Everything You Need to Know About Perimenopause

Our experts answer your questions about the mood swings, hot flashes, and other symptoms that may hit in the decade before your periods stop.

Q. What is perimenopause, anyway, and how can I tell if I'm in it?

A. The average woman goes through natural menopause (meaning she's had no period for 12 months) at around age 51, but changes in your body begin years earlier. The years leading up to menopause are called perimenopause. It's just a process, not an illness. In fact, some lucky women hardly notice the transition. But others experience annoying symptoms. Here's why: In perimenopause your ovaries start to produce less estrogen as your follicles (the sacs that hold your eggs) diminish. You may not produce enough estrogen one month to stimulate your ovaries to release an egg. If that happens, your brain may try to compensate by sending more follicle-stimulating hormone (FSH) into your bloodstream. As a result, you can have high levels of estrogen some days and low levels on others. This unpredictable hormonal activity confuses your body and causes the common symptoms of perimenopause: hot flashes, night sweats, breast tenderness, decreased vaginal lubrication, and mood swings. On average, women have these symptoms for five to eight years.

Q. I've heard birth control pills can help you manage symptoms, but are they safe for women in their 40s?

A. Today's lower-dose oral contraceptives are safe for many women. The pill stabilizes hormone levels in the blood and can help manage hot flashes and irregular periods, says Isaac Schiff, MD, chief of the department of obstetrics and gynecology at Massachusetts General Hospital. Oral contraceptives also protect against pregnancy and bone loss. They are the preferred hormone treatment for perimenopausal women, but they do have potential side effects. Your risks rise with age if you're overweight, a smoker, or have a history of blood clots, hypertension, stroke, or diabetes. You and your doctor can make a decision on what's best for you after reviewing your health history as well as yoursymptoms.

Q. How do I know if I'm having a hot flash and what can I do about it?

A. Your first hot flash will take you by surprise. You get a sudden sensation of heat in your face and chest, and then you sweat as the flash dies down and your body tries to cool off. Before the hot flash, some women feel anxious and have a rapid heartbeat. During it, your face may get red and flushed. Afterward you may get the chills. Hot flashes usually last less than five minutes and they can happen several or many times a day. The only thing known to eliminate hot flashes is estrogen, says Lauren Streicher, MD, an assistant clinical professor of obstetrics and gynecology at Northwestern University's medical school in Chicago. But since stress is a trigger, getting regular exercise can help. You should also dress in layers you can remove easily and keep the thermostat low. At night wear light pajamas and sleep with a fan by your side of the bed. And keep track of your personal triggers, which could include not only stress but alcohol, spicy food, or too much caffeine.

Q. What does it mean if my usual, like-clockwork periods get very unpredictable? Do I need to see my doctor?

A. See your gynecologist if you have extreme bleeding patterns such as very heavy periods or bleeding that lasts more than seven days in a row. If you have spotting and bleeding between periods or bleeding during or after sex, it's also smart to get checked out. "Most women fear the worst and assume that heavy or continuous bleeding is a sign of cancer," says Dr. Streicher, a member of the LHJ Medical Advisory Board (learn more about her and other board members at LHJ.com/advisoryboard). But most abnormal bleeding, she says, is a result of those fluctuating hormones, which can cause the lining of the uterus to build up more tissue than usual. Your body has to shed it, just as it does when you get your period. While cancer is a rare possibility, heavy bleeding could also signal noncancerous growths such as polyps or fibroids, so it's important to tell your doctor about any symptoms.

Q. I'm on a birth control pill, so how will I know when I'm really in menopause?

A. Birth control pills stop ovulation, so the bleeding you experience each month while on the pill is from hormone withdrawal and is not a real period. Because of that, you may actually go through menopause while still bleeding every month. So how do you know if your real, ovulation-based periods have stopped for good? "As you approach your early to mid-50s," says Dr. Schiff, "you might consider stopping the oral contraceptives for about 10 days and having your doctor test your level of FSH, which can confirm if you're in menopause or not." At that point, especially if you're having bad symptoms, you may want to discuss hormone therapy with your doctor. (Check out "Should You Try Hormone Therapy?" below.) Or see how you feel just staying au naturel.

Q. Can I still get pregnant in perimenopause?

A. The simple answer is yes, as long as you're ovulating. But after age 40 your fertility drops dramatically. It becomes harder to get pregnant, you're more likely to miscarry, and the chance of complications increases for you and the baby, says Jan L. Shifren, MD, director of the Vincent Menopause Program at Massachusetts General Hospital. Of course, every woman is different, and chronological age doesn't always track with ovarian age. Some women stay fertile well into their mid-40s. If you don't want to get pregnant, use birth control until you've gone a year without a period.

