Perimenopause and Menopause Overview

Written by Tamara L Wexler MD, PhD

Menopause is a normal part of aging. It refers to the time when ovarian reproductive function ends—when a woman’s ovaries stop producing eggs and making the hormones estrogen and progesterone. Menopause is retrospectively diagnosed 1 year after your last period.

Menopause tends to occur in a woman’s late 40s to early 50s, but varies by country, with an average age of 51 years in the United States. Occasionally, women may have premature ovarian failure or early menopause. In addition, menopause may occur abruptly in a woman who has her ovaries removed or who undergoes chemotherapy or radiation.

What is Perimenopause?
Perimenopause refers to the time period leading up to menopause (premenopause) and the time following it (postmenopause). During the years preceding menopause, hormone levels fluctuate and average estrogen levels may even be higher. After menopause, hormone levels gradually decline.

You can still become pregnant during premenopause, even with erratic periods, making contraception important for women who don’t wish to become pregnant.

What are the Symptoms of  Perimenopause?
During the years leading up to menopause, periods are often irregular, and vasomotor symptoms such as hot flashes and night sweats often occur. Vasomotor symptoms refer to a difficulty regulating body temperature. These vasomotor symptoms may persist for years but do usually dissipate over time.

During the postmenopausal period, estrogen levels gradually decline, which may cause symptoms of vaginal dryness and increase the risk of cardiovascular and bone problems (discussed below). Sleep disturbances also are common throughout the entire perimenopausal period.

A host of other symptoms have been reported in association with perimenopause, but it is unclear whether they are directly related to menopause or are a result of aging. These other symptoms include fatigue, depression, irritability, anxiety, memory difficulties, weight gain, and urinary incontinence (trouble holding your bladder).

Signs and symptoms of perimenopause vary not only during a woman's perimenopausal period, but also from person to person.  

Health Changes with Menopause
The hormone changes that occur after menopause increase the risk for bone thinning (osteopenia and osteoporosis) and fracture, and heart disease. Thus, it is important to see your doctor during this time to monitor for these conditions and get treatment if necessary.

Management of Menopause Symptoms
Many women have difficulty with perimenopausal symptoms and may benefit from lifestyle changes and/or medications to manage symptoms and other health risks that occur with menopause. It is important to talk to your doctor about these issues.

Lifestyle Changes

Medications

Hormone replacement therapy (HRT)—sometime given in the form of birth control pills or a patch—consists of estrogen, plus progestin in women with a uterus to protect against the increased risk for endometrial cancer with use of estrogen alone. HRT often helps with hot flashes, sleep difficulties, and vaginal dryness. It also reduces the risk of bone fracture. However, HRT carries known risks, including increased risk of blood clots, stroke, and urinary incontinence, and an increased risk of breast cancer in combined estrogen and progestin; recent data suggests a potential additional risk for lung and ovarian cancer.  The risks may be related to the timing and duration of hormone therapy—how old you are, how long ago menopause occurred, and for how long you take hormone replacement. While the risks are real, the benefits of HRT may outweigh these risks in some patients at some times.  It is important to discuss the known risks and benefits of hormone treatment with your doctor.  

Vaginal estrogen creams offer one option for local hormonal treatment that may help with vaginal dryness and discomfort while limiting systemic absorption (meaning that less hormone enter your bloodstream than with pills or patches)

A word on supplements: While supplements and phytoestrogens have been touted as helping with symptoms of menopause, there is no consistent evidence showing benefit without risk. For example, data is not consistent on whether phytoestrogens such as soy protect against some of the risks of estrogen or carry the same risk. In addition, black cohosh has been linked to liver toxicity.

Other Medications: Medications that are used to treat other conditions such as depression (SSRIs) and high blood pressure may help with hot flashes and mood changes in menopausal women. Other medications such as bisphosphonates may help protect bones in women with bone thinning. Since all medications are linked to side effects, talk to your doctor to see if these medications are right for you.

 

 

Sources

Sources
Fischer B, Gleason C, Asthana S. Effects of hormone therapy on cognition and mood. Fertil Steril. 2014;101(4):898-904.

Grady D. Clinical practice. Management of menopausal symptoms. N Engl J Med. 2006;355(22):2338-2347.

Nelson HD, Walker M, Zakher B, Mitchell J.Menopausal hormone therapy for the primary prevention of chronic conditions: a systematic review to update the U.S. Preventive Services Task Force recommendations. Ann Intern Med. 2012;157(2):104-113.

Taylor HS, Manson JE. Update in hormone therapy use in menopause. J Clin Endocrinol Metab. 2011;96(2):255-264.

U.S. Department of Health and Human Services, Office of Women's Health. Menopause. September 2010. Available at: http://www.womenshealth.gov/menopause/menopause-basics/index.html

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