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Six

Perimenopause: The Storm Before the Calm

The ups and downs of the your menstrual cycles, relationship drama, and family responsibility may seem like enough to manage, but just at the moment you might begin to think you have everything under control, there comes another curveball: perimenopause. And it comes earlier than you may have thought.

Actual menopause lasts one day. It is the one-year anniversary since your periods have completely stopped. The average age for menopause is fifty-one, but anywhere from the forties to the midfifties is considered normal. Perimenopause, however, is the long, drawn-out transition from fertility to infertility, which begins seven to ten years prior to your period stopping. Things don’t usually get problematic until the late forties, but this is a marathon, not a sprint. As you near the finish line, things will likely get intense. You learn to expect the unexpected: worsening PMS that seems to come earlier every month, flying off the handle for no good reason, feeling horny one day and completely turned off the next, and periods that come and go unexpectedly.

We’ve got an entertaining situation here in my house. Just as my teenage daughter, Molly, is entering into her cyclical moodiness, her mother is ungracefully exiting. Don’t you wish you were my husband, sandwiched between a cadet just joining the ranks of the menstruation nation and a retired general who’s bowing out? Both of us are having fits and starts of our ovaries, but only one of us gets a pass on her pimples and emotional outbursts. Puberty gets an allowance. Perimenopause gets bupkis.

Nearly a quarter of women with teenagers are in their fifties. Not only are we feeling terrorized by our moody little bitches, but many of us are also caring for aging parents. We are torn between two generations that compete for our attention, accommodation, and care. I marvel that my mother did not go completely batshit while raising three daughters and driving an hour a day to check on her parents to make sure my grandfather gave his wife her insulin and she his meals. Perimenopausal women today are not just balancing work and family; they’re also trying to avoid putting their parents in a nursing home. It’s not only stress inducing or anxiety provoking, it’s depressing. We all have fears around aging and becoming “infirm.” Watching our daughters blossom in the springtime of their fertility as we fade out in the autumn of ours, plus seeing what lies ahead as our mothers wither and weaken, is poignant and painful and very nearly too much to handle.

Hormonal surges and cycles are a major part of being a woman. Once those cycles finally stop, after we’ve weathered the hot flashes and mood swings, then how will we feel? According to plenty of older women, great. I cling to one Gallup poll from 1998 that asked older women when they felt happiest and most fulfilled, and a slim majority chose the years between fifty and sixty-five. So hang in there, baby. Fifty’s coming. In the meantime, forewarned is forearmed. Just knowing you can get a little crazy and angry can help the whole process not get the better of you, and there are real ways to harness the powerful changes your body has in store for you.

Nuts and Bolts: Symptoms and Complaints

During perimenopause, symptoms change month to month, and day to day, as they gradually pick up steam, crescendoing right before your periods stop. And then start again, out of the blue. The absolute hormone levels matter, but what affects the brain most are the abrupt changes in those levels. Every little fluctuation triggers a symptom. Complaints during this stretch include weight gain, fatigue, low libido, and vaginal dryness and irritation. No, wait, it gets worse. Because collagen is estrogen sensitive, it becomes less elastic as you age, so say hello to wrinkles and good-bye to dry underwear; three-quarters of women between forty-five and fifty-four have some episodes of urinary incontinence. Weakened sphincters with less collagen lose their elasticity. Insomnia is the biggest issue, coming early in the transition and lasting for years. It can occur on its own or result from night sweats—the hot flashes that hit you while you sleep.

Hot flashes affect 80 percent of women in perimenopause, last between one and five minutes, and occur over a span of nearly a decade, starting years before, and continuing years after, your periods stop. Sudden dips in estrogen levels cause a drop in the set point of the hypothalamus, the brain’s temperature regulator. Your brain then tells your body that it’s overheating and goes about lowering your body temperature the only way it knows how, with sweating and bringing blood to the skin. Your face flushes as the blood vessels dilate, and the whole upper body breaks out in a sweat, sometimes followed by chills. Some women experience an “aura” before a hot flash, a sense of dread, suddenly feeling weak, or heart palpitations, all thanks to spiking norepinephrine levels, your brain’s adrenaline. If this happens to you, it’s normal. Your brain is trying to give you a heads-up that you’re about to overheat, like a warning light on your dash.

Estrogen Dominance: Too Much of a Good Thing

For most women, perimenopause has two phases. At first there is a relative overabundance of estrogen due to rapidly falling progesterone levels. Because these two hormones balance each other out, this is referred to as unopposed estrogen, or estrogen dominance. Later in the transition, estrogen levels finally fall and you get a slightly different cluster of symptoms.

