Why does it take us so long to recognise we’re in the perimenopause?
Many women who I see in our clinic tell me it has taken them several years, if not longer, to join the dots and associate their symptoms to their perimenopause. With more awareness I hope that women will recognise these signs earlier and we can help them prevent damage to relationships, careers, and their quality of life through early treatment.
Considering most women in the UK will have their last period sometime after the age of 45, it is not uncommon for women to start experiencing perimenopausal symptoms from in their mid 30’s.
Unfortunately, for many of these women who start experiencing these symptoms, it can take several years to associate the different signs and symptoms as the perimenopause. Compounding this issue is a lack of awareness amongst healthcare professionals that symptoms can start up to 10 years before a woman’s last period and so women often undergo misdiagnosis and inappropriate assessments before being diagnosed as perimenopausal.
The average age of the menopause in the UK is 51. However, this varies from person to person and can happen as early as a teenager or into your sixties. Premature ovarian insufficiency (POI) is diagnosed when your Last Menstrual Period (LMP) is below the age of 40 years and occurs in 3% of women. An early menopause is diagnosed between the ages of 40 and 45 years of age and affects 12% of women. Excluding women whose menopause is induced by a medical or surgical intervention.
What exactly is the perimenopause?
The perimenopause is the phase when physical and emotional signs and symptoms of the menopause become apparent, as a result of declining and fluctuating hormone levels leading up to the menopause. The menopause is officially diagnosed 12 months after your LMP.
The perimenopause or the menopause transition is the time running up to this LMP where we experience any number of the >30 symptoms at varying severity. Up to 80% of women will experience symptoms over 2-10 years.
The perimenopause signifies a change in function of our ovaries. As our ovarian function declines, ovulation is erratic and the production of oestrogen, progesterone, and testosterone, the three main reproductive hormones decrease.
Unpredictable ovarian function in the perimenopause can often result in oestrogen surges and dips. In general testosterone declines quickly, resulting in reduced libido, brain fog symptoms and deterioration in muscle mass. Progesterone levels are dependent upon production by both the ovaries and the released egg after ovulation (corpus luteum) and so progesterone levels will vary month on month depending on whether ovulation has occurred.
Presenting with symptoms
We are all individual and the way we present with symptoms is also different from person to person. Many women will struggle with increasing headaches/migraines, heavy menstrual periods, low energy levels and motivation, and put this all down to the poor sleep they are experiencing or just struggling to prioritise their own health. We hear constantly of women being wrongly offered antidepressants for low mood and anxiety, and pain killers for joint and muscle ache. A thorough assessment by a professional with additional menopause care experience would be able to see the bigger picture and diagnose the perimenopause instead of individual problems.
Due to constriction or dilation of blood vessels, hormonal changes affect the mechanisms that control blood pressure and temperature control, resulting in worrying vasomotor symptoms such as heart palpitations, shortness of breath, changes in blood pressure, night sweats and hot flushes. It is not surprising that many women undergo unneeded cardiac assessment, and while its reasonable that your GP may consider this, without holistic assessment the underlying cause can often be undetected for some time.
When might be appropriate to seek help in the perimenopause?
Women generally come to our clinic when their symptoms have impacted their lives enough to be detrimental to their health, relationships, marriages, families, careers, or otherwise impacting the quality of their lives.
The influence on our careers is increasingly more significant as women of menopausal age are the fastest growing demographic in the workforce. Recent surveys of women over 45 have said 60% have been negatively impacted by their symptoms at work, predominantly linked to problems with concentration, memory, fatigue and vasomotor symptoms. 25% of women had considered giving up work due to the menopause.
Recent surveys of the impact of the menopause on divorce suggest that 7 in 10 women blame the menopause for their divorce. Considering in 2020 alone there were over 100,000 divorces in the UK and a national divorce rate of 42% of all marriages, could happy marriages be saved if diagnosis and treatment was pursued earlier? Women often share their guilt during consultations of the impact of their symptoms on their relationships with their family and friends. Particular concerns around libido, irritability, motivation, fatigue and low mood negatively impacting the quality of their relationships.
The psychological symptoms of the perimenopause are often troubling for many women as they experience periods of anxiety, low self-esteem, low mood, poor motivation and confidence. These symptoms are often the first time in a woman’s life when they are experiencing mental health symptoms which can itself cause fear, worry and self-doubt.
Recognising symptoms early is key to having a positive menopause experience, being able to attribute both physical and psychological changes to your hormones can give control and reduce worry. Whether women choose to use HRT or try alternative lifestyle adjustments, knowing effective treatments are available is very reassuring.
There are many different options for women in the perimenopause and I like to discuss all the treatment choices during my patient consultations.
Research-based evidence confirms, that for the majority of women HRT is very safe and the benefits to our future bone, cardiovascular and cognitive health, in addition to symptom relief far outweigh any risks or side effects. I do however like to clarify this for women so that they feel confident they are making an informed decision that is effective and safe.
Hormone replacement therapy
There are four main treatment options to consider
Systemic oestrogen: treats the whole body, usually applied to the skin in the form of patches, gels, sprays. Used to replace the declining oestrogen levels in the whole body.
Progesterone: micronised progesterone is body-identical and is an oral capsule or can be used vaginally in some circumstances. Progesterone is not required if you have had a total hysterectomy as it is predominantly used to maintain a healthy lining of the uterus and prevent hyperplasia. It can also be beneficial to support sleep and reduce anxiety in some women.
Localised vaginal oestrogen: topical treatments in the form of vaginal creams, tablets, pessaries or the Estring (oestrogen releasing silicone ring). Used to treat and prevent further deterioration of the urinary vaginal symptoms such as itching, soreness, irritation, painful sex, urinary frequency, and leakage.
Testosterone: cream or gel applied to the skin, used to treat low libido but may also have beneficial effects on cognition, concentration, brain fog and bone/muscle health.
Using body-identical HRT is always my first-line recommendation due to the reduced side effect and safety profiles. HRT works relatively quickly, and most women see improvements in their physical, vasomotor, and psychological symptoms within a few weeks to months after starting treatment at the optimal dose. Testosterone replacement for improvement in libido with possible additional cognitive improvements can take slightly longer, up to 6 months to see the full effects.
The lifestyle Medical Approach to care
In addition, or as an alternative, we encourage a lifestyle medical approach to our treatment choices and plans for our patients. We review the 6 pillars of lifestyle medicine; exercise, nutrition, sleep, mental well-being, reduction of harmful substances and relationship issues. This allows our clients to explore and address circumstances in their lives that may be negatively impacting on their overall health and well-being. We offer a 12-week lifestyle programme focusing on nutrition and movement as the primary method to improve health.
In addition to improving well-being, increasing your weekly exercise and making positive diet choices helps to reduce cardiovascular and diabetes risk, improve bone health and helps to improve weight management.
Start thinking about recognising possible symptoms from your mid 30’s onwards
Discuss your holistic options with a healthcare professional with menopause care experience
Safe and effective treatment in the form of HRT or non-hormonal alternatives are available
Complete the menopause questionnaire on our website to self-assess your symptoms.