Let’s start with the basics: Perimenopause is not premature ovarian failure (POF) or early menopause. It is the time leading up to menopause — a transition period that can last for years.
It’s part of the natural progression your body makes as it shifts from being fertile to infertile, as your ovarian hormones begin cycling down and your eggs being dwindling.
This helpsheet will help you understand perimenopause — what it is, how to figure out if you’re going through it, and how to cope. Here’s a quick snapshot of what’s happening in your body during perimenopause:
As you get older, your ovarian follicles are aging as well. They produce less and less estrogen and progesterone and, in response to this, your pituitary gland secretes higher and higher levels of FSH (follicle stimulating hormone) and LH (luteinizing hormone).
It’s your body’s attempt to get your ovaries working as they used to — an effort to get your ovaries to continue developing follicles which, in turn produce estrogen… and then, after ovulation, progesterone too. And, for a number of years, this actually works.
The increased FSH and LH levels do keep the “ovary factory” running. But over time, the levels must continue increasing to get the job done — and ultimately, the FSH and LH fail to kick off the production of enough estrogen and progesterone.
Usually, FSH levels begin rising about 5 years before actual menopause; and LH levels rise a bit later than this — about 1 year prior to menopause. Estrogen levels begin declining, but often this occurs later in the continuum — much closer to actual menopause.
Summary
In an effort to maintain declining ovaries, your pituitary gland secretes follicle stimulating hormone (FSH) and luteinizing hormone (LH) in increasing quantities. Over time, however, estrogen and progesterone levels fall anyway as you approach menopause.
The Emergence Of Symptoms
Because of the shifts in hormone production, perimenopause is hallmarked by the emergence of symptoms — changes in your period, hot flashes, mood swings, all those things that are often referred to as just plain menopause.
Unlike full-fledged premature ovarian failure (POF) or early menopause (EM), when you’re in perimenopause, you often ovulate and you typically still are producing estrogen at higher than post-menopausal levels. In fact, most often, you’ll be producing hormones that test in the “normal” range — one of the reasons this can be a difficult condition to diagnose.
This is a crucial difference between perimenopause and POF or EM. And it’s one of the reasons, if you’re still in your late 30s and think it might just be perimenopause, to ascertain your hormone levels — particularly your estradiol levels.
For more information on hormone levels, go to Hormone Tests.
Most doctors concur that women with POF or EM should replace their hormones until the normal age of menopause, as there are numerous consequences for a woman faced with years of low estrogen. Perimenopause, on the other hand, isn’t marked by these extremely low estrogen levels.
Yes, your levels might be dropping but they’re still typically in what’s considered the average range. This is why there’s a distinctly different approach to coping with POF or EM on one hand, and with “normal” perimenopause on the other.
Summary
Unlike early menopause, perimenopausal women tend to have estrogen levels that test in the “normal” range to begin with. Hormone testing is therefore a useful diagnostic tool to explore with your doctor, because it can help you determine an appropriate treatment plan to fight back against symptoms.
More Information
• Most women begin perimenopause in their mid-to-late 40s, but some women do begin noticing symptoms in their early 40s or even their late 30s.
• On average, perimenopause lasts about six years, but it can be as short as one year, or as long as ten or more.
Frankly, perimenopause is a very inexact thing to predict — so it’s one of those situations — “there’s no knowing how long it will last until you’re through it”.
Perimenopause is “officially” over when you have your last period — and haven’t had another in at least a year. At that point, you’re considered to be post-menopausal and the transition is complete.
It’s the logical question — but, unfortunately, it’s not always an easy question to answer. As stated above, most women begin perimenopause in their mid-40s or later, but some do begin seeing symptoms in their late 30s or early 40s.
So age is probably the first tip-off:
• If you’re younger than your late 30s, it’s likely not perimenopause, but rather the beginning of premature ovarian failure (POF) or early menopause (EM). In this case, it’s important that you see your doctor and ask for testing.
• If you are in your late 30s or early 40s, then it could be perimenopause… or it STILL could be POF or EM. Again this illustrates the importance of working with your doctor to establish a diagnosis.
Usually, you get the indication that something is going on differently with your body when you notice changes in your period. This is one of the most common symptoms to appear. Sometimes, in the earliest stages of perimenopause, your cycle length shortens. In other words, your period comes more frequently — every 25 days, say, instead of ever 28.