In early perimenopause, when you’re still ovulating, your cycles may shorten, perhaps going from twenty-eight or thirty days down to twenty-one or twenty-four days. This is your body’s way of giving you more opportunities to become pregnant one last time before the shop closes down. The first half of your cycle, the follicular phase, shrinks from fourteen days down to ten. This is when you feel halfway decent and may even be attracted to your partner, thanks to estrogen and testosterone levels being relatively high. Then you ovulate, the egg dies, and it’s all downhill from there in terms of mood and libido.

Around the early forties, the quality of the released egg starts to fall precipitously, as does the leftover part that makes progesterone, the corpus luteum. Lower progesterone levels become the norm. Progesterone is what stabilizes the uterine lining, so expect heavier, longer periods with more cramping. Weight gain, water retention, headaches, breast tenderness, cysts, moodiness, and disrupted sleep cycles all characterize this high estrogen / low progesterone state. The closer you get toward menopause, when your periods stop, the more likely you are to have longer cycles where no egg is released at all, called anovulatory cycles. Then you’re stuck in the follicular phase, where there’s a buildup of unopposed estrogen. Your boobs hurt, you feel bloated, and, man, are you moody. This is PMS for the big girls.

Both estrogen and progesterone levels decline with age, but progesterone goes first, and the slope is steeper. A menopausal woman has 5 percent of the progesterone she had in her twenties, but perhaps still 40 percent of her estrogen thanks to her fat cells, which continue to pump out that hormone throughout her life. This means estrogen dominance is a bigger problem if you’re overweight. As usual, there’s a vicious cycle. Estrogen promotes fat storage and weight gain, and the fat cells make more estrogen. Add to this the xenoestrogens, external sources of estrogen coming from meats, plastics, pesticides, and soaps, which are stored in fat cells, and you have a recipe for disaster. Unopposed estrogen is not just uncomfortable, it’s dangerous, putting you at risk for uterine, ovarian, breast, and colon cancer.

In the second stage of the perimenopause transition, your ovaries finally poop out and estrogen levels take a nosedive. Estrogen dominance is gone, and you have a new set of symptoms due to low estrogen, not low progesterone, but still topping the list are moodiness and irritability, even “rages.” Lower estrogen levels mean memory loss and decreased concentration, bone loss (osteoporosis), and a lot more hot flashes and night sweats. Your appetite for food goes up. For sex, it goes down. The urge to mother or nurture, reliant on estrogen all those years, starts to give way to thoughts of Why do I have to do everything around here? When is it my turn? More on this later. First, let’s talk about my belly.

The Menopot: Abdominal Obesity in Perimenopause

I can’t get rid of my menopot and it’s driving me crazy. I always had wide hips and thighs, but my belly used to be relatively flat. No more. After two kids and waning hormones, I am now the not-so-proud owner of a “muffin top.” I can grab a handful of flab and cop a Scarface accent. “Say hello to my little friend.” In the fertile years, estrogen dictates that fat gets deposited at the breasts and hips, forming the hippy gynoid shape. The waist stays small, creating that low waist-to-hip ratio every (heterosexual) man goes gaga for. In the nonfertile forties, it’s all about belly and back fat.

Women between thirty-five and forty-four gain weight faster than at any other time in their lives. By their late forties, a majority of women are overweight or obese. The biggest reason is that by menopause, our caloric requirements are about 65 percent of what they were when we were in our twenties. And it’s not a gradual decline but a fairly abrupt shift. You’ll need to learn how to eat all over again. Your risk for diabetes rises as your hot flashes worsen, and carbs, more than ever before, can make you fat. So can stress. As estrogen levels fall, the pelvic paunch becomes more sensitive to cortisol-stimulated fat accumulation. Menopausal women have an increase in abdominal fat, increasing their risk for cardiac disease.

Where’s progesterone when you need it? Progesterone can help with weight loss and enhances the action of thyroid hormones, which help to keep your metabolism revving along. In pregnancy, women commonly feel overheated because progesterone signals the hypothalamus to run hot. Perimenopause, with its low progesterone levels, does the opposite. The metabolism downshifts and slows way down, so you’re cold when you’re not burning up.

