For the Centre for Menstrual Cycle and Ovulation Research—World Menopause Day October 18, 2024
Jerilynn C. Prior BA, MD, FRCPC
In Dr. Nicky Keay’s just published and important book, Myths of Menopause, I have already discussed some of the things that are unique about perimenopause. Here I’d like to focus on things about perimenopause that are surprising or paradoxical.
Why are women+ in their mid-forties surprised when they suddenly have very heavy periods and clots that won’t stop? Why are they startled by waking suddenly at night feeling scared—puzzled until they begin to sweat and suddenly realize: That’s what a night sweat means! Then they can’t fall asleep again.
The surprise is because women are taught to expect menopause. But what they see first is not NO PERIODS. It is way too many! Cycles first get shorter and flow may become heavier.
So, the first paradox of perimenopause is that perimenopause happens before menopause.
What is perimenopause? It is a puberty-like time of change lasting several-to-many years. Experiences, periods and concepts of ourselves all change. Ideally, in perimenopause we learn, finally for some of us, to advocate for ourselves. Heavy flow, sleep problems, night sweats the night before the period, mysterious weight gain, sore breasts, more cramps, heart palpitations, overly stretchy cervical mucus and migraine headaches are all possible. Or none of these occur.
Cycles eventually start getting unpredictable and we celebrate with our first totally skipped period. Things start to settle down, although hot flushes may become worse. Eventually we graduate into a life without periods = menopause. We will know that we have reached that menopause milestone of maturation when we’ve been without a period for a full year.
“Menopause means estrogen deficiency”. What about perimenopause? Getting about month-apart periods means we are making enough estrogen. But we are taught to think of night sweats and hot flushes as meaning low estrogen levels. Yet they may start in perimenopause when periods are still regular. Estrogen can’t be low! Although we are taught that perimenopause/menopause are about “estrogen deficiency”. The second paradox of perimenopause is that perimenopausal estrogen levels are NOT low—rather they soar!
Perimenopausal estrogen levels swing wildly to double or triple the usual menstrual cycle’s peak, then down to normal. Although estrogen levels are higher through most of perimenopause they eventually decrease during that last year without flow.
You are old if you get hot flushes and night sweats (together called vasomotor symptoms). Right? Not at all right because most women live into their 80s. So, when perimenopause starts, we have half a life still to live. A third paradox is that perimenopause is NOT old.
The focus is on estrogen whenever we talk about women’s cycles or young women. But progesterone is made in huge amounts by the special, short-lived corpus luteum gland that produces it for a few days to a couple of weeks in the normal menstrual cycle that includes egg release. Estrogen rises to a large midcycle peak (as we learned in grade seven and see in Google diagrams). That estrogen peak is 220 percent above its low-level during flow! (Did you know that every normal menstruation has estrogen levels almost as low as during menopause?)
Progesterone is a slow starter. It remains low through the whole first half of the cycle. Only after egg release does it rise to its plateau that is 1400% above its low during menstrual flow. Does progesterone keep being high for two weeks a cycle during perimenopause? No, it begins to decrease in amount and also in duration during perimenopause and before cycles stop. So, it is another perimenopausal paradox that perimenopausal progesterone is decreasing, ovulation becomes infrequent and often disturbed despite (or because) estrogen levels are too high.
Women are deeply mystified by the way perimenopausal changes preoccupy. “I don’t feel like myself!” The most efficient multi-taskers suddenly feel incompetent, worrying about memory loss. Another paradox of perimenopause, and one rarely discussed—the major multi-dimensional stresses of the perimenopausal transition.
It is not fun to be getting older (which is how we interpret the changes we feel) in a society that values the beauty and sexual allure of teens and young adults. This is especially hard for those of us whose identity or occupation depend on our looking vibrantly young. It becomes tragically sad if we are perimenopausal and haven’t had the children for which we dreamed. There are perimenopausal stresses besides teenager chaos and elder-care.
But not only are perimenopausal stress hormones increased by culture, they skyrocket because of the wildly swinging estrogen levels. The brain views each estrogen downswing as an emergency! These downswings cause hot flushes, depression, and rapid bone loss all because they trigger a massive release of every neurotransmitter and stress hormone the body makes. No wonder we feel anxious or on edge! So, the unspoken, multicentred major stressors are an important paradox of perimenopause.
A final paradox relates to something that will help those having a rough time in perimenopause—oral micronized progesterone treatment. This is a paradox because hot flushes mean low estrogen (NOT in perimenopause) and are well-treated by estrogen in menopause, usually as menopausal hormone therapy (MHT). But MHT, or combined hormonal contraceptives (CHC) if birth control is needed, are universally and officially recommended by guidelines for treatment of perimenopausal hot flushes and night sweats. Have MHT and CHC been proven to effectively and safely treat perimenopausal vasomotor symptoms? NO!
What hormone is lower in perimenopause? Progesterone! Could progesterone treatment help perimenopausal night sweats? The answer is yes. A 4-month randomized double-blind placebo-controlled trial (RCT) of oral micronized progesterone significantly decreased night sweats, hot flush intensity, and improved sleep in 189 Canadian women. The results were published here where anyone can read them. We gave progesterone in a dose of 300 mg at bedtime daily. This is a Health Canada, FDA and other drug regulating body approved therapy, that is the same as our bodies used to make. We are giving it in a dose that keeps the progesterone blood level in the post-ovulation range for 24 hours. Why at bedtime? Because otherwise it causes drowsiness (its major “side effect”); this becomes a major sleep-improving benefit!
Knowing the six paradoxes of perimenopause is the key to surviving and thriving in this complex, but normal life phase:
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Estrogen's Storm Season: Stories of Perimenopause (Second Edition) by Dr. Jerilynn Prior. Discover the evidenced-based, lively, and relatable stories of perimenopause through a unique blend of storytelling and scientific fact. All book royalties support CeMCOR's research and future through our Endowment Fund. Purchase your Paperback copy (with updated insert) on Amazon. Purchase your e-book copy via our Amazon Kindle or Google Play storefronts.
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