June 18th, 2012 by Hasham

Perimenopause: Rocky road to menopause

You’re in your 40s, you wake up in a sweat at night, and your periods are erratic, and often accompanied by heavy bleeding: Chances are, you’re going through perimenopause. Many women experience an array of symptoms as their hormones shift during the months or years leading up to menopause — that is, the natural end of menstruation. Menopause is a point in time, but perimenopause (peri, Greek for “around” or “near,” + menopause) is an extended transitional state. It’s also sometimes referred to as the menopausal transition, although technically, the transition ends 12 months earlier than perimenopause (see “Stages of reproductive aging,” below). Perimenopause has been variously defined, but experts generally agree that it begins with irregular menstrual cycles — courtesy of declining ovarian function — and ends a year after the last menstrual period.

Perimenopause varies greatly from one woman to the next. The average duration is three to four years, although it can last just a few months or extend as long as a decade. Some women feel buffeted by hot flashes and wiped out by heavy periods; many have no bothersome symptoms. Periods may end more or less abruptly for some, while others may menstruate erratically for years. Fortunately, as knowledge about reproductive aging has grown, so have the options for treating some of its more distressing features.
Dance of the hormones

The physical changes of perimenopause are rooted in hormonal alterations, particularly variations in the level of circulating estrogen.

During our peak reproductive years, the amount of estrogen in circulation rises and falls fairly predictably throughout the menstrual cycle. Estrogen levels are largely controlled by two hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH stimulates the follicles — the fluid-filled sacs in the ovaries that contain the eggs — to produce estrogen. When estrogen reaches a certain level, the brain signals the pituitary to turn off the FSH and produce a surge of LH. This in turn stimulates the ovary to release the egg from its follicle (ovulation). The leftover follicle produces progesterone, in addition to estrogen, in preparation for pregnancy. As these hormone levels rise, the levels of FSH and LH drop. If pregnancy doesn’t occur, progesterone falls, menstruation takes place, and the cycle begins again.

Menopause and Perimenopause – Treatment Overview

Menopause is a natural change that doesn’t require treatment. But symptoms of hormonal change can be difficult. If you have insomnia, mood swings, hot flashes, cloudy thinking, heavy menstrual periods, or other menopause symptoms, treatment can help you manage this transition more comfortably. As you review your options, consider the following:

Healthy lifestyle habits will help you reduce menopause symptoms. These habits include eating a balanced diet; reducing stress; getting regular exercise; and avoiding smoking, heavy caffeine, and heavy alcohol use. An unhealthy lifestyle can make symptoms worse.
Low-dose hormone therapy (HT) or low-dose birth control pills may be an option if you are still having periods and have multiple or severe symptoms. Birth control pills aren’t used after menopause because they contain higher levels of hormones than women need.
After menopause, hormone therapy can be used as a short-term treatment for severe symptoms when taken in as low a dose as possible.
You may only need a specific treatment for certain symptoms, such as hot flashes or vaginal dryness.
Meditative breathing or supplements such as black cohosh or soy may help relieve symptoms.

Research has led to a big change in how doctors use hormone therapy after menopause. For a long time, estrogen-progestin, or hormone replacement therapy (HRT), was thought to protect against heart disease or dementia. But for a small number of women, HRT may increase the risk of certain health problems, such as blood clots, heart disease, or stroke.5, 6 The heart disease risk does not seem to affect women during their first 10 years after menopause.7

Average HRT- and ERT-related risks are low among the general population of women. But your personal risk that hormone therapy may stimulate breast cancer, ovarian cancer, cardiovascular problems, blood clots, or neurological changes may be lower or higher, depending on your risk factors for those health problems.

Hormone Therapy for Menopause and Perimenopause

Not long ago, a friend told me about a coffee date she’d had with a 50-something former office mate, Susan. As the two women were sipping their lattes and catching up on each other’s lives, Susan nervously glanced around the coffee shop, then leaned across the table and confided in a low voice, “I’m taking estrogen.”

So it’s come to this. Whereas women once chatted openly about their hormone-therapy regimens, they now confess their dependence on estrogen in a whisper, as though it were an illicit street drug. Chalk it up to the 2002 report from the Women’s Health Initiative, when researchers announced that the popular drug Prempro — a combination of estrogen and progestin — raised the risk of breast cancer, stroke, heart attack, and blood clots. The study was stopped, and millions of women threw away their hormones.

But then came what sounded like a reversal: In 2004, additional WHI data crunching showed that women taking estrogen alone were not more likely to develop breast cancer or have heart attacks (though the higher risks for strokes and blood clots still stood). And just last year, two studies on women in their 50s suggested that taking estrogen alone might actually protect middle-aged women’s hearts.

Even researchers have been scrambling to sort out what’s behind the seeming contradictions. Is it the type and mix of hormones that are making a difference? The timing of when women start hormone therapy and how long they stay on it? All of the above — and more?

Answers are still coming in, but meanwhile, thanks to studies already completed, doctors today have a more nuanced understanding of how to weigh the benefits and risks of taking hormones. Better information is helping them tailor prescriptions to individual patients. And an ever-growing number of new formulations offer options that may minimize dangers while still easing the often stormy passage through perimenopause and menopause.

The Long Goodbye

Typically, perimenopause starts in your 40s. It may take mere months or drag on for years. During this time, your ovaries shrink, causing drop-offs in the amount of estrogen and progesterone circulating in the bloodstream. But don’t think “gentle, steady decline.” Rather, hormone levels spike and sputter. That’s why periods become irregular or sometimes shockingly heavy. It also may be why some women struggle with irritability and moodiness that echo PMS but strike more randomly and, frequently, more often. Somewhere between 45 and 55, perimenopause becomes true menopause, which is confirmed only after 12 months pass without a period. After menopause occurs, estrogen and progesterone flatline at a low, even state that many women find more comfortable than the sudden fluctuations.

Not that every woman is miserable during the transition. Right now, Charlotte Pierce, a 51-year-old mother of two who runs a home-based publishing company, is only mildly bothered by irregular periods and occasional forgetfulness. That’s true for plenty of women, says Margery Gass, M.D., director of the University Hospital Menopause and Osteoporosis Center in Cincinnati. You’re just less likely to hear about those who cruise through with little disruption to their lives.

But if you’re less fortunate than Pierce, there is help, whether you’re struggling with wildly unpredictable periods, annoying hot flashes, or sexual difficulties. What will work best depends on your symptoms. Here’s a guide to the new hormone decisions you may confront.

If You Have Irregular or Heavy Bleeding

Early in perimenopause, the time between menstrual cycles frequently shortens. Later, it’s typical for cycles to both shrink and expand as out-of-whack hormones stop triggering ovulation and releasing progesterone like clockwork. Skipped periods are common, sometimes contributing to heavier bleeding in the next cycle. Don’t be fooled by those missed months: Pregnancy is still a real possibility.

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