You’ll notice changes in your flow — often your bleeding will be heavier; other times lighter. As time goes on and you get closer to menopause, your periods often become more irregular and you might even begin skipping periods from time to time.
And, as menopause comes even closer, the frequency of skipped periods increases. About 75% of women will notice their cycle length slowly increase — from the norm of 28 days to 60 days — usually in the last 5 years before menopause itself (source).
Progressing further, your periods become less and less frequent, skipping periods becomes the norm (not the exception), and you ultimately pass through menopause itself, the last period you’ll have. (Note: In this case, you’re not considered post-menopausal until one full year has passed since your last period).
In addition to changes in your period, you might also notice other symptoms of hormone fluctuations — such as hot flashes, night sweats, mood swings, and changes in body-fat distribution. Vaginal dryness often increases too as a result of slowly dropping estrogen levels.
Summary
The only way to firmly establish what’s happening with your body is to consult your doctor and get testing. Perimenopause is a more likely scenario if you’re in your 40s and you’ve noticed the onset of common symptoms, particularly changes in your period.
The Hormonal Side Of Perimenopause
One key thing to remember: in perimenopause, your hormones are gradually transitioning to post-menopausal levels, just as your ovarian function is gradually winding down.
It’s not a sudden shift in hormone levels, but a progression — which is one of the main reasons that symptoms can vary greatly.
However, hormone levels do bounce around quite a bit in perimenopause, so it’s not unusual to have these symptoms one month (or one day!) and feel perfectly fine the next. This is in contrast with POF or EM. In these cases, typically your symptoms remain more stable.
Some researchers have linked body type with the the severity of menopausal symptoms. The theory developed from the observation that fat cells can both store and produce estrogen. However, evidence as to whether heavier women have more or fewer symptoms to date has been contradictory.
Interpreting Hormone Test Results
If you’re in your late 30s or early 40s and begin noticing symptoms arise, you will still want to ask your doctor to test your hormone levels — particularly your follicle stimulating hormone (FSH) levels. As your ovarian function starts to wind down, your FSH levels usually start to rise.
This is especially important if you’ve begun skipping periods, as there is a chance that what you’re experiencing isn’t plain old perimenopause, but rather the onset of premature ovarian failure or early menopause.
As we mentioned though, in perimenopause your hormones can fluctuate a great deal. This means there’s a chance that when you get your blood drawn for a hormone test, your levels will appear completely normal even though you certainly don’t feel normal. So some doctors might slough off your complaints, since they’re not corroborated by your test results.
In this case, you have a few options:
• You might want to consider getting your FSH tested again, at least a month later. This is especially recommended if you have actually begun to skip periods.
• In addition, many doctors feel it best to not go by an FSH test alone, but also think testing other hormone levels (particularly estradiol) can give a better picture of whether or not you’re dealing with perimenopause or with POF.
While some women may begin noticing symptoms of perimenopause as early as their late 30s, it’s not terribly common to have low estrogen levels at this point, since low estrogen tends to occur very close to actual menopause. It’s also wise to get your thyroid levels tested, as the symptoms of thyroid disease overlap with those of menopause.
You can find more helpful information regarding hormone testing on our Hormone Tests helpsheet.
Understanding Your Hormone Levels
If you do get tested and learn that your hormone levels are either normal or not at post-menopausal levels, but getting closer (and you’re getting symptoms), then chances are that you’re in perimenopause.
• If you learn that your levels are at post-menopausal levels, then — again — it’s wise to get re-tested at least once more. This should be at least one month later (on cycle day 3 if you’re still bleeding). This will help determine with higher accuracy whether you’re dealing with premature ovarian failure (POF) or early menopause (EM) rather than perimenopause.
How To Deal With Perimenopause
Because perimenopause is a natural transition — something that is “normal” for lack of a better term, there’s quite a bit of latitude in terms of treatment options, and quite a bit of debate!
The key with treating perimenopausal symptoms is focused on maintaining quality of life. This is different to the situation faced by women with POF or EM, who may replace hormones in part to tackle long-term health risks associated with extended exposure to low estrogen.
With perimenopause, the issue is “how do you feel?” not “what will the consequences be (of low estrogen down the line)?”
