Vol. 3 No. 3: Fall Equinox, 2001

Perimenopause: The Ovary's Frustrating Grand Finale


Clues that estrogen levels are high or out of balance with progesterone

There are many things you can observe that will tell you that you are experiencing the typical perimenopausal hormone imbalance-too-high estrogen and too-low progesterone levels. You'll need to be a record-keeper and a sleuth to discover what is happening for you because such a wide array of experiences is possible. Early in the process of my perimenopause I had a disturbing dream-more like a nightmare. I woke suddenly, early one morning, from a most vivid dream that I was pregnant! I could feel my swollen and tender breasts, my moist and heavy-feeling vagina, the heat and expectation in my body. In my dream I felt like I had a belly full of a full term 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 my fertile years.

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 similar to cramps. High estrogen and progesterone levels in pregnancy are normal and necessary. In perimenopause however, estrogen levels are high but progesterone levels are not.

Heavy flow, bleeding less than 3 weeks apart, continual spotting or clotting and increased cramping are all signs that estrogen is too high. For the amount of estrogen, progesterone levels are also too low [Santoro, Rosenberg, et al. 1996]. Canadian researcher, Dr. Patricia Kaufert, who has done one of the best studies about what women experiences during perimenopause, found that women who have flooding menstruation are likely to start the time of skipped periods in perimenopause [Kaufert, Gilbert, et al. 1987].

Heavy and unpredictable flow is not only horrible to live with but they can cause iron deficiency, low blood counts (anemia) and deep fatigue. Although some women will soak a half a box of tampons a day, soaking 16 or more pads or tampons in any (entire) period is abnormal. The culprits are too much estrogen and too little progesterone or whether or not your uterine muscle has a fibroid. Fibroids disturb the endometrium (uterus lining) less than 10% of the time and are therefore, rarely the cause for abnormal flow.

What about breast swelling and tenderness in perimenopause? It is normal for the breasts to swell a bit during the week before flow. It is sometimes normal to feel tenderness in the front or nipple area of the breast at the middle of the cycle when estrogen hits its high peak. But continuously swollen breasts, front-of-the45breast soreness before flow or for more than three days each month means high estrogen levels. During perimenopause women may become forgetful. We now know that stress makes for memory problems. And the high estrogen levels of the perimenopause (added to the stress of this major life change) make cortisol and other stress levels higher (Kirschbaum, Schommer, et al. 1996). 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" (Kelsea 1991).

Are hot flushes (or flashes) from low estrogen?

Periods once a month tell us our estrogen levels are normal. Many doctors still believe that night sweats and hot flushes are caused by low estrogen levels. If that were true, how come so many perimenopausal women start having night sweats when their periods are perfectly regular? The answer is that hot flushes/night sweats are caused by decreases or swings in estrogen levels even if they are still high. The brain becomes used to the young normal estrogen levels and, when it has been exposed to the high levels during the perimenopause, it rebels as those levels drop, even to normal. What happens with a hot flush is similar to what a drug addict goes through during withdrawal-a major brain discharge of stress and other hormones. It is this hormonal discharge (along with the flush) that causes the anxious feelings, nausea and chest pain as well as the feeling of heat and the sweating that go with them. So if someone tells a you your flushes are in your head just tell them that "darn tootin" they are!

I first twigged that I was perimenopausal when I woke abruptly one dark November morning in 1990 feeling MAD! I looked for a cause-my dog and my partner were sleeping soundly, all was quiet in the house and in the neighborhood. But my heart was pounding, my legs wouldn't lie still and I was ready to do battle.

Then I felt a weak and woozy wave of heat and began to sweat. A day later my period started. I had no more night sweats until the day before my next period.

I had learned an important thing-in the early years of perimenopause; night sweats are a clue that your period is coming (Figure 3) [personal communication, G. Hale, 2001].

Another new observation is that women who have increased premenstrual symptoms early in the perimenopause are more likely to have a difficult time with hot flushes at the end of perimenopause and in early menopause. That information came from the same Australian study I told you about earlier {Guthrie, Dennerstein, et al. 1996}. High estrogen levels cause premenstrual symptoms. It makes sense that the brain would react when these high levels do their chaotic dance in perimenopause or eventually settle out to the normally low levels of menopause.

What can I do to help myself through the rough times in the perimenopause?

The first and most important thing to realize about perimenopause is that, ready or not, we must go through a major life change-change in body, change in fertility, even change in concepts about ourselves [Page 1994]. A number of years ago I was captured on a National Film Board video "Is it hot in here?" saying I was only 22 times 2 and was looking forward to menopause as a normal phase of life! But, when perimenopause hit me, though my mind said I was okay with it, although I have all the children I ever wanted, and despite my fulfilling job and lots to look forward to, I went through times of real sadness. Losing youth, fertility and even predictable periods are justifiable reasons for feeling blue. It helped me and will help you to deal with this natural sadness if you talk with friends, family and perhaps even a counselor about these important and often hidden feelings. I also suggest reading a book by Vancouver counselor, Lafern Page, Menopause and Emotions: making sense of feelings when feelings make no sense [Page 1994].

The next most important thing we can do to help ourselves in perimenopause is to take time to care for ourselves. A friend and important pioneer in the work of bringing perimenopause information to BC women, retired public health nurse, Pat Chadwick, said, "The first two letters of the word menopause are ME!" That means we need to take time out for exercise, meditation and having a latte with a friend. We also may need to say "no!" to more overtime or to continuing to make our 12 year old's lunch. Get your priorities straight-take care of yourself!

I was significantly helped in my perimenopause by keeping the Daily Perimenopause Diary ((c)1991). To allow many women access to this self-record tool we have made a video that both describes the hormonal changes of perimenopause and explains what you can learn from using the diary [Prior 1999]. A completed diary showing 8 days of flow in which you soaked 6-10 tampons a day is more likely than your complaints about it to convince your family doctor that you need a blood count and some progesterone therapy!

Vol. 3 No. 3: Fall Equinox, 2001