Perimenopause

Overview: At birth, a female infant has all the eggs she will ever have -in contrast to males who manufacture new sperm throughout life.  Each egg in the ovary is contained in a structure called a follicle. Female sex hormones such as estrogen and progesterone are produced by the cells of the follicle walls.

As ovulation (egg release) takes place on a monthly basis, follicles gradually diminish in number. This reduction begins to be noticeable after age thirty-five resulting in a measurable decrease in average monthly hormone production. In fact, perimenopause is the period of time during which a women’s ovaries are getting prepared to “retire” and enter a new phase which is “menopause”. The duration of this process varies by individual but can plausibly take many years!

The gradual reduction in progesterone and to some extent estrogen levels which occurs during perimenopause has an enormous influence on the body and the way it functions. Cycles may become longer or shorter or fall into a “no change” pattern. Menstrual bleeding may be heavier or lighter, more prolonged or shorter, or entirely absent for months at a time. Daily fluctuations in hormone secretion as well as declining hormone production are the underlying cause of perimenopausal symptoms.

Symptoms and Signs of Perimenopause:

  1. Night sweats
  2. Mood swings
  3. Vaginal dryness
  4. Fluctuations in sexual desire (libido)
  5. Forgetfulness
  6. Trouble sleeping and fatigue, probably from loss of sleep
  7. Breast pain
  8. Bloating
  9. Cravings
  10. Irregular bleeding intervals
  11. Heavier or lighter menstrual flow

Brief Over view of Menstrual Cycle Hormonal Production

A. In a women of childbearing age:

  1. First day of the bleeding is day one of the menstrual cycle.
  2. Follicular phase: For the first 14 days, ovaries produce mainly estrogen and very little progesterone.
  3. Mid-cycle: Ovulation occurs, as a results of ovulation progesterone is produced.
  4. Luteal phase: during second half of the cycle levels of progesterone and estrogen are high, with their maximum levels around day 21 of the cycle with the ratio in the favor of progesterone> estrogen (progesterone dominance).
  5. Almost fourteen days after ovulation, levels of both estrogen and progesterone drop which is a signal for the onset of the next menstrual cycle/bleeding.

B. In Perimenopausal women:

  1. First day of the bleeding is day one of the menstrual cycle.
  2. Follicular phase: For the first 14 days, ovaries produce mainly estrogen and very little progesterone.
  3. Mid-cycle: ovulation starts to happen less frequently (first event to be effected in perimenopausal ovaries), as a result low level of progesterone will be produced.
  4. Luteal phase: during second half of the cycle the level of progesterone drops due to lack of regular ovulation which shifts the ratio of estrogen to progesterone in the favor of estrogen > progesterone (estrogen dominance).
  5. Estrogen secretion is also subject to frequent fluctuations.
  6. Combination of low progesterone and fluctuating estrogen contribute to sign an symptoms of perimenopause.

Diagnosing and Evaluating Perimenopause

Factors to be considered:

  1. Age; ovaries start their perimenopausal changes from mid to late thirties.
  2. Symptoms (see “Symptoms and Signs” section above)
  3. Change in menstrual cycle regularity and flow in the absence of other contributory factors such as hypothyroidism, hyperthyroidism, polycystic ovarian syndrome, uterine fibroid, chronic stress and other life style related issues.
  4. Measurement of ovarian/female hormone levels in blood during special time of the month (day 21 or a week before the next cycle) looking for estrogen dominance feature seen commonly in a perimenopause.

When assessing a “perimenopausal” ovarian production of hormones, it is important to have a snap shot during the time of the month in which ovaries would have produced maximum level of it’s hormones: a week before the onset of the next cycle. Ovaries of women in height of reproduction produce maximum level of estrogen and progesterone during this time of the month.

Until recently, doctors often tested women for follicle stimulating hormone (FSH) to determine whether their ovaries were producing enough estrogen. FSH testing was based on the knowledge that in menopausal women, the FSH level is high because of low estrogen production. The pituitary gland is sending out high levels of FSH in an effort to get the failing ovaries to produce more estrogen. The problem with FSH testing in premenopausal women however is that estrogen production may wax and wane from one month to the next, therefore a consistent result is not possible. For this reason, most doctors no longer rely on FSH blood levels to diagnose perimenopause.

Hormone trial

An option often advocated by leading experts in the field, is to do a clinical test: administer a trial dose of a hormone supplement. If the premenopausal symptoms are improved, then patient and doctor are on the right track. If not, other potential root causes, such as thyroid abnormalities, ovarian disease, or perhaps plain old stressful need to be investigated.

Personally, I prefer to have a complete a work up including female hormonal status as described above to root out the cause before moving on to formulating a proper treatment. A key hormone whose levels should be tested is estradiol, the main estrogen produced by the ovaries. Estradiol levels drop as the function of aging ovaries diminishes. Another hormone besides estrogen that I check is progesterone. A low progesterone level can be another indication that ovulation has ceased.

The final diagnosis is made by putting together:

  1. Physical and psychological symptoms
  2. Menstrual cycle change pattern
  3. Blood hormone levels
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