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The Perimenopause Explained

The 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 and diabetes.

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 later perimenopause.

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 disturbances.

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.

Learn more about Remifemin brand of Black Cohosh

Learn 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:

  1. weight gain
  2. growth of fibroids
  3. how long to remain on the pill
  4. 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 with:

  1. a low incidence of break-through-bleeding and spotting
  2. low incidence of acne, hair growth and weight gain
  3. 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 exercise.


  1. McKinlay SM, Brambilla DJ, Posner JG. The normal menopause transition. Maturitas 1992;12:103-115.
  2. Schellenberg, R. Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randomised, placebo controlled study. BMJ 2001:322:134-137
  3. 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.