All things perimenopause
Perimenopause … It's something many people face, but it can’t be diagnosed with a simple blood test, many things can mimic its symptoms and, contrary to popular belief, it’s not all about our hormones.
So what is it? How do we know we are experiencing it? And how do we manage it?
To understand perimenopause and menopause, we first need to know what’s going on inside our bodies throughout our life cycle.
The biology is quite complex
It all starts with the menstrual cycle – a complex interplay between the body (via the uterus and ovaries) and the brain (via the pituitary gland and the hypothalamus).
The menstrual cycle can also be impacted by the overall health and wellbeing of the body and other endocrine systems (such as thyroid and adrenals).
But first, let’s start with the hypothalamus and pituitary gland.
Together, they form the ‘hypothalamic-pituitary axis’. The hypothalamus is connected to the pituitary gland and hangs like a little bulbous gland via a stalk in the base of the skull, on the underside of the neocortex (what we might classically see as the ‘brain’). For such a small area, the axis has wide ranging impacts in the body. The pituitary is involved with stimulating many organs involved in hormone production.
The pituitary gland is stimulated by hormones secreted by the hypothalamus. Each individual hormonal and endocrine system has different ‘messengers’ which dictate what is secreted. For the menstrual cycle, the hypothalamus secretes gonadotrophin releasing hormone (GnRH) which stimulates the pituitary gland to stimulate egg production in the ovaries by secreting a hormone called follicle stimulating hormone (or FSH for short) and a small amount of lutenising hormone (we’ll talk more on this down the track).
FSH travels through the bloodstream, down to the ovaries and its presence tells the cells in them to start growing eggs for fertilisation.
At this point, multiple cysts start to grow all at the same time. As they mature, the eggs start to produce oestrogen.
This has wide ranging effects on the body, including:
Stimulates the lining of the uterus to grow to support an embryo and its placenta for pregnancy.
Thickens the cervical mucus to allow sperm to enter the uterus.
Stimulates breast tissue growth.
Increases skin moisture and elasticity.
Impacts mood regulation, cognitive function and memory.
May have beneficial effects on heart health via increasing HDL and lowering LDL. When the ratio of HDL to LDL is that HDL is higher than LDL, this is associated with less heart attacks and strokes.
Promotes bone formation and inhibits the bone from being broken down.
Ensures vaginal lubrication and skin health in the vulva (to be soft, with lubrication, like the inside of the mouth).
Oestrogen rises as the eggs are maturing. When one egg is maturing faster or better than the others, signals tell the other eggs to stop growing and let the strongest egg shine as the egg of the month!
This rise in oestrogen is registered by the pituitary gland which stops producing FSH. When it detects the level of oestrogen is high enough, the pituitary gland releases more of a hormone called ‘lutenising hormone’.
Lutenising hormone (LH) tells the ovaries, the egg is now mature, let it free! The cyst then releases the egg into the fallopian tube, waiting to be fertilised by a sperm. It will survive approximately 24 to 48hrs in the fallopian tube.
Interestingly, around this time, when there are higher levels of oestrogen and LH, there is also a natural increase in libido. This makes sense, as that is the time when it is most possible to fall pregnant.
The leftover cyst is called the ‘corpus luteum’ and its job is to produce a hormone called progesterone. Progesterone helps to maintain the lining of the uterus, waiting for a newly fertilised egg to implant into the uterus. The corpus luteum survives for about 14 days until it naturally degrades.
As both the mature egg and the corpus luteum degrade, oestrogen levels and progesterone levels drop dramatically. This triggers the uterine lining to ‘shed’ the new growth - which is menstruation (aka a period).
This is noted by the hypothalamus and pituitary who begin the stimulation of their respective hormones. The cycle continues.
Knowing about the menstrual cycle and our hormones is important because it can help us understand how contraception works, make decisions about fertility, understand the changes that come with perimenopause and menopause, and see how things that impact the mind can also impact the body/cycle.
So what happens as we age and the cycle changes? Introducing … menopause!
You might be thinking that we’ve skipped an important step – perimenopause, but that’s because we need to explore what happens after first!
Menopause is a ‘retrospective diagnosis’. It is given when a cis-female has had no menstrual bleed for 12 months. That means we diagnose it on month 12 of no period. You are told that you have ‘been through menopause’.
You are suddenly menopausal.
Menopause happens because:
Cis-females are born with a finite amount of eggs in the ovaries (they actually start forming in utero, whilst they are still inside their own Mum’s uterus!) .
Each month as the eggs grow and either get released or don’t win the ‘mature egg’ race, their numbers decline.
Over the course of a lifetime, these eggs are used, and once they are gone, they are gone. As we age, the older eggs grow to be less mature and less robust. They start to produce less oestrogen.
This results in cycles with no ovulation (no mature egg) or delayed ovulation (it took the ovaries a little while longer to mature the eggs).
As this happens, less oestrogen is produced or variable amounts are produced.
The pituitary gland tries really hard to counteract this and starts pumping out loads of FSH to tell the ovaries to work harder at producing eggs. Unfortunately, the ovaries don’t actually have any eggs to recruit!
As the eggs stop maturing, oestrogen falls and the body goes into ‘oestrogen withdrawal’.
Oestrogen has so many effects on the body, so when it drops, the body has to adjust. It goes into ‘oestrogen withdrawal’.
