Perimenopause is defined as the 10 years prior to menopause, so most women in their 40’s are in perimenopause. The 40’s are characterized by a decrease in fertility, which is due to the decrease in hormone production.
This decline in fertility is the same reason for the increase in complaints of women in their 40’s. We commonly hear about irritability, nervousness, depression, anxiety, sleep disturbance, belly fat, water retention and weight gain from female patients in their late 30’s and 40’s. These symptoms are usually from the declining production of estrogen, progesterone, and testosterone.
It’s a little bit like a symphony. Most of us have all the notes, they are just not playing in key. The ovaries produce three different estrogens; estradiol, estrone, and estriol, progesterone, and about half of the body’s testosterone production. The other half of testosterone production is produced in the adrenal glands.
Each month during a woman’s menstrual cycle, the ovary has a list of things to do, and the endometrium, or lining of the uterus, has a list of things to do. In the role of the egg development and lining development, there are four different hormones (FSH, LH, estrogen and progesterone). Note, your body requires a pretty big jump of progesterone in the luteal phase, and when the body doesn’t produce that, it is pretty noticeable (i.e. PMS symptoms). Hence the symphony analogy, you probably have all the right hormones, but if you don’t have the spikes of them during this cycle, then the notes are not playing in tune. Don’t worry, it is fixable.
In the ovary, the egg, or follicle growing stage which are from days 1-14, is called the “follicular stage”.
The second stage of the ovary, days 14-28, is called the” luteal phase”. These terms are important since testing of hormones, whether for infertility or hormone imbalance, need to be timed.
Usually, most testing is done in the luteal phase, around days 19, 20 or 21. This is the phase when PMS symptoms are at their peak, so I always tell patients you want to be tested on your bad days. If you have had an endometrial ablation or hysterectomy, but you still have your ovaries, it’s hard to know when you are in this phase of your cycle. These are day you find yourself reacting differently to something that day that normally would not have bothered you.
Get tested first to see where imbalances are. Usually testing of all hormones is done in the luteal phase, day 19, 20 or 21. That is the right time to test estrogen, progesterone, and testosterone. The other timed test is an FSH (follicle stimulating hormone).
We perform a day 3 FSH. An elevated level is suggestive of menopause, but this test is not a perfect test. This test is testing the brain talking to your ovary; it is not testing the ovary itself. In the years prior to menopause, your brain and ovary can have moments of good communication and plenty of moments of bad communication, thus don’t be burdened by the results of this test, especially if you are still having periods.
Each woman is different when it comes to symptoms, including changes in menstruation. Often times, especially in the perimenopause period, the ovary can be secreting too much testosterone. In this zone of life, patient’s ovaries are either “screaming” or “whispering” hormones. Sometimes your ovary will struggle and hormone production will be low, or it will thrive and the hormones will look high. This is why some months your symptoms may seem severe and some months you are just fine.
If you are on the birth control pill, all of your hormones in the ovary are suppressed so there is NO egg production (how it prevents pregnancy) and no thick, fluffy lining built up to accept a fertilized egg (why periods are lighter on the pill).
Balancing hormones for women on the birth control pill can be done, but it is trickier. Often times, the birth control pill is the cause of some of the problems which is quite an eye opening statement to some patients. A lot of women have been on the birth control pill for a majority of their lives, so they never suspect their birth control pill could be the problem. But, maybe it is. Why? Well, the pill is not changing, but you are. When we are older, the pill could drop our hormone production down so much that it is more of the problem than the solution. Most women who are done having their children might be better off finding a non-hormonal method of birth control (tubal ligation, vasectomy, Essure®). Then when you are hormone free, and the birth control pill is out of your system, test your hormones and see how many problems being off the pill fixed or caused, and go from there.
Most women, after thorough testing, usually get a huge relief of symptoms by adding progesterone to balance the estrogen already produced by the ovary. A consultation to thoroughly test hormones, vitamins, and other metabolic indicators, and replacement of hormones, stress management, and good exercise and nutrition, can make the perimenopause for women more manageable.