Along these lines, the main concern when it comes to coping with perimenopause is the severity of your symptoms. Many doctors prescribe low-dose birth control pills or, more recently, low-dose hormone replacement therapy.
Low-dose Birth Control Pills
This is probably the most common method of coping with perimenopausal symptoms. The pill suppresses the production of ovarian hormones and so regulates your period (which is typically very irregular at this point) in addition to preventing pregnancy.
Today’s low-dose oral contraceptives that combine estrogen and progestin not only prevent pregnancy but may also help lift perimenopausal symptoms. Keep in mind, though, that use of birth control pills is generally not recommended for women with a history of blood clots, heart disease, hypertension, breast cancer or for those who smoke.
In addition, because birth control pills supplant your own ovarian cycle with the schedule of the pill and also hides the symptoms of lower hormone levels, it’s sometimes difficult to determine when you indeed have gone through actual menopause.
Remember, the estrogen in birth control pills is much more potent than that used in regular hormone replacement therapy — so doctors often advise that you go off birth control pills and either onto hormone replacement or no replacement in due course.
Generally, it’s recommended that when you reach the average age of menopause (age 50 or so), you either simply switch off of birth control pills, or get your FSH levels taken (either on the placebo week of the pill or after taking a complete break from the pill for a while) to determine whether you are indeed menopausal at this point and whether it’s time to go off the pill.
Low-dose Hormone Replacement
This is another prescription method of dealing with perimenopausal symptoms. In this case, you’re put on low doses of the HRT used for post-menopausal women. More and more hormones are now available in low doses (particularly since the Women’s Health Initiative study) so there are numerous options.
The treatment is usually intended to help mitigate the dropping levels of estrogen in your own body, thus helping to ease the transition.
The only problem with this?
Because you are still producing ovarian hormones of your own and because some perimenopausal women are actually sometimes producing “normal” levels of these hormones, there’s the chance that these additional low-doses provide an unnecessary hormonal influx (of hormones you may already have in sufficient quantities).
On the other hand, however, low doses can help greatly with symptoms. Again, it’s a matter of choice, personal preference, and your own specific situation. This also once again illustrates the importance of working with your doctor to tailor a treatment plan to your needs.
Non-prescription Coping Strategies
There are, of course, non-prescription ways of coping with symptoms. Generally women will use these in an effort to deal directly with symptoms without resorting to hormone replacement.
Probably one of the best methods of symptom control is through phytoestrogens — such as flaxseed or soy. Phytoestrogens are very weak plant hormones that mimic (to a much lesser degree) the estrogen in the human body. As such, they can help minimize symptoms — while doing other beneficial things, such as helping to lower cholesterol.
Other supplements like black cohosh may help with specific symptoms, but the scientific evidence supporting the use of these treatments is not conclusive.
We suggest reading our helpsheets on Natural Remedies and Vitamins for a more thorough discussion of the different options from an evidence-based viewpoint.
Keep in mind that — as with anything — while these options work well for some, they don’t necessarily work for everyone. There may be some trial-and-error involved while you figure out something that works for your particular set of symptoms.
What About Over-the-counter Progesterone Cream?
This is an area that has received heavy publicity. Unfortunately, many of the claims which sound too good to be true are too good to be true.
A recent double-blind, controlled placebo study published in Menopause (the journal of the North American Menopause Society) found that progesterone cream that delivered 32 grams of progesterone a day worked no better than the placebo cream (source).
If you want to try progesterone cream, you’re best off being sure you’re getting a cream that delivers a higher amount — typically one you’d get from a compounding pharmacy as opposed to over-the-counter.
Finally, there’s also the “watchful waiting” method of dealing with perimenopausal symptoms — in which no intervention is made until if and when you feel it strictly necessary. In truth, this can also be a very valid option. Cool showers, fans, and just bearing it and remembering this too shall pass.
A Final Word
Regardless of how you choose to handle your perimenopause, one useful thing you can do is take this time to do a “lifestyle” check — and make sure you’re doing the most you can health wise.
A good diet, exercise (weight-bearing exercise in particular to help keep your bones strong) and making choices such as quitting smoking can make a difference not only in terms of symptoms, but also for your overall health — both during this transition and afterwards!
Also, as ever, its wise to work closely with your doctor to figure out the right path for your needs.
