Perimenopause

Perimenopause

The perimenopause is sometimes called “second puberty”. It is the time running up to the menopause and is associated with fluctuating hormone levels that can lead to changes in your periods with the period becoming lighter or heavier and the cycle shorter or longer. Fluctuating hormones lead to good days and bad days, in no predictable pattern. This can affect how you feel, how you think and your overall quality of life. 
 

When does it begin?

Menopause is when you have had no period for 12 months. In the UK, the average age of menopause is 51. However, our hormones start to change many years before this with progesterone levels starting to fall before estrogen. This can result in perimenopausal symptoms starting up to 10 years before the menopause.
 

What are the symptoms?

Many and varied with each woman having a unique experience. Some women will have few symptoms of short duration. For others, symptoms will affect many parts of the body and last for many years, sometimes decades.

  • Period changes. This is often the first sign. Periods can become lighter or heavier, the cycle can shorten or become irregular before finally stopping. Women who have no periods as a result of the Mirena coil or progesterone only contraceptive will miss this clue.
  • Hot flushes and night sweats. These are the most common symptoms and affect approximately 75% of women, with 25% reporting these as severe. Night sweats can lead to disturbed sleep which adds to the tiredness associated with this phase of life.
  • Palpitation. This is an undue awareness of the heartbeat and is often associated with hot flushes and night sweats.
  • Muscle and joint pains. Estrogen is anti-inflammatory. As levels fall in the body, joints can start to ache more and recovery time from injury can increase.
  • Worsening headaches/migraine. These can become more severe or more frequent.
  • Low mood. This can often be associated with worsening premenstrual syndrome and can impact on relationships at home and at work.
  • Anxiety. Increased anxiety can lead to increased worry about work performance, an increased tendency to ruminate over health concerns and can negatively affect confidence.
  • Brain fog. This describes a set of symptoms including poor concentration and recall, difficulty with word finding, forgetting names and problems with retaining information. Many women fear they have early onset dementia.
  • Loss of libido. Many women report a lack of interest in sex around this time. Falling levels of estrogen and testosterone can impact on sexual arousal, receptiveness and pleasure. This can cause distress.
  • Vaginal dryness. Estrogen plays a vital role in keeping the vagina well lubricated and maintaining its elasticity. As levels of estrogen fall, the vagina thins, becomes dryer and is less able to expand. All of these can contribute to painful sex.
  • Urinary frequency and recurrent urinary tract infection. Estrogen receptors in the bladder, vulva and pelvic floor all combine with estrogen to maintain normal bladder control and flow. As estrogen levels fall, changes to these structures lead to urinary frequency, urgency and recurrent urinary tract infection.

This list is not exhaustive. Estrogen receptors exist throughout the body leading to a wide range of symptoms in the perimenopause and menopause.
 

How will I know it is happening to me?

If you are age > 45, have noticed a change in your periods and have some of the symptoms listed above, you are likely to be perimenopausal. Tracking your symptoms can be a useful way to monitor the changes. You can download a Menopause Symptom Checker here. This, along with your story, will enable a health care professional to diagnose perimenopause without the need for any tests.

If you are age 40-45 the same holds true. However, a health care professional may check some blood tests to exclude other causes for your symptoms such as anaemia and/or an underactive thyroid gland. Tests to check the Follicle Stimulating Hormone (FSH) level can be helpful if raised but can also be normal at this time. A blood test is a single snapshot in time, levels fluctuate in perimenopause and cannot be relied on for making a diagnosis.

If you are age < 40, you may have Premature Ovarian Insufficiency. This is an important diagnosis because of the impact on fertility and future long-term health, in particular the prevention of cardiovascular disease and osteoporosis. Blood tests will be needed to investigate this further.
 

What can I do?

This is an opportunity to pause and reappraise lifestyle choices. The decisions that you make now will impact your long-term health and determine your quality of life in your post-menopausal years.

