For all the education, emphasis, and preparation regarding a girl’s first menstruation, so little seems to be understood and shared about what happens decades later when she stops menstruating. Perhaps it’s because perimenopause is much less a universal experience; in fact, it’s such an unpredictable period of transition that it can last months or up to a decade.
Called the “ill-defined period” in one medical journal, perimenopause is highly individual because it involves the interplay of not just the two hormones primarily associated with femininity—estrogen and progesterone—but also a host of other chemical messengers that regulate our bodies and protect our health.
Not to be confused with menopause, which is defined by the cessation of a period for 12 consecutive months, perimenopause is the season leading up to it. And for some women, it can be terribly uncomfortable with symptoms such as hot flashes, heavy bleeding, forgetfulness, brain fog, fatigue, skin changes, vaginal dryness, insomnia, cramping, and more.
It’s enough for many women to hightail it to their doctor in desperation, which often leads to hormone replacement therapy (HRT), sometimes without hormone levels tested at all.
Those who find themselves facing the desire for relief might want to know that symptoms of COVID-19 and long COVID also mimic perimenopause. The medical establishment has noticed, too, and it was noted in a December 2021 Lancet article that women in perimenopause and menopause could be misdiagnosed with long COVID. The commentary offers this advice to physicians: “ diagnostic uncertainty …offers an opportunity to treat perimenopause and menopause symptoms with safe and effective hormone replacement therapy.”
Even before COVID, functional and integrative experts had advice of their own: Don’t rush into HRT without being informed about the risks, educated about natural remedies, and most importantly, knowing about the root causes of your symptoms.
Caught in the middle of confusing symptoms and contradictory messaging, women are increasingly frustrated by this chapter of life hallmarked by secrecy, shame, and “grin and bear it” messaging.
Defining Perimenopause
There are women who transition symptom-free to menopause from menstruation, the time in life when your ovaries regularly (usually monthly) release eggs. Typically menstruation lasts from about 13 to the late 40s, so long as there are available eggs.
A French physician coined the term menopause in 1821. There were many harmful and bizarre treatments leading up to the development of synthetic estrogen in 1938, during which time menopause was still described as a “disease” rather than a normal physiological transformation.
“Peri” means around, and what makes perimenopause different from menopause is its unpredictability. Hormone levels don’t gradually taper off as once suspected. Studies in the 1980s discovered they rise and fall with symptoms in tow.
Starting at age 35, both estrogen and progesterone levels begin their erratic decline. Cycles might become more irregular including lighter, heavier, farther apart, or closer together, yet it doesn’t impact a woman’s ability to conceive. About 90 percent of women seek physician help for symptom relief in perimenopause, according to a 2016 article in the “Journal of Women’s Health.”
The most complained-about symptoms in perimenopause are typically hot flashes, sleep disturbances, and vaginal dryness. Adult women who struggle with painful cycles, PMS, mood swings, irritability, and heavy periods are often the ones who also have difficulties in perimenopause, said Andrea Jones, functional nurse and holistic hormone coach.
Her clients tend to seek help resetting their hormones in their 20s and 30s at the first sign of trouble—both to get relief in the present moment and to set themselves up to enter menopause more at ease.
“There is this fear that if this is how bad I feel now, then how bad am I going to feel when I go through menopause,” Jones said. “There’s a huge need for having these conversations. Mood swings aren’t normal.”
Besides a lack of information about perimenopause, Jones said a lot of resources are biased, making it hard to make informed, medical decisions. PMS has been normalized. Remedies outside hormones are rarely discussed in most physician offices. The history of hormone replacement therapy is controversial with contradictory studies about whether it’s a cause of or protective for diseases such as cancer, osteoporosis, and heart disease.
Even bioidentical hormone therapy, which utilizes plant hormones that more closely resemble human hormones, isn’t considered the best long-term solution by Jones or Dr. Sean McCaffrey, physician and founder of McCaffrey Health Center.
Both say this approach should be reserved as a first line of defense only in dire situations to help women with quality of life in the short term. A long-term remedy ought to consider a woman’s holistic health.
“If you can balance the body, bring it back to normal, and give it what it needs to repair, symptoms go away. And you don’t need the hormone therapy to do it,” McCaffrey said.
The Interworking of Hormones
What does it mean to bring the body to balance? First consider that estrogen and progesterone are two of more than 50 human hormones, and they work especially close with those that regulate stress, sleep, metabolism, and more. An imbalance in other hormones and systems will undoubtedly impact perimenopausal symptoms.
What many women don’t realize is that the ovaries aren’t the only place in their bodies that produce estrogen and progesterone. As a woman reaches menopause, the adrenal glands, which are located on the kidneys, begin to take over production. Adrenal glands are most known for making adrenaline and cortisol, hormones associated with our stress response and circadian rhythm. If the adrenal glands are already overworked, it can cause a cascade of uncomfortable symptoms when this shift takes place.
Low adrenal function might be responsible for symptoms that can include poor stress management, blood sugar fluctuations, mood changes, brain fog, and trouble sleeping. Healthy adrenal glands are important leading up to and in menopause.
