Perimenopause: The Years When Your Body Stops Following The Rules

Although changes and irregularities in bleeding patterns are often one of the first signs that you are in perimenopause, there are many other signs that the coming years may be filled with unexpected and surprising ups and downs.

Variations in estrogen production account for many of these changes. For part of the month, the ovaries seem to be following directions sent to them by the brain's control center (the pituitary gland). Estrogen is then produced in amounts that support clear thinking, high energy, comfortable body temperatures, stable moods, a high interest in sex, and the lubrication to enjoy it. That can last all month long or only a few days; then, somehow and without warning, the ovaries seem to wind down. They do not respond to the brain's signals. Estrogen levels drop, and along with that drop come signs of low estrogen: brain fog, fatigue, hot flashes, irritability, anxiety, and vaginal dryness. These two extremes repeat themselves in irregular cycles until you seek help to stabilize them or until you go into menopause.

Ovulations also become rarer in perimenopause, and with that decrease, progesterone levels plummet. Once progesterone levels go low, there is not as much fluctuation; they usually just stay low. With that decline come more difficulty falling asleep and staying asleep, more hot flashes and night sweats, and an increase in mood swings and depression.

PMS, or premenstrual syndrome, may suddenly become much worse. The physical and mood-related symptoms that seem to occur cyclically can become more pronounced and severe. Irritability, mood swings, anxiety, bloating, and fatigue that last longer as menstrual cycles become irregular are other signals of the hormonal disruption of perimenopause.

Sleep can actually start to deteriorate before night sweats appear. Difficulty falling asleep is common, but middle-of-the-night waking is one of the most frequently reported symptoms of perimenopause. Staring at the clock as the minutes tick by is a common occurrence in midlife, even among women who had previously been sound sleepers.

Breast tenderness, headaches, bloating, and appetite changes can also come and go as hormones fluctuate. One week can be “great,” and the next one can be terrible. Keeping track of symptoms and where they tend to occur in the cycle can be helpful.

So how do we treat symptoms when they seem to always be changing? The goal of treatment is not to make perimenopause predictable; it is to provide enough tools to successfully navigate the unpredictability. When hormonal fluctuations are the problem, creating some type of stability is the solution.

What Are Some of the Ways to Create This Stability?

In perimenopause, if you are not having hot flashes, you may not yet want to take or use estrogen. Taking a progestogen alone can be an option. There are several ways to do this:

1. Cyclic Oral Progestogen

   A progestogen may be prescribed for part of each month to induce predictable “withdrawal” bleeding and limit the amount of blood that builds up inside the uterus. Taking a progestogen for 14 to 21 days of the month should cause a predictable bleeding episode when it is stopped monthly.

   This can be done with:

   • Micronized progesterone
   • Medroxyprogesterone (a progestin)
   • Norethindrone acetate (a progestin)

   The exact dose and duration can be decided. Each medication is available by prescription and has its own side effects, risks, and benefits.

2. Continuous Progestogen

   Taking an oral dose of a progestogen daily means no counting or skipping days. Any of the three progestogens above can be used for this regimen: one pill every night before bed.

3. A Levonorgestrel-Releasing IUD

   Levonorgestrel is a progestin and is particularly useful for heavy menstrual bleeding. It is inserted into the uterus during an office visit and provides continuous progestin activity at the level of the endometrium, keeping the uterine lining thin. It also provides contraception.

4. Oral Contraceptive-Dose Progestins

   One of the major differences between treating perimenopause and treating menopause is the possibility of ovulation. In perimenopause, if pregnancy is not desired, there are options to take an oral birth control pill that contains only a progestin. (Most birth control pills are combinations of estrogen and a progestin.) These can provide the benefits of progestin-related effects, such as mood stability and better sleep, along with the benefit of birth control.

Once more symptoms of menopause, such as hot flashes, begin—although many women have these symptoms during perimenopause as well—estrogen therapy is usually the most effective treatment for those who are candidates. Estrogen in various forms can be added to any of the progestogen plans above to relieve hot flashes and night sweats. You do not have to wait 12 months without a period to use estrogen therapy. However, if you add menopausal doses of estrogen during these times of instability and hormonal fluctuation, there is likely to be an increase in irregular bleeding.

The important point to realize when seeking treatment during perimenopause and the transition to menopause is that there is no “one-size-fits-all” approach. Hormone plans must be individualized and personalized. Stability feels better than volatility; there are many ways to get there.