Irregular periods? Hot flashes? Night sweats and trouble sleeping? Emotionally short-fused? If you’re in your 40s or 50s and self-diagnosed “menopause,” you may be correct. And while menopause is more commonly understood as being defined by hormonal changes, perimenopause isn’t. And perimenopause is a crucial part of the reproductive health conversation , too.
In short, perimenopause refers to the time during which your body makes the natural transition to menopause , marking the end of the reproductive years. You shouldn’t feel blindsided when your body experiences these hormonal transitions , so read on for answers to the most common questions about perimenopause and menopause to demystify the process.
Your period doesn’t just start one day and stop another day, decades later. The process is a lot more complex. It’s easier to recognize what happens during perimenopause and menopause if you first understand the regular female reproductive cycle . Here’s a refresher:
There are 3 phases in the menstrual cycle: follicular, ovulatory, and luteal. (You may hear the period referred to as its own phase, but during your period your body is actually ramping up for ovulation.)
In a typical 28-day cycle, the follicular phase is day 1 to 14, and during this time estrogen is the predominant hormone. Day 1 is the first day you begin to bleed. This is because estrogen and progesterone drop, which triggers the lining of your uterus (the endometrium) to shed, resulting in what is commonly known as your “period” (roughly day 1 through 7). The drop in these hormones also sets off a cascade in your brain. When estrogen and progesterone decrease, the pituitary gland releases follicle-stimulating hormone (FSH), which stimulates the growth of the follicles in your ovaries to ready an egg for ovulation.
Day 12 through 14 is when your ovaries ramp up estrogen production, and this stimulates the pituitary to release luteinizing hormone (LH). The LH surge triggers ovulation and an egg is released. The egg then travels down the fallopian tube and either implants in the endometrium (if fertilized by sperm) or slowly dissolves and passes out of the body (along with the uterine lining) during your period.
Day 15 through 28 of the reproductive cycle is the luteal phase, during which progesterone is the more prominent hormone. Progesterone peaks 5 to 7 days after ovulation. After 28 days if the egg was not fertilized, the reproductive cycle begins again, marking day 1 of your new cycle.
Perimenopause is the time that leads up to menopause, which is when a female’s menstrual period ends entirely (marked by 12 consecutive months without a period). It is also when many new hormonal symptoms can surface such as trouble sleeping , weight gain, irritability, and mood swings.
When the body approaches perimenopause it has fewer follicles producing estrogen (or the follicles are less viable) and the lack of estrogen prevents ovulation from occurring. This creates one of the hallmark symptoms of perimenopause: irregular periods . A period may disappear for a cycle or two, or your bleeding may appear closer together or farther apart. You may also have menstrual cycles in which your ovaries don’t release an egg (in other words, you don’t ovulate). And without ovulation, there isn’t an increase in progesterone, which typically follows ovulation.
In perimenopause, progesterone is typically the first hormone to drop. Progesterone plays a major role in stress management and the reduction of anxiety . Progesterone promotes gamma-aminobutyric (GABA) receptor production in the brain, which is the calming neurotransmitter. And the lower progesterone levels are, the more we are prone to irritability and anxiety. Lower progesterone levels may also cause sleep disturbances because of a lack of this calming hormone.
Estrogen dominance is also common during perimenopause, given that progesterone levels usually drop before estrogen levels. And estrogen levels during perimenopause may also fluctuate, becoming erratic and unpredictable. Because estrogen levels may not be high, but because progesterone levels are low, the ratio of these hormones tricks the body into thinking estrogen levels are too high. Symptoms of estrogen dominance are bloating or puffiness, irritability, heavy periods, breast tenderness, and weight gain (especially around the hips, buttocks, and thighs).
As perimenopause continues, and estrogen levels fluctuate, symptoms of estrogen deficiency may also surface: hot flashes, night sweats, vaginal dryness, depression, fatigue , poor memory, brain fog , decreased concentration, stress incontinence, and decreased libido .
Well, menopause is actually just one single day. It is the day that marks your 12-month consecutive time without a menstrual cycle. After this, you are considered post-menopausal.
Perimenopause lasts, on average, for 4 years before this final period, but it varies depending on the woman. The average age for menopause in the U.S. is 52 years old , but typically happens between 40 and 58 years old. The age at which your mother experienced menopause may actually be the biggest predictor for your menopausal age.
Lifestyle factors may also influence the age of menopause: smoking, chemotherapy, and major surgeries. Smoking creates free radicals that damage the ovaries and can cause a woman to enter early menopause. Chemotherapy, used in the treatment of certain cancers, is also toxic to the ovaries and may cause early menopause onset. Race may also play a role : Hispanic and Black women reach menopause earlier, and Chinese and Japanese women a little later, on average.
Stress management is the single greatest impact you can have on your body’s response to perimenopausal symptoms. Prioritizing meditation , breathwork , walking, and yoga during this stage of life can make a noticeable difference in symptoms.
Because your ovaries are no longer producing the same amount of estrogen and progesterone, your body starts to rely on the adrenal glands. The adrenal glands are two small glands that sit on top of your kidneys. They are also capable of producing sex hormones.
In premenopausal women who are fertile, the adrenal glands only produce a small amount of sex hormones (the ovaries produce the majority during this time). But in post-menopausal women, the adrenal glands produce up to 80 percent of progesterone and estrogen.
The adrenal glands also play a role in stress management; they produce the stress hormone, cortisol . The precursor to progesterone and estrogen is also the same precursor to cortisol : the hormone called pregnenolone. If the majority of pregnenolone is being shunted to cortisol, less will be available for the production of the sex hormones estrogen, progesterone, and testosterone (so named the “pregnenolone steal”). By lowering lifestyle factors that lead to stress, the body is naturally supporting the adrenal gland production of sex hormones, thus minimizing menopause symptoms.
It is also common for women to gain weight during this hormonal stage , and most will try to increase exercise intensity and duration to offset this change. However, too much high-intensity exercise can further increase the demand for cortisol and perpetuate pregnenolone steal, making symptoms of menopause worsen.
Adaptogenic herbs like ashwagandha, schisandra, and rhodiola support the adrenal gland’s function and may benefit menopausal women by helping with stress management and therefore decreasing cortisol production. Black cohosh is another adaptogenic all-star herb because it helps support estrogen levels and reduce hot flashes. Maca is also helpful for relieving hot flashes and improving vitality, energy levels, and libido.
Parsley Health providers practice holistic-lead medicine and are available to work with perimenopausal and post-menopausal women. Whether you feel you need stress management techniques, nutritional and movement guidance, and/or lifestyle adjustments (that may impact sleep, mindfulness, and more), our practitioners can help guide you during the transition. Personalized care for your symptoms may also include a supplement plan to support hormone and libido levels and address adrenal dysfunction—all developed to help you live a vibrant and healthy life.
Dr. Lilli Link is a board-certified Internist and Functional Medicine Practitioner who graduated from medical school at the University of Chicago, and completed her residency at Columbia Presbyterian Medical Center in New York.
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