An Overview of Perimenopause

What to expect as menopause approaches

Forty Six Years Old
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You may experience a number of symptoms during perimenopause, including changes in your menstrual pattern. Perimenopause lasts for about five to 10 years and occurs right before menopause (defined as no longer having your period for at least a year).

This stage, which typically affects women during their late 40s, is caused by a natural decline in estrogen hormones. It is important to see a doctor for your symptoms, however, because medical illnesses such as thyroid disease, type 2 diabetes, and endometrial cancer can produce similar effects.

Hormonal changes occur gradually and, while you can't stop perimenopause, you can reduce some of the uncomfortable effects.

Symptoms

The average age of menopause ranges from 48 to 58 and most women experience perimenopause in their 40s and early 50s. Symptoms can vary, and you may be more prone to some of the effects than others.

Common symptoms of perimenopause include:

Period Changes

Changes in your usual menstrual pattern are among the most noticeable signs of perimenopause. You may have irregular bleeding, intermittent spotting, or changes in your PMS symptoms.

While it is more common to experience lighter periods or to miss periods during the perimenopausal years, increased frequency and/or bleeding can occur as well.

Hot Flashes and Night Sweats

Hot flashes can occur at any time, regardless of the temperature in your environment. Some women also frequently feel warm and are prone to sweating during perimenopause. Night sweats usually occur at night and can leave you and your blankets soaked.

Mood Changes

During perimenopause, you may be surprised by feelings of depression, anxiety, irritability, or mood swings, especially if you are usually emotionally stable.

Vaginal Dryness

You might feel pain or discomfort during sexual intercourse, and you may experience vaginal dryness, fragile vaginal skin, or even bleeding for a day or so after sex.

Sleep Problems

Night sweats, hot flashes, and anxiety can contribute to sleeping problems. Sleeping difficulties, in turn, can worsen mood changes. 

Weight Changes

During perimenopause, women often have a slight to moderate weight gain and are prone to gaining an increase in fat around the waist area.

Urinary Problems

Urinary problems common in perimenopause include urinary tract infections (UTIs) and decreased bladder control or urinary incontinence. You may "leak" when laughing, exercising, or holding urine for long.

Lower Sex Drive

Many women have less interest in sex during the perimenopausal years, and it can be distressing for women and their partners.

Skin Changes

Women may notice skin dryness or a change in skin elasticity, which can make skin appear "saggy" or older.

Hair Problems

You may lose hair, resulting in thinning hair on your head. You may also get more hair on your face due to the shift in hormones.

Causes

The symptoms of menopause are caused by hormonal changes. During perimenopause, your body's production of estrogen hormones gradually declines.

Throughout the reproductive years, women produce several different estrogen hormones. These hormones help regulate a woman's menstrual cycle and facilitate pregnancy through the action of complex feedback mechanisms.

Estrogen's Role Before Perimenopause

Decreased estrogen causes many of the effects that occur during perimenopause. Ovulation (ovaries releasing an egg) stops and a woman can no longer become pregnant.

The processes that normally accompany ovulation, such as monthly production of the uterine lining, also decline during perimenopause. Menstruation, which is the release of the uterine lining when a woman does not become pregnant, gradually ceases as well.

Effects of Low Estrogen

Decreased estrogen during perimenopause can lead to other symptoms besides menstrual irregularities, such as vaginal dryness, moodiness, hair problems, hot flashes, and weight redistribution.

Estrogen helps lubricate the vagina, which promotes fertilization of an egg by a sperm. Estrogen also helps regulate mood, and the body has to adjust when estrogen's effect on mood changes during perimenopause.

There are a few asymptomatic (do not cause obvious symptoms) physical effects that begin during perimenopause and continue after menopause. Estrogen helps maintain bone health and heart health in women.

Thinning bones, a predisposition to osteoporosis, and an increased risk of heart disease can develop slowly when estrogen drops during perimenopause.

Health Impacts Perimenopausal Symptoms

Many of the symptoms that occur during perimenopause have multiple causes, and decreased estrogen can exacerbate them. For example, urinary incontinence can occur due to a number of health problems, and perimenopausal changes add to the problem.

Depression, insomnia, and weight gain are all more common with advancing age, and perimenopause can worsen them.

