Learn About Perimenopause
What is Perimenopause?
Key Symptoms
What Causes Perimenopause?
Conventional Treatments
Medications
Tests and Procedures
Treatment and Prevention
How Supplements Can Help
Self-Care Remedies
Alternative Therapies
References
When to Call a Doctor
Evidence Based Rating Scale
What is Perimenopause?
Menopause is that natural phase of a woman's life when her ovaries no longer are releasing eggs for fertilization or producing the female hormones estrogen and progesterone. Perimenopause is the collection of signs that may indicate you are shifting towards your menopausal years. During perimenopause, women still release eggs, or ovulate, during some cycles. But during others, you may not ovulate at all and therefore may not produce as much progesterone. This can cause wild fluctuations and imbalances in her hormone levels. As these hormones decline, menstrual periods first become irregular then finally stop. When a woman has had no periods for 12 months or if a blood test shows her ovaries are not responding anymore, she is said to be in menopause. For more information on Menopause see the Whole HealthMD Healing Center on Menopause.
As with all maturation processes in the body, this phasing out of menstrual periods is a gradual process, and the decrease in hormones can take several years. If a woman is beginning to experience symptoms from her declining hormones, but still having menstrual periods, she is considered to be in perimenopause. Perimenopause can take from five to 10 years and begin as young as age 40 or even 35. Most women are in menopause by the time they reach their early to mid fifties.
These years are an opportunity for women to take stock of their attitudes to health and wellness. Reflecting on your current state of health, and the practices and behaviors that have brought you to this point in your life is prudent. Perimenopause can be considered a cross-roads from young adulthood into your maturing years. Often in early adulthood our bodies needs in the form of fitness, diet, and overall health and wellness come secondarily to those of the responsibilities of work and family. Perimenopase signals women that it is time to reconsider the practices that they have adopted, what works for them and what doesn't. Of course, neither perimenopause nor menopause is a disease, but simply names for natural phases in a woman's life. It is up to you how you want to spend your mature years – magazine articles tout that forty is the new thirty! Now is the time to implement the changes necessary to ensure that you will enjoy total health and wellness well into your maturity.
Three health issues emerge during perimenopause that affect some, but certainly not all women. Each is caused by fluctuating levels of estrogen and the imbalance that occurs between estrogen and progesterone levels. The first medical concern is a familiar group of symptoms, including hot flashes, night sweats, mood swings, fatigue, and menstrual irregularities. The second is an increased risk of developing heart disease because of changes in cholesterol and blood pressure. And the third is an increased risk of osteoporosis (brittle bones) as the bones themselves lose calcium into the urine. These changes can all be anticipated and addressed through a variety of therapies depending on a woman's personal preference.
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Key Symptoms
· Menstrual irregularities, including spotting
· Hot flashes
· Night sweats
· Sleep problems
· Irritability or mild depression
· Lack of focus or concentration
· Vaginal dryness with painful or uncomfortable intercourse
· Aches and pains in fingers, shoulders, and other joints
· Weight gain particularly around the abdomen
· Loss of interest in sex
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What Causes Perimenopause?
During the years leading up to menopause, called perimenopause, the ovaries' production of the hormones estrogen and progesterone dwindles gradually, a shift experts believe may begin as early as a woman's thirties. Perimenopausal symptoms become more noticeable as menopause approaches and are due not only to the lower levels of hormones being produced but also to unpredictable hormonal fluctuations. In addition, women who have had total hysterectomies in which the uterus and both ovaries have been surgically removed develop immediate and usually severe menopausal symptoms. This is because their female hormone levels fall so abruptly and completely--and not gradually as in perimenopause.
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Conventional Treatments
There are no treatments for preimenopause per se, because perimenopause is not a disease. However, if you decide to treat the symptoms of perimenopause the most common conventional method is to take oral contraceptives. More than for the birth control aspect of this medication, the pill helps regulate your menstrual cycle, reduce or eliminate hot flashes, and combat vaginal dryness and premenstrual syndrome (PMS). The regulation of your hormones can also help improve your mood swings. Oral contraceptives can help make the transition into menopause smoother.
An option for women with truly troublesome symptoms is hormone replacement therapy (HRT)--although some doctors advise against HRT until after menopause when it is used to reduce the risk of heart disease and osteoporosis. However, no matter the age when HRT is given, there are possibilities of unpleasant side effects (bloating, breast tenderness, menstrual cramps, headache, and weight gain) or even health risks (blood clots, breast cancer, gall bladder and liver disease). In fact, of all women placed on HRT, one in three discontinues it after one year due to side effects.
