Before the Change


For many women, perimenopause is a bumpy ride. Here’s help smoothing the road.

Perimenopause is not a disease. But it sure feels like one.

Hot flashes, sleep disturbances, irregular menstrual cycles, mood swings, muscle aches and the ballyhooed foggy brain are among the most common complaints. But wait, there’s more: irritability, anxiety, weight gain, incontinence, heart palpitations and&emdash;everyone’s favorite&emdash;dry vagina.

Remember puberty, when your hormones threw a party and had the last laugh on you? In perimenopause, you get to be the guest of honor all over again&emdash;only this time, you’re aging, too.

Welcome to hormonal hell, the sequel.

A Roller-Coaster Ride

Perimenopause&emdash;meaning around menopause&emdash;is the time when ovarian hormone production is declining and fluctuating in preparation for menopause. Unlike menopause, which enjoys such clear-cut definitions as average age of onset: 51 and can be confirmed after 12 consecutive months without menstruation, the lines around perimenopause are as fuzzy as a perimenopausal woman’s memory. It typically starts in a woman’s mid-to-late 40s, but sometimes as early as 35. It can last six years or more and ends the first year after menopause, according to The North American Menopause Society. But just how much more is a matter of some debate: Some experts maintain it can take as long as 15 years.

All of which illustrates just how bafflingly broad perimenopausal parameters are. It is highly individual and different for everyone, says Michael Goodman, M.D. And he should know: The Davis-based doctor is a certified menopause practitioner with 35 years of experience as an OB-GYN. Perimenopause also is a good time to fasten your seat belt, warns Goodman: It’s bound to be a bumpy ride. It’s a roller-coaster time. It can be very dramatic.

Yet what’s an Oscar-worthy event for one woman may appear as a mere blip on the screen for another. About 50 percent of women never see a doctor about it, notes Goodman, suggesting that some sail through perimenopause on relatively smooth seas. But for millions of others, the passage takes on such titanic proportions that the question is not whether to do something about it, but what.

For 56-year-old Ginger Westbrook, perimenopause began at 49 and turned into a nightmare nonpareil. When sleep disturbances and joint pain left her incapacitated, her primary care doctor sent her to a rheumatologist, who suggested it might be fibromyalgia. They prescribed pain medication, but it just gave me bad side effects, says Westbrook, who also was diagnosed with hypothyroidism (low thyroid), a common adjunct to perimenopause. The drugs really weren’t helping, and the doctors didn’t seem to know what to do. So she sallied forth on her own, stepping up her workout with a personal trainer and supplementing her already healthful diet with vitamins and herbs. She also tried bioidentical hormones (which are plant-derived and, she hoped, might be safer than traditional hormones) to supply her body with what it was no longer making itself. Nothing worked.

By the time Westbrook found Tian Li Wu&emdash;a local Chinese herbalist and acupuncturist she reverentially refers to as Dr. Wu&emdash; her list of symptoms had expanded to include hot flashes and cold sweats. Fortunately, Wu’s herbal remedies were just what the doctor ordered: In a matter of days, most of her symptoms were gone. I think if I had come to Dr. Wu in the beginning, I could have prevented all that suffering, says Westbrook, who now calls Wu not only her savior, but also her boss. (She’s Wu’s receptionist.)

Westbrook’s experience highlights a few key truths about perimenopause:
• Symptoms can easily be mistaken for something else&emdash;even by doctors.
• Educating and empowering yourself is key.
• You may need to try, try again before you find an approach that works.
• With all the options available today, there is no need to suffer.

Are You In Perimenopause?

If you’re a woman of a certain age, any number of changes in your health profile can mean perimenopause&emdash;and if your doctor doesn’t bring it up, don’t hesitate to ask. But don’t expect to be given a diagnostic blood test: Most don’t use them.

Perimenopause is more of a clinical diagnosis than a lab diagnosis, says Mwanga Kazadi, M.D., an OB-GYN for Mercy Medical Group. While FSH (follicle stimulating hormone) tests are sometimes used, the fluctuating hormones of perimenopause render test results unreliable, making symptoms a better guide.

When people come to me in their 40s or early 50s and they’re having those classic symptoms, you can almost definitively say what’s happening, says Kazadi. True, not everyone wakes up in the middle of the night wearing a sweat-drenched nightgown. But there are typically subtle but telling signs, such as shorter menstrual cycles (every 25 days instead of 28, for example) or a tendency to forget where you left the car keys.

Such mild symptoms may require no treatment at all. But when hot flashes, mood swings, muscle aches or other symptoms are so menacing as to make you miserable, you owe it to yourself to take action. 

To Take Hormones or Not?

The Great Debate

The big question for most is, Should I use or not use hormones? The subject has been a matter of heated debate since 2002, when data from the Women’s Health Initiative study indicated hormone therapy, which had for decades been the preferred method of managing menopausal symptoms, could raise the risk of heart attack, blood clots, stroke and breast cancer. Millions of frightened women threw away their hormone pills in search of safer alternatives&emdash;a continuing trend.

Conventional doctors tend to err on the side of caution where hormone therapy is concerned, says Trudi Shiu, M.D., an OB-GYN for Kaiser Permanente in South Sacramento. The emphasis now is to do less&emdash;less hormones, says Shiu, who first recommends lifestyle changes, such as reducing stress and cutting back on caffeine and alcohol, to perimenopausal patients whose symptoms are out of control.

