The Change Before the Change : Everything You Need to Know to Stay Healthy in the Decade Before Menopause

Book by Laura E Corio MD Linda G Kahn

Chapter 1
How Do I Know If I’m in Perimenopause?

There was a huge snowstorm raging outside, and we’d been receiving cancellation calls all day. So I was surprised to open the door to one of our examining rooms and find Marian perched on the end of the table. Marian started seeing me twelve years ago, when she was single and living in the city. A husband and two children later, she now lived in the suburbs but still remained a loyal patient.

“Why didn’t you reschedule?” I asked. “You took your life in your hands driving all the way in from Long Island.”

“I couldn’t wait another day, Dr. Corio,” she replied.

“What’s wrong?”

“What isn’t? I feel like my whole body is falling apart — in fact, it doesn’t even feel like my own body anymore!” Marian went on to list a host of symptoms: migraines, hot flashes, insomnia, dry itchy skin, urinary tract infections, irregular periods, and decreased libido. “Poor Skip,” she continued, referring to her sweetheart of a husband. “My moods have been all over the place and I haven’t let him touch me in weeks. He’s been really understanding, but I know that for both our sakes I can’t put off dealing with this any longer.”

“Well, Marian — how old are you now?” I glanced down at her chart. “Forty-three? It sounds to me as if you may be in perimenopause.”

“You’re kidding!” she responded. “But my mother didn’t go through menopause until she was 50.”

“And you may not, either. Perimenopause can begin up to a decade before menopause,” I reminded her. “When was your last period?”

“About three weeks ago.”

“And how was it? Longer or shorter than usual? Heavier or lighter?”

“A little heavier and longer than normal. And I had wicked PMS — my breasts were killing me and I had really bad cramps. I told Skip he should buy some stock in Motrin! It was like being a teenager all over again.”

“Funny you should say that,” I said, “because in some ways perimenopause is the mirror image of puberty. One of the reasons you’re experiencing irregular periods, mood swings, and PMS is that after twenty years of relative stability, your hormones are beginning to fluctuate again. In your case, it’s because your body is winding down its reproductive life; in a teenager’s, it’s because her body is winding up.”

“Lovely,” Marian said, rolling her eyes. “But if I’m reliving those happy teenage years, how come I have no sex drive?”

“Because perimenopause is like puberty in reverse. Although your estrogen levels are bouncing around, they’re basically on their way down, whereas a teenager’s are basically on their way up. Your skin is getting drier; a teenager’s gets oilier.”

“So is there anything I can do to feel like a human being again, or do I just have to wait this out?”

“Of course there are things you can do — why should you suffer?” We went on to discuss a myriad of options, from vitamin and mineral supplements to herbs and foods she could try to relieve her various symptoms. “Before you leave today I’d like to write you a prescription for saliva testing to check your estrogen, progesterone, and testosterone levels,” I added. “This is the perfect time because you’re in the middle of the second half of your cycle. If these levels are no longer in the normal range and your symptoms aren’t improving with just the complementary treatments, we can talk about the possibility of adding a low dose of hormones.”

“I can’t tell you how relieved I am to know I’m not completely falling apart!” Marian sighed as she leaned back on the table so I could begin her physical examination. “It was definitely worth braving the hazards of the Long Island Expressway to see you today.”

What’s Happening to My Body?

Perimenopause is a transitional time between your childbearing and post-childbearing years. Basically, your ovaries, the organs that sponsor your reproductive life, are signing off. Once stuffed with as many as 6 to 7 million follicles (sacs that contain immature eggs), they now have many fewer, and the ones that remain are no longer in peak condition. Your ovaries are therefore producing less and less of the sex hormones needed to help those follicles mature.

Sex hormones don’t only affect the stimulation and release (ovulation) of mature follicles, however. There are receptors for estrogen, progesterone, and testosterone in virtually all your tissues. That’s why when you’re in perimenopause you’ll not only notice that your periods are becoming irregular, but you’ll probably also experience other symptoms in seemingly unrelated parts of your body.

The swan song of your ovaries is often not a graceful “adieu.” Rather, they tend to try to make several comebacks before their final exit, resulting in sometimes wild fluctuations in hormone levels. Overall, however, the changes in your hormone levels occur in three stages:

1. During the first phase of perimenopause your progesterone level declines, leaving you in a state of estrogen dominance. You might feel like you’re constantly in PMS, with bloating, cramps, mood swings, and tender breasts. My patients describe it as feeling like their period is coming every day.