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Medications
The following conventional drugs may be used to alleviate the symptoms of perimenopause:
· Oral contraceptives help to regulate your menstrual cycle and stop unwanted spotting or irregular bleeding. The pill can also help reduce or eliminate hot flashes, vaginal dryness, and mood swings attributable to PMS. Side effects include nausea, bloating, and breast tenderness. Women who smoke while on the pill are at increased risk for developing blood clots.
· Hormone replacement therapy is only recommended for women who are seriously hindered by perimenopausal complaints. HRT works by supplying a low dose of estrogen and or progestin by pill, patch, cream or vaginal ring. It has been shown to be effective in combating hot flashes, vaginal dryness, and sexual discomfort. However, the administration of HRT has become a controversial issue in recent years. Unpleasant side effects (bloating, breast tenderness, menstrual cramps, headache, and weight gain) or even health risks (blood clots, breast cancer, gall bladder and liver disease). You should discuss your medical and family medical history with your physician before beginning HRT. HRT may not be suitable for women with a history of breast or endometrial cancer, heart disease, stroke, or liver disease.
· Antidepressant medications may help to relieve hot flashes, irritability and insomnia. There are many forms of antidepressant medications, all with varying side effect profiles. Talk to your doctor to see which if any of these forms of drugs may be right for you.
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Test and Procedures
There is no one definitive test that can determine whether you are in the perimenopausal stage of life. If you go to see your physician with this concern they will talk to you about your age, menstrual history/ regularity, constellation of symptoms (both physical and emotional). Changes in any of the above can be caused by a variety of causes. Some doctors may also order tests to check your hormone levels. Increased levels of follicle-stimulating hormone (FH) and decreasing levels of luteinizing hormone may signal the estrogenic changes associated with perimenopause. Keeping a journal of your menstrual cycle and associated complaints can help your doctor in making their assessment.
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Treatment and Prevention
Perimenopause is a natural stage of life and may not necessarily require any treatment at all. However, if your symptoms are severe enough to interfere with your life, you should talk to your doctor about different treatment options.
In addition to the conventional modalities listed above, there are a number of complementary approaches to perimenopause that have proved to be very helpful at easing symptoms. These range from gentle herbs for hot flashes and mood swings to a variety of alternative therapies including dietary changes, vitamins, yoga, meditation, acupuncture, Chinese herbs, aromatherapy, and homeopathy for all the troubling symptoms of perimenopause.
A number of herbs have been used for centuries to control perimenopause symptoms. Although these herbs can work singly, for some women combinations of certain herbs seem more effective.
You cannot prevent perimenopause. Instead you can take interpret this as a wake-up call from your body. Women today are living longer, healthier more productive lives thanks to various medical advances. If you take the time now to plan for your future by implementing diet, exercise, a vitamin/ supplement routine and an emotional wellness plan your older years have the opportunity to be your most productive years yet. Take the lessons of your youth and plan ahead for a healthy and prosperous tomorrow.
Just a reminder: If you have a serious health condition, always talk to your doctor before beginning a supplement program.
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How Supplements Can Help
Black cohosh, a relative of the buttercup, may reduce levels of LH (luteinizing hormone), a pituitary hormone that may contribute to hot flashes. Black cohosh is also a source of phytoestrogens that may help alleviate vaginal dryness. Adding some vitamin C and flavonoids can help reduce swings (1,2).
Chasteberry, the fruit of the chaste tree also called vitex, is often recommended by European doctors to help with PMS symptoms and may also help with hot flashes (3). Chasteberry causes the pituitary gland, which directs the interplay of female hormones, to signal the release of progesterone, bringing it into better balance with estrogen already circulating in the system.
Rhodiola, an herb from the mountainous regions of Asia, Europe, and the Arctic, is often prescribed to help combat overall stress, whether it be physical, emotional, or mental. This adaptogenic herb can help people who are wound up during a stressful time; and also someone who is fatigued from having just been through a stressful time. Rhodiola regulates the monoamines in your endocrine and nervous system to bring your system back into homeostatic balance.
St. John's wort is a popular herbal supplement that has been shown to be as effective as conventional antidepressants in treating mild to moderate depression. And because it helps promote sound sleep, St. John's wort is particularly beneficial for those who suffer from the fatigue, low energy, or insomnia that sometimes accompanies perimenopause (4).
Siberian ginseng has been used as a tonic for both men and women for centuries in China. Recent evidence indicates that this all-purpose herb relieves stress, boosts mood, and increases mental alertness; it also seems to stimulate the immune system and lower blood pressure.
Dong quai has been referred to as "female ginseng." As such, it seems to act as an adaptogen balancing a variety of functions throughout the body to increase energy, counter the physical effects of stress, and enhance physical and intellectual performance. Although it is not a phytoestrogen and doesn't have any hormone-like effects on the body, this herb seems to have a balancing effect on the female hormone system (5). Polyherbal supplements containing dong quai have proven to be the most effective. Many Traditional Chinese medicine supplements for perimenopause are multi-herbal preparations that include dong quai.