This might look like:
Skin changes: drier, sometimes itcher, is more pronounced in vulva and vaginal skin; where skin becomes less like the inside of the mouth and more like the skin on the outside of the face.
Menstrual changes: as oestrogen is not being produced, cycles can be skipped and periods are heavier (because the lining was growing) - so change in length of period and either lighter or heavier periods.
Reduction in the lubrication of the vulva and vagina, making sex more uncomfortable.
Vasomotor: hot flushes.
Mood: irritability, low mood, anxiety, more cyclical mood shifts, difficulty sleeping.
Bone: decreased bone density.
Heart: change in cholesterol markers (lower HDL, higher LDL) and an increased risk of heart attacks.
Breast: decreased breast density and growth (saggy boobs).
Changes in libido.
But this withdrawal doesn’t happen overnight. It happens over the course of many years.
And that’s how we find ourselves in perimenopause.
Myths about perimenopause
Perimenopause is the period of a woman’s life, where changes resulting from oestrogen withdrawal are starting to happen. It’s estimated to be between four and eight years.
And this is where things get complicated. Why?
There is no ‘blood test’ to diagnose perimenopause.
We know that a follicle stimulating hormone (FSH) level over 30 combined with 12 months of no bleeding indicates that a cis-female woman is no longer fertile. This tells us that the pituitary is producing a lot of FSH, but the ovaries are not responding.
However, in perimenopause, the FSH can rise and fall, depending on how the ovaries respond. We can do a blood test one day of the month and the FSH can be high, but the next week it can be at a normal physiological level. The same is true for oestrogen and progesterone.
Oestrogen, progesterone, FSH and LH levels rise and fall naturally throughout the month anyway, and the physiological levels for each on every day and time of the month are different for each woman. We have ranges and ratios to help us determine what is happening, but we would need to do regular cyclical bloods to figure out what is happening (which we will often do in fertility treatment or subfertility investigations).Signs of perimenopause are not just related to the period.
New research suggests that mood changes can come before menopause-related changes to the menstrual cycle. This can include irritability, anxiety, low mood and shifts in how the premenstrual mood is experienced. Sleep changes are also common.
As less and less oestrogen circulates, ‘vasomotor’ symptoms also develop i.e. ‘hot flushes’.
Those changes related to the period can include irregular or erratic cycles, different lengths of time between cycles, and changes in how much bleeding occurs.There are a lot of things that can mimic ‘perimenopausal symptoms’.
Problems with thyroid, stress, suboptimal nutritional intake, uterine abnormalities and psychological factors can all mimic symptoms in this perimenopausal state.
All these require consideration – we don’t want to put everything down to ‘perimenopause’.
Even if you are in your very early forties, changes to periods or vasomotor symptoms would be concerning for ‘early menopause’ and we would want to look into that further.Working with perimenopause is not just about hormones.
While oestrogen replacement is something that can be considered, management at this phase of life often involves ensuring that the body and mind are functioning really well to support our body’s transition.
There is good evidence that menopausal symptoms can be ameliorated by lifestyle interventions such as:
Reducing alcohol use
Exercising regularly
Eating in line with the Australian Guide to Healthy Eating
Not smoking or vaping
Reducing stress via relaxation and nervous system regulation
Contraception is still required.
Many women think that as they enter perimenopause, they are unlikely to need contraception. Whilst there is less chance of pregnancy as the eggs have lower quality, pregnancies do still occur. There is also a higher chance of genetic abnormalities in the baby.
So unless you are over 50 and have not had a period for 12 months OR you are not having sex with a partner who has sperm, the recommendation is to still be covered for pregnancy – those eggs are really trying hard right up until the end!Hormone replacement is an individual choice and requires time.
Hormone replacement therapy (HRT) around this time takes the form of oestrogen, as it is the largest hormone which impacts on symptoms. If you still have a uterus, progesterone is required to ensure that the oestrogen does not overstimulate the lining.
Whether you have continuous therapy or cyclical depends on whether you are still menstruating intermittently or not. The types of HRT available to you also depend on whether you need contraception or not.
There is growing evidence of the role hormone therapy can play in perimenopausal mood problems.
There is also established and clear evidence that hormone therapy helps with vasomotor symptoms. Different types of hormone preparations can help with the issues related to period changes.
And, remember, all medications have risks! Starting these treatments requires detailed, in depth discussions around risks and benefits, including monitoring efficacy of whether the intervention is helpful or not.
And it’s good to keep in mind that it is not a magic remedy. If you have too much going on in your life, are stressed, in overdrive, have little time to recharge or struggle to say ‘no’, oestrogen replacement will not necessarily fix that for you.
When we know about how our bodies work, we can start to understand what happens when things are happening differently. Or why we would use different medications. We can also predict what may be an issue and plan for it in advance (such as monitoring bone density and doing a cardiovascular risk profile).
It is important to have a basic understanding of physiology to be able to make decisions about your health.
It is also important to be aware of how the body, mind and lifestyle impact each other.
This is why my new offering Mind-Body Medicine exists.
It’s a tailored four-session package where you can have extended 1:1 time with a Specialist GP to unpack complex issues like perimenopause and how they are impacting, or might impact, your life.
You can ask questions, share concerns and gain a deeper understanding of the health issues you’re facing.
If this is something you’re interested in, you can learn more here.