly used test
(FSH; follicle stimulating hormone) for the diagnosis of menopause
can be especially misleading in the perimenopause. The most
prudent use of FSH testing and estrogen levels during the
perimenopause has not been determined and should always be
used in the context of a person's menstrual history and symptoms.
The transition to menopause can be diagnosed after no menses
for a 12 month period of time and signifies cessation of ovarian
function. Often associated with symptoms, this diagnosis does
not routinely require laboratory testing.
There are a number of proposed treatment options for the perimenopause.
These treatments in large part depend upon the symptom complex
that is most troubling for the individual. There is no treatment
that works well for every person. If your symptoms are dominated
by vasomotor alterations, like hot flashes, certain natural
herbal products work well.
Commonly used products include phytoestrogens such as soy,
red clover derived phytoestrogens and Dong Quai. Black Cohosh
is a natural herbal supplement that has been used for many
years in Germany for menopause and perimenopause symptoms.
It is formulated to work with your body to promote physical
and emotional balance during menopause. Years of clinical
research has shown Black Cohosh helps reduce hot flashes,
night sweats, related occasioal sleeplessness, irritability
and mood swings. Irritability and anxiety can be relieved
with products such as Chaste Tree Berry extract, Kava Kava
and Valerian root.
more about Remifemin brand of Black Cohosh
more about Oona brand Black Cohosh and Chaste Tree Berry blend
A recent study in The British Medical Journal(2) found Chaste
Tree Berry (Vitex agnus castus) was effective and well tolerated
when used to treat the symptoms of PMS. Outcome variables
included women's self assessment of irritability, mood alteration,
anger, headache, bloating and breast tenderness. Mood disturbances
can be treated with products such as St. Johns Wort. Prescription
products that are sometimes useful include low dosed oral
contraceptives, antidepressants such as fluoxetine, as well
as antianxiety products like lorazepam.
Use of oral contraceptives can minimize the fluctuations in
estrogen levels associated with the perimenopause. A study
by Casper, et al from Canada(3) using low dose birth control
pills in the perimenopause found treated women experienced
fewer and less severe hot flashes, less irregular bleeding,
and improved quality of life. The birth control pill should
be considered a primary strategy during the perimenopause
years. For appropriate patients, the birth control pill can
serve to provide relief of perimenopause symptoms, such as
hot flashes, mood changes and night sweats. They also regulate
the menstrual cycle, provide effective contraception, protect
against ovarian and endometrial cancers and prevent bone loss.
Some common concerns among women who are prescribed the birth
control pill include:
- weight gain
- growth of fibroids
- how long to remain on the pill
- breast cancer fears
Fortunately, these fears can be alleviated in most patients.
For instance, studies do not report a demonstrable amount
of weight gain with the new, lower dose pills. Also, the pill
does not cause an increase in fibroid growth. Lastly, a recent
study did not reveal any increase in breast cancer among former
and current birth control pill users. This study (N. Engl
J Med, Vol. 346, No. 26 June 27, 2002) interviewed 4575 women
with breast cancer about birth control pill use and did not
find an increased risk of breast cancer among women 35-65
years of age. Therefore, the birth control pill can be taken
effectively during the perimenopause transition until the
menopause is achieved.
An exceedingly popular strategy for pill use in the perimenopause
is the concept of 'bicycling' the pill. In this manner, a
woman takes 42 active pills followed by 7 placebo (i.e. 'sugar')
pills. This reduces the number of 'periods' by 1/2 and provides
very effective perimenopause symptom control.
A very effective and well tolerated low dose pill that can
be used in the perimenopause is Ovcon-35. In addition to a
low dose of estrogen, Ovcon-35 contains the ‘progestin’
norethindrone. All combination birth control pills contain
a ‘progestin’. The combination of estrogen and
norethindrone in Ovcon-35 results in a low dose pill with
many desirable features. For instance, Ovcon-35 is associated
- a low incidence of break-through-bleeding and spotting
- low incidence of acne, hair growth and weight gain
- excellent cycle control and tolerability
Contraindications to the birth control pill are similar in
all women and include history of myocardial infarction, blood
clotting disorders, stroke, breast cancer or serious liver
disease. Women who use oral contraceptives should not smoke.
Importantly, it is prudent to avoid using the birth control
pill in women who smoke and are over 35 years of age. Oral
contraceptives are not appropriate for all patients, and serious
as well as minor adverse reactions have been reported with
the use of all oral contraceptives
If the perimenopause is being treated with hormones, such
as the birth control pill, then the diagnosis of menopause
can become more difficult. Often, the use of the FSH test
can be quite useful in this circumstance. Measuring the FSH
level on the day before starting a new pack of pills (the
seventh day of the pill-free week) and obtaining a level greater
than 20 may suggest that the menopause transition has occurred.
Lifestyle changes can also be beneficial in the perimenopause.
Proper diet with vitamin and mineral supplementation is vital
for optimal health. Weight loss, tobacco cessation and moderation
of alcohol intake will improve long term health prospects.
Lastly, stress reduction is very important. The peri-menopause
is a period when many changes are occurring in a women's life.
Changes in her family, career stressors, and hormonal fluctuations
can wreak havoc on many women. Stress relief cannot be emphasized
enough to help deal with these multiple factors. Examples
for stress relief include yoga, hobbies, and other forms of
- McKinlay SM, Brambilla DJ, Posner JG. The normal menopause
transition. Maturitas 1992;12:103-115.
- Schellenberg, R. Treatment for the premenstrual syndrome
with agnus castus fruit extract: prospective, randomised,
placebo controlled study. BMJ 2001:322:134-137
- Casper RF, Dodin S, Reid RL, and Study Investigators.
The effect of 20ug ethinyl estradiol/1 mg norethindrone
acetate, a low-dose oral contraceptive, on vaginal bleeding
patterns, hot flashes and quality of life in symptomatic
perimenopausal women. Menopause. 1997;4:139-147.