Perimenopause: too young for \"the change\"

by Elissa Sonnenberg

Is it hormones or is it aging? Perimenopausal women and their health care providers search for answers about perimenopause.

When Elizabeth was 42, she thought she was going insane. Intense rage often overtook this normally happy, energetic mother of two. She once rushed out of a darkened movie theater, terrified because she felt unable to breathe while her heart raced out of control.

"I felt like I was losing it," says Elizabeth, now 47, of St. Louis. "The worst part was not knowing what caused it."

She suspected that hormones might explain her sporadic symptoms, which included intense mood swings and irregular bleeding. Still, after a round of testing, her gynecologist told her nothing was wrong. After starting her own research, Elizabeth became convinced that she was going through perimenopause, a little-known and under-researched time of life that all women experience differently.

Even the World Health Organization (WHO) has found it difficult to pin down perimenopause.

WHO broadly defines it as the 28 years before women stop having periods and the one year after their last period. In practice, some doctors believe perimenopause lasts only a couple of years; others think it ranges from five to six years before menopause. Since menopause itself is defined retroactively—two years after a woman's final period—the stage that comes before it remains unclear.

"The latest evidence is that perimenopause begins when fertility begins to decline," says Claire Warga, PhD, health psychologist, researcher and author of Menopause and the Mind. As a woman's focus on reproduction begins to taper off, other priorities for health and well-being become more important. Warga says, "Perimenopause is the beginning of a new biological agenda."

Significant changes mark this very natural yet unpredictable new agenda. Ovulation slows down and the ovaries produce less estrogen. In response, the pituitary gland increases its production of follicle-stimulating hormone (FSH) to stimulate the ovary to secrete more estrogen. This can lead to dramatic variations in estrogen levels, from lows that mimic those of menopause to highs that equal those of early pregnancy.

Since estrogen effects so many different body and brain functions, these variations can result in symptoms that are a challenge to effectively treat.

"The [hormonal] fluctuation makes it difficult," says Robert Rebar, MD, associate executive director of the American Society for Reproductive Medicine. "The symptoms may come and go, even for a couple of years, and then return," he explains.

Other factors, like timing and individuality, further confound the diagnosis and treatment of perimenopause. Because perimenopause can occur simultaneously with other mid-life conditions—such as diabetes, thyroid disorders and hypertension—it is easily overlooked. And while some women breeze through the perimenopausal years without a single symptom, others, like Elizabeth, note an overall decline in quality of life.

The peaks and valleys of perimenopause vary from woman to woman, but experts agree that symptoms include:

• Any changes in menstrual cycles - shorter or longer periods, more or less bleeding, change in patterns
• Hot flashes or night sweats - affecting up to 85 % of women
• Panic or anxiety attacks
• Sleep disturbance, such as insomnia
• Intensified mood swings, irritability, depression
• Vaginal dryness and/or increase in urinary tract infections
• Decreased libido
• Wide variety of cognitive changes - forgetfulness, foggy thinking, reversing words
• Breast tenderness

In the midst of their busy lives, women may overlook mild symptoms as age-related, while attributing others to worsening premenstrual syndrome (PMS). "These symptoms are subtle and hard to detect," says Dr. Warga. She adds that stress, which often results in similar symptoms, adds yet another wrinkle to the already complicated fabric of perimenopause.

Rebar and other doctors are quick to point out that not all perimenopausal women are symptomatic, nor does every woman with symptoms necessarily require medical treatment. "It's very difficult to make generalized statements about the perimenopausal years," says Rebar, who believes individualized care offers the best solution.

Rebar also stresses that when women see their doctors for help with perimenopause, they should first undergo appropriate screening to confirm the diagnosis and rule out other serious conditions, like thyroid conditions and hypertension.

A few options can offer relief of more extreme perimenopause symptoms:

Hormone therapy

While there have been no long-term studies of the effects of estrogen replacement therapy (ERT) and hormone replacement therapy (HRT) on perimenopausal women, many doctors agree that low doses can relieve some troublesome symptoms without negative side effects. For Elizabeth, natural progesterone alleviated her feelings of rage, but it wasn't until she began supplementing with natural estrogen that her anxiety lifted. Low doses of estrogen have also been shown to eliminate hot flashes, according to Rebar. Because of possible risks and side effects, all hormonal therapy should be carefully monitored, especially during perimenopause when natural estrogen fluctuations can be so drastic. Family and medical history also need to be taken into account to minimize risks.

Birth control pills

For perimenopausal women with contraception needs, the birth control pill can be a good option, says Dr. Rebar. Since the amount of estrogen in even the lowest-dose birth control pill is high enough to effectively stop a woman's ovaries from producing estrogen, it provides a relatively constant level of the hormone, which can alleviate many perimenopausal symptoms. "The down side to birth control pills is that there are risks," Dr. Rebar says, adding, "They're certainly small in an average, healthy woman."

Anti-depressants

Another approach to alleviating extreme mood swings and other PMS-like symptoms of perimenopause is with the use of selective serotonin reuptake inhibitors (SSRIs), like Prozac™, Zoloft™ or Sarafem™. "SSRIs are clearly the most effective medications we have for [the symptoms of] PMS," says Dr. Rebar. But he cautions that SSRIs should be dispensed only after considering all symptoms and all methods of treatment first. "I'd hate to medicate someone who doesn't require it," he says.

Preventive care

Experts agree that any comprehensive approach to perimenopause must include discussions about diet, stress and lifestyle issues. "This is a wake-up call," Dr. Rebar maintains. "You're talking about beginning a new phase in your life and paying attention to the things you didn't pay attention to before." Getting proper rest, eating well and steering clear of cigarettes, alcohol and caffeine can minimize a variety of perimenopausal symptoms while improving overall health.

Women's health expert Stephanie DeGraff Bender, MA, who founded the Full Circle Women's Health Center in Colorado, believes that women must educate themselves about their changing bodies. Knowing that perimenopause is a normal phase in life-long development can be a comfort, as can tapping into the resources of the millions of other women who share the wide range of symptoms.

Bender, who wrote The Power of Perimenopause, also encourages women to communicate with each other and with their health care providers about symptoms and treatment options. She believes that the millions of Baby Boomer women who are entering perimenopause every year will help blaze a trail of increased understanding about the condition.