Understanding “Perimenopause”

For a professional party planner like Bonnie Leopold, irritability is about as welcome as gate crashers. But there it was: Leopold, 48, of Manhattan Beach, Calif., started feeling nonstop grouchy and snappish. She also got hot flashes so often that she didn't dare leave the house without her portable fan. And when she had two menstrual periods in one month, she was convinced she had ovarian cancer. Susan Santacaterina, 46, a Chicago nurse, didn't think she had a fatal disease, but after suffering for months from insomnia and headaches before every period, she had an MRI scan of her brain anyway. Donna Lambert, 47, sums up her situation like this: "I feel like I'm brain-dead." The former day-care director, who lives in Charlottesville, Va., walks into rooms and wonders why she is there; once able to memorize a two-page grocery list, Lambert now can't go shopping without one.

The three women's disparate symptoms would seem to suggest they've got totally different illnesses. But, in fact, they're all on the same wild hormonal roller-coaster ride, and it's called perimenopause.

The body of a seventysomething man makes more than twice as much estrogen as that of a woman the same age. This is because small amounts of testosterone, which the testes produce throughout life, are converted to estrogen. If you like the prospect of menopause, you'll love perimenopause. Literally "around menopause," perimenopause begins when hormone-related changes kick in, as long as 10 years before menopause. Menopause itself begins 12 months after a woman's final period, and in the United States comes at an average age of 52. If you define perimenopause as lasting 10 years, then more than 20 million American women are now going through it. Perimenopause promises many of the same hot flashes, concentration gaps, mood swings, sleep troubles and migraines associated with menopause, as well as irritability and memory loss, with an added sweetener: the symptoms come earlier and last longer. As early as 35 but almost certainly in your 40s, your hormones start to betray you. Estrogens, progesterone and other reproductive hormones no longer work together with the precise timing of a Rolex, but instead act like "a Swiss watch that's gotten rusty," says Dr. Wulf Utian, a reproductive biologist at Case Western Reserve University and executive director of the North American Menopause Society. That is a radically new understanding of perimenopause. Despite claims that its symptoms reflect plunging levels of estrogen, and that women should seek relief through estrogen replacement, perimenopause is marked by hormones riding a roller coaster. Breast surgeon Susan Love, in her "Dr. Susan Love's Hormone Book," calls it "the mirror image of puberty," and that has important implications for treatment.

There is no typical perimenopause, just as there is no typical puberty. But in general perimenopause brings, first and most obviously, wacky menstrual periods: more often, less often, heavier or lighter. It can also worsen PMS, cause night sweats, diminish libido and cause skin, hair and vaginal walls to thin and dry out. Each of these reflects changes in the river of hormones coursing through a woman's body. The better a woman understands these changes, the better care she is likely to get from her doctor, for although perimenopause has been recognized by the American medical establishment since the 1970s, many doctors had not heard of it before the 1990s. It still isn't part of most med-school curricula, and there are still physicians who dismiss a woman's perimenopause symptoms as all in her head. Here's what really happens:

A typical woman might have very low estrogen at the beginning of her menstrual cycle. That could give her hot flashes for two weeks, explains Susan Love. (But you needn't expect the worst: although as many as 70 percent of women in their 40s experience irregular menstrual periods, only 30 percent suffered hot flashes in the three years before menopause, a 1991 study found.) Low estrogen will also goad the pituitary to churn out more FSH. That, in turn, will stimulate the ovaries to produce twice as much estrogen as normal, ushering in the PMS-like symptoms of high estrogen-low progesterone.

What can women do to alleviate the symptoms of perimenopause? Some things are easy calls. It makes sense to avoid alcohol and spicy foods to minimize hot flashes, and to swear off caffeine (especially after midday) to sleep better. Weight-bearing exercise (that includes walking) stimulates the production of new bone, which is a good way to enter menopause itself. But after these no-brainers, the treatment advice depends on what a woman's hormones are up to (or down to).

