The Opportunity of Perimenopause
By Dr. Bronwyn Hill
Naturopathic Doctor, NAMS Certified Menopause Practitioner
I met with a 42 year old woman yesterday who came to me for help with her “hormonal hot mess” as she put it. Periods coming too soon, sometimes later. Heavier bleeding. More intense PMS symptoms including insomnia, night sweats, and breast tenderness. Fatigue and brain fog. Non-existent sex drive. Persistent bloating and stubborn weight she just cannot lose despite her efforts. She felt overwhelmed & unprepared for what she chalked up to “getting older”.
This accomplished but frustrated woman is not alone in asking THE question: Could it be….Perimenopause?
Let’s Break it Down
Perimenopause refers to the transitional time between our reproductive years and our final menstrual period – which is Menopause (or “The” Menopause as our UK friends like to say). The average age of menopause in Canada is 51, and perimenopause typically occurs over 4-8 years; sometimes shorter, sometimes longer. Some research suggests up to 20% of women at the age of 40 are in perimenopause.
If you are 35 and older, experiencing menstrual cycle variability and/or any of the symptoms/experiences below, perimenopause should be considered. Many of the concerns noted below can very well be experienced before your period even changes.
**This is not an exhaustive list of possible experiences/changes, nor does it mean you will experience any/all of them. Everybody is different – the point is to raise awareness about possible changes.
HOT & BOTHERED BY THE EXPERIENCES/CHANGES??
I like to refrain from using the word “symptom”, which typically is used to describe a disease-state. You may have heard this before; but perimenopause and menopause are NOT diseases. Anyone with ovaries who lives long enough will experience these normal hormonal transitions.
Now, if you are feeling like this whole midlife hormonal ride IS a disease – you are not alone and you don’t have to grin and bear it.
I also think it is important to emphasize that not all people with ovaries are a “hot hormonal mess” at this time of life. Some experience minimal changes and disruption to their life. This transition is really variable, and the most important thing to keep in mind: if you are experiencing changes/symptoms that are impacting your quality of life & day-to-day, raise them with a knowledgeable health care provider.
THE HORMONE CHANGES OF PERIMENOPAUSE
The best analogy to describe what is happening hormonally in perimenopause is a rollercoaster. In a typical menstrual cycle estrogen and progesterone fluctuate; they steadily increase and decrease resulting in ovulation, the premenstrual phase and the actual period or bleed itself.
Over the age of 40, it’s normal that the menstrual cycle becomes less consistent. In a perimenopausal menstrual cycle the fluctuations may become “steeper” and more erratic than our younger years. This is all due to the normal ovarian aging process; as the “eggs” or follicles in your ovaries are dwindling in their numbers, this causes the brain’s command center hormones to fire more erratically. Ovulation may or may not happen, which results in variable estrogen & progesterone production, prompting the changes you may feel.
The picture below is a good schematic representation of the hormonal “ride”. Note the change in the “rhythm” of the estrogen & progesterone.
Photo credit from Lara Briden – larabriden.com
HOW DO WE ASSESS FOR PERIMENOPAUSE?
The diagnosis of menopause is pretty simple, in that if it has been 1 year or longer since your last period – you’re there!
The assessment of perimenopause is typically based on the presence of menstrual cycle length changes, but sometimes other subtle (or not so subtle) experiences/changes show up before your period fluctuates. Every woman is different! Premenstrual symptoms like mood changes, breast tenderness, headaches, hot flashes that are new or feel more pronounced can occur. Heavier or lighter periods. Spotting. Sleep disruption.
This is where cycle tracking can be incredibly helpful – for you and your healthcare provider.
Tracking the start and end of your periods, any premenstrual symptoms, and any signs of ovulation (changes in cervical mucous, lower abdominal cramping) can all be insightful.
Early perimenopause can be defined by persistent cycle length changes of ~7 days , either shorter or longer. “Late” perimenopause is often characterized by cycle lengths of 60+ days – much longer stretched out periods. **ref
It’s imperative to remember that cycle changes can really vary, so if you are unsure about what yours mean, talk to a healthcare provider.
Is there a Blood Test for Perimenopause?
The short answer is NO. This often surprises women I work with.
Remember that estrogen and progesterone fluctuate substantially – so if we are testing these hormones, all we may be catching is a “high” or a “low” point – and this is normal. If a woman is 35 or younger and experiencing changes, or has had their uterus removed – we may be more inclined to run hormone testing to understand the likelihood of perimenopause. But really, it’s an assessment made by listening to what the experience & changes are. Once again, tracking really helps.
Blood tests in perimenopausal women should be more focused on establishing a baseline for overall health. Cardiovascular health markers (blood pressure, cholesterol, etc) metabolic health (blood sugar and related tests), markers of organ function, and certain nutritional status tests are really the most impactful assessments a mid-life woman can do!
BUILDING HORMONAL RESILIENCY IN PERIMENOPAUSE
Considering how much your hormones are likely to fluctuate in this stage and that there is a “normal” physiological reason for it, I avoid using language like “balancing hormones” when discussing goals. I like to focus on building awareness & resiliency in the women I work with. They can ride the potential bumps, twists & turns and feel more themselves while doing it.
Yes, your hormones are happening to you – but you are also happening to your hormones.
Your stress levels, mindset, nutrition, movement patterns, sleep, capacity for joy/pleasure/play, environmental exposures – all of these “habits” can hugely impact how you experience perimenopause.
This stage of life does present a real opportunity to get to know your body better. To put yourself first and let go of things that don’t “fill your cup”. The resiliency you build in perimenopause will help you navigate the next transition, and impact your health for years to come.
I hope this has helped increase your understanding and expectations of the perimenopause transition.
Below are some excellent resources to further your knowledge:
Naturopathic doctor and NAMS Certified Menopause Practitioner Bronwyn Hill is an active member of the North American Menopause Society, The International Menopause Society, & The Newson Health Menopause Society. Her areas of clinical expertise include: Perimenopause & Menopause, Menopause Hormone Therapy, Women’s metabolic and cardiovascular health, PCOS, Vaginal & vulvar health and Menstrual wellness. She welcomes patients from all over Ontario to her Virtual Practice, and also sees patients in person in Owen Sound.
Menopause Practice. A Clinician’s Guide, 6th Ed. The North American Menopause Society
McLeod, G. F. H., Cleland, L., Welch, J., Spittlehouse, J. K., Fenton, A., Boden, J. M., & Horwood, L. J. (2021). Menopause status and climacteric symptoms in a birth cohort of mid-life New Zealand women. Climacteric: The Journal of the International Menopause Society, 1–7.
Menopause Foundation of Canada. The Silence & the Stigma: Menopause in Canada. 2022