Today we are going to review early vs. late perimenopause symptoms and treatments. Perimenopause is defined as: the period before menopause when bleeding cycles begin to change (both in timing or character) and extends until one year after the last monthly bleed. This can take anywhere from just a few years to up to 10+ years. The symptoms that a woman experiences during this transition change from early to late perimenopause.
Often the symptoms that women experience in early perimenopause are irregular periods, sleep disruption, and anxiety. All of these are brought on by falling progesterone. As a woman’s egg supply gets depleted, she stops ovulating and in turn, stops making progesterone. Because progesterone is needed to stabilize the uterine lining, as levels dip the bleeding pattern becomes irregular, often producing periods that come closer together and sometimes heavier and crampier. In the brain progesterone has a calming effect. So, in its absence we have increased anxiety and restless sleep. Not surprisingly, the way we treat this is to support progesterone. If we’re going to do that with herbs, I would choose chasteberry. If we are doing that with hormones, we can give progesterone for 10-14 days a month, mimicking the body‘s natural release of progesterone during the second half of the cycle, or we can give it every day of the month.
Once a woman enters late perimenopause she starts missing periods for 2-3 months at a time (or longer). At this point most women begin to experience hot flashes and night sweats. These symptoms come from falling estrogen. Other low estrogen symptoms are joint pain, vaginal dryness/pain with sex, weight gain or redistribution (belly fat), brain fog, and some women just don’t feel like themselves. Now we need to support estrogen. The non-hormonal ways we do this are with plants phytoestrogens such as soy, equol, siberian rhubarb, etc. If we are prescribing hormones we simply add estrogen.
There are many different acceptable hormonal regimens. I typically start with topical bioidentical estrogen patch or gel along with bioidentical progesterone capsule at night. We know that if estrogen is delivered through the skin, there is lower risk of blood clots in the legs and lungs, heart attack, and stroke. There are certain scenarios, however, where a woman might find herself needing to take an oral estrogen, and that’s OK. For instance, if a woman’s period becomes extremely heavy, sometimes we need to use something stronger like birth control pill or progestin containing intrauterine device (IUD). These have the advantage of better bleeding control than menopausal hormones. Honestly, I wish we had a term other than “birth control” for these options. Please think of them as just a different hormonal regimen.
As you can see, early vs late perimenopause brings different sets of symptoms. Of course, I have simplified this: there are even more variations in how women experience hormone changes. I will post another blog on estrogen and hot flashes which will go into more depth on what is happening with estrogen throughout the transition. But for now, please recognize that perimenopause is the time when a woman naturally sees a decline in progesterone and then eventually decline in estrogen. Not every woman needs treatment for perimenopause, but if she does, we support her symptoms as they evolve, modifying her regimen as her hormones continue to shift and her needs change as she moves toward menopause.
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