Peri-menopause

Women in my peer groups tend to be high-functioning, multi-tasking people. They’re used to having things under control, and they’ve got enough experience to know what’s coming. 

All of this makes the unpredictable years of the peri-menopause incredibly inconvenient, if not downright infuriating.  We want answers! We want ice cream! We want it to go away!

Are you in peri-menopause? Who knows! It generally starts sometime between the age of 44 to 50, and can last a few months or maybe an entire decade. The most identifiable symptom is menstrual irregularity, but if you’ve had a hysterectomy, are using hormonal contraception, or have always had irregular cycles, that’s not a helpful indicator.

75% of women in their 40s report some combination of the symptoms that characterize peri-menopause: irregular cycles, brain fog, insomnia & fatigue, mood changes (including exacerbation of depression or anxiety), vaginal dryness, low libido, and painful intercourse.

The underlying mechanism of menopause is that the cells of the ovary (the eggs and the cells that support the eggs) get less efficient with age. The predictable rise and fall of ovarian hormones in your earlier adulthood that consistently led to a week of menstrual flow, then three weeks without bleeding, stops happening predictably or consistently. Instead the hormone levels start to swing wildly at mid-life.

These years tend to start with extra estrogen that might lead to increased libido mid-cycle and heavy flow. Lower progesterone levels may show up as spotting in the week before your cycle. As estrogen levels decrease, menses become light or absent, and you might start to have night sweats or hot flashes. Then you might have years where you’re skipping months at a time but never quite making it a whole year without a bleed. 

I’m often asked for a “hormone test” to diagnose peri-menopause, but that doesn’t exist. These hormone swings mean that a snapshot of today’s hormone levels may look completely different from tomorrow’s. Period tracking apps have introduced  “peri-menopause scores” but what use is a score that doesn’t predict anything?

I have a friend who was trying for another baby and when the fertility doctor checked her hormone levels, they told her she was close to menopause and would likely never conceive even with IVF. With this knowledge, she decided to take on a very demanding job… and a year later, she was pregnant. This is a prime example of why you should never trust someone who’s advertising a diagnostic test for peri-menopause. When you’ve been a full year without a period, you’re officially in menopause. Congrats! 

Of note, if you’re under 45 when you complete menopause, you should continue to take hormones until at least age 52. The guidelines on this are clear, and yet very few women are offered this important therapy. Untreated early menopause leads to higher mortality from heart attacks, stroke and osteoporosis. Your doctor should run some tests and offer either continuous oral contraceptive pills, which contain enough hormones to protect bones and blood vessels, or a slightly higher dose than usual of menopausal estrogen and progesterone therapy.

So how are you going to get through these years? You’re going to work with your doctor to treat the most bothersome symptoms. Heavy periods can be treated with hormonal contraception or with tranexamic acid, which is a medication taken only during the cycle to decrease flow. If neither of those is an option, your gynecologist may be able to offer an outpatient procedure called endometrial ablation. Poor sleep can be improved with CBT-I, a type of counselling which improves sleep for most people. A weighted blanket was a game-changer for me! Nightly prometrium or magnesium with melatonin may also help for some people. Hot flashes are best managed with estrogen therapy, but SSRIs (often used to treat anxiety or depression) can help as well. Mental health changes can also be supported with these medications. Sexual and bladder changes are often improved with low-dose vaginal estrogen and pelvic physiotherapy.

One of the most frustrating and least treatable symptoms of the peri-menopause is brain fog. Similar to the brain fog of pregnancy, this is a time-limited condition that does resolve once hormones have stabilized. Between ages 45 and 55, women experience decreased information processing speed and a drop in performance on short-term memory tests. In her book The Menopause Manifesto, Dr. Jen Gunter points out that women still outperform men on memory tasks even after peri-menopausal changes. 

Women often struggle with weight gain during these years. People of all genders gain an average 1.5 pounds per year after age 40. We can’t blame it all on hormone changes, or men wouldn’t get that middle-aged spread. There is a natural decline in muscle mass that slows metabolism so that you burn fewer calories at rest. If you don’t shift your eating and exercise habits to match that decline, the weight will add up over the decades. Reduced estrogen levels also shift the fat distribution to be around the waist rather than in the hips and thighs, so clothes fit differently and weight gain may feel more noticeable. Shifting your exercise routine to build more muscle mass may help bump up your metabolism and reduce your risk of osteoporosis. 

Women have too often been belittled and ignored by their healthcare providers, but there are more and more options available to help us navigate this stage of life. If your doctor doesn’t have expertise in peri-menopause, try searching for a NAMS-certified provider at this website https://menopausefoundationcanada.ca/resources/find-a-physician/