Perimenopause – The Change

with Paul Lucca, M.D., obstetrician/gynecologist with Advanced Healthcare

Last Updated: May 1, 2003

Women in their 40s are not the same creatures they would have been a century, or even a generation, ago. Younger in appearance, with healthier diets and more active lifestyles, the last thing many of them are thinking of is “the change.” Some may even be first-time mothers or mothers-to-be. So when the first troubling symptoms of approaching menopause (the perimenopause) begin, women may be concerned that they are symptoms of cancer or another serious disease. Some may see the problems as stress related.

Indeed, the stress connection is well documented. Women dealing with aging parents, empty nest syndrome (or young children), job-related difficulties or unemployment may experience erratic menstrual cycles.

The symptoms
Perimenopause, the time our mothers referred to as “the change,” can start as early as 40. The closer a woman gets to 50, the more symptoms she will have. Common symptoms include hot flashes, erratic and often painful periods that may be extremely heavy or too light or skipped altogether, forgetfulness, insomnia, night sweats, headaches and, given the other symptoms, a hardly surprising tendency to mood changes and depression.

“The most notable thing about these symptoms is that they can be very erratic. After months of problems a woman can become symptom-free for six months or more,” said Dr. Paul Lucca, an obstetrician/gynecologist with Advanced Healthcare.

“At first perimenopause is disconcerting, scary and confusing. But once a woman talks over her symptoms with her doctor and is reassured that these are normal symptoms, when they happen again, she may not be as alarmed or concerned,” the doctor added.

The biological cause
The cause of all these diverse symptoms is the slowing down of the function of the ovaries. “Ninety-eight percent of the time a woman is fine physically but the ovaries are starting to falter in their production of good eggs, which is kind of what nature intended,” Dr. Lucca said.

As a result, women will begin to have anovulatory cycles in which eggs are not released. This may result in a lighter period, similar to those a woman may have had while taking the birth control pill, or one that is skipped altogether. However, the ovaries are still producing estrogen which causes the lining of the uterus to thicken. Progesterone, released by the egg, causes the uterus to slough off that lining, resulting in a menstrual period. When no egg is released the lining continues to thicken until the next “normal” cycle when a woman’s bleeding can become very heavy.

Dr. Lucca said that many women will forgo any hormone medication once they understand what is happening. However, for some women, extended heavy and painful bleeding can cause serious problems. For them, a doctor may recommend progesterone to regulate rhythm and flow. Other women may elect to go on the birth control pill, which usually reestablishes a normal rhythm through perimenopause. “This is a good way to control periods for women who do not smoke and who are having disturbing symptoms,” Dr. Lucca said.

“When the pill was approved for use by women over forty it cut down radically on the number of hysterectomies for uncontrolled bleeding. It also cuts down on the risk for ovarian and endometrial cancer, a boon to many women in perimenopause. However these hormones will not delay or stop a woman from going into menopause. When a woman’s ovaries are destined to stop functioning, they will stop,” the doctor added.

Late perimenopause - heading into the “change”
It is the faltering production of hormones in the ovaries that causes the other symptoms of perimenopause – the night sweats, hot flushes and vaginal dryness. Menopause, defined as the time when a woman has not had a period for a year, is a time when these symptoms gradually diminish. During perimenopause, they may increase in severity, then gradually taper off.

“Many women will tell their doctor, ‘I’m hot all the time,’ but that’s not menopause. Hot flushes are feelings of warmth that pass over the face and upper body from the shoulders on up, followed by perspiration. They usually last no more than two minutes or so. They may happen five or six times a day,” Dr. Lucca said.

There are also night sweats when a woman has to throw her covers off two or three times a night. Sometimes she’ll even have to change her nightgown. Vaginal dryness occurs when the lining of the vagina becomes thinner, making it more sensitive to intercourse. This also causes thinning in the bladder wall and urethra. “Women may begin having incontinence problems because support tissues aren’t as strong as they once were. These symptoms are all caused by the lack of estrogen,” the doctor explained.

According to Dr. Lucca, about half of women become symptomatic as their estrogen levels fall. Often, thinner women have more problems. This is because the small amount of precursor hormones released by the adrenal glands are converted to estrogen in fat tissue. While this is one time excess weight seems desirable, Dr. Lucca stresses that this estrogen is not balanced by progesterone, putting women at greater risk for endometrial cancer. “Under certain circumstances these women might be good candidates for progesterone-only therapy,” Dr. Lucca said.

Of the women who become symptomatic, about half used to elect to go on HRT (hormone replacement therapy). Since the Women’s Health Initiative studies released troubling statistics about HRT, fewer women go on them, he said.

“It really depends on the woman and to what extent her symptoms are interfering with her lifestyle, and her own prejudices for or against HRT. It’s a personal choice. I do think it is a good thing in that it makes patients and doctors think a lot more about it,” the doctor concluded.

What women can do for themselves
“Some of the general things women can do during perimenopause include watching what they eat and exercise. These are clichés but clichés become clichés for a reason. Women’s metabolism is slowing down and they start putting on weight. They may have the same diet and exercise program as earlier in life but they begin to gain weight. Watching the diet and doing more exercise not only keeps off weight but it’s also good for the heart and bones,” said Dr. Lucca.

With regard to symptoms, Dr. Lucca said the only cure for estrogen deficiency is estrogen replacement. “Over the counter treatments are uncontrolled and some can have harmful effects on health if taken in excess. For a woman with minimal symptoms, some of these they may provide some relief. I wouldn’t advise against a woman trying one of these but women shouldn’t have any great expectations, especially if they suffer from moderate to severe symptoms,” the doctor said.

He added that there are other ways of taking estrogen besides pills. These include patches, vaginal creams and vaginal rings (especially good for women with significant vaginal symptoms).

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