Say a woman has erratic estrogen levels. The surest sign of such a hormonal roller coaster is weird menstrual cycles, but also mood swings like those of PMS. More doctors are therefore recommending birth-control pills, which even out hormone levels. Alesse, Lo-estrin and Mircette are called low dose, but in fact they contain enough estrogen to suppress ovulation (that's the original point of the pill, after all). This wallop of estrogen "will basically shut down the ovaries," says Dr. Brian Walsh of Brigham and Women's Hospital in Boston, so they no longer secrete estrogen. Hormone levels, now set completely by the medication, settle down. (A woman who smokes or has high blood pressure should not take the pill, however, because it can raise her risk of fatal blood clots. And all women need to consult their doctor about the best way to alleviate the symptoms of perimenopause.)

If a perimenopausal woman is suffering from a dearth of estrogen, she needs different treatment. How can she tell if she's running on empty? Estrogen stimulates production of the brain chemical serotonin, which, among other jobs, regulates sleep and emotion. Less estrogen can bring insomnia and mood swings. In addition, estrogen can twiddle the body's thermostat--the hypothalamus, which sits deep inside the brain. "When estrogen declines," says Walsh, "it causes the temperature center to become unstable." That can trigger hot flashes. Chronically low estrogen can also impair verbal memory. How bad can the memory loss be? Novelist Anna Quindlen, 46, wrote in 1997 about waking up in the middle of the night and "forgetting the names of my children." The reason, new research shows, is that estrogen stimulates neurons to sprout new branches, helps generate new synapses and triggers production of substances that promote neuronal growth--all of which weave brain neurons into networks that learn and remember.

To kick estrogen levels back up, hormone-replacement therapy might seem an obvious choice. Bonnie Leopold, the party planner, swears by the Vivelle estrogen patch on her backside. A two-inch clear oval that resembles a nicotine patch, it slowly releases the form of estrogen called 17 beta-estradiol; she credits it with wiping away her irritability. But many doctors are wary about putting premenopausal women on HRT; such use is not approved by the Food and Drug Administration. An authoritative 16-year study of some 40,000 nurses found, in June 1997, a 43 percent higher risk for fatal breast cancer among postmenopausal women who took HRT for 10 years or more. Other studies have shown a risk even at five to seven years, says Dr. Nananda Col of New England Medical Center in Boston. That makes starting HRT at, say, 42 a potentially dicey proposition. "It would seem to me that giving estrogen when somebody's got high levels already," says Dr. Gerson Weiss of New Jersey Medical School, "is not the best idea."

Women who reject HRT often turn to "natural hormone replacement." Supplements like black cohosh (one used by Native Americans) promise to deliver phytoestrogens (from plants) and relieve perimenopausal symptoms. But this market is so underregulated that you can't be sure what's in any of these pills; few have been thoroughly studied. They probably won't cause any harm, but a surer bet is to obtain phytoestrogens from foods like soy (as tofu, soy milk, tempeh, miso) and flaxseed oil. How much do you have to eat? In one study a daily regimen of six tablespoons of soy flour reduced hot flashes, sleep disturbances, depression and loss of libido. You don't have to close your eyes and hold your nose, either. The 1998 book "Estrogen: The Natural Way" contains more than 250 phytoestrogen-packed recipes for, among other delicacies, orange-apricot bars, noodles with creamy sesame sauce and mackerel-and-onion quiche.

Although some women's health activists complain that doctors are "pathologizing'' a normal stage of life, there are two sound medical reasons for acknowledging perimenopause. The first is that if a woman doesn't understand that waking up every night at 3 has the same underlying cause as the worst PMS she's ever suffered, and that her insomnia is in turn related to irregular periods and mood swings and an inability to remember where she was in a conversation before the phone rang, she may wind up with a fistful of symptom-by-symptom prescriptions. She'll get sleeping aids, tranquilizers, antidepressants and appointments with therapists, but not treatment for the underlying hormonal swings. Worse, if doctors don't recognize that hormonal upheavals kick in long before menopause, they may dismiss women's perimenopausal complaints as imaginary. "It used to be thought that women didn't really have symptoms until their final period," says Walsh. "But in reality, hot flashes are worst about three or four years before that. If you wait for her final period before you listen to her concerns and treat her, you'll miss most of the misery."

