After years of periods that were as regular as clockwork, everything began going crazy when Denise Crandall turned 40. "When I started getting very heavy periods every two weeks I thought, 'This is ridiculous,' and went to see my gynecologist," says Crandall, a 42-year-old mother of two active boys, 12 and 9, who lives in Manhattan Beach, California. She was also suffering from crippling migraines and would sometimes awake in the middle of the night drenched in sweat.
When a series of tests ruled out all the scarier possibilities, such as uterine cancer, it became clear that Crandall was going through perimenopause, the transition between normal menstrual cycles and full-blown menopause. Her doctor prescribed birth control pills, which steadied the hormone swings that were causing her symptoms, and Crandall felt like her old self again. "It's heaven," she says.
Many women in their early 40s and even mid-30s are caught off guard by symptoms like Crandall's that they don't connect to the menopause transition -- from early hot flashes that feel a lot like fever to menstrual bleeding that becomes more or less frequent, heavy, light, or just plain unpredictable. These changes may come on gradually and often mimic PMS: feeling cranky, anxious, and depressed; gaining weight; having trouble sleeping; being exhausted. Some might also signal serious conditions that aren't related to menopause.
But they're most likely connected to the wildly fluctuating levels of estrogen and progesterone women get as the ovaries begin to shut down.
The Change Before the Change
"Perimenopause" is a term that gets tossed around a lot without people knowing exactly what it means. As Crandall learned, doctors define it as the transition period when normal menstrual cycles begin to change in frequency and duration and ending at menopause, which you reach after 12 months with no period. Although menopause is technically just one day in your life (after that you are "postmenopausal"), you can be in perimenopause for 10 years or longer, during which time you are still very much capable of becoming pregnant. The average age for reaching menopause not brought on by surgery or chemotherapy is 51.4, according to JoAnn V. Pinkerton, MD, medical director of the Midlife Health Center at the University of Virginia. Only about 1 percent of women reach it before 40 and an additional 5 percent between 40 and 45.
Perimenopause's swings in hormone levels are what spark abnormal bleeding. Expect two distinct phases: First, periods become shorter and come closer together as the egg sacs (follicles) in the ovaries produce less progesterone. Over time, estrogen production also drops and women enter the later stage: "Women are still producing some estrogen, but it's not enough to necessarily stimulate the endometrium and ultimately result in a period," says Isaac Schiff, MD, a professor of obstetrics and gynecology at Harvard Medical School. This makes periods even more unpredictable and other symptoms more intense. Intervals between periods can be shorter or longer, and blood flow may be scanty to profuse.
As ovulation becomes more erratic, diminishing levels of progesterone (the hormone that prevents too much tissue buildup in the uterus) may lead to longer and heavier periods. You might go a few months without a period and worry you're pregnant -- and then get one again. Or you might actually be pregnant.
Although fertility declines with age, women in their 40s are second only to teenagers in their rate of unintended pregnancies, says Dr. Pinkerton, who is also on the board of the North American Menopause Society. "Because they are not ovulating regularly, perimenopausal women are at risk for getting pregnant throughout their cycle, even when they are bleeding," she says. "As a consequence, they really need to be conscientious about contraception."