The ovaries and adrenals work like a physiological triangle with the thyroid gland, a small butterfly-shaped gland in the front of the neck that makes hormones associated with energy. It’s sometimes called the ovarian–adrenal–thyroid, or OAT, axis. If one side of the triangle is weak, the consequence is instability. Weak adrenal glands can cause thyroid malfunction and menstrual cycle irregularity. Women who are estrogen dominant can experience hypothyroidism and adrenal fatigue.
Hypothyroidism is an underactive thyroid that can slow down many of the body’s functions including heart rate, breathing, metabolism, digestion, and moods.
Doctors often will reach for an HRT prescription first thing based on symptoms alone, rather than taking other hormones and systems into consideration, Jones said.
“In my opinion, they’re kind of working backward, when this is the last thing they should address,” she said.
“It’s all very problematic. You should not be doing (HRT) unless you’re addressing why (patients) aren’t producing hormones right in the first place.”
Jones uses the dried urine test for comprehensive hormones (DUTCH test), which examines estrogen, progesterone, cortisol, testosterone, and melatonin. Some doctors use it to help monitor precise hormone replacement therapy.
But it’s not the only thing Jones examines. She will also investigate other organ imbalances that can impact a woman’s perimenopausal experience.
Correcting Imbalances
Identifying the root cause of perimenopausal symptoms requires an examination of how a woman’s body is operating, along with cues about her lifestyle.
Excess estrogen can come from prolonged stress, being overweight, a poor diet, or from xenoestrogens, which are chemicals found in the environment that mimic estrogen in the body. Too much estrogen can lead to fibroids, cysts, weight gain, and poor liver metabolism as the metabolic pathways are taxed trying to get the estrogen out.
Gut issues, such as a change in microbiota, motility problems, or stress can all affect estrogen and progesterone production.
“Hormones are a way the body tries to balance itself. You have an entire adrenal system, an endocrine system, a glandular system in the body that is trying to try to harmonize and adapt to stress,” McCaffrey said.
He points to social media and media consumption as big stressors, especially in the past few years. Mental health and suicide rates are at all-time highs. Thoughts will manifest themselves in the body if they aren’t dealt with, he said, and bring negative or positive effects or energy with them.
“It’s constant stress and chaos,” McCaffrey said. “There’s never a moment to settle down. I believe that does it.”
Constant stress is also a trigger, causing symptoms such as sweating and hot flashes, brain fog, body aches, and headaches that can be confused with perimenopause. McCaffrey said stress will knock the body out of balance and express symptoms in weak points, which can affect digestion, elimination, reproduction, or respiration.
The message for women is to make sure they are taking care of their own needs, as they often put the family’s needs ahead of themselves, Jones said. Like the pre-flight announcement explains, you need to put your own oxygen mask on first.
“The longevity of our health matters, and it matters what we’re doing now. We all have different triggers and different capabilities and different resiliency,” she said, adding that solutions for lowering stress are also very individualized based on personality.
Help for Hormones
There are strategies that all women can use to balance their bodies naturally. It can be a preventative tool for avoiding a lot of symptoms before and during perimenopause or a first line of defense when symptoms begin to emerge.
Jones said the four top things she advises everyone to do right away are:
- Stay hydrated to support the liver and kidneys in ridding the body of excess hormones.
- Eat plenty of fiber from one or two handfuls of vegetables at every meal. Fiber binds to estrogen and sends it out through the digestive system.
- Optimize sleep, especially getting to bed as early as possible to lower cortisol levels.
- Have lavender and vanilla essential oils on hand, which can be effective in quickly lowering stress.
Additionally, Margie King, a holistic menopause health coach, offers these tips:
- Clean up your diet to eliminate processed foods, sugar, genetically modified foods, trans fats, and chemical additives that spike estrogen levels.
- Increase vitamin D levels, including spending time in the sun, to reduce the risk of breast cancer, heart disease, and bone fractures.
- Consider herbal remedies to balance hormones, such as black cohosh, red clover, dong quai, and chasteberry.
- Boost gamma-linolenic acid, an essential fatty acid associated with moderating symptoms that’s found in evening primrose oil and black currant.
- Meditate daily with deep belly breathing that’s been shown to reduce hot flashes and lower stress.
- Exercise to help balance stress, increase energy, improve your mood, and reset your circadian rhythm.
- Avoid personal care and cleaning products with hormone-disrupting chemicals such as parabens, phthalates, and bisphenol-A (BPA).
Jones said it’s very easy for women to be confused by information and discouraged by options offered by physicians, which can cause them to put off taking care of their needs. If they aren’t practicing self-care, she suggests they seek to understand why.
“Don’t wait for it to be validated by a physician to take charge of it. Don’t wait for help,” she said. “There’s so much you can do. It’s just finding the right person to help us.”
Additional sources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240496/
https://www.mayoclinic.org/diseases-conditions/menopause/in-depth/hormone-therapy/art-20046372
https://www.sciencedirect.com/science/article/pii/S2666776221002283?via%3Dihub
https://wholisticmedicalcentre.com.au/managing-menopause-with-adrenal-support/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240496/
https://www.drlamcoaching.com/articles/hormone-imbalance-symptoms-and-the-oat-axis/