The second reason to recognize perimenopause is to treat it as a wake-up call. You are approaching the next stage of your life, but you've got advance warning. So heed it: give up cigarettes, eat right, exercise, reduce. That way, when you go through menopause itself you will be in the best shape you can. In the meantime, just knowing that your crazy symptoms have a name and a cause might be relief enough.

Changes Before 'The Change'

There is no typical perimenopause. Some women experience few or no symptoms. Others are not so lucky; they suffer from a wide range. Some of the most common:

Memory lapses and loss of concentration Some women who take estrogen report an improvement in cognitive function.

Headaches May be caused by fluctuating hormone levels. Some women begin to suffer migraines.

Mood swings Changes in hormone levels may interfere with the production of the body's mood-regulator serotonin. Some women feel anxious or weepy.

Dry skin A decrease in the protein collagen-which may be linked to a decline in estrogen-means less elasticity and more wrinkles.

Bone loss Declining reproductive hormones translates to less protection for bones. The problem is at its worst after menopause.

Hot flashes Many perimenopausal women experience them, mostly around the head and upper body. They usually last several minutes. Nocturnal hot flashes, which are known as night sweats, can lead to insomnia.

Erratic menstrual cycles A classic symptom of perimeno-pause. Cycles vary widely from 18 days to missed periods. Excessive bleeding is common.

Vaginal dryness As estrogen levels decline, the vaginal wall thins and becomes less elastic. Intercourse may become painful.

Urinary incontinence As the vaginal wall weakens, the bladder loses support and urination is harder to control.


Low-dose birth-control pills Pills such as Alesse combine the hormones estrogen and progestin (synthetic progesterone) to alleviate perimenopausal symptoms that result from roller-coastering hormone levels.

Hormone-replacement therapy Pills such as Premarin boost estrogen levels. But if your symptoms reflect erratic hormone levels, rather than falling ones, HRT might make them worse.


Vitamin B6 Available in supplements or foods such as chicken, this vitamin helps turn amino acids into the neurotransmitter serotonin, which affects mood. The RDA for women 31 to 50 years old is 1.3 mg.

Vitamin E This antioxidant may alleviate hot flashes. The RDA is 8 mg for women 31 to 50. Soy Loaded with plant estrogens, soy may reduce hot flashes. Available in capsules, soy milk, soy flour and tofu (about 2 ounces contain 45 mg).

Flaxseed An herb containing omega 3 fatty acids that may reduce heavy menstrual bleeding. Sprinkle 1 to 3 tablespoons of crushed flaxseed on cereal each day or use a few teaspoons a day of flaxseed oil in cooking.


Evening primrose About 3 grams a day of the oil from this plant might help alleviate breast tenderness and regulate hormone levels.

Black cohosh root Available in capsules and tinctures, this root seems to work like estrogen, reducing hot flashes and relieving painful periods.

Dong quai A Chinese herb, it is often taken to relieve menstrual cramps. But a recent study found it's no better than placebos. Women typically take 4.5 grams a day in capsules or tinctures.

Kava Made from the root of a shrub, kava purportedly helps reduce mood swings, irritabil-ity and stress. It is usually taken in 60- to 120-mg capsules.

Chasteberry This berry may help with menstrual irregularities and painful breasts, apparently by increasing progesterone levels. Available in capsules or tincture.

St. John's wort The flowering tops of this plant have been called "natural Prozac" because they seem to lift depression and anxiety. The capsules and tinctures should not be taken with prescription antidepressants.