Vitamin E improves the stability of blood vessels and may block the erratic dilation of the blood vessels just beneath the skin that are responsible for hot flashes when estrogen levels fall. Research as early as from the 1940s postulated that vitamin E can prevent hot flashes. Studies have shown that the decreased frequency of hot flashes with vitamin E supplementation is only modest (6). However, sometimes rather high doses are required (up to 1,200 I.U. per day), so you might want to discuss this therapy with your physician.
Vitamin C and flavonoids may slow the heavy menstrual bleeding that often appears in perimenopause. These substances strengthen capillary walls that normally weaken before and during the menstrual period. Flavonoids may also relieve hot flashes and moodiness because of their estrogenic properties (7). The bioflavonoids hesperidin and quercetin are particularly beneficial.
Women who live in countries where soy is a staple also suffer fewer hot flashes and other perimenopausal symptoms as well. Foods high in plant like estrogens include chickpeas pinto beans, lima beans and lentils. The best sources of soy are cultured whole soy products like miso and tempeh. Look for whole soy roasted snacks, cereals, meat replacement products and soy milk. Products like soy powders and capsules have been shown to be lest effective. Another alternative to soy foods are supplements containing soy isoflavones, natural chemicals that scientists believe to be the protective ingredients in soy. The major isoflavones of soy, genistein and daidzein are now available in capsule form. However, most of the research on soy has been done with women who ate soy products regularly, so foods such as soy milk and tofu are probably your best bet.
The essential fatty acids found in flaxseed oil and in evening primrose or borage oils help regulate naturally occuring hormonelike chemicals called prostagalins. They will help control the irregular menstrual bleeding so common during perimenopause, including heavy or scant flow and cramping. There is only minimal evidence of benefit from supplementation with evening primrose oil, further research is necessary before evening primrose oil can be accepted as a first line of defense against menopausal complaints (2).
Get supplement dosages and tips in our WholeHealthMD Supplement Recommendations for Perimenopause.
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Self-Care Remedies
Reduce stress with techniques such as meditation, yoga, or aerobic exercise. This can reduce hot flashes and improve mood during this time of reduced reserves against stress. Regular exercise can also help you sleep and improve mood. You should try and incorporate a mix of aerobic and weight bearing exercises to promote cardiovascular and musculo-skeletal health.
Practice good nutrition. Examine your diet to see if you are getting all of the nutrients your body needs to transition into healthy mature years. You should eat a low-fat, high-fiber diet that includes lots of fruits vegetables and whole grains. Now is also a time to start ensuring that you get enough calcium and other minerals to fend off the ravages of osteoporosis that often accompany later life. If you are lactose intolerant or are not getting enough calcium rich foods try calcium supplements. Calcium supplements come in many forms from pills to chewable candies.
Avoid food triggers, such as alcohol, coffee, chocolate, and spicy foods, which can add to the stresses on your system and aggravate hot flashes.
Wear your clothing in layers. When hot flashes arrive, layers can come off until the amount of clothing is comfortable. Also dressing in natural fabrics such as cottons and silks that naturally breathe, may make you more comfortable when hot flashes arise.
Use cotton pajamas, sheets and blankets. Cotton allows heat to escape quickly.
Relaxing in a tepid bath for 20 minutes each morning can help prevent hot flashes.
Quit smoking. Smoking increases your risk of heart disease, stroke, and cancer. These risks increase after menopause anyway, be proactive and lessen you chance of suffering from serious malady.
Celebrate. Find reason in your life to celebrate how far you have come! The years that accompany perimenopause often bring with them reflection on your life and the choices that you have made. Learn from your experiences to this point and incorporate that wisdom into making your coming years “wise woman†years. Exchange your bad habits for healthy ones as you approach your second half of life with renewed enthusiasm and a commitment to total wellness.
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Alternative Therapies
One natural alternative for women who are seeking to alleviate the symptoms associated with perimenopause are bioidentical hormones. Bioidentical hormones are synthesized from wild yams or soybeans. The molecular structure of these hormones is indistinguishable from that of natural hormones produced in the body. Other names for bioidentical hormones are: “natural†hormones, Human-identical, and Human-iso-molecular.
Bioidentical hormone therapy is important to separate from other hormone replacement strategies. Conjugated Equine Estrogen (Premarin) contains equilin sulfate that naturally occurs in horses, but not in humans. Progestins, such as medroxyprogesterone acetate (MPA) and norethindrone, are not bioidentical to human progesterone.
