How to recognise the tell-tale signs of perimenopause and what to do about it

The menopause itself is often thought of as a sudden big bang event. There is some truth in this, in the sense that the menopause marks a moment in time but in reality, it is just the very end point of a lifelong process of ovarian decline, typified by follicular loss. Let me explain. The ovaries are full of follicles, small sacs, each containing an egg. You’re born with around 1-2 million of them and they reduce in number month on month, year on year in a continuous free fall from the very moment of your birth. By the time you reach perimenopause, your reserves are running low and the ovaries are faltering. When they finally stop functioning, there is loss of ovarian oestrogen, progesterone and testosterone output. You are officially considered “post-menopausal” when you have been without periods for a year.

As with so many of our hormone producing organs, our ovaries are being directed from a central control centre in the brain called the pituitary gland. Imagine it like the conductor of an orchestra. The communication between brain and ovaries works both ways, rather like a conversation. When perimenopause sets in, the ovaries are unable to respond in quite the way they once did and that harmonious relationship begins to breakdown. The result? Distress signals, otherwise known as symptoms.

The symptoms women experience in perimenopause and beyond are firstly, wide ranging and secondly, specific. The wide ranging nature of symptoms is a reflection of the fact that there are reproductive hormone receptors in almost every tissue of the female body. For some women, they are plagued by insomnia, night sweats and rage. For others, it’s a non-existent libido, crippling anxiety and a sore vagina or the disorientating panic of struggling to complete sentences, leaving your keys in the fridge and being unable to recall the name of your neighbour.

The specificity of symptoms is a reflection of your individual physiology. Your particular spread and expression of hormone receptors is like a fingerprint, its specific to you. This being so, you cannot compare one woman’s experience directly to another.

A common problem in perimenopause is sometimes down to diagnostic uncertainty. The broad and varied nature of the symptoms, alongside symptom overlap with over conditions such as hypothyroidism, iron deficiency and fibromyalgia (to name but a few) can be particularly confusing and frequently women will seek blood testing for clarity. Unfortunately, whilst there is a blood test which screens for the menopause (namely Follicle Stimulating Hormone), its helpfulness in perimenopause is limited as the hormonal output from the ovaries is rapidly changing. So, whilst guidelines would tell us to offer it to women under 45 years of age, a normal result doesn’t exclude perimenopause.

So what is the answer? As a menopause specialist, if I have strong suspicions of perimenopause, I will usually suggest a trial of hormone replacement therapy (HRT), assuming the patient is open to this and its medically appropriate. Symptomatic response to treatment is often the best way to confirm the diagnosis. Most women begin to feel better within a few weeks of starting on treatment. However, I must stress that there is no one size which fits all with HRT. If a particular regime does not have the desired effect, a doctor who is experienced in menopause care should be looking to tailor the regime accordingly.

Of note, the benefits of HRT extend well beyond symptom management. Providing women with treatment in perimenopause can be a really effective way of maximising the health benefits of replacing hormones. There is excellent data to demonstrate that HRT prevents bone thinning and reduces the risk of cardiovascular events (eg heart attacks and strokes) provided it is started either during perimenopause or within 10 years of a woman’s periods stopping. Replacing hormones is also considered to be metabolically advantageous, reducing risk of centralised weight gain, high cholesterol levels, high blood pressure and insulin resistance.

When we refer to HRT, this typically includes progesterone and oestrogen, assuming that the woman has an in tact womb (those who have undergone a hysterectomy, may be candidates for oestrogen only HRT). The primary role of the progesterone is to protect the womb lining from oestrogen stimulation. However, some patients also gain additional therapeutic advantages from progesterone. The manner in which the progesterone component is prescribed will usually depend on whether the patient is still having periods or not.

Some patients will choose to add in testosterone replacement. Testosterone is well established in improving libido in menopausal women but some women also report additional associated benefits, such as improvements in cognition, energy levels and mood. Testosterone replacement in women is commercially off license in the UK and this being so, GPs are not always comfortable prescribing it. It also requires some bloods monitoring. However, for some patients it can be a symptomatic game changer.

Whichever way you chose to manage your own menopause, the best advice I can offer to all perimenopausal and menopausal women is listen to your body and speak up when something’s not right. If the first person you speak to isn’t listening, speak up again. Menopause management is about more than controlling symptoms, it is about quality of life, health and regaining control of your own narrative.

I hope that you found this article interesting. Please note that this does not constitute individual medical advice. If you would like to discuss your specific menopause needs, please reach out to me at www.thewomenshealthgp.co.uk

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