Vol. 1 No. 1: Spring Equinox, 1999
The Ovary's Frustrating Grand Finale
Jerilynn C. Prior MD, FRCPC &mdash Adapted from a Script for Menopause Telehealth Conference Nov., 1998 B.C. Women's Hospital Foundation
Women in midlife increasingly hear the words "estrogen deficiency" spoken as the ultimate in bad news. "Everyone knows" that low estrogen levels cause heart disease, osteoporosis, Alzheimer's and frigidity. But as Dr. Susan Love (renowned breast surgeon and author of Dr. Susan Love's Hormone Book) states, "If estrogen deficiency's a disease, all men have it!" .
Our purpose here first is to put women's midlife concerns into a new and more accurate hormonal picture. Specifically, I'd like to present new information about high estrogen levels in the perimenopause. Not low, not even normal, but estrogen levels that are higher than those of the (sexiest) 20 year old female! Secondly, I'll discuss how a woman can tell when her estrogen levels are high and out of balance with progesterone, the other important hormone for women. And finally, we'll review the many ways a woman can help herself through perimenopause,"Estrogen's storm season!".
What is perimenopause?
Women have often called "menopause" everything they experience during the changing times of midlife, but now that we know about perimenopause, it's important to use the right names. Menopause means that a year has passed since a woman's last period. Perimenopause refers to the long and changing time until the end of no flow. The first change may be more PMS, night sweats, a new migraine, or sleep trouble and fatigue. On average the perimenopause lasts several years and commonly lasts six or seven. The good news is that perimenopause ends! I am an expert on the perimenopause primarily because I have now graduated! I survived a rough perimenopause and my own experiences told me that the experts had it all wrong about dropping estrogen!
What's the evidence that perimenopausal estrogen levels are high?
A dozen or so studies in the last 20 years have set out to measure hormone levels in perimenopausal women. Each study reports the data and summarizes by saying that estrogen levels are dropping. Surprisingly, few bother to mention the high levels they found . When all of the studies are put together (Figure 1),and the average perimenopausal estrogen levels are compared with average levels in young women, it is clear that the levels are higher, and significantly so .
Let's consider estrogen levels from 300 Australian perimenopausal women taken during the end of flow . The data presented as a scatter plot (Figure 2) indicates a wide range of hormone levels. Not only are most of the levels as high or higher than the average end of flow estrogen level for 20-35 year olds but many are even higher than the average mid cycle estrogen levels (peak in the cycle) in 20-35 year olds. Clearly many of these perimenopausal women had very high estrogen levels. But what did the very good scientists say in summary about their data?"Perimenopause is characterized by dropping estrogen and inhibin levels and rising FSH levels" .
The study cited above  mentioned a strange hormone called "inhibin". I believe it is because inhibin, the normal brake type hormone begins to slack off in its job of keeping the pituitary's Follicle Stimulating Hormone (FSH) in line, that the perimenopausal ovary goes through its grand finale . FSH starts to increase, stimulates several rather than just one follicle (the nest of estrogen producing cells surrounding an egg( and estrogen levels increase and become unpredictable .
How can a women know when her estrogen levels are high or out of balance with progesterone?
There are many clues and they differ between women, and in one woman over time. Early in the process of my baby, I woke thinking that I had really lost it! At fifty, with my two children grown, the last thing in the world I wanted was to be pregnant. But after some thought, I began to understand that it was my subconscious self's way of saying goodbye to the fertile part of my life.
Many of the things I felt in that dream, however, are also high estrogen signs: swollen and tender (sometimes lumpy) breasts, increased vaginal mucous and a heavy pelvic feeling almost like cramps or swelling. High estrogen and progesterone levels in pregnancy are normal and necessary, but in the perimenopause, estrogen is high but progesterone is not. It is this imbalance that can cause significant difficulties for many women.
Dr. Patricia Kaufert, a scientist from Winnipeg who has done one of the best studies about what women experience during perimenopause, found that women were likely to have a flooding menstruation just before their periods changed from regular to skipping . But heavy flow, bleeding at shorter intervals than 3 weeks, continual spotting or flow every two weeks, and clotting with cramping are all signs that estrogen is too high and progesterone is too low. Any period is too heavy if you soak more than 16 pads or tampons.
It is normal for the breasts to swell during the week before flow and it is sometimes normal to feel tenderness in the front or nipple area when estrogen hits a high midcycle peak. But swollen breasts most of the time, or front-of-the-breast soreness for more than a couple of days of the month means high estrogen.
During the perimenopause many women occasionally become forgetful and sometimes can't remember what they were saying. We now know that stress makes for memory problems. And the high estrogen levels of the perimenopause (on top of the necessary stress of moving through this major life change) make cortisol and other stress levels higher. No wonder it feels like PMS-city! One nurse said it very well, "At (peri)menopause life can turn into one long pre-menstrual experience. Hormones slap you up against the doors of your unfinished business" .