  • Diet – try to eat the rainbow. The British Heart Foundation has guidance available at https://www.bhf.org.uk/informationsupport/heart-matters-magazine/nutrition/5-a-day/colourful-foods.
    A diet rich in calcium will help to keep bones healthy and should be supplemented with a daily dose of Vit D 10 micrograms once daily. Dietary calcium intake can be calculated at https://www.osteoporosis.foundation/educational-hub/topic/calcium-calculator
    Weight gain around the menopause is common due to changes in metabolism that result from a reduction in bone and muscle mass. Try to keep a food diary to better understand your eating habits. Record:
    • Date and time
    • Description of the food
    • Description of quantity
    • Any symptoms that you are getting
    • Why you are eating it
  • Exercise - It is never too late to get moving. NHS guidelines recommend 30 minutes of moderate exercise 5 times per week. Impact exercise such as walking, running, jumping, skipping, racquet sports and dancing can all help to strengthen bones and prevent osteoporosis. Furthermore, regular exercise improves mental health, reduces stress, blood pressure and future risk of breast cancer.
  • Alcohol – many women find that alcohol precipitates and exacerbates hot flushes. Alcohol is a depressant and disrupts normal sleep. Tolerance to alcohol is often reduced around this time. Government guidelines recommend that alcohol intake be limited to 14 units per week and that two days are kept alcohol free. Calories in alcohol can contribute to unwanted weight gain.
  • Smoking – women who smoke are more likely to have an early menopause and can experience more severe hot flushes and night sweats. Try to reduce the number of cigarettes smoked with a view to stopping completely.
  • Stress management – this can be a demanding time of life with work, children, partners and elderly relatives making demands on your time. Self-care is particularly important. How you relax will be personal to you but may include yoga, meditation, relaxation, walking in nature, spending time with friends or loved ones. Make a commitment to yourself to stick with this no matter what demands are placed on your time. Stress management can help with weight control.
  • Sleep – this can be disturbed by night sweats, anxiety, itchy skin, vaginal dryness, the need to get up to pass urine etc. Attention to the cause will help.
    • Aim for 7-8 hours of sleep per night.
    • Try to stick to a routine and avoid “catching up” at the weekend.
    • Go outside in the day. Exposure to daylight reduces melatonin, our sleepy hormone, so we feel more alert
    • Avoid caffeine after 6pm, earlier if it is particularly stimulant for you
    • Avoid alcohol - while it is initially sedative, it disrupts the sleep cycle
    • Have a bedtime routine and stick to it. This is your way of signalling to the brain that now is the time for sleep. Taking a warm shower or bath can help as the drop in core temperature facilitates sleep.
    • Ban mobile phones, laptops and TVs from the bedroom. Your brain needs to associate bed with sleep
    • If you waken in the night and fail to get back to sleep after 10-15 minutes, get up and go and do something. Only return to bed when you feel sleepy.

What if I am struggling to do all of this?

We can all aspire to achieve lifestyle change but it can be a challenge when you do not feel at your best. This is not failure but an acknowledgement that you need help. If you have symptoms that are reducing your quality of life and impacting on your home life, work life or relationships, speak to a health care professional to get specific advice about what might work for you. Everyone is different, no two women have the same experience of perimenopause. Knowledge is key.
 

What about HRT?

In the perimenopause, when hormone levels fluctuate and decline, the objective of treatment with HRT is to supply the body with a steady dose of hormones. Hormone replacement therapy refers to the replacement of one or more of the hormones estrogen, progesterone and testosterone:

  • Estrogen – the type of estrogen in HRT is 17 beta-oestradiol and it is derived from the root vegetable, the yam. This has an identical biological structure to the estrogen produced in the body. It can be given as a patch, gel or spray delivered across the skin, and also as a tablet taken orally.
  • Progestogen – all women who still have a womb and who use estrogen replacement will also need a progestogen. If given alone, estrogen causes the lining of the womb to thicken with an increased risk of abnormality and cancer. The progestogen keeps the lining of the womb thin and prevents this from becoming abnormal. In the perimenopause the Mirena coil is often a good choice as not only is it an effective contraceptive, but it also releases progestogen into the womb to prevent the lining from thickening and can remain in place for 5 years before it needs to be changed. As an alternative, natural progesterone (Utrogestan in the UK) is the safest type of progesterone and is taken orally as a capsule. Utrogestan is also derived from the root vegetable, the yam.
  • Testosterone – some women continue to experience symptoms of low libido, low arousal and poor sexual satisfaction despite adequate replacement of estrogen. This is often accompanied by fatigue and brain fog. For these women a trial of testosterone can be of benefit. Currently there are no testosterone products licensed for use in women in the UK, but menopause doctors and some GPs are happy to prescribe a cream or a gel off license and under supervision.
  • Local vaginal estrogen – symptoms of vaginal dryness, pain on intercourse, soreness of the vulva and vagina, recurrent urinary tract infection and urinary frequency benefit from treatment with vaginal estrogen. This can be used alone or in combination with HRT as a patch, gel or spray.
     

