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Perimenopause is the transitional period leading up to menopause, typically starting in a woman’s 40s, though it can begin earlier. This phase can last between two to ten years and is characterized by hormonal fluctuations that bring about various physical and emotional change. It is important to understand that perimenopause is happening alongside ageing but is not caused by ageing. Perimenopause is a sequence of hormonal events and changes that are more akin to puberty or “second puberty” (more to come). Symptoms of perimenopause include anxiety, insomnia, weight gain, night sweats, and a reduced ability to cope with stress.
Menopause is the life phase that begins one year after the final period.
Four phases of perimenopause + menopause:
1. Very early perimenopause, when cycles are still regular
2. Early menopause transition, from the onset of irregular periods
3. Late menopause transition, from the first cycle of more than sixty days
4. Late perimenopause, which is the 12 months from the final period
+ menopause which is the life phase that begins one year after your period
How do I know if I am perimenopausal?
Great question. According to Canadian endocrinology professor Jerilynn C. Prior, a midlife woman with regular menstrual cycles is likely to be experiencing perimenopause if she observes any three of the following nine changes:
new-onset of heavy and/or longer flow
shorter menstrual cycles (<26 days)
new sore, swollen or lumpy breasts
new mid-sleep waking
increased menstrual cramps
premenstrual night sweats
new or markedly increased migraine headaches
new or increased premenstrual mood swings
weight gain without changes in exercise or eating.
What are the hormonal changes of perimenopause?
During perimenopause, the initial hormonal change is a decrease in progesterone due to shorter luteal phases and more anovulatory cycles (without ovulation), even if periods remain regular. This loss of progesterone can lead to symptoms such as anxiety, breast pain, heart palpitations, night sweats, frequent migraines, and unusually heavy periods.
As progesterone levels drop, estrogen levels can surge up to three times their normal levels, contributing to an irritable mood, breast pain, and heavy menstrual bleeding.
Adapted from JC Prior, 'Perimenopause lost - reframing the end of menstruation', Journal of Reproductive & Infant psychology, 2006, vol. 24, pp323-35
Sourced from: Lara Briden – Women’s Health Natruopathic Dr
Adapted from JC Prior, 'Perimenopause lost - reframing the end of menstruation', Journal of Reproductive & Infant psychology, 2006, vol. 24, pp323-35
The primary cause of perimenopausal symptoms is often the loss of progesterone rather than estrogen. Therefore, progesterone cane be a more effective treatment than estrogen (individual hormone tests are commended to support nutrition therapy).
Fun Fact: Progesterone helps the brain cope with stress. If you are feeling like you aren't as resilient anymore than there is a reason for this. I encourage you to support your nervous system during perimenopause (remember, this phase doesn't last forever).
Quick refresh on what is a natural healthy menstrual cycle.
How can we support ourselves in perimenopause?
Supporting perimenopause is very individual but there are some things women can all do to make for a smoother transition to menopause.
Work with a professional – Test, don’t guess!
During perimenopause it may be beneficial to test a variety of nutrients and hormones, and screen for osteopenia. Test’s I like:
Insulin
Purpose: Insulin Resistance - it’s the most common cause of weight gain in perimenopause. Insulin is a hormone made by the pancreas to help move blood sugar out of the blood stream into your cells. You can reverse and manage insulin resistance through diet, lifestyle and supplement support
When to test: Fasting in the morning
Follicle-Stimulating Hormone (FSH)
Purpose: FSH levels rise as the ovaries start to produce less estrogen. High FSH levels can indicate reduced ovarian function, which is common during perimenopause.
When to Test: Since FSH levels fluctuate, testing might be recommended at specific points in your menstrual cycle or multiple times to get an accurate assessment.
Oestradiol (Estrogen)
Purpose: Estradiol is the primary form of estrogen in women of reproductive age. During perimenopause, oestradiol levels can fluctuate widely, affecting menstrual cycles and causing symptoms like hot flashes.
When to Test: Testing should be done in the early follicular phase (around days 2-5 of the menstrual cycle) for the most accurate results + 7 days after ovulation
Luteinizing Hormone (LH)
Purpose: LH works with FSH to regulate the menstrual cycle. Changes in LH levels can reflect the changing ovarian function during perimenopause.
When to Test: Like FSH, LH should be tested at specific points in the menstrual cycle for an accurate assessment.
Progesterone
Purpose: Progesterone is produced after ovulation and is crucial for regulating the menstrual cycle. Levels can drop during perimenopause, contributing to irregular periods.
When to Test: Typically, progesterone is tested in the mid-luteal phase, 7 days after ovulation (about day 21 of a 28-day cycle)
Vitamin D
Purpose: Vitamin D is crucial for maintaining bone health by aiding the absorption of calcium and phosphorus from the gut, which are vital for bone mineralisation. Adequate levels help prevent bone-related disordered such as osteoporosis, which is a concern for women in perimenopause.
Thyroid Panel (TSH, T3, T4)
Purpose: Your thyroid gland produces hormones that regulate growth and energy expenditure. Many of the symptoms of thyroid dysfunction overlap with perimenopausal, such as fatigue, weight changes, mood swings, and irregular periods.
DEXA Scan
Purpose: DEXA scans measure bone mineral density (BMD). This helps assessing the strength and density of bones. It is the gold standard when diagnosing osteoporosis. Some DEXA scans also do a thorough body composition analysis, which can also be valuable for managing and understanding your health.
Treatment and Management for Perimenopause
It is important to take a holistic approach when managing this stage in life. Most women, after thorough testing, usually get relief of symptoms by hormone replacement therapy (HRT) by adding body-identical micronized progesterone (such as Prometrium) to balance estrogen already produced by the ovary. The other tests suggested will continue to inform the direction of dietary and lifestyle changes to best support the individual. Broadly speaking, a diet high in fibre, protein and healthy fats, stress management, and exercise in the form of aerobic and resistance-based exercise can support overall health and make perimenopause for women more manageable.
References
Prior, J.C. (2011) Progesterone for symptomatic perimenopause treatment - progesterone politics, physiology and potential for perimenopause, Facts, views & vision in ObGyn. = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987489/
Mirkin, S. (2018). Evidence on the use of progesterone in menopausal hormone therapy. Climacteric, 21(4), 346–354. https://doi.org/10.1080/13697137.2018.1455657
Erdélyi A, Pálfi E, Tűű L, Nas K, Szűcs Z, Török M, Jakab A, Várbíró S. The Importance of Nutrition in Menopause and Perimenopause-A Review. Nutrients. 2023 Dec 21;16(1):27. doi: 10.3390/nu16010027. PMID: 38201856; PMCID: PMC10780928.
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