Bioidentical estrogen and progesterone are available and the research on both looks promising. Preliminary findings suggest women treated with micronized estrogen and progesterone treatment find significant relief from vasomotor complaints with no dangerous endometrial cell growth (8). Results from progesterone only therapy are equally as optimistic. In a study of 102 women suffering from hot flashes, nearly 83% found relief with the application of a transdermal progesterone cream. You should discuss with your physician which hormone combination and mode of delivery is right for you. Some forms of bioidentical hormones are available through conventional pharmacies, while some have to be ordered through compounding pharmacies. At your local pharmacy you will find bioidentical oral tablets/ pills, transdermal patches, and creams. In addition to these applications, compounding pharmacies also offer vaginal suppositories and intra-muscular injectables. Your physician can help determine the type of estradiol and progesterone, amount, and method of delivery that best suits you.
As with other hormone replacement strategies, safety is a concern. Bioidentical estrogens must be prescribed with progesterone in women with a uterus. Oral micronized progesterone is recognized as effective protection. However, more research is needed before scientists can say that transdermal progesterone is protective. Preliminary study results suggest that transdermal progesterone has an anti-proliferative effect on estrogen-stimulated endometrial cells (9). You should fully discuss your personal risk profile with your doctor before pursuing any form of hormone replacement therapy. With open communication and thoughtful consideration you and your doctor can tailor a program that addresses your specific needs.
Mind-Body Skills instructors may also be able to benefit you during this often overwhelming transition. Meditation, guided imagery, and relaxation techn
Supplement Recommendations for Perimenopause
From Sharon Montes, M.D. at WholeHealthMD:
If you're troubled by hot flashes or other perimenopausal symptoms, and HRT isn't on your (or your doctor's) agenda, try taking some of the supplements suggested here. All are safe as recommended, but they do have hormonelike effects. So while they're effective at quelling perimenopausal symptoms, supplements shouldn't be used when hormones aren't appropriate, such as when breast cancer is a concern.
How to Take the Supplements
Start with black cohosh, a reliable herbal hormone stabilizer. If your symptoms are especially uncomfortable, add either chasteberry or a women's herbal combination product, which includes small amounts of a number of herbs (dong quai, soy isoflavones, chasteberry) and other nutrients. Alternatively, if your symptoms are mild and you only need minimal doses of the various herbs, an herbal combination product alone may be all you need.
You can also add other herbs, such as Siberian ginseng,dong quai, which seems to enhance the effects of other herbs. Both are considered "female tonics" and are used worldwide for menopausal symptoms. If your symptoms don't respond to these herbs, move on to the topically applied natural progesterone cream, which can be very beneficial.
There's also recourse if you're having menstrual problems associated with perimenopause. The essential fatty acids in flaxseed oil and evening primrose oil or borage oil can help to regulate sudden hormonal shifts that can lead to irregular bleeding or cramping.
Eating plenty of soy can also reduce your symptoms, improve your cholesterol, and lower your blood pressure. Soy isoflavone capsules are a good option if you don't want to consume soy foods or beverages.
Recent studies have shown that antioxidant vitamins can be beneficial for perimenopause as well. Vitamin E in particular helped reduce the risk of heart by keeping LDL ("bad") cholesterol from adhering to artery walls.
Two other herbs have also proved beneficial for certain symptoms. Ginkgo biloba can aid women with menopausal-related concentration or memory problems. And St. John's wort has a long track record as a safe, effective remedy for the melancholy that plagues some women as their estrogen supply declines.
Of special note:
· Adding a calcium and magnesium product (800-1,200 mg calcium and 400-800 mg magnesium twice a day) can be a protective step against osteoporosis-induced fractures, and it's particularly important during perimenopausal years.
· If you're suffering from mood shifts, anxiety, and nervous tension, kava (250-500 mg 2 or 3 times a day) can be an herbal miracle. It works quickly, doesn't make you drowsy, and improves your concentration. Kava should be taken under medical supervision due to risk of liver damage.
· Sleep disturbances during perimenopause are extremely common. Melatonin (1-3 mg at bedtime) can be a real lifeline--a safe, effective sleeping aid that's not addictive.
Important:
We at WholeHealthMD strongly recommend that everyone take a high-potency multivitamin/mineral and well-balanced antioxidant complex every day. It may be necessary to adjust the dosages outlined below to account for your own daily vitamin regimen. All of our supplement recommendations also assume you are eating a healthful diet.
Be aware that certain cautions are associated with taking individual supplements, especially if you have other medical conditions and/or you're taking medications. Key cautions are given in the listing below, but you need to see the WholeHealthMD Reference Library for a comprehensive discussion of each supplement's cautions and drug/nutrient interactions.