Perimenopause marks beginning of end of women’s reproductive years

It is different for every woman, some make it through with barely a scratch, others are so beset with symptoms that just getting through the day is a struggle. Welcome to perimenopause.

During this beginning stage of menopause, complex hormones such as estrogen and progesterone that have been involved in a kind of perfectly choreographed dance start to change the routine, often erratically, as the body prepares for the end of the reproductive years.

While menopause is specifically defined as the point when menstruation has ceased for 12 consecutive months, perimenopause is a combination of physical changes and symptoms distinct to every woman. The average duration is about four years, yet for some it lasts much longer. And the way it manifests itself can be a stone-soup mix of genetics, medical history, lifestyle - and pure mystery.

"We don't really understand why that is, but menopause just affects everybody differently and there are some women who say, you know, 'I woke up and I've never had a period again and I felt fine,' and there are other women who still have a period and say, 'I feel horrible,' so it does affect women differently," said Dr. Annette Mayes, a local gynecologist and obstetrician.

Most women are not aware of the fluctuation in their hormones until they start to experience a range of symptoms, noted Dr. Petar Planinic, assistant professor of obstetrics and gynecology for the University of Nevada School of Medicine. Women 45 and older are the majority of those experiencing the stages of menopause, he added.

The most frequently reported symptoms include hot flashes, which feel like a rush of heat in the chest area that moves toward the head and then on to the body's periphery, he said. They can last from one to five minutes and be accompanied by increased perspiration, racing heart, chills and anxiety.

"Our cardiovascular system has to, let's say, adjust to a new situation in which the estrogen level is going to be much lower than it was and this causes what we call certain basal motor instability, which means that the vessels may suddenly dilate and increase blood flow, which brings this release of heat from the body," Planinic said.

A woman's menstrual cycle will begin to fluctuate, too. In early perimenopause, say the first two years, periods may become more frequent and the flow unusually heavy. In the late stages of perimenopause, periods often start coming farther apart and with a lighter flow, Planinic said.

Although it is not unheard of for women in their 30s to enter perimenopause, it is rare, Planinic said. Women younger than 40 who experience perimenopausal symptoms may be suffering from another medical condition, such as premature ovarian failure, and should consult their doctor, he said.

Dr. David Kartzinel, a local obstetrician and gynecologist, noted that women can often look to their own family members such as mothers and sisters to help them determine when they might be entering this initial stage of menopause.

In his practice he commonly sees perimenopausal women who are experiencing hot flashes that often disturb sleep. Patients also report anxiety, irritability, weight gain, fatigue, headaches and a decrease in sex drive, he added.

"Most women say, 'I can't explain it but I just don't feel right. I don't have the same energy level I used to have. I don't sleep as well as I used to. I just don't feel as sharp as I used to be, I'm just not on top of it. I'm a lot more irritable, things set me off a lot easier that I used to not even care about. There's just something wrong,' " he said.

Among the most difficult symptoms for women to connect to perimenopause are cognitive and emotional issues, but they are definitely real, the experts agreed.

Mayes joked that her sister has a term, "mental-pause," that refers to the forgetfulness and foggy thinking that can plague some women at this stage. There was even a study released earlier this year by scientists at the University of Rochester Medical Center and the University of Illinois at Chicago that confirmed memory problems in women approaching menopause.

The stages of menopause can also compound pre-existing struggles with anxiety or depression, Mayes said.

What is important is that women seek help for any symptoms that are significantly affecting quality of life, the experts noted. There are lifestyle changes that can be recommended and treatments that are available, including hormone therapy, which is still considered the most effective medication for certain problems such as hot flashes, they said.

Opinions about hormone therapy have gone in cycles. There was a time when it was automatically prescribed, but the release of the National Institutes of Health Women's Health Initiative results in 2002 changed that. The study, which looked at the possible benefits of hormone therapy in postmenopausal women, linked it to risks of heart disease, blood clots, stroke and breast cancer.

Eventually, as the study was looked at more closely, it was decided that hormone therapy is an acceptable option for healthy women who are relatively young, such as those younger than 59, according to the North American Menopause Society. The risk grows, however, when it is used for women who are several years beyond menopause or if it is prescribed over a long period of time.

"(The study) was not designed nor did it intend to answer the question about women using it for symptoms at the time of menopause, and when the WHI results were analyzed by age it fortunately appeared that younger women have fewer of the risks compared to older women if older women were given hormone therapy. So that's good news," said Dr. Margery Gass, North American Menopause Society executive director.

Gass says, however, new research keeps "fine tuning" what we know on this topic, and there will always be a mix of risk and benefits. Women at a high risk for heart disease, blood clots, stroke and breast cancer, for example, need to think carefully about taking hormone therapy, she said.

The results from research such as the WHI means there is much more discussion between patients and their doctors about hormone therapy's pros and cons, Mayes said. Another difference is that it is prescribed for a limited amount of time, say a few years, rather than indefinitely

Besides oral and transdermal hormone therapy, there are localized treatments such as vaginal-estrogen creams to combat pain during intercourse caused by symptoms such as dryness, Mayes said. It also improves the strength and elasticity of the vaginal tissue.

"There's some women who ... need to be on hormones because they just feel so horrible and it affects their day-to-day living, it affects their working ability, so for those patients I do say, 'OK, let's start you on something and we'll try to keep you on it for a limited amount of time and see how you do,' " she said.

"Hopefully there's a balance somewhere that will make sense," she added, "but I think it's just hard because there are so many studies going on and a lot of them contradict each other. So I tell my patients to hang in there with us."

For women who have milder symptoms that they want to address naturally, healthy lifestyle changes can often make a difference, the experts said. These changes can include getting regular exercise; establishing routines at bedtime such as keeping a room comfortably cool to help diminish night sweats and hot flashes; eating a healthful diet; limiting alcohol; quitting smoking; and getting support from family and friends.

There are also practical tactics such as wearing open-necked tops and layers of clothing that can be removed in a warm room to help diminish the effects of hot flashes.

Kartzinel says the body has amazing ways of compensating for the hormone imbalances that come with perimenopause, but it needs some help.

"The problem is if you're under a lot of stress, you're not getting a lot of exercise, you're not getting a lot of sleep, you're having a very poor diet, you're more likely to feel these symptoms and have it affect you a lot more," he said.

Finally, in a youth-obsessed culture it may feel like an uphill battle for many women to accept the realities of the physical changes that are going on, but the good news is it provides the chance to reflect and regroup.

"I think that's kind of the benefit of menopause. It is a sign that says, 'OK, wait a minute, this is the end of this reproductive era and I've got all these years left, I want to think seriously now about what I should be doing to make those as healthy a set of years as I can,' " Gass said.