What about alternatives to HRT?

  • Cognitive Behavioural Therapy – this talking therapy is recommended by NICE for the management of anxiety and low mood. There is evidence of benefit in the relief of hot flushes.
  • Prescription Medications – NICE recommends HRT for first line treatment of symptoms of the menopause in women who have no contraindications. For women who cannot take HRT or who choose not to, there are various prescription medications that are indicated for the relief of menopausal symptoms. These include antidepressants such as Venlafaxine and Citalopram which show some benefit in reducing hot flushes. However, they are not first line for the management of low mood or anxiety associated with the menopause. Other medications such as Clonidine and Gabapentin can be considered but are frequently associated with side effects.
  • Herbal remedies – some women find traditional herbal medicines such as black cohosh, red clover, sage and St John’s Wort to be of benefit in relieving hot flushes. However NICE guidelines state that there is insufficient evidence of benefit beyond that which would be expected from placebo. Natural does not equate with safe and some herbal medicines can interfere with prescribed medications. If you are considering using herbal medicines, please consult with a health professional specialising in this field and ensure that all herbal medicines carry the Traditional Herbal Registration (THR) mark to certify safe standards of manufacture and delivery.
     

What can I expect from HRT?

  • Relief of your symptoms. This is the primary indication for the use of HRT. Often in the perimenopause the dose needs some adjustment, but generally hot flushes and night sweats are relieved within a few weeks of starting; low mood, anxiety and sleep disturbance take longer to settle but have usually improved within 3 months.
  • Reduced risk of osteoporosis. After the menopause there is a period of rapid bone loss. HRT reduces this bone loss resulting in reduced risk of osteoporosis and future bone fracture.
  • Reduced risk of cardiovascular disease. There is evidence that HRT started within 10 years of the menopause or below the age of 60 is associated with a reduced risk of cardiovascular disease; cardiovascular disease is the second most common cause of death in post-menopausal women
     

Are there any risks from taking HRT?

NICE guidelines state that for the majority of women, the benefits of HRT outweigh the risks. For each individual this decision is based on your medical history, any pre-existing medical conditions, your family history and whether or not you still have a womb (uterus).

Many women worry about two risks:

  • Breast cancer
  • Blood clots
     

Breast Cancer

Your personal breast cancer risk depends on many things including age, family history, age at puberty, number of pregnancies etc. Lifestyle factors play an important role in breast cancer risk with obesity, smoking and alcohol consumption of 2 or more units per day all increasing breast cancer risk while regular moderate exercise of 2 ½ hours per week reduces this.

Studies have shown that women who take estrogen only HRT do not have an increased risk of breast cancer. Women who take combined HRT, containing estrogen and progestogen, may have a small increased risk of breast cancer. This risk can be minimised by using Body Identical HRT (estrogen through the skin in combination with micronised progesterone if required) as some studies have shown the risk of breast cancer with HRT is reduced if micronised progesterone is used.
 

Blood Clots

There are many risk factors for thrombosis (blood clots) and the risk increases with age. HRT taken orally as a tablet is associated with an increased risk of blood clot and should be avoided in anyone with a personal history of blood clot, liver disease or migraine. HRT taken across the skin as an estrogen patch, gel or spray carries no increased risk of blood clot.

It is important that each woman has an individual assessment and discussion to facilitate a shared decision on the way forward.

Dr Alice Duffy

Last updated May 2021

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