What is perimenopause? A recent article in "Menopause Magazine" (yes, that's a thing) concluded "Women in the Late Reproductive Stage (LRS) experience symptoms strikingly similar to those often associated with the menopause.  Women do not expect these changes until the age of 50 years or later and are surprised by such symptoms before cycle irregularity." Uh, no kidding. 

We doctors typically avoid esoteric diagnoses. We like things to be black and white: is that bone broken or not? Does the patient have diabetes or not? Unfortunately, there is no good test to determine if a woman is in perimenopause, so we diagnose based on symptoms.

The most common symptoms I see in my practice are sleep disturbance, irregular periods, and irritability. Sleep can be affected by night sweats, but I also often see a general increase in anxiety and even palpitations. I have so many patients report that anxiety was not an issue until they approached menopause.

Weight gain is also common, but this is trickier. I do not know of any hormone replacement that will reliably help with weight loss. However if you sleep better and feel better, you will have an easier time maintaining or losing weight.

There are all sorts of nice euphemisms, like "the change before the change," but I prefer to call it what it is: reverse puberty. Just like puberty, our hormonal peeks are higher and the valleys are lower, leading to unpredictable emotions, changes in metabolism, and the dreaded hot flashes. This can be a roller coaster for women, and not the fun kind.

Hormones are complicated, but we can simplify a little by dividing them into three main categories, and all categories come into play when describing the Perimenopause.

To be honest, this is all one big ven diagram and every hormone directly or indirectly affects every other hormone. Example: if you are a female with high cortisol, you will likely have higher insulin and lower thyroid function. 

Despite this complexity, there are a few key points that women should understand.

Progesterone deficiency is a major factor in the perimenopause.
Progesterone is made by the ovaries when a woman ovulates. Women who are transitioning into menopause will sometimes skip ovulation and thus not make progesterone. This is the main reason for irregular and sometimes heavy bleeding.

Progesterone and estrogen are the yin and yang of hormones. Progesterone deficiency leads to estrogen dominance. In my experience, most women in perimenopause benefit from extra progesterone, usually in the form of bio-identical progesterone. 

So why don't we just draw blood to determine progesterone levels? Because like most hormones, it is constantly fluctuating. It also cannot be measured in isolation. One must evaluate other hormones to get the full picture.

When I was a youngster in residency, I was taught that all progesterones were the same and that bio-identical hormones were a bunch of BS. Any experienced doctor will tell you that their knowledge has evolved over time. I have changed my mind and I truly believe that bio-identical progesterone is safer and superior to synthetic progesterones.

Hypothyroidism is underdiagnosed. The symptoms of a low-functioning thyroid can mimic symptoms of perimenopause, such as fatigue, hair loss and weight gain. Thyroid labs, specifically TSH, have "normal" ranges that are far too broad and miss many cases of hypothyroidism.

Functional medicine has long recognized that a normal TSH should be closer to 2.0 instead of under 5, and main stream endocrinology organizations are beginning to agree. However, a lot of primary care providers are still using old data and missing this.

Hormone replacement is not poison. Not every woman going through the transition needs extra hormones, but many will and they will feel better and function better. There are risks with any hormone replacement, but these risks have been greatly exaggerated.

The Women's Health Initiative (WHI) caused millions of women (and their providers) to fear hormones . This was a flawed study but was made big headlines. It is important to note that the women who were studied in the WHI were considerably older than the average woman going through menopause, and the hormones they were given were at higher dose and almost exclusively synthetic. 

Do not forget the stress hormones. Stress and the adrenal glands play a huge role in the symptoms of perimenopause. These are best evaluated with saliva or urine testing. A lot of mainstream doctors will dismiss this as bogus without looking at the data. Again, I feel that functional medicine addresses this more thoroughly than conventional Western medicine.

What about Adrenal Fatigue? I am not sure if I totally embrace the existance of "adrenal fatigue," but I think there is some validity. A family practice doctor whom I respect explained it this way: we know that there are disorders of excess cortisol (Cushing's Disease) and deficiency of cortisol (Addison's), so it makes sense that there is a spectrum of adrenal function. 

Take home points:

  1. Perimenopause is often a time of progesterone deficiency and replacing progesterone can ease the transition and help many symptoms.
  2. Thyroid is under-diagnosed. If you have symptoms of hypothyroidism that are not fully addressed or are dismissed, get a second opinion.
  3. Do not fear hormones. They might do you some good.
  4. Do not only focus on the sex hormones. Appreciate the complexity of our hormonal milieu, including stress hormones like cortisol, and seek providers with expertise in this.
Dr. Cynthia McNally, MD

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