If you don’t ovulate, you’re going to feel even fatter, because unopposed estrogen means more water retention and bloating. Worse still, high estrogen levels signal the liver to make a protein called thyroid-binding globulin, drastically lowering the available free thyroid hormone. You need this to keep your metabolism humming. So if you’re feeling sluggish, your thoughts are slowed down, you feel cold all the time, your skin is dry, and your weight is up, make sure your doctor measures your free thyroid hormone levels and not just your TSH, which is the typical test to order when looking for thyroid troubles. An underactive thyroid is seen fifteen times more often in women than in men. It is quite common for my female patients to have undiagnosed thyroid problems at any age, but especially at perimenopause. Fifty-year-old women produce half the thyroid hormones that twenty-year-olds produce. Many of the complaints of depression are also seen in hypothyroidism: low mood, low energy, low libido, and problems concentrating. This is another reason not to jump on the SSRI bandwagon right off the bat. Have your thyroid checked first.

To compound the effects of a sluggish metabolism, welcome your new companion, a ravenous appetite. Rats that have their ovaries removed, mimicking menopause, have an increased desire to eat and drink, which is normalized when they are given estrogen supplements. You know how you get hungry during PMS? It’s a bit like that, only it’s not just for a day or two every month.

Reproductive Depression Revisited

Somewhere along the way in my psychiatric training I heard a term for perimenopause that I just loved, “climacteric psychosis.” Climacteric is an older term for the menopausal period, and psychosis, well . . . in effect, perimenopause can make you crazy. This is a prime time for psychiatric complaints. I will often get a patient in her late forties or early fifties coming into my office. She’s never seen a psychiatrist before, but she’s at her wits’ end due to insomnia, panicky sweats, crying at the drop of a hat, or just not giving a shit anymore. Often, one of the first symptoms of perimenopause, before the hot flashes, before the disrupted sleep, is depression. Your risk of depression nearly triples in the perimenopausal transition. The prevalence of depression is highest in women aged forty to forty-nine and lowest in women older than sixty; hence, the storm before the calm.

When you remove a female rat’s ovaries, depleting her of estrogen, she shows increased anxious and depressive behaviors, which can be reversed by administering estrogen. Lower estrogen levels will lower overall serotonin activity. Remember, if you’re prone to reproductive depressions—if you get significant PMS or if you’ve had postpartum depression—you’re more likely to have mood complaints with your perimenopause. Reproductive depressions are responsive to hormones. Once you’re past menopause, major depressions need to be treated with antidepressants because hormones won’t work as well.

Insomnia and Anxiety

I was on the phone with a therapist talking about our mutual patient. The conversation quickly turned to the therapist’s own issues and struggles. She’s fifty and miserable, not depressed so much as she is agitated. She gets anxious during the day, and then her sleep is interrupted by frequent panicked awakenings.

The estrogen-dominant phase of perimenopause can be an anxious, depressed time for a couple of reasons. High estrogen, when it tamps down the thyroid function, ends up inhibiting the activity of a calming neurotransmitter, GABA. Lower progesterone levels also lead to lower GABA activity and therefore more anxiety. In the later transition, when estrogen levels fade, anxiety can become even more of a problem. There are estrogen receptors on the amygdala (the brain’s fear and panic center) as well as the hippocampus (memory) and limbic system (emotional control). When the brain’s hormone control center, the hypothalamus, sees lower levels of estrogen, it seems to panic, decreasing production of serotonin and dopamine but ramping up norepinephrine. The end result: low mood, insomnia, and fatigue, but with a touch of anxiety and agitation thrown in. It’s not an anxious fear so much as it is irritation, often aimed at partners. Any little thing can set you off and make you angry. This is “ roid rage,” truly: agitation brought about by a change in steroid hormones.

Insomnia is a biggie during perimenopause. Throughout their lives, women experience insomnia more than men do, but it jumps from 36 percent of women at age thirty to 50 percent at age fifty-four. A few issues are at play here. Cortisol helps to establish circadian rhythms (your body knowing when it’s day and night), so when cortisol levels drop during perimenopause, not only is your ability to cope with stress severely limited but also your sleep cycle is a mess. High estrogen levels in early perimenopause can deplete magnesium. For many women, magnesium supplementation can treat insomnia and anxiety, and it’s also great for restless leg syndrome. While progesterone is calming on the brain, estrogen is more excitatory. Estrogen dominance exacerbates insomnia; progesterone replacement can help restore sleep. In early perimenopause, supplementing with natural progesterone can help with insomnia. Once you hit the waning estrogen phase of the transition, you’ll probably see better effects on sleep by using estrogen.