Everything You Ever Wanted to Know About Perimenopause

perimenopause
If you’re in your 40s then chances are you are entering your perimenopausal years. Dr Rebecca Lewis, a GP and menopause specialist, explains exactly what you can expect - and what you can do about it.

What is the perimenopause?

The perimenopause is the name for when the first changes in the menstrual cycle occur, which can be subtle. It could show up as a shortening of your cycle – maybe from 28 days down to 25 or 26 – or your cycle could get longer.

Your periods may become a little shorter or lighter or indeed longer and heavier.

How you feel will vary from month to month. That’s because your ovaries don’t just stop producing oestrogen. Levels of oestrogen fluctuate over some years, going towards a kind of up and down, stuttering stop. Levels of progesterone vary too at this time, and this plays a part too.

How do you know you’re in perimenopause?

It can be hard to know, as the symptoms are so variable. And the fact that hormone levels fluctuate can make it difficult for women to know what’s happening. You might have a bad month where oestrogen levels are low and you have more of the symptoms. You might feel really tired, low, irritable one month, or have some hot flushes or feel anxious. Then the next, your oestrogen levels are up again and you feel fine.

So often women will put their symptoms down to other things – stress, work, children. It can take a while to realise there is a pattern. Despite the up and down fluctuations, what is happening is that oestrogen levels are, over this time, generally heading downwards as your ovaries run out of eggs. 

When does perimenopause start?

The average age of the menopause – when periods have stopped for a year – is 51, and the perimenopause can last five, six, even eight years. So it often starts in the early or mid 40s. But it could even start in your 30s, if you have an early menopause. One in a hundred women will have the menopause under the age of 40.

Can you take HRT as soon as you have perimenopause symptoms?

Most women can. During perimenopause, an area of the brain called the hypothalamus is registering that oestrogen production is low, so pushing to make the ovary produce more oestrogen, which is what causes the fluctuations. If you add in oestrogen from the outside – orally or in a cream – it switches off that drive from the brain, so hormone levels even out. 

It’s a good idea to take HRT because of all the health benefits. Especially when it’s taken earlier, it protects heart health, prevents and can treat osteoporosis, reduce the risk of bowel cancer and may well help decrease the chance of getting dementia and type two diabetes. That’s especially true if you’re between the ages of 50 and 60, when the benefits far outweighs any risks for the vast majority of women, according to NICE guidance of 2015.

Why does everyone get different perimenopause symptoms? 

We don’t know, what we see is that it’s individual for every woman. We know 80% of women get hot flushes and night sweats, the other 20 per cent don’t. In fact, in Japan, only seven per cent of women get hot flushes, which could be down to diet or genetics or a combination of the two. Some women get no symptoms at all, and don’t even realise they are in the perimenopause. Most women get a combination of symptoms. 

What other treatments or lifestyle changes have you seen help patients during the perimenopause?

Starting to do regular exercise, if you don’t already, is not only good for stress but also for bones. That’s especially true of weight bearing exercise. Cognitive Behavioural Therapy (CBT) is helpful for anxiety and there’s even some evidence it helps hot flushes too. Some women say taking a magnesium supplement helps with sleep. And some women find yoga helpful to soothe and calm the mind. 

I advise women to think of the perimenopause as a chance to take stock of their life, to look at the next 40 years and to make sure you’ll be as fit and healthy as possible. Look at your diet, the relaxation techniques you use, your stress management, your work-life balance.

What are other perimenopause symptoms? 

Women will come in very worried about their bad memory and/or brain fog. It’s such a relief for them when they find out this is a symptom of the perimenopause, rather than the start of dementia as they’d feared. 

Women are often relieved to know that the risks of HRT are not anything like what has been reported in the past ten years or so. It’s so nice for me, that I’m able to reassure women how safe HRT is. They are relieved to know that there is no extra risk of breast cancer above their background risk if they are under 51 yrs and taking HRT or at any age if they are taking oestrogen only HRT. There could be a very small extra risk of breast cancer in women taking oestrogen and progesterone HRT over the age of 51. But this risk is less than drinking two glasses of wine a day and far less than being overweight or obese.

I explain how the risk is balanced by the benefits of HRT: halving the risk of heart disease, decreasing the risk of osteoporosis and decreasing the risk of bowel cancer. There may also be other beneficial effects, for example decreasing the risk of Alzheimer’s and type 2 diabetes.

Dr Rebecca Lewis is based at the Newson Health Menopause & Wellbeing Centre, www.newsonhealth.co.uk.

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