Induced Menopause

For health reasons, some women don’t experience natural perimenopause. If you have a total abdominal hysterectomy, with both of your fallopian tubes and ovaries removed, you can expect to experience surgical menopause (also called induced menopause).

There are also other causes for induced menopause, including pelvic radiation chemotherapy. 

Menopausal symptoms can be quite intense for women who have undergone induced menopause, and many women have to use hormone replacement after having these procedures.

Diagnosis

Typically, perimenopause is diagnosed based on your medical history, physical examination, and possibly diagnostic testing as well.

Often, women seek medical attention for the more distressing effects of perimenopause. For example, irregular periods are usually a cause of concern. Similarly, mood changes, hot flashes, and UTIs often prompt a visit to the doctor. All of these issues could be caused by perimenopausal hormonal changes, but they could be caused by medical illness as well.

For example, abnormal bleeding can be a sign of uterine fibroids or pituitary dysfunction, even during the perimenopausal years. Your doctor may need to rule out other causes of your symptoms, which can also include infections or tumors.

Common Diagnostic Tests

Pelvic examination: During a pelvic exam, your doctor will examine the cervix (birth canal), and can also examine the lower part of the uterus. This test can help your doctor assess whether you have fibroids, a tumor, or infectious lesions.

Pap smear: A Pap smear can help identify pre-cancerous lesions of the cervix. It is a relatively fast test, during which your doctor scrapes the inner lining of your cervix to collect a sample of cells that can be examined under a microscope.

Imaging tests: If there is a concern that you may have a growth or an abnormality of your cervix, uterus, ovaries, or bladder, you may need an imaging test, such as computerized tomography (CT) or ultrasound.

Biopsy: A biopsy is a sample of tissue that can be examined under a microscope. It involves a more invasive procedure than a PAP smear, and it may be guided by abnormalities seen on imaging studies.

You may need testing and treatment for the hidden health problems of perimenopause, such as osteoporosis and hypertension, even if you don't have any symptoms.

Treatment

Most women do not need to take medication to relieve perimenopausal effects. Often, lifestyle strategies can have a big impact on symptoms. For some women, symptoms are especially bothersome and hormone replacement therapy (HRT) can be helpful. In other instances, symptomatic treatment aimed at controlling specific effects, such as depression, anxiety, or hair loss, are the best fit.

Lifestyle Strategies

Taking practical steps to ease your comfort may be all you need. This is especially true if your symptoms are mild and intermittent. You might not want to take a daily medication for a problem that only bothers you once every few weeks.

Dressing in layers, drinking cold drinks (keep in healthy, like water or real fruit juice), and using a fan can cool you off. Exercise can help control your weight and can help you sleep better. Paying attention to your diet helps control weight and can help maintain healthy looking skin.

For many women, using a facial or hand moisturizer can help with skin appearance. And absorbent liners can help catch bladder leaks as well as irregular vaginal bleeding.

Hormone Replacement

Because a decline in estrogen is the main cause of perimenopausal symptoms, taking estrogen or a combination of estrogen with progestin (the synthetic form of the hormone progesterone) is often used to manage the effects.

Hormone replacement therapy (HRT) can be taken systemically (a skin patch or a pill) or locally (vaginal estrogen to treat dryness).

Keep in mind that some women can't use HRT and it does carry some health risks, even for healthy women.

Symptomatic Treatment

Often, women opt to take treatment to help control the most bothersome symptoms of perimenopause. Treatments can range from simple over-the-counter (OTC) medication to prescription therapies.

For example, OTC vaginal lubricants can help relieve vaginal dryness.

Prescription medications such as an antidepressant or antianxiety medication to help stabilize your mood. And prescription medications to help maintain bladder control can be helpful for some women. For some women, prescription medication is necessary to manage sleeplessness and insomnia.

A Word From Verywell

You will experience many changes during perimenopause. For some women, entering a new phase of life represents getting older and can be an emotional challenge.

Many of the symptoms of perimenopause are temporary and do not continue after menopause. However, some of the health effects of decreased estrogen, including the predisposition to heart disease and fragile bones, remain throughout a woman's life after menopause. Be sure to get regular preventative health check ups so that you can avoid developing health problems.

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