Perimenopause and You: What to Expect

Perimenopause sounds, misleadingly, a little bit like a flower or maybe a lovely shade of lavender but, alas, perimenopause isn’t always pretty and it’s most certainly not predictable. So many things can happen to a woman’s body during perimenopause, which can last months for one woman but years for another with seemingly no rhyme or reason. The word literally means ‘around menopause,’ and that’s it. This vagary is appropriate because the array of physical and emotional changes experienced during this phase of life can be low-key or dramatic, subtle, bold and anywhere in between.  

What is perimenopause?

The good people at Johns Hopkins sum up perimenopause this way: Perimenopause is a natural process caused when your ovaries gradually stop working. Ovulation may become erratic and then stop. The menstrual cycle lengthens and flow may become irregular before your final period. Symptoms are caused by the changing levels of hormones in the body. Terrific. But what does that mean to you and me?

Perimenopause is the stage between fertility and menopause. It marks the beginning of the end of your reproductive years. It begins whenever it wants to – some women notice signs of its impending approach in their 40s; others in their 30s. Some women launch straight into menopause with no in-between. Menopause begins, officially, 12 months after a woman’s final period. 

Perimenopause is also sometimes called the menopausal transition. The body’s production of estrogen and progesterone, hormones produced by the ovaries, begins to ebb and flow during this phase. Our bodies use estrogen in a variety of ways. It improves muscle mass and bone density, boosts your mood, helps protect your brain, keeps your vagina lubricated and protects your heart.

For people assigned female at birth, it also helps the body develop breasts and pubic hair. As puberty hits, estrogen levels rise. During fertile years, estrogen levels surge each month, triggering the uterus to prep for possible fertilization. If fertilization doesn’t happen, estrogen levels decrease again and Aunt Flow comes to visit. In other words, menstruation occurs.   

What are perimenopause symptoms?

Here are some of the most – and least – common symptoms and side effects of perimenopause, and what you can do about them:

Hot flashes. A hot flash is exactly what it sounds like. All of the sudden, your face, head, chest heat up. And sweat. A hot flash can feel like it’s creeping up your body, from your chest to the top of your head. You may feel yourself flush or turn red and/or blotchy. After a hot flash, some women feel chilly, often because they’re soaked in sweat. Mild hot flashes can come and go in less than a minute. Doozies can last ten minutes and can be so stunning that they wake you up in the night. 

Some ways to mitigate the effects of hot flashes are simple: dress in layers so you can shed and replace clothing as needed, sleep with a fan on and layer your sheets and blankets for maximum versatility. Consider carrying a little battery-operated fan. Go easy on spicy foods, alcohol and caffeine – these can make hot flashes worse. Maintain a healthy weight and if you smoke, stop. Medications to treat hot flashes can include paroxetine, a selective serotonin reuptake inhibitor (SSRI) antidepressant may help. Some women opt for hormone replacement therapy to steady their estrogen levels. Talk with your doctor to see if these might be right for you. 

Sexuality and vaginal health. Each woman is unique, so while one may feel suddenly free and sexually liberated because unintended pregnancy is no longer a concern after menopause, others may feel less interested in sex. Lower estrogen levels can decrease desire and make arousal more difficult. Johns Hopkins reports that more than a third of women in perimenopause (or who are postmenopausal) report having sexual difficulties, from lack of interest in sex to trouble having an orgasm. A common physical change that many experience is vaginal dryness, which can make sex feel pretty unsexy.

For vaginal dryness, try using a water-based, nonprescription lubricant. You can find these at the drugstore or grocer. Over-the-counter vaginal moisturizers can also help. You and your doctor may decide that a prescription hormone treatment is the best plan. There are localized, site-specific treatments with lower hormone doses, such as estrogen rings, tablets or creams, which may offer relief.

Sleep problems. Most commonly linked to hot flashes and night sweats, sleepless nights during perimenopause are pretty common. Even without these overheated rude awakenings, sleeping through the night may become difficult. One reason could be more frequent urination and less bladder control. Loss of tissue tone can lead to urinary incontinence.

The NIH offers these tips to help you up your sleep quantity and quality:

• Set – and follow – a sleep schedule. Go to bed and wake up at the same time each day.
• Keep your bedroom quiet and cool.
• Don’t exercise too close to bedtime.
• Avoid caffeine later in the day.
• Don’t eat a big meal close to bedtime.
• Skip afternoon naps.
• Ditch screentime when you’re in bed.
• Avoid too much alcohol – it won’t help you sleep.

Mood changes. Guess what? Perimenopause is probably not going to make you more cheerful. Psychology Today tells us that 23 percent of women will experience mood swings during perimenopause. Many women experience depression and/or anxiety for the first time in their lives. Women report that perimenopausal mood swings come fast and furious, often seemingly out of nowhere. It’s an exhausting rollercoaster. We can chalk these swings up to reduced estrogen and progesterone with the added bonus of hormone fluctuations. There’s a commonly used phrase, ‘perimenopause rage,’ an intense, irrational-feeling anger that can take hold suddenly, destroy everything in its wake (metaphorically, hopefully) and disappear just as fast.

Medications can help with mood swings, anxiety, depression and rage. Low-dose antidepressants can offer relief. Talk therapy can also help, giving women tools to help shift their minds out of raging negativity and back into neutral territory. Also proven helpful? Half an hour of daily exercise. 

Bone loss. When perimenopause comes calling, you start to lose bone faster than your body can replace it, thanks to decreasing estrogen levels. This can lead to an increased risk of osteoporosis, which causes your bones to weaken.

Here are some terrific tips for taking good care of your bones.

Changes in cholesterol levels. Lower estrogen levels are associated with higher levels of low-density lipoprotein (LDL) cholesterol, AKA ‘bad’ cholesterol. Higher LDL levels can increase the risk of heart disease. At the same time, ‘good’ cholesterol (high-density lipoprotein AKA HDL cholesterol) tends to decrease in women as they age, which also increases the risk of heart disease. 

To manage your cholesterol, be sure to get plenty of exercise, eat a heart healthy diet with lots of fruit, vegetables, low-fat dairy, fish and poultry, stop smoking and maintain a healthy weight. You may need to add a cholesterol-lowering medication to your regimen if your unhealthy cholesterol levels persist. Called ‘statins,’ these drugs cause the liver to slow down its cholesterol production. 

‘Different’ periods. With a lower hormone level throwing a wrench into regular ovulation, your periods may become irregular. Your bleeding may be lighter than normal. Or heavier than normal. Your periods may become shorter. Or longer. And your cycle may shorten or lengthen. Or both. 

If your new, less predictable cycle doesn’t bother you, then just ride it out. If your flow is too heavy or is lasting too long or if you’re having too many periods too close together, consider talking with your doctor about using a very-low-dose birth control pill – containing 20 micrograms of estrogen instead of the 30 to 50 micrograms in regular birth control pills. They’ll help regulate your period and keep you from getting pregnant.

If you think you’re experiencing the symptoms of perimenopause, talk with your doctor about ways you might find relief. INTEGRIS Health Gynecology provides women with preventive gynecologic care and offers clinical programs to address the needs of women throughout every stage of their lives.