The perimenopause predicament

People in my peer groups tend to be high-functioning, multi-tasking people. They’re used to having things under control, and they’ve got enough experience to know what’s coming. All of this makes the unpredictable years of the peri-menopause incredibly inconvenient, if not downright infuriating. We want answers! We want ice cream! We want it to go away!Is your patient in peri-menopause? Maybe! It generally starts sometime between the age of 44 to 50, and can last a few months or perhaps an entire decade. The most identifiable symptom is menstrual irregularity, but if they’ve had a hysterectomy, are using hormonal contraception, or have always had irregular cycles, that’s not a helpful indicator.Many, indeed about 75% of women in their 40s report some combination of the symptoms that characterize peri-menopause: irregular cycles, brain fog, insomnia and fatigue, mood changes (including exacerbation of depression or anxiety), vaginal dryness, low libido and painful intercourse.The predictable rise and fall of ovarian hormones in earlier adulthood that consistently led to a week of menstrual flow, then three weeks without bleeding, stops happening predictably or consistently. Instead the hormone levels start to swing wildly at mid-life. These years tend to start with extra estrogen that might lead to increased libido and heavy flow. Lower progesterone levels may show up as spotting in the week before a menstrual cycle. As estrogen levels decrease, menses become light or absent, and patients might report night sweats or hot flashes. They might have years of skipping months at a time but never quite making it a whole year without a bleed. I’m often asked for a “hormone test” to diagnose peri-menopause, but that doesn’t exist. These hormone swings mean that a snapshot of today’s hormone levels may look completely different from tomorrow’s. Period tracking apps have introduced “peri-menopause scores” but what use is a score that doesn’t predict anything?I have a friend who was trying for another baby, and when her infertility specialist checked FSH and AMH levels, they told her she was close to menopause and would likely never conceive even with IVF. With this knowledge, she decided to take on a very demanding job . . . and a year later, she was pregnant. This is a prime example of why diagnostic tests for peri-menopause may be inaccurate due to the unpredictability of these years. Menopause is a clinical diagnosis; one full year without bleeding means it’s official.Of note, if your patient is under 45 when they complete menopause, they should continue to take hormones until age 51. The guidelines on this are clear, and yet very few women are offered this important therapy. Untreated early menopause leads to higher mortality from heart attacks, stroke and osteoporosis. Consider either continuous oral contraceptive pills or higher-dose menopausal hormone therapy (100mcg transdermal estradiol and 300mg prometrium).So how are you going to get your patients through these years? You’re going to work with them to treat the most bothersome symptoms. Heavy periods can be treated with hormonal contraception or with tranexamic acid taken during the cycle to decrease flow. If neither of those is an option, referral to gynecology for consideration of endometrial ablation is indicated. Poor sleep can be improved with CBT-I, teaching specific techniques for better rest. A weighted blanket was a game-changer for me! Nightly prometrium or magnesium with melatonin may also help for some people. Hot flashes are best managed with estrogen therapy, but SSRIs and gabapentin can help, as well as treating any associated mental health changes. Sexual and bladder changes are often improved with low-dose vaginal estrogen and pelvic physiotherapy.One of the most frustrating and least treatable symptoms of the peri-menopause is brain fog. Similar to the brain fog of pregnancy, this is a time-limited condition that does resolve once hormones have stabilized. Between ages 45 and 55, women experience decreased information processing speed and a drop in performance on short-term memory tests. In her book The Menopause Manifesto, Dr. Jen Gunter points out that women still outperform men on memory tasks even after peri-menopausal changes. Women often struggle with weight gain during these years. People of all genders gain an average 1.5 pounds per year after age 40. We can’t blame it all on hormone changes, or men wouldn’t get that middle-aged spread. There is a natural decline in muscle mass that slows metabolism, thus burning fewer calories at rest. If eating and exercise habits don’t shift to match that decline, the weight will add up over the decades. Reduced estrogen levels also move the fat distribution to be around the waist rather than in the hips and thighs, so clothes fit differently and weight gain may feel more noticeable. Modifying an exercise routine to build more muscle mass may help bump up metabolism and reduce the risk of osteoporosis. Women too often report feeling belittled and ignored by their healthcare providers when requesting help for peri-menopausal symptoms. The Canadian Menopause Society has a great Pocket Guide for Menopause Management available for free online that can provide practical help for clinicians. For more complicated patients try searching for a NAMS-certified provider.