There is nothing “Peri” about Perimenopause
If you are still getting your period with any semblance of regularity, you can’t be perimenopausal right? If you haven’t hit your 50s, you can’t be perimenopausal right? If you are XXX, you can’t be perimenopausal right? Yeah, none of that stuff is true.
Perimenopause is a name given to the last few years of menses prior to menopause and while it’s been a thing for all of human history, we are finally starting to talk about it out in the open. For some women, this time of life is a breeze and they never have any major issues and will eventually say, “one day my period stopped and it was great." I call these women “the unicorns” because I rarely see them. What is far more common is that starting in the second half of the thirties you notice some changes in the cycle and these changes progress over the next decade. Then, one day you wake up and you are drenched in sweat, but know your period should be starting in a day or so and you are emotionally exhausted becasuse you cried three times yesterday and haven’t been able to stay awake past 9 pm, but can’t get back to sleep at 3 am when you have to make this new middle of the night bathroom stop.
As women get into the later years of the menstrual cycle, we face two main problems. Problem one is that you begin to run out of eggs so its harder for your body to recruit follicles every month and it has to work so hard to get you to ovulate 1 egg, you might get two eggs and nearly double the hormones - for five minutes at least. The second problem is that because all the eggs are “old” your ability to maintain the whole corpus luteum with it’s progesterone production is declining and everything feels like its falling apart. All of this leaves you with about a week where you feel good and normal - and that week is when you get your period.
So, is there anything we can do so you don’t require having a nervous breakdown? Why yes there is and I’m so glad you asked. Step one is a thorough review of your symptoms and when in the cycle you are having them. We can then work on the part of the cycle that’s bothering you and add either supplements, activities, or warning labels for friends and husbands. For some women this will look like progesterone supplementation in the second half of the cycle, and for others, it might looks like magnesium supplements the second week of the cycle. For yet more women, this is using a low dose prozac for a week starting a few days before the period. For others, doing a low dose HRT every day might be enough to help smooth out the peaks and valleys. My point in describing this is to say that you have options. So, if you have been to your doctor and been told - “there’s nothing to do until you havne’t had a period for a year” or even worse, “you don’t want to even talk about hormones because they cause breast cancer” (which isn’t now and never was true), then yes, there is something we can offer to help make you feel like yourself again.
Let’s talk blood tests for a moment. I wish with all my heart that there was a simple blood test we could do to tell you how close to menopause you are. Unfortunately, that’s not really the case. Our friends in the fertility world also desperately want this and most of what we have to offer is extrapolating from their data. So, below I will detail what we have and where it might be useful.
AMH - This test has become the foundation of fertility testing. It can be drawn any day of the cycle, doesn’t require complicated lab equipment and is pretty good at predicting how the ovaries will perform in an IVF stim cycle. Not planning to have IVF? Then this test really only offers an exclusionary value. If you number is high for your age, you probably aren’t close to menopause, but that doesn’t mean you can’t start having the hormonal swings that cause symptoms.
Cycle Day 3 FSH - Prior to AMH, this was our main measure of ovarian reserve. If the number is < 10, probably not that close to menopause. If it’s > 10, you are probably perimenopausal. If it’s > 50, you are probably menopausal. Again, if the test is elevated, it helps you know where you stand, but it may still be normal when perimenopause is just starting.
Cycle Day 3 estradiol - the lower this number, the closer you are to menopause. A very low estradiol in combination with a very elevated FSH is diagnostic of menopause. This number may be normal or even elevated because as you enter the perimenopausal years, your FSH starts bumping up earlier and earlier and this triggers increases in estrogen. This is why at the start of perimenopause, the menstrual cycle actually gets a little shorter - 25-26 days insteat of 28. Eventually, the eggs will respond slower and slower and then the cycle will start to stretch out.
Random estradiol/progesterone/testosterone - for some reason this website program doesn’t let me add pictures, but click here to see why this is completely useless. It looks like someone threw spaghetti at the wall. The “normal ranges” provided are sometimes broken out by what part of the menstrual cycle you are in, but sometimes, they just give a normal range that is for the entire month. It’s the pattern, not the level that we desire to know and see. For a version of what perimenopause might look like, click here.
Day 21 progesterone - will likely still be >10 for a long time, or at least greater than 5.. However, the rapid rise and more rapid fall off as the follicle falls apart will cause alot of the symptoms and we can’t see this with static measurements.
Free and/or Total Testosterone - This rises and falls with estrogen - guess why mother nature makes you want sex while you are ovulating and doesn’t care about the rest of the month. Your desire for sex will likely be reduced further and further as testosterone levels decline over time. While this is the most noticeable side effect, the ones that matter more are loss of muscle tone, core body strength and bone density, all of which are hard to recognize until you see a major decline after a few years.
What does perimenopause management look like at Advanced GYN and Wellness? The first thing we do is a complete history and physical exam. Because our appointments are 40 minutes, we have time to fully explore your symptoms. It’s important to rule out other issues - this is also a time of life where thyroid dysfunction is common and many women with crazy periods become deficient in vital nutrients like iron and B12. There is a place for labs, but it may not be checking hormone levels. Hormone levels are best checked as a response to treatment. And even then, their usefulness prior to full menopause is doubtful. As part of your exam, we perform a pelvic ultrasound, which allows us to evaulate the uterine lining, any potential causes of irregular bleeding and assess ovarian reserve by direct visualization. Once we know what we are dealing with, we can go through options to see what works for your body, your values and maybe even the other poeple in your life.
Bottom line is, if weird stuff is happening, track it and ask about it until someone can satisfactorily answer your questions. If the person you are seeing can’t or won’t address your concerns. look for another provider.
One final note, the problem with perimenopause is that there are also no long term solutions. You’ll find a regimen that works really well for 4-6 months and then it won’t seem to work anymore or you will get a month long period or you will suddenly have teenage acne. Why? Throw some spaghetti at the wall three times in a row and see if the pattern is the same? The “pattern”of perimenopause is that there is no pattern. We often change medication doses and regimens every 3-6 months trying to nail down all the sympotms. It’s actually way easier to treat women who are fully menopausal, which may be why so many women get told that until they go 12 months without a period, they can’t be helped. Don’t get discouraged, get a good women’s health doctor who has time to listen to you.