Vol. 3 No. 3: Fall Equinox, 2001
Perimenopause: The Ovary's Frustrating Grand Finale
Our bones face at least three challenges during later perimenopause: swinging estrogen levels (causing increased bone loss), too low progesterone levels (causing less new bone to be formed) and higher stress hormone levels (causing both bone loss and less new bone) [Prior 1998]. It is therefore a good idea to increase your daily calcium intake (from food and supplements) to 1500 to 2000 mg/d (spread across the day with food and 400-600 mg at bedtime). Calcium supplementation also decreases premenstrual symptoms [Thys-Jacobs S, Starkey, et al. 1998] and will help with sleep and with restless legs that can start in perimenopause. In addition to calcium, you should also take at least one multiple vitamin to provide 400 IU of Vitamin D each day. Our skin can't make vitamin D during October through March from the slanty northern sunshine we get in most of Canada and the northern U.S.. If you have a family member with osteoporosis (by bone density measure or a broken bone with low trauma) you probably should take 800 IU/d of Vitamin D.
Night sweats are troubling and sleep-disturbing. Vitamin E in a dose of 400 to 800 IU each day may help in addition to regular exercise (both walking and heart-rate raising aerobic exercise), decreasing stress [Swartzman, Edelberg, et al. 1990} relaxation and slow deep breathing. It may also be that eating foods made from soy such as tofu or drinking soy beverages on a regular basis will decrease hot flushes [Murkies et al., 1995].
Heavy and too frequent periods are the most urgent problem for us in perimenopause. What can we do about periods, flooding, cramps and the risk for anaemia? If you are regularly soaking over 12 pads or tampons during a whole period, I suggest you start taking iron because you are likely to have low iron stores if not anemia. Take one (inexpensive) tablet of ferrous gluconate a day (34 mg of iron, an inexpensive, green pill). This can be purchased from the drugstore without a prescription (but be sure to tell your doctor). For menstrual cramps, as well as to decrease heavy flow, ibuprofen (Advila, Motrina or generic) 200 mg, can be used at the first hint of cramps and repeated four or more times a day. Ibuprofen use has been shown to decrease the amount of blood loss. If the cramps are really bad, take two tablets at the first hint of cramps and take one more each time you start to get the heavy pelvic feeling that cramps are returning.
If taking ibuprofen and iron doesn't resolve the perimenopausal flow problems and anemia and if bleeding lasts longer than a week or occurs at shorter than 3-week intervals, you need to see your family doctor. Ask for a prescription for progesterone (Prometrium(r) or medroxyprogesterone) which works to prevent estrogen's over-stimulation of the endometrium.
Progesterone also controls or even stops flow depending on