Demystifying Perimenopause: Let’s Talk About It!

My first clue was fleeting, inexplicable rage. Not that there aren’t all kinds of things that warrant anger nowadays, but this was different. It felt like the calm before the storm one minute, then the eye of the hurricane the next. But nothing had happened. Neither an external offender nor an interior thought. And yet, I wanted to lash out.

It happened multiple times over the next couple of weeks. I felt like I had regressed by 30 years and was back in my hormonal, frustrated puberty funk.

Then I read All Fours by Miranda July, a novel that tracks a narrator’s reckoning with her aging body — her self-love and self-hatred. Quite frankly, it’s a novel that reveals the inner thoughts of middle-aged women in a raw and genuine rendering that’s rarely seen, in my opinion. It is, in turn, funny, shocking, and a little explicit. There are things we don’t often talk about when it comes to women of a certain age. Yet, here it was …

So, what is perimenopause? When does it happen? What are the symptoms? Let’s dig in.

“There it was in black and white: perimenopausal changes.”

My friends had been talking about it in bursts. One said that her body smelled different, and another said that her body seemed to be changing shape. We all knew losing the extra pounds we gained over the summer holidays was nearly impossible.

Just maintaining the status quo suddenly became a lot more work. I upped my beauty routines, added weight-bearing exercise, and planned my meals more diligently. I worried about not being feminist enough. I apologized for my moods (which were bewildering and isolating for me and extremely confusing for my husband) and joked about my body getting hijacked.

But, surely, this phase of life is due … later? I really don’t have the time right now, I thought.

It didn’t take long to get my answer. Receiving the result of a routine smear test, there it was in black and white: perimenopausal changes. Ouch. Hello, unwelcome news. At the same time, looking back on the past couple of months, it all suddenly made sense. My body seemed to be betraying me, but the worst part wasn’t that. The worst part was knowing so little about what to expect.

I needed to know more and extend a hand to younger women — to inform and empower them and those around them. I spoke to Amy Boone, MD, an assistant professor at the OBGYN Department at the University of Alabama in Birmingham, for some additional information.

When does it happen?

Perimenopause marks the transition period before menopause, typically beginning in your 40s. It’s a natural process where your body gradually produces less estrogen, leading up to menopause, when menstruation stops completely. Perimenopause can last between a few months to around a decade, with the average length being four years.

Dr. Boone understood my confusion and why I felt blindsided.

“Menopause is a defined point in time,” she told me. “Once you have gone 12 consecutive months without a cycle, there is a finite snapshot where you transition over. It’s kind of like a birthday.” But it turns out that the symptoms most of us associate with menopause are what happens in the years leading up to it, the period known as perimenopause.

And this may be why even my friends and I, all educated professionals, were caught off-guard.

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“Most of the time, menopause happens between 45 and 55,” says Dr. Boone. “Some data say the perimenopausal transition lasts four years, but others say it lasts seven on average. The symptoms can sometimes be vague and sometimes also mild, so it’s hard to pinpoint when it starts.”

“Some people can have symptoms for up to 10 years before they have that final 12-month timeframe without a cycle,” she adds, “and so, you can generally start seeing some of these symptoms as early as 40. Between 40-45 is considered ‘early menopause,’ and 45-55 is the expected period.”

What are the common symptoms associated with perimenopause, and how can we manage them?

Historically, some health issues belonging to the female body have been understudied, and women (particularly those of reproductive age) have been excluded from clinical studies and trials. In many ways, women’s health is ‘behind.’ And so, unfortunately, it doesn’t surprise me that we don’t know enough about what’s inevitable if we reach a certain age.

“The topic of perimenopause is also often excluded from the medical training curricula,” Dr. Boone shares.

Hot flashes and night sweats are the most talked-about and commonly experienced symptoms, with mood changes, sleep disturbances, menstrual changes, and vaginal dryness also being up there with the most recognized signs.

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These changes look wildly different for every woman and can range from the mildly annoying to the debilitating. Most symptoms will improve after menopause, but it is up to the individual (and their doctor) to ascertain how bothersome the changes are and what kind of relief to seek.

Other symptoms are associated with the decline of the hormone estrogen, and this can involve changes to the labia, vaginal opening and vagina, clitoris, bladder, and urethra. Women can experience dryness, irritation, and pain during penetration. Urinary changes can also occur, and some women may find themselves waking up twice or three times a night to urinate.

“The most important pillars of healthy menopausal transition are the same as those for overall health,” Dr. Boone says. “These are adequate exercise and healthy diet (such as the Mediterranean diet), not smoking, and minimizing alcohol consumption. We know that alcohol, cigarettes, and certain dietary choices can increase inflammation in the body, and this makes many symptoms worse.”

Phew! No extra work. Right?

While these lifestyle tenets are not going to be a cure-all for the symptoms of perimenopause, there is supporting evidence that people who regularly do all three things (exercise, eat healthy, and avoid smoking/alcohol) tend to report less distress.

Menopausal Hormone Therapy (MHT, sometimes also called Hormone Replacement Therapy or HRT) treats symptoms like hot flashes and night sweats as well as symptoms associated with mental health like mood changes.

One of the standards of care for insomnia and other sleep disturbances made official by The Menopause Society is Cognitive Behavioral Therapy or CBT. This low-risk, low-side-effect treatment has been shown to help with hot flashes, too.

“There are lots of non-hormonal options that are effective at providing some relief,” Dr. Boone shares.

Should I bother my doctor with this?

Here’s where we encounter some problems. Women are often busy; they don’t want to bother anyone with their distress, so some may resort to social media for quick solutions. Dr. Boone clarifies, “Many non-evidence-based treatments that are promoted on social media don’t pan out in the literature and research studies. It adds to the confusion. Some of these products may even contain harmful ingredients.”

“The last thing that most doctors want is for their patients to be miserable and suffering,” she says, “but we can’t fix or help what we don’t know. So, if there’s any concern or a change, it’s always a good idea to bring that up.”

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This includes any changes in the menstrual cycle, such as a longer cycle, blood clots that are above the size of a quarter, or bleeding after intercourse. Dr. Boone also emphasizes the importance of an annual visit, even if your pap smear test isn’t due. This is the time to discuss any changes with your reproductive health provider because patients often realize that a symptom is worth bringing up during that visit.

Dr. Boone also recommends taking advantage of patient portal access or discussing symptoms with a nurse over the phone if you’re not sure about going in for a visit. That way, there’s less chance of something potentially serious falling through the cracks.

Let’s talk about it!

“Why shouldn’t we treat it? Why should we just ‘deal with it’ and not consider our quality of life?” asks Dr. Boone. “Many safe options can smooth the peaks and troughs of this transition, and it won’t be forever. Symptoms, on average, last for about five years after you go through menopause, and for most people, there are still a lot of years on the other side of that.”

“There’s a lot our foremothers and fathers have gone through to find us safe and reasonable options to make these symptoms less miserable,” Dr. Boone adds. So, let’s use those options and talk about it!

Learn more by reading Dr. Boone’s recommendation, The Menopause Manifesto by Jen Gunter.

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