Unlocking the Secret to Managing Perimenopause: What Every Woman Needs to Know

by Megha Gokals Sanghi, ND

Naturopathic Doctor at New England Integrative Medicine

As women go through the normal process of aging, there are many natural hormonal changes that they experience. These manifest in different ways, which many women can attest to. Menopause is essentially a decrease in the two dominant female reproductive hormones – estrogen and progesterone. The reason for this decline is due to the loss of ovarian follicular function, meaning the ovaries are unable to continue producing these hormones at a high enough rate to produce a menstrual cycle.3 

Menopause is achieved when a woman has not had her period for 12 continuous months, and the transition leading up to this is perimenopause. The onset and duration of perimenopause is dependent on numerous factors. Some studies have evaluated variables such as race, BMI, environmental factors, nutrition, sleep, stress, smoking status, and alcohol intake. The average duration of perimenopause is 7 years, though several factors can either lengthen or shorten this time.4   

Perimenopausal Symptoms3

• Irregular periods: As the ovaries grow less responsive to hormones coming from the brain to secrete specific hormones such as estrogen and progesterone, cycle length can vary significantly. For some cycle length increases, while for others it decreases. Menstrual flow can also change whether that is getting heavier, lighter, longer or shorter. Women should reach out for medical care if they find that they are experiencing excessive bleeding as this may be a sign of endometrial hyperplasia (where the inner most lining of the uterus becomes too thick).

• Hot Flashes and Night Sweats: These are very common and frustrating symptoms that many women experience. It feels like a quick rush of warmth, typically contained to the upper body including the face, neck and chest. It is important to distinguish the root cause of these symptoms between perimenopause and other conditions such as hyperthyroidism, anxiety, medications, or food. Hot flashes and night sweats are due to declining levels of estrogen and the temperature control in the brain (also known as the hypothalamus) being overly sensitive to slight changes in temperature. The hypothalamus essentially thinks the body is too warm and increases body temperature to induce some sweating to cool the body down. Sometimes, this can leave women feeling cold after a hot flash. 

• Vaginal Dryness: Due to the lack of estrogen as women transition through perimenopause, vaginal tissues lose some of their lubrication, elasticity, and thickness. This can make vaginal penetration painful, and cause discomfort or itching of the area. Vaginal dryness can be addressed with lubricants. We recommend checking the Environmental Working Group’s Skin Deep Catalogue for a low toxin, clean product. These vaginal changes can leave women at a higher risk for infections and urinary incontinence. It is important to rule out allergies, malignancies, infections, and skin conditions if these symptoms continue to get worse despite perimenopause support.

• Lower Libido: Another symptom caused by the lowering of these hormones is a decrease in libido. This can be due to numerous factors such as the painful intercourse, and other symptoms including change in mental health and energy levels.  

• Skin Changes7: Skin health is directly tied into estrogen levels, and with lowering estrogen levels throughout perimenopause, there is a decrease in collagen, fibrin, elastin, vascularity, and numerous enzymes that focus on skin health. This can cause dryness, redness, wrinkles, impaired wound healing, and an increased perception of aging. There have been some studies showing that topical estrogen may be able to reverse some of these changes. 

 

• Insomnia and Fatigue: Disrupted sleep can be quite common during perimenopause due to night sweats. Women can find themselves waking up frequently to cool off during the night or some even need a change of clothes due to the sweating.  Fatigue is an inevitable symptom of this poor sleep. In this case, addressing the night sweats as the root cause will be the best way to address these symptoms. Evaluating cortisol levels along with reproductive hormones is ideal since cortisol levels can also significantly impact sleep and fatigue. 

• Bone Loss2: Estrogen plays a big role in inhibiting bone resorption, and as women develop an estrogen deficiency during this transition and once a woman has entered menopause, bone resorption is increased. This results in most women developing osteoporosis, defined as decreased bone mineral density and bone mass. Bone mineral density scans (DEXA scans) can be performed to evaluate bone mineral density which can prompt necessary supplementation. Many women find themselves in need of a calcium supplement once they approach this phase of their lives, however women should always consult a physician prior to supplementing with calcium as too much calcium can be detrimental to cardiovascular, kidney or parathyroid health. 

• Cholesterol Changes: Lowering estrogen during this transition negatively affects cholesterol levels by increasing LDL cholesterol (commonly known as the “bad” cholesterol) and decreasing HDL cholesterol (the “good cholesterol”). Cholesterol should be closely monitored once this transition begins. There are many lifestyle changes or if necessary, herbs or medications that can support cholesterol levels. 