Q. Is weight gain just a fact of life during these years?

A. Yes -- your metabolism slows as you age, so you have to increase your exercise and decrease calories just to stay even. If you do nothing you'll likely add a pound or two a year -- and the fat will go more to your belly, too. Add weight-bearing exercise such as lifting weights or walking stairs to encourage your metabolism to speed up. And try cutting your caloric intake by controlling portions and decreasing sugary drinks and simple carbs.

Q. Are there any natural and safe remedies for perimenopause symptoms?

A. Despite much research on soy, vitamin E, red clover, black cohosh, dong quai, and other herbal supplements, there's little evidence that these are effective in reducing hot flashes or other symptoms compared to a placebo -- and they may cause harmful side effects or drug interactions. Acupuncture has been shown to help some symptoms. Exercise and yoga may be the safest and most effective natural remedies you can try.

Q. I never used to be forgetful, but I feel as though I can't concentrate or remember anyone's name these days! Is this just a phase?

A. Yes it is, says Baltimore neurologist and author Majid Fotuhi, MD, a member of the LHJ Medical Advisory Board. Many women have difficulty with concentration during perimenopause. It's not necessarily from low estrogen, he says, but more about all the crazy hormone fluctuations going on (it can happen during pregnancy, too). "It's probably due to the ratio of different hormones and their rate of change that affects the brain -- sort of a fog that comes and goes," he says. Verbal memory is often affected, too, so you may find yourself searching for a word that seems to be on the tip of your tongue. But don't worry: This type of forgetfulness is common during perimenopause and usually goes away after menopause. There's no long-term brain damage from it and it generally doesn't mean you're developing Alzheimer's or dementia. Exercise can help by actually increasing the size of the memory part of the brain.

Q. What happens to your skin and hair during perimenopause?

A. As your estrogen declines, so does oil production and collagen in your skin. You probably need to use a richer moisturizer now. You may notice your hair getting a little thinner on top, too. That can happen when your testosterone doesn't decrease at the same rate as your estrogen. The balance shifts and the relative rise in testosterone causes your hair to thin. This hormonal shift can also cause hairs to sprout in unexpected places such as your chin or upper lip. You can take care of those with tweezers, waxing, electrolysis, or laser hair removal.

Q. Why does my sex drive seem to have gone missing lately? And is there anything I can do to get it back?

A. Let's face it: Hot flashes, night sweats, sleep disruption, fatigue, and vaginal dryness resulting from low estrogen aren't exactly sexy. Medications like oral contraceptives and antidepressants can also reduce your sex drive. Of course, so can relationship problems, stress, worry, and changes in your health or even your weight. And there's no easy take-a-pill solution as there is for men. Testosterone therapy has been shown to help some women but has not yet been approved by the FDA. The relationship between your hormones and your sex drive is complex, and while hormones can contribute to low libido, there can be other factors as well. Figuring out the cause can be tricky, so start by making a list of what's going on in your life that may be contributing to your lack of libido and schedule a talk with your doctor.

Q. Is there anything good about perimenopause?

A. Perimenopause is nature's early warning system, designed to alert you that the next phase of your life will soon begin. You may feel sad if you were hoping to have another baby. But many other women are relieved to hear that they won't have to worry about contraception, PMS, cramps, or tampons much longer. Women plagued by fibroids and hormonal migraines usually see both problems disappear in menopause. Many women live more than a third of their life after menopause, Dr. Streicher reminds us, and it can be the most productive and interesting time. Your kids are often grown and on their own and you probably have more time to pursue the things you love. Why not make yourself as healthy as possible now so that you can maximize this next great chapter in your life?

Should You Try Hormone Therapy?

After you reach natural menopause, you might still experience symptoms such as hot flashes. If these are significantly interfering with your life, you can consider trying hormone therapy (HT), a combination of estrogen and a progestin or progesterone. You've probably heard about the potential risks (such as heart attack, stroke, and breast cancer), including the recent research showing that women who use hormone therapy have a slightly higher risk of getting invasive breast cancer and even dying from it. But these represent relatively small numbers overall.

Talk to your gynecologist about whether the benefits of alleviating symptoms justify the risks. According to most experts, HT appears to be safer if you start at the onset of menopause rather than starting it many years later (although a newer study may dispute this). Hot flashes can last 10 years or longer, and many women stay on HT for years or even decades. Most doctors say you should use the lowest dose that alleviates your symptoms for the shortest amount of time. You can try pills, patches, creams, gels, and sprays. The forms that are applied to the skin may be safer for some women because the estrogen goes straight to the bloodstream, bypassing the liver, which decreases the risk of blood clots.

You've probably also heard about bio-identical hormones. Some of these products are regulated by the FDA, which means they have to meet standards of safety and efficacy. Other bio-identical products made in compounding pharmacies are not approved by the FDA. So far there is no evidence that hormones from compounding pharmacies are either safer or more effective than other forms of hormone therapy.


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