2. During the second phase your estrogen level also declines, leading to such symptoms as hot flashes, memory problems, heart palpitations, migraine headaches, and vaginal dryness. Patients with these symptoms often are up all night and feel like they’re losing their minds.

3. The third phase, or late perimenopause, sets in when estrogen and progesterone levels decline to near menopausal levels. At this point many of your symptoms may recede, although you may continue to experience some, such as hot flashes, well into your menopausal years.

To fully understand the changes your body is going through in perimenopause, you need to have a grasp of what your ovaries have been doing up to now. Although I’m sure you learned the basics in high school biology, if you’re like most of my patients you probably could use a refresher course. It’s especially important to be familiar with the key hormones involved in the menstrual cycle: estrogen, progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), gonadotropin-releasing hormone (GnRH), and testosterone. It is when their levels change that you experience perimenopausal symptoms. So sharpen your Number 2 pencils and read on!

The Menstrual Cycle 101

At least ten times a week my perimenopausal patients ask questions that cause me to whip out a piece of paper and sketch the three phases of the menstrual cycle — the follicular phase, ovulation, and the luteal phase — and explain the hormones that control them.

The day you begin to bleed is called day 1. If you have a 28-day cycle, you ovulate on day 14, right in the middle. From day 1 to ovulation is called the follicular phase. From ovulation to the first day of your next period is called the luteal phase. The length of your cycle depends on the length of your follicular phase. For instance, if you have a 28-day cycle, your follicular phase is 14 days; if you have a 21-day cycle, your follicular phase is only 7 days; if you have a 35-day cycle, your follicular phase could be as long as 21 days. In a normal cycle your luteal phase should remain constant at 14 days. In perimenopause, however, it can shorten or even disappear altogether if you’re not ovulating.

Follicular Phase

Your body’s main aim during the follicular phase of your cycle is to produce enough estrogen to mature the egg in your follicle. At the beginning of your menstrual cycle, your estrogen levels are low. Detecting this, the hypothalamus gland in your brain releases gonadotropin-releasing hormone (GnRH). This stimulates the pituitary gland, also in the brain, to release follicle-stimulating hormone (FSH). As its name implies, FSH stimulates follicles to begin developing and producing estrogen.

By the end of the follicular phase, your ovaries are producing not only high levels of estrogen but male hormones (androgens) such as androstenedione and testosterone as well. My normally cycling patients tell me they feel great at this time of the month — energetic, outgoing, creative, and clear-thinking.

By contrast, perimenopausal women who do not ovulate get stuck in the follicular phase, building up more and more unopposed estrogen. This estrogen dominance makes them feel horrible — they become bloated, their breasts hurt, they get cramps, and their moods fluctuate wildly.

Ovulation

When the estrogen circulating in your bloodstream reaches a critical level, it stimulates your pituitary to release a surge of luteinizing hormone (LH). The subsequent LH peak lasts 48 to 50 hours. Your ovaries release an egg approximately 24 to 36 hours after the estrogen peak and 10 to 12 hours after the LH peak. Ovulation kits measure LH, indicating the optimal time to have intercourse if you want to conceive.

LH stimulates your ovaries to luteinize, or convert cholesterol into progesterone. Along with LH and FSH, progesterone stimulates breakdown of the tissue supporting the follicular wall. The wall becomes thinner and thinner until the follicle ruptures and the egg is released. Progesterone also raises your basal body temperature, which is why, if you take your temperature at the same time each day, you’ll notice a rise when you’re ovulating and thus are most fertile. (See Chapter 7 for a discussion of how to use a basal body thermometer to track ovulation.)

You’ll probably find yourself in a romantic mood around the time you ovulate. This is because the high androgen levels reached at the end of the follicular phase stimulate the libido. So you may experience a wave of lust right around the time your ovaries are releasing a mature egg — Mother Nature’s way of ensuring the continuity of the species. In addition to feeling sexy, my patients tell me that around the time they ovulate they feel open to being cared for emotionally and physically, content, and energetic.

