Unravelling the Mystery Around Perimenopause

Cultural Understanding of Perimenopause

According to the North American Menopause Society, more than 1 billion women worldwide will be post-menopausal. Despite decades of scientific study, why do patients still say to me: No one told me it would be like this? Why didn't my mother talk about it? Until recently, people rarely discussed perimenopausal symptoms, often suffering in silence. 

The further back in history you go, the more outrageous the concepts around menopause. According to "The Curse: A Cultural History of Menstruation," by Emily Toth, Janice Delaney and Mary Lupton, doctors in the 19th century believed that menopausal women grew scales on their breasts. They also believed that receiving bad news could cause early menopause.

Longitudinal studies in the 1980s, which followed the same cohort of women, expanded our understanding of the impact of hormones on menopause. They learned that hormones like estrogen bounce from low to high rather than a slow decline. They also clarified the symptoms associated with perimenopause, including hot flashes, poor sleep, changes in mood, pain during sex and vaginal dryness.

Definition of Perimenopause

According to Santoro, Perimenopause "is an ill-defined time period that begins with the first onset of menstrual irregularity and ends after a year of no longer having periods". After a year of no longer having periods, a person is considered menopausal.

In Canada, the average age of menopause is 51, with most people reaching menopause between 45 - 55 years old. Symptoms of perimenopause can begin 2 to 7 years before a person's last period.

The stages of perimenopause

The three main stages of perimenopause include, as described in the workshops with the acronym STRAW - Stages of Reproductive Aging Workshop, are:

1) the late reproductive stages

2) the early and late menopause transition stages

3) the early postmenopause

Late reproductive stage

In the late reproductive stages, pregnancy is still possible, and ovarian reserve fluctuates over this period of time. An ovarian reserve is the reproductive potential of the ovaries based on the number and quality of eggs. At this stage, cycles may become slightly irregular. 

Early perimenopause

In early perimenopause, ovarian reserve is low, and there will be a missed period. Periods may last longer than seven days, and cycles become shorter. Fluctuations in estrogen, lower progesterone, and high FSH mark this early perimenopausal phase. This stage also includes symptoms of hot flashes, poor sleep, and mood changes. 

Late perimenopause

In late perimenopause, ovarian reserve is low, but now cycles are greater than 60 days apart. 

Late menopausal transition

Now periods are scarce, estrogen is generally low, and there is an increase in menopausal symptoms when there are no periods. When a person does have a period, there can be high or low estrogen levels.

What are the symptoms of perimenopause?

Symptoms of perimenopause include irregular menstrual cycles, often shorter cycles in the beginning, but they can become longer over time. Other changes include hot flashes, night sweats, mood changes, poor sleep, difficulty falling asleep and waking at night, headaches, low libido, brain fog, and memory changes. Symptoms associated with reductions in estrogen include vaginal dryness and pain during sex.

Not all people who go through perimenopause will experience all or any of these symptoms. Although these signs are associated with perimenopause and menopause there are other conditions that can cause similar symptoms, so it’s important to see your doctor when you’re experiencing new symptoms. 

When should I see a health practitioner regarding perimenopause?

If you’re experiencing symptoms that disrupt with quality of life and affect you on a regular basis you should consider seeing a health care provider. If you’re noticing disruptions in sleep, low energy to the point that it’s effecting your ability to work and your relationships it’s important get help. Another reason to see your doctor beginning in your 40’s is for regular screening including mammograms, screening for heart disease, osteoporosis, and other conditions that can arise at that age. 

If you’re in your 20s, 30s or early 40s and you are experiencing any of these symptoms it’s important to see your health care provider, especially if you have fertility goals, where treatment may be time sensitive. 

References:

1. Shifren, J. L., & Gass, M. L. S. (2014). The North American Menopause Society Recommendations for Clinical Care of Midlife Women. Menopause, 21(10), 1038–1062. https://doi.org/10.1097/gme.0000000000000319 

2. Grose, J. (2021, April 29). Why is perimenopause still such a mystery?. The New York Times. https://www.nytimes.com/2021/04/29/well/perimenopause-women.html

3. Santoro N. (2016). Perimenopause: From Research to Practice. Journal of women's health (2002), 25(4), 332–339. https://doi.org/10.1089/jwh.2015.5556

4. Menopause - what everyone should know. The Menopause Foundation of Canada. (2023, July 31). https://menopausefoundationcanada.ca/resources/menopause-what-everyone-should-know/