Perimenopause

There’s a lot of information about perimenopause circulating around but here I will give you my definition and how I view perimenopause based on my years of clinical experience as a hormone coach and years of extensive research in the field of estrogen and estrogen deficiency diseases. Let’s start by simply defining the phases of menopause to get a better perspective:

• Premenopause is the relatively normal menstrual cycling reproductive aged women experience typically in the age range of 28-35.
• Perimenopause is the staged transitional phase leading up to the menopause where ovaries are petering out that accompanies mental, emotional, behavioral, and physical changes such as irregular menstrual cycles, mood swings, headaches, etc.
• Menopause refers specifically to the last menstrual period but is rarely used as a diagnosis in itself because it is impossible to know at the time if a menstrual period is the last one; therefore ‘post-menopause’ tends to be used more than ‘menopause’.
• Postmenopause is the time after the last menstrual period (the menopause) and there are stages to postmenopause.
• Premature Menopause is when women experience their last menstrual cycle before the age of 40.
• Early Menopause is when women have their last menstrual cycle before 45. Certain events other than natural aging can result in an earlier menopause:
  • Hysterectomy (uterus removed)—symptoms appear gradually
  • Oophorectomy (ovaries removed)—symptoms appear immediately
  • Premature Ovarian Failure (POF)—underactive or inactive ovaries due to genetics, surgery, gut dysbiosis, medications, or cancer treatments, such as radiation therapy or chemotherapy. POF can also be due to ovarian dysfunction or insufficient follicles.

Perimenopause has often been referred to as the period of time leading up to the menopause, which is defined by not having a period for 12 months, but it’s really a process of ovarian decline. In terms of the reproductive life cycle, perimenopause is the transitional time between being in a state of reproduction and a state of no production, or postproduction of child bearing.¹ 

The Cause Perimenopause

            The biggest difference between premenopause and perimenopause (and menopause) are your estrogen levels. Estrogen dictates when the perimenopausal transition will take place, if at all.² When estrogen gets too low for too long, perimenopause gets triggered.³ Perimenopause does not take place if estrogen is maintained in levels that mimic a woman in her premenopause, reproductive stage of life. Hormones are messengers to the brain and estrogen is the main sex hormone messenger for women. When estrogen stays too low for too long, this sends a message throughout the body that you are no longer in a premenopause reproductive state but rather a transitional state preparing for your last menstrual cycle (the menopause) as your ovaries continue to decline. Perimenopause does not take place if your estrogen levels are sending signals to your brain of being in a state of reproductive prime.

Factors That Determine The Onset of Perimenopause 

• Estrogen levels^2,3
• Age of Last Delivery⁷
• Gut Health Ecology⁵
• Lifestyle⁴

The Age Of Perimenopause

           I’d like to be clear that perimenopause could happen to any post menarche woman no matter how old she is if her ovaries are dysfunctional. Perimenopause is a phase of declining ovarian function and there are many things that impact how or if your ovaries will produce the amount of estrogen your brain and body require to thrive.

            Most women reach menopause between the ages 45-55 with an average age of 48^6,8, but can occur as early as early 30s or 40s. Old data suggest the average age of menopause to be 51, but that’s not the case so much now for a handful of reasons including exposure to endocrine disrupting compounds and a crappy diet and lifestyle. With 48 being the average age of menopause, and perimenopause as the time leading up to the menopause, women can go into perimenopause as young as early 30s⁹. Some young women never really make it into the state of reproduction and always live in a state of perimenopause.

            The truth is, if estrogen stays low enough for long enough your periods will stop, and you don’t have to be old to have this happen. The average age of the onset of perimenopause for most women is around 35¹⁰. I’ve seen this to be mostly true in my clinical experience about ten years ago but now I often see this age of onset getting younger and younger. It is not unusual to see young women in their late 20s and early 30s in perimenopause.

Measuring Perimenopause

            Most people don’t realize that you can measure perimenopause to see if you’re in it, and can be measured with a combination of three criteria:

1. Blood Serum Estradiol Lab Test—Your ovarian function will dictate how much estrogen your body will produce. Blood serum lab ranges for a healthy reproductive woman are between 150-650 pg/mL depending on where in your menstrual cycle you get your blood drawn. Perimenopausal women tend to fall well below this range most of the time.
2. Blood Serum FSH Lab Test—Your FSH should be looked at as a barometer to whether your brain thinks you need estrogen or not. It’s estrogen that dictates whether this number will go up or down, just as it’s estrogen that dictates whether you go into perimenopause or not. When estrogen is low and remains low, your FSH will rise. When your brain thinks you have enough estrogen, it will lower to optimum. An FSH between 6-35 would indicate you’re in perimenopause, and how high or low that number would indicate the stage of perimenopause you’re in. (Read about perimenopause stages below.)
3. Indicators (Clinical and Biological Manifestations)—With low levels of estrogen comes a slew of mental, emotional, behavioral, and physical dysfunctions women and doctors would never think to relate to estrogen deficiency. There are millions of functions in the female brain and body that are dependent upon estrogen to optimally function. Below are some of the top issues women deal with and experience during the perimenopausal transition:

