Perimenopause: The What, When, How, Why

Bloating. Heavy periods. Weird mood swings. It could be perimenopause.

By Alice Lesch Kelly

What is perimenopause?

Type the word into most computers and spell check will correct you with either per menopause or Peru menopause. Perimenopause isn’t even in the database — a symbol, perhaps, of how poorly this phase is understood. But it’s not that complicated. Technically, perimenopause is the span of six to 10 years during which your body moves toward menopause. And menopause is really just one day in your life: the 365th day from the date of your final menstrual period.

"Perimenopause is not a disease, any more than adolescence is. It is a physiological life stage," says Marcie Richardson, MD, director of the Harvard Vanguard Menopause Consultation Service, in Boston. That said, it’s important to note that all the drugs or hormones in the world won’t prevent perimenopause; they’ll merely change how you experience it.

Can I predict when mine will begin?

No, but look for it somewhere between the ages of 45 and 55. A few factors are believed to hasten its arrival: smoking, never having had a baby, exposure to toxic chemicals, and a history of heart disease, pelvic surgery, epilepsy, or depression. There is no clear correlation between age at perimenopause and that of your first period, or your use of birth control pills. And you can’t bank on starting early or late based on your sister’s or your mother’s timing.

Can testing tell me where I stand?

Generally, measuring blood hormone levels is not a reliable way to determine whether you’re in perimenopause, because levels tend to be erratic in women who are still menstruating. "Estrogen and other hormone levels fluctuate widely, largely because the ovaries are starting to fail," says Lila E. Nachtigall, MD, professor of obstetrics and gynecology at NYU Medical Center. Although your estrogen level gradually declines during these years, it can at times be higher than it was before you entered perimenopause. While testing can provide some information about fertility, it can’t necessarily determine whether you’re in perimenopause. "Most of the time, even doctors have to go by symptoms," Nachtigall admits.

Why do I need to know whether I’m in it?

"You benefit from knowing what’s normal and what’s abnormal; it’s one of those areas where some baseline knowledge will save you a lot of worrying and wondering what is going to happen," says ob-gyn Jan Herr, MD, a menopause expert at Kaiser Permanente Northern California. For example, if you begin to experience vaginal dryness, knowing you’re in perimenopause can help you understand that discomfort during intercourse may be caused by physical changes, not problems with your romantic relationship. (Although it could be that too. Be honest: Perimenopause is not an excuse.)

"It’s good to know, just so you can get emotionally prepared for the endgame: not getting periods anymore," says Jerilynn Prior, MD, director of the Centre for Menstrual Cycle and Ovulation Research at the University of British Columbia, in Vancouver.

Perimenopause should also send up the red health-alert flag: Your risk for certain illnesses, such as cancer and heart disease, increases with age, and once you start toward menopause, you should consider making risk-lowering lifestyle changes and scheduling early-detection screening exams. Realizing you’re in perimenopause can be the starting gate for being more vigilant and proactive about your health.

What will my periods be like?

Erratic, to say the least. Ninety percent of women experience four to eight years of irregular periods before menopause. For most of us, periods start occurring closer together: A 28-day cycle turns into a 27-day cycle; then it’s 26 days, then 25. "You feel like you have your period all the time," says Jan Shifren, MD, director of the Vincent Menopause Program at Massachusetts General Hospital, in Boston. Then you might start to skip some cycles, and perhaps you’ll go 40 to 60 or more days between periods (which is why continuing to use contraception is important). Premenstrual syndrome often gets worse during this time because of unstable hormones, and bleeding may become heavier or lighter, notes Leslee Kagan, director of the menopause program at the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital, in Boston.

Although bleeding changes are normal during perimenopause, some merit a doctor’s assessment to rule out the presence of cancer or other diseases. Consult your doctor if or when you:

  • first notice a change in your cycle
  • experience very heavy bleeding
  • have bleeding that lasts longer than normal
  • bleed more often than every three weeks
  • spot or bleed after sex or between periods

Do I still have to use birth control?

Yes, unless you don’t mind having a baby when you’re in your 40s or 50s. Although ovulation is erratic during perimenopause and fertility steadily decreases, unprotected sex can still lead to pregnancy. "There are more unplanned pregnancies as women get older, because they’re assuming they’re less fertile," Richardson says. In fact, some 75 percent of pregnancies in women over 40 are unexpected. (The rate is second only to that for teenagers.) The chance of becoming pregnant diminishes with each year; nonetheless, record numbers of over-40 women are having babies: In 2005, the birth rate for women over 40 was the highest it’s been since 1970.

However, maternal age does increase the risk of medical complications for mothers, which can include gestational diabetes, high blood pressure, miscarriage, and stillbirth, according to the March of Dimes. Babies born to such women have an elevated risk of premature birth, low birth weight, genetic disorders, and other birth defects. If you don’t want to get pregnant, "be sure you use birth control until you have gone one year without periods," Richardson recommends.

Will I gain weight?

Probably. "As you approach 50, your metabolism drops," Herr says. That means your body needs fewer calories. The average daily calories needed by a moderately active woman to maintain her body weight goes down from 2,000 in her 40s to 1,800 in her 50s — a difference equivalent to two Oreo cookies and a glass of fat-free milk every day.

Even if you eat the same amount of food and do as much exercise during perimenopause as you did before, you’ll end up gaining weight. To avoid it, you have to ramp up exercise or reduce calories. "You basically have to run to stay in place," Shifren says. Two (painless) moves: Burn 10 extra calories an hour by doing two minutes of moderate activity, such as stair climbing, jumping jacks, or walking lunges. At each meal, try to leave two bites on your plate.

Even if you don’t gain weight, your body mass may redistribute, with fat accumulating more around your middle. Not only is excess belly fat cosmetically undesirable, it can raise your risk of cancer, heart disease, and diabetes. Belly fat promotes insulin resistance and reduces your ability to use blood sugar effectively. Your risk is elevated to unhealthy levels if your waist measurement (at the level of your navel) is 35 inches or more.

Gauging Your Perimenopausal Status

If you’re not sure whether you’re in it or not, keeping a diary can help. Prior has developed a daily diary format that helps you track your body’s changes over time. To download a copy of Prior’s diary, go to her Web site:

Keeping track "is important if you’re puzzled about what’s going on," Prior says. It may help you see, for example, that emotional stress is related to your cycle and your body, rather than to your marriage or your job. "Even the least symptomatic women — those who are not experiencing menstrual flooding, not having night sweats, not having sore breasts — will often notice disturbed sleep or that their weight is going up in a way they don’t understand. It’s all part and parcel of perimenopause."

You can keep your own journal by charting cycle dates, how long your period lasts, your menstrual flow (number of pads or tampons used), breast tenderness, fluid retention, hot flashes, mucus secretions, and stressful feelings. (Start the month with day one of your period.) Rank each symptom on a scale of 0 to 4, and over time you may notice useful patterns. You can also use your diary to keep track of your morning body temperature (it’s higher after you ovulate), treatments, supplements, and lifestyle changes that may impact your symptoms. For example, you may find that symptoms improve when you exercise or get worse when you are overstressed.

Originally published in MORE magazine, October 2008.

First Published Mon, 2009-04-06 18:04

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