So we all know the three major hormonal milestones in a women’s life – your first period, pregnancy and the menopause – but, in fact, there’s a fourth. The perimenopause is the transition from reproductive years to the menopause, and it can affect women as early as their 20s. We sat down with Consultant Clinical Oncologist Anita Mitra, aka the Gynae Geek, to find out more...
What exactly is the perimenopause?
While the menopause officially starts one year after your last period, the perimenopause is the period of time leading up to that. The menopausal symptoms people often refer to are often actually perimenopausal symptoms. Levels of the female hormones oestrogen and progesterone are fluctuating as our periods stop and eventually drop to very low levels after the menopause. Levels of testosterone, which is classically thought of as a male hormone, are also dropping, which contributes to the majority of symptoms and physiological changes.
When does it happen?
The perimenopause typically kicks in when a woman is in her mid-forties and can then last for years – the average age for women to go through the menopause in the UK is 51, and anything from 45-55 is considered normal. Generally speaking, the age at which your mother went through the menopause will be the best estimate of when it will happen to you. It’s also worth noting that premature menopause is surprisingly common, affecting one in every 1,000 women in their 30s and one in every 10,000 in their 20s, not including the women for whom the condition goes undiagnosed. In short, for some, the perimenopause could start as soon as their 20s.
So how long will the perimenopause last?
It varies significantly from woman to woman. The average duration of the perimenopause is four years, but it can range from a few months to ten years.
What are the symptoms?
Hot flushes are the most talked about symptom of the pre-menopausal years, as well as erratic menstrual bleeding, poor sleep and breast tenderness. There’s also the less sexy stuff that women are often shy to talk about – vaginal dryness/irritation, urine leakage, low libido, hairs in places that were previous fuzz-free, low mood and depression. Don’t forget that in spite of the symptoms, you can still get pregnant, so don’t think that contraception can go out of the window at the first hint of a hot flush.
Is it possible to get treatment?
Absolutely. Treatment largely depends on what your symptoms are and whether you want to go down the HRT (hormone replacement therapy) route or not. Your GP can start HRT, and should review you after three months. Referral to a gynaecologist specialising in the menopause is recommended by the British Menopause Society if you have a complex medical history and if your doctor is uncertain if HRT is right for you. Cognitive behavioural therapy can also be helpful for mood-related symptoms, and may be more effective than anti-depressants.
Is HRT safe?
No medical treatment is without its risks. An assessment of the risks versus the benefits should always be undertaken when starting any medication. The main risks are:
Blood clots: There is a slightly higher risk with tablets compared to transdermal HRTs (patches, creams and gels) and in women with a BMI over 30. Therefore, doctors often avoid prescribing tablets to women with a higher BMI in favour of transdermal options.
Stroke: Again, there is a slightly higher risk with tablets, especially for those over 60. Below this age, the risk is very negligible.
Breast cancer: HRT that contains oestrogen and progesterone has been linked with a slight increase in breast cancer. The theory is that the medication promotes the growth of a small number of cancer cells already present, rather than actually causing the disease.
Are there any alternatives?
Yes – bioidentical hormones (those with an identical structure to those found naturally in the human body) have gained a lot of attention over the last few years. Whilst there is some evidence to show they are effective, particularly for hot flushes, there isn’t any robust evidence to show they are any safer than the synthetic hormones used in conventional HRT.
Are there any dietary changes that can ease symptoms?
Studies show a phytoestrogen-rich diet can lower the risk of breast cancer. Flaxseeds, sesame seeds, chickpeas, lentils, tofu and soy are all plant-based sources of natural oestrogen (phytooestrogens). Supplements like red clover and black cohosh are both phytonutrient rich and can ease symptoms, but always discuss with your GP before taking them.
Is there anything younger women can do to minimise potential problems later on?
The earlier you get your hormones in check, the better. Your hormones naturally go haywire during the perimenopause, so whilst it’s not too late to do anything about it, if you’ve got good ‘hormone hygiene’ before it happens then you’re likely to fare better.
Gynae Geek’s top tips for hormone hygiene:
Stress less: Cortisol is the stress hormone, and is made from the same ingredients as the female hormones oestrogen and progesterone. From a survival point of view, if your body needs to make cortisol it will do this at the expense of other hormones, which means oestrogen and progesterone get thrown out of whack. If you can dial down cortisol production you’ll see a big impact on hormone balance.
Sleep more: Not only does this help to restore hormonal balance by reducing excess cortisol production, but tiredness also increases hunger hormones so sleep deprivation can increase the slight weight gain associated with menopause.
Drink less: Sorry to be a party pooper, but alcohol doesn’t do your hormones any favours. Think quality over quantity.
Quit smoking: Smokers have been found to go through the menopause earlier, have more severe symptoms than non-smokers, and a higher risk of heart disease and breast cancers after the menopause. It’s never too late to quit.
Eat well: Make an effort to eat as much fresh fruit and veg as you can and plenty of phytooestrogen-rich foods. Be sure to avoid a very low-fat diet – female hormones are made from fat and if we don’t eat enough, we can’t make enough. Think avocados, olive oil, eggs, nuts and salmon.
Move often: You need to load your bones and joints to maintain bone density, and doing this from a young age is key to reducing the risk of osteoporosis, which can arise due to a decrease in oestrogen after the menopause. Muscle mass also drops at the onset of the perimenopause – and thus metabolism – and exercise will help to maintain both.