• Mental Health Challenges: Every single symptom that a woman experiences throughout this transition takes a toll on a woman’s mental health. Symptoms can include depression, anxiety, mood swings, increased irritability, and more. Sleep deprivation is also a significant factor that can worsen these symptoms. Many healthcare systems do not acknowledge this transition period that a woman experiences which can further worsen mental health. 

• There are many other symptoms associated with perimenopause such as hair loss, acne, nausea, facial hair growth, headaches, and changes in memory/cognition. Be sure to talk to your provider about any of these symptoms as you go through this transition. 

Obstacles in Healthcare 

It is extremely unfortunate that due to the natural progression of perimenopause through a woman’s life, many times she is not given any help to manage these symptoms or ease the transition. Access to healthcare varies depending on age, race, socioeconomic status, and education. As perimenopause typically begins around the age of 45, if a woman begins to experience this at a younger age, practitioners are sometimes hesitant to believe that it is in fact perimenopause that a woman is experiencing. Racial bias is also something that is extremely unfortunate to continue to be a factor in physician’s decisions regarding the severity of symptoms that a person is experiencing. Socioeconomic status can contribute to whether a woman even reaches out for any healthcare support due to the financial burden of healthcare visits, labs, any lifestyles change costs or any costs of medication. 

Many practitioners are also not knowledgeable on different factors such as nutrition, environmental exposures, stress, and mental health. The most common tool implored by healthcare practitioners is hormonal replacement therapy, but typically as a last resort without addressing any other modalities that could possibly help. Many times, healthcare providers are hesitant to order labs to review to understand a woman’s perimenopausal status as she goes through this transition. These labs can help to confirm whether all the symptoms align with perimenopause or if further investigation is necessary. Evaluating reproductive hormones such as LH, FSH, estrogen and progesterone levels as these symptoms begin can provide an insight about where a woman is in her journey towards menopause, and how she can be supported through this. Other important hormones to evaluate will be cortisol and thyroid hormones. 

Dealing with Perimenopause and Other Conditions 

• Endometriosis5: Endometriosis is a condition that affects 1 in 10 females and is characterized by growths of tissue similar to the tissue of the innermost layer of the uterus. This condition can have the following symptoms of painful menstruation, pain with intercourse, heavy menstruation, pain with bowel movements or urination, fatigue, abdominal bloating, and fatigue. Endometriosis is an estrogen sensitive condition, and as estrogen levels fluctuate significantly before lowering in perimenopause, endometriosis symptoms can get worse during this period. Many people with endometriosis find some level of relief once they have passed this transition and entered menopause.

• Polycystic Ovarian Syndrome6: PCOS affects 8-13% of females and is the most common cause of infertility. It is characterized by irregular menstruation, hyperandrogenism (acne, increased hair growth, deeper voice, increased muscle mass), or polycystic ovaries detected on ultrasound. It is typical for those with PCOS to have some level of insulin resistance as well since PCOS is a reproductive and metabolic condition. Hyperandrogenism persists during perimenopause and menopause in people with PCOS, which can pursue in a frustrating way as one of the more common symptoms with PCOS is weight gain – a symptom that most women experience during the menopausal transition. There are different lifestyle changes, herbs and medications that can help lower androgen levels and keep these symptoms at bay. 

• Fertility: As reproductive hormone levels decline through perimenopause, unfortunately ovarian reserves are diminished, and fertility prospects decline significantly. There are numerous medical interventions that may be attempted such as in vitro fertilization if perimenopause has already begun, and a woman wishes to conceive. 

• Hypothyroidism: Fatigue is one of the biggest symptoms that strongly overlaps between hypothyroidism and perimenopause. For those with an existing condition of hypothyroidism, it is crucial for hormone levels to be continued to be monitored and well managed at all times. For some, due to the hormonal connection between thyroid hormones and reproductive hormones, perimenopause is a time where they are diagnosed with hypothyroidism. Hypothyroidism symptoms include weight gain, fatigue, hair loss, constipation, cold sensitivity, depression, dry skin and joint pain. This is yet another example of why thorough hormonal evaluation to confirm perimenopause progression is so important. 