But Goodman, who also recommends lifestyle changes (he’s especially big on exercise), cautions not to throw out the baby with the bath water where hormone therapy is concerned. There are pros and cons to hormone therapy, and every woman has to decide for herself, he says. On the plus side, estrogen supplementation helps to protect a woman’s bones and heart, he notes, potentially reducing the risk of osteoporosis and heart disease. He also points out that the WHI study was done on older women (average age: 63), not perimenopausal women, who are typically in their 40s. So while hormone use in the older, postmenopausal population was found potentially dangerous, less is known about the risk to younger women.

The bottom line: If you do decide to take hormones, follow the FDA recommendation: Use them at the lowest doses for the shortest duration needed to achieve treatment goals.

Pre-Perimenopause:Time To Get It Together

Doctors may disagree about treatment options, but on this they do agree: If you haven’t been taking care of your health up to now, perimenopause is a swift kick in the pants that your time has come.

Until they hit 40, most people are young and healthy and can eat and do what they want, says Richard Sweet, M.D., a professor and vice chair for the department of obstetrics and gynecology at the UC Davis School of Medicine and director of the UC Davis Women’s Center for Health. But after that, your metabolism slows down, your immune system isn’t as strong as when you were younger, and for women, heart disease becomes a major threat. He urges women to begin taking especially good care of themselves in their early 40s in order to bolster their health for the dramatic hormonal and physiological shifts ahead.

You want to go into the perimenopause with the best bone structure and in the best condition you can be in as you move forward, because everything is going to deteriorate if you don’t. Sweet emphasizes a well-balanced diet with plenty of fruits and vegetables, regular exercise, weight management (you can’t take in as many calories because you’re not 25 or 30 anymore), and calcium and vitamin D supplements.

By the time you reach perimenopause, concurs Goodman, your health is more fragile, giving you yet another reason to take extra-good care of yourself. You’re more fragile because of hormonal shifts, he explains. New symptoms will appear and old ones will be amplified. For example, says Goodman, If you’re hypoglycemic, it will affect you a lot more at this time.

In brief, your body is changing&emdash;you’re getting older.

An Emotional Journey

That getting older business is not only a physical hurdle in perimenopause, but a psychological one.

I see people getting really sad about this [perimenopause] because it’s a reminder that they’re getting older, notes Kaiser’s Shiu. They worry that they won’t be attractive anymore, or they get sad because they’re not fertile anymore. It is a loss for a lot of people. They can get depressed.

On the other hand, Shiu says, some women simply can’t wait for the nuisance of the monthly rag to come to an end.

Some are just thrilled to think they won’t have to contend with periods anymore, she says. Yippee! No more tampons, no more pads, no more hassle.

10 Tips for a Healthy Perimenopause

Your hormones may be shifting, but there’s plenty you can do to feel better, function better and reduce symptoms as you navigate perimenopause. Here are 10 tips from the experts.

1. Move that body.  I actually prescribe exercise, says Michael Goodman, M.D., a certified menopause practitioner and OB-GYN in Davis. It’s nature’s Prozac. Not only will daily physical activity reduce your risk of heart disease, help to maintain strong bones, lift your mood and reduce stress, it also will help to promote sleep&emdash;something most perimenopausal women don’t get nearly enough of.

2. Follow a balanced diet&emdash;and add some soy. You know the drill: A balanced, low-fat, high-fiber diet (with lots of whole grains, beans, fruits and vegetables) is essential to good health. Adding soy foods such as tofu, tempeh, soy milk and soy powder may be particularly helpful during perimenopause, as the isoflavones in soy have been found to reduce hot flashes, vaginal dryness and other symptoms.

3. Watch your weight. In addition to all the usual health-promoting reasons for staying slim, here’s one especially for the perimenopausal woman: When you’re heavier, hot flashes may be worse, notes Trudi Shiu, M.D., an OB-GYN for Kaiser Permanente.

4. Get your calcium. As estrogen production declines, bone loss speeds up, making calcium especially critical as you move into the perimenopausal years, notes OB-GYN Richard Sweet, M.D., director of the UC Davis Women’s Center for Health. To maintain bone density and protect against osteoporosis, Sweet recommends 1,500 daily milligrams, plus vitamin D (400–800 I.U.) to help absorb the calcium.

5. Avoid or limit your intake of alcohol, caffeine and spicy foods. All can make hot flashes worse.

6. Reduce stress. Reducing stress is one of the best ways to reduce perimenopausal symptoms, says Kaiser’s Shiu. Hot flashes, insomnia, mood changes, difficulty concentrating&emdash;lots of these symptoms are made worse by stress. Shiu suggests at least 15 minutes a day of meditation, yoga or whatever works for you.

7. Try paced respiration. The deep, slow abdominal breathing known as paced respiration, practiced 15 minutes daily, has been shown in studies to decrease hot flashes, notes Shiu. Paced respiration also may help provide relief from a hot flash as it is starting.

8. Wear layered clothing&emdash;and carry a fan. When a hot flash strikes, you can peel off the layers and cool yourself down with the fan.

9. Have regular health screenings. The list of recommended tests gets longer in the perimenopausal years. In addition to mammograms and pap smears, make sure your screenings include thyroid, diabetes and lipid/cholesterol panels.

10. Quit smoking. Smoking reduces estrogen levels, increases hot flashes and increases the risk of osteoporosis. If you haven’t quit already, now’s the time.