Luteal Phase

In the first week or so after ovulation, your body is preparing to support a possible pregnancy. The follicle cells left behind after the egg has been released reorganize to form the corpus luteum, which continues to pump out progesterone. (The name, which means “yellow body,” refers to lutein, the yellow pigment these cells fill up with.)

High levels of progesterone prevent more follicles from developing and keep your uterine lining plush. Without a certain amount of circulating progesterone, your uterine lining will not be able to sustain a fertilized egg. This is why perimenopausal women, whose progesterone levels may be falling, are susceptible to spontaneous miscarriage in the first trimester of pregnancy. To get them through this time, I often monitor progesterone levels and, if needed, prescribe natural progesterone supplements for the first eleven weeks of pregnancy. The corpus luteum also produces estrogen and a protein called inhibin. Estrogen, progesterone, and inhibin together send a message to the brain to suppress GnRH, FSH, and LH secretion.

If fertilization occurs, the embryo will produce a hormone called human chorionic gonadotropin (HCG). HCG signals the corpus luteum to continue producing estrogen and progesterone, ensuring that you don’t menstruate and shed your uterine lining. However, if an egg has not been fertilized by eight days after ovulation, your ovaries begin to prepare for the next cycle. Your estrogen, progesterone, and inhibin levels fall, allowing GnRH and FSH to rise again. The corpus luteum self-destructs, and without the hormonal support it provides, your uterine lining collapses. You get your period just as new follicles are being stimulated, and the cycle begins all over again.

For some women, the luteal phase can be rough. They may feel nervous, anxious, irritable, lethargic, depressed, bloated, hungry, crampy, and weepy — in other words, they may suffer premenstrual syndrome (PMS).

Patients often ask me whether they’re feeling lousy because they have PMS or because they’re in perimenopause. The key here is that perimenopausal symptoms occur throughout your cycle, while PMS symptoms occur in the second half and improve when you get your period.

Is There a Test to Show If I’m in Perimenopause?

My patients would love to have a way of confirming that they’re in perimenopause. The test for menopause is clear-cut: twelve months without a period, or FSH and LH in the menopausal range. Unfortunately, however, there’s no sure-fire method to identify perimenopause. The best way for your doctor to determine whether you’re in perimenopause is to take a thorough medical history, reviewing all your symptoms, and perform a physical exam. A blood or saliva test to check the levels of the hormones listed in the table on page 17 can confirm your doctor’s diagnosis but should not be relied upon 100 percent.

Why not? Because perimenopause is characterized by hormonal fluctuations, so a blood or saliva test of your hormones could indicate normal levels even if you’re in the throes of the transition. But the same test performed next month could show your hormones to be completely out of whack. Reading these tests is like looking at a still from a movie. They can never give you a true sense of what’s happening. I use them, but I interpret them guardedly.

The reason your hormone levels may swing in and out of the normal range in perimenopause is that they are determined by the condition of the particular follicle that matures each month. If you happen to release a healthy egg, your circulating estrogen, progesterone, FSH, LH, and inhibin levels will be normal; if instead you release a worn-out egg, your hormone levels will be in the perimenopausal range.

Of all these hormones, inhibin is the most sensitive marker of follicular health. But as of yet, there is no known way to measure inhibin levels. Instead, we measure circulating FSH levels, because without adequate inhibin, FSH is released in greater than normal amounts. In other words, as your inhibin goes down, your FSH goes up.

To determine a patient’s FSH level, I take a blood sample on the third day of her cycle. This also tells me her levels of estradiol — one of the three main kinds of estrogen your body produces — and LH. To find out her serum level of progesterone, I take blood either ten days after she’s ovulated or four days before she expects her next period.

Saliva testing of hormone levels is becoming increasingly popular, as it is simple and painless: all you need to do is to spit into a test tube during the second half of your cycle (around days 20 to 23 of a 28-day cycle). The drawback of saliva testing is that at present it can only be used to measure estrogen, progesterone, and testosterone levels, not FSH or LH.

Other Important Hormones to Have Checked in Perimenopause

While I’m testing blood levels of the reproductive hormones, I always check TSH (thyroid-stimulating hormone), free T4 (thyroid hormone), and prolactin levels, as well. As you’ll learn in Chapter 12, thyroid disease often sets in when women reach their forties and early fifties, and it can affect the menstrual cycle in a way that mimics perimenopause. If thyroid disease is a culprit, your periods should return to normal as soon as it’s treated.