• Autoimmune Conditions1: Estrogen and progesterone are known to be protective in numerous autoimmune conditions such as rheumatoid arthritis and systemic lupus erythematosus. During perimenopause, as estrogen and progesterone decline despite increasing LH and FSH, women are more susceptible to developing an autoimmune condition. For those with pre-existing autoimmune conditions, this decline may cause significant flare ups due to the increase in inflammatory processes. 

• Cortisol Dysfunction8: Cortisol levels naturally increase as men and women age. Due to the lifestyle in many countries surrounding high stress jobs and always working on keeping up with life’s constant demands and responsibilities, many people struggle from dysfunctional cortisol levels. Typically, cortisol levels are highest in the morning, and slowly decline by the night. Cortisol plays a big part in the Circadian Rhythm and helping with those sleep-wake cycles. Based on different lifestyles and stressors, this curve can get dysfunctional, meaning that it may be too low at times it needs to be higher, or too high at times it should be lower. This can show up as a variety of symptoms such as fatigue, insomnia, weight gain, depression, anxiety, and brain fog. During perimenopause, studies have shown that cortisol levels increase significantly in the morning. Cortisol levels also have a direct correlation with severity of hot flashes, so the higher the cortisol levels, the more intense the hot flashes tend to be. If a woman struggles from cortisol dysfunction prior to perimenopause beginning, this can put her at an even higher disadvantage, leaving her with more intense symptoms from perimenopause. 

Hormony’s Goals

• To support women during the “prelude” or crucial transition period in their lives
• To not only evaluate reproductive hormones, but other hormones such as cortisol and thyroid hormones to get a whole-body picture of how to best support a woman during this phase of her life 
• To evaluate the root cause of symptoms with our testing

One of the key things that Hormony would like to bring to light is the significant portion of a woman’s life that is taken up by perimenopause. It is not merely a transition period that has a set duration, but a prolonged phase that a woman goes through. By understanding different hormone levels, a specific plan can be formulated to help that specific woman as an individual rather than just managing symptoms in ways that are not always helpful to everyone.  Hormony can support a woman’s journey through this phase of her life so that she is not left feeling plagued by a long list of symptoms when there are numerous options of how to target the root cause of her hormonal imbalance. 

Citations

1. Angum, F., Khan, T., Kaler, J., Siddiqui, L., & Hussain, A. (2020, May 13). The prevalence of autoimmune disorders in women: A narrative review. Cureus. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292717/#:~:text=Evidence%20has%20shown%20that%20the,its%20effect%20on%20inflammatory%20processes. 
2. Cheng, C.-H., Chen, L.-R., & Chen, K.-H. (2022, January 25). Osteoporosis due to hormone imbalance: An overview of the effects of estrogen deficiency and glucocorticoid overuse on bone turnover. International journal of molecular sciences. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8836058/ 
3. Delamater, L., & Santoro, N. (2018, September). Management of the perimenopause. Clinical obstetrics and gynecology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082400/#:~:text=Perimenopause%2C%20or%20the%20menopausal%20transition%2C%20encompasses%20that%20period%20of%20time,final%20menstrual%20period%20(FMP). 
4. Gold, E. B. (2011, September). The timing of the age at which natural menopause occurs. Obstetrics and gynecology clinics of North America. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3285482/ 
5. Jakson, I., Hirschberg, A. L., & Gidlöf, S. B. (2023, October). Endometriosis and Menopause-management strategies based on clinical scenarios. Acta obstetricia et gynecologica Scandinavica. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10540918/#:~:text=Endometriosis%20is%20largely%20considered%20a,symptoms%20and%20inquire%20about%20treatment. 
6. Lenart-Lipińska, M., Matyjaszek-Matuszek, B., Woźniakowska, E., Solski, J., Tarach, J. S., & Paszkowski, T. (2014, December). Polycystic ovary syndrome: Clinical implication in Perimenopause. Przeglad menopauzalny = Menopause review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4352911/#:~:text=The%20perimenopausal%20period%20is%20associated,metabolic%20disturbances%20connected%20with%20PCOS. 
7. Lephart, E. D., & Naftolin, F. (2021, February). Menopause and the skin: Old favorites and new innovations in cosmeceuticals for estrogen-deficient skin. Dermatology and therapy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859014/ 
8. Woods, N. F., Mitchell, E. S., & Smith-Dijulio, K. (2009). Cortisol levels during the menopausal transition and early postmenopause: Observations from the Seattle Midlife Women’s Health Study. Menopause (New York, N.Y.). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2749064/