Irregular menstrual cycles

Painful and irregular periods

PMS/PMDD

Depression

Anxiety

Insomnia

Gut dysbiosis

Fatigue

Fibromyalgia

Headaches

Hot flashes

Mood disorders

Heart palpitations

Joint pain

Weight gain

Shortness of breath

Isolation

Loneliness

Urinary issues

Decreased metabolic function

Insulin resistance

Irritability

Abnormal uterine bleeding

Anger issues

Emotional detachment

Cravings (sugar, alcohol, drugs, simple carbs)

Cognition issues

Behavioral disorders

Memory issues

Low self esteem

Low self worth

Low self confidence

Decreased executive function

Inability to cope

Decreased desire to live

Though this list is minimal compared to what women experience during the perimenopausal transition, women with healthy amounts of estrogen and low FSH levels tend to not have these symptoms, or to the severity of which women experience these things.

Stages of Perimenopause

            Perimenopause is a staged process a woman goes through leading up to the time her period has been missing for a year, of which time she is in post menopause, which is also a staged process.¹¹ The FSH range for perimenopause is wide and your level will tell you what stage of perimenopause you’re in. Using the FSH as the loose gauge for the stages:

1. Stage 1 Perimenopause — FSH between 6-10
2. Stage 2 Perimenopause — FSH between 10-20
3. Stage 3 Perimenopause — FSH between 20-30
4. Stage 4 Perimenopause — FSH over 30

            For most women, menopause will hit somewhere after 30 but average FSH is about 35.

            Depending on what stage of perimenopause you are will influence your clinical indicators. The higher the stage of perimenopause the more symptoms you will have and the severity of symptoms will increase.¹² 

Women, Sexuality, And The Self

            As hormones are declining throughout the stages of perimenopause, there is also a transitioning taking place in the mind of a woman and an adjustment process as to how she will exist in this world, and how she sees herself in this world. There is a mental, physical, and physiologic transition taking place heading for the grand climacteric of post menopause, where a woman is completely out of her reproductive years. During this transition there is an evaluation that takes place where the mind of a woman tries to reconcile with what her life is now, what it was in the past, what didn’t come to fruition, and what’s to come. There is self-adjusting and surrendering that takes place mentally as well as physically while adapting to alterations in sexuality.¹³ Through this transition, a woman tries to adapt to her new mind and body as it impacts all those who surround her, and it’s usually not very good. This tends to be a depressing transitional experience for women and as there is a lot that is lost or will never be, and most women aren’t happy with what’s taking place in their minds and body’s, as well as the emotional and behavior issues that accompany perimenopausal and menopausal women.

Perimenopause Is Avoidable And Reversible

            Women and doctors are under the impression that perimenopause is something every woman will experience but I see this to not be the case for most women. When women are producing the right amount of estrogen with their own ovaries, or taking the right hormones, dosed in the right amounts, and administered in the right manner by someone who know how, then perimenopause does not exist for most women. Not every woman will be able to escape the perimenopausal transition, but most can if doing the right things and taking the right things.

If you're experiencing perimenopause or suspect you're getting ready to go into perimenopause and don't want to, do my How To Reverse (Or Prevent) Perimenopause program and get your life back today.

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^Reference:

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^{7.  Shin YJ, Song JY, Kim MJ, Choi JI, Han KD, Lee HN. Relationship between age at last delivery and age at menopause: The Korea National Health and Nutrition Examination Survey. Obstet Gynecol  Sci. 2017;60(4):362-368.}

^{8.  Edwards H, Duchesne A, Au AS, Einstein G. The many menopauses: searching the cognitive research literature for menopause types. Menopause. 2019;26(1):45-65.}

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^{11.  Sammel MD, Freeman EW, Liu Z, Lin H, Guo W. Factors that influence entry into stages of the menopausal transition. Menopause. 2009;16(6):1218-27.}

^{12.  National Collaborating Centre for Women's and Children's Health (UK). Menopause: Full Guideline. London: National Institute for Health and Care Excellence (UK); 2015 Nov 12. (NICE Guideline, No. 23.)     5, Diagnosis of perimenopause and menopause.}

^{13.  Wilmoth MC. The middle years: women, sexuality, and the self. J Obstet Gynecol Neonatal Nurs. 1996;25(7):615-21.}