Not Yet!: Exploring Peri-Menopause
When I tell women I’m a menopause provider, one of the most common responses I hear is “Not yet for me! I’m still getting periods” and then they list a whole host of peri-menopausal symptoms they are having. In our society menopause seems to evoke an image of a cranky woman in her 60’s with hot flashes. So far from the truth! Having (and managing) symptoms of menopause is not reserved exclusively for women who aren’t having periods any more. In fact, MANY women with bothersome symptoms would benefit from hormonal treatment prior to their final menstrual period (and well before they turn 60!).
There are three stages to menopause:
1. Peri-menopause (the menopause transition): the period of 5-10 years before the final menstrual period. Often diagnosed by changes in the menstrual cycle but can be diagnosed by other symptoms
2. Menopause: the final menstrual period marks this, however it can only be diagnosed in retrospect. You don’t know it’s your last period until you haven’t had a period in a year
3. Post-menopause: The time period after the last menstrual period. The terms menopause and post-menopause are often used interchangeably.
Menopausal symptoms are most common in the late peri-menopausal time and then 5-10 years after the last menstrual period however there is significant variability from person to person.
Early peri-menopause is most often defined as a time period when the time in between periods lengthens by 7 days. In a woman having regular cycles, it can also be defined having any 3 of the following symptoms:
New onset heavy and/or longer flow
Shorter menstrual cycles (<26 days)
New sore, swollen or lumpy breasts
New mid-sleep wakening
Increased cramps
Onset of night sweats, particularly premenstrual
New or worsened migraines
New or worsened premenstrual mood changes
Weight gain without changes in exercise or diet
If a woman is young and experiencing these symptoms, her physician may conduct several tests to eliminate the possibility of other causes. These tests may comprise of a pelvic ultrasound, thyroid testing, as well as other hormonal testing like prolactin, estradiol, progesterone, FSH, and LH.
When it comes to managing peri-menopausal and menopausal symptoms, estrogen therapy is considered the gold standard treatment. There are various ways to take estrogen, and the dosages can vary. For women with a uterus, it's essential to add progesterone to estrogen therapy to safeguard the uterus. Taking estrogen alone, without progesterone, can increase the risk of pre-cancer and cancer of the lining of the uterus (endometrial cancer). Besides protecting the uterus, progesterone has additional benefits such as improving sleep and reducing anxiety in peri-menopausal and menopausal women.
The treatment of symptoms during menopause varies from person to person and depends on whether or not contraception is necessary. Standard hormone therapy for menopause is not effective in preventing ovulation or pregnancy. Therefore, it is crucial to use contraception until the final menstrual period has passed, as pregnancy has been documented in women even in their 50s, although it is rare. Low dose birth control pills can be a viable option for many women of reproductive age, as they can prevent pregnancy and alleviate peri-menopausal symptoms. These pills can be taken until the early 50s. Alternatively, progestin-containing IUD and estrogen replacement therapy can also be considered as treatment options.
For women who don't need contraception but still have a uterus, there are several options available. These include using progesterone only during specific days of the month, a combination of estrogen and progesterone, or non-hormonal medications. In some cases, we may recommend that women in peri-menopause cycle their progesterone (use it during only half of their cycle) to reduce irregular bleeding.
Women without a uterus don’t technically require progesterone therapy and so estrogen therapy alone is an option. However, some women can benefit from the off-label prescribing of progesterone for the sleep and mood effects.
Peri-menopause is often undiagnosed and undertreated, causing women to suffer unnecessarily. As usual, find a provider who will LISTEN to your symptoms and take them seriously. If your provider doesn't hear you, don't be afraid to find a new one.
