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Perimenopause: the hormonal roller coaster

If you're in your 40s or 50s and have a uterus and/or ovaries, you might have noticed something a little crazy going on. Your periods might be getting irregular. Or heavier. Or lighter? Perhaps fewer and father between. Or maybe closer together! Maybe you notice some mood swings, maybe some hot flashes. Not sleeping well? That could be part of the picture as well. And then suddenly you might find that you feel normal again for a long stretch. Yes, you guessed it, you are experiencing perimenopause, the transitional time before menopause when your periods come to an end. It can be a wild roller coaster ride of hormonal changes and yes, we need to talk about it!

I've realized this topic doesn't get a lot of coverage and that many, many people are blindsided by the changes that can happen during perimenopause. I recently talked to a patient who had assumed that her hormone levels would just gradually decrease and periods would get lighter and then just fade away. Unfortunately, that is not always the case. In reality, the ovaries might sputter, give out, then start up again, then rev up like crazy before another round of sputtering and giving out. Hormone levels might vary widely and periods can be all over the place. Symptoms can include:

  • Irregular or otherwise abnormal menstrual periods (including heavier periods)

  • Hot flashes or night sweats

  • Bloating (water retention)

  • Breast swelling and tenderness

  • Fibrocystic breasts

  • Headaches (especially premenstrually)

  • Mood swings (including anxiety, irritability, and depression)

  • Body changes

  • Hair loss

  • Foggy thinking, memory loss

  • Fatigue

  • Trouble sleeping/insomnia

  • Decreased sex drive

  • Worsening PMS

For a lot of people the hormones get really out of balance during this time. We talk a lot about estrogen levels dropping, but often it's progesterone that decreases first, leading to an estrogen-dominant picture. That means heavier periods, because excess estrogen will cause a greater buildup of the uterine lining. It might also mean that periods are closer together and PMS is more severe. What a fantastic combination! Other times it'll seem like there's a buildup to your period that lasts and lasts, with all the PMS symptoms in the world but no relief from actually getting your period... until it finally arrives, weeks late.

This chart is a great demonstration of the type of hormonal chaos that can happen during perimenopause. Things are pretty predictable before and after, but during perimenopause hormones can be all over the place.

It's pretty hard to predict exactly how perimenopause will go for any individual. The average age of menopause is around 50-51, but with a pretty wide variation in what is normal, so some people may hit menopause in the early to mid 40s, and others may still be getting periods into their later 50s. I can't say how long your perimenopause will last, or how it will go for you. Uncertainty is the name of the game here! However, there is a lot you can do about it and no one should suffer from lack of sleep or anemia caused by heavy, frequent periods. Here are a few key points:

  • Exercise: exercise is beneficial in mitigating a lot of the unpleasant symptoms of perimenopause, including hot flashes and night sweats

  • Herbal medicine: there are many good herbal combinations out there. Read labels carefully. Some herbs are more promoting of progesterone, others of estrogen.

  • Hormone therapy: for some people, taking a low dose of progesterone or estrogen can be a game changer.

Some people will be able to get through the perimenopausal time with few symptoms, needing very little help. Others may have symptoms that are moderate or severe and require treatment of some kind. Either way, no one should have to just sit back and suffer during this transitional time. More about my approach, including options for testing, in my next blog post.


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