The Perimenopause Puzzle
Signs you’re in it & how to cope
By Ruth Diamond

The signs and symptoms are there – kind of. They often just creep in, fleeting moments that happen now and then. Some women don’t even notice while others brush it off with a simple excuse. But symptoms like a feeling of intense heat or difficulty sleeping or even increased anxiety could be a sign of perimenopause. 

Ruth Hennebery, MD

“A lot of women know menopause is when they stop having periods, but they may not realize that a lot of the symptoms and changes in their bodies occur before that happens, during perimenopause,” says Ruth Hennebery, MD, an OB/GYN with Cooper University Health Care.

The information gap

Menopause is officially marked by a full year without menstrual bleeding, typically occurring between the early 40s and age 60, with the average onset at age 51. The precursor to this phase, perimenopause, presents a vaguer picture, often leading to confusion and misunderstanding.

In the past, perimenopause and its symptoms were rarely discussed openly, partly due to cultural taboos around aging and reproductive health, leaving many women uninformed and feeling isolated, says Wendy Martinez, MD, an OB/GYN and founder of Advocare The Women’s Group For OB/GYN. While the tide is shifting, thanks in part to high-profile women and social media influencers sharing their experiences, misinformation remains a challenge, says Martinez. 

“Most physicians didn’t get much training about menopause and many are afraid to discuss it,” says Martinez, a member of the North American Menopause Society. “It always surprised me to see how many doctors attended my menopause lectures, learning alongside my patients.”

Wide-ranging symptoms

Wendy Martinez, MD

During perimenopause, women experience a decrease in estrogen, the hormone responsible for reproductive organ health. Estrogen also affects many other systems and functions of the body. 

The fluctuation of estrogen can trigger everything from hot flashes and night sweats to mood swings and disrupted sleep. Women may also experience vaginal dryness, discomfort during sex, breast tenderness, unexpected weight gain, hair thinning and brain fog.

“Everyone will go through perimenopause differently,” says Martinez. “It depends on how your ovaries are slowing down. Some women might have had regular periods their whole lives and then that stops on a dime. That sudden change often comes with more symptoms, including severe weight gain, as well as anxiety and depression disorders.”

For those whose menstrual cycles taper off more gently, the impact of these symptoms may be less pronounced. Approximately 15% of women never have a hot flash or night sweats, Martinez says.

HRT: What You Need to Know

For women who don’t want to become pregnant, hormone replacement therapy (HRT) can be started during perimenopause, says Hennebery. HRT is effective for a wide range of symptoms, primarily by replenishing estrogen levels. Available in various forms such as gels, creams, injections, vaginal rings and pills, it can be tailored to fit different needs and preferences.

She notes that HRT is most suitable for women who are not at risk for heart disease or certain cancers. “There is not a specific dose we use for women who are perimenopausal as opposed to those in menopause,” Hennebery says. “It depends on the individual. We try to use the lowest dose adequate at controlling symptoms while minimizing any risks.”

Alternatives to HRT 

Those looking for alternatives to HRT, whether due to a history of breast cancer or other health concerns, have lots of options too. Some prescription antidepressants alleviate the number and frequency of hot flashes while also addressing mood issues, adds Hennebery. 

For vaginal dryness, Hennebery notes some moisturizers address general dryness and painful sex. There are also medications, both oral and in suppository form, that can improve lubrication. 

Don’t overlook exercise

Exercise for managing mood and weight gain as well as to boost energy levels 

during perimenopause cannot be overstated, says Martinez. Hormonal changes and a slower metabolism contribute to an average weight gain of 15 pounds, particularly around the midsection. And decreased physical activity coupled with sleep issues – brought on by hot flashes and night sweats – further compound these challenges.

“A lot of mood issues can be counteracted by exercise,” Martinez says. “If you’re working out 30 minutes a day for 5 days a week, getting your heart rate where you’re huffing and puffing and sweating, when you finish, your endorphins will counteract a lot.” 

Reach out for help

Hennebery notes that it’s often difficult to sift through the sea of contradictory information about perimenopause. 

“Societally, we still minimize a lot of issues that women go through related to perimenopause and menopause, and these are pretty significant changes,” Hennebery says. “It’s important to let your OB/GYN know if you’re dealing with bothersome symptoms so we can get you the best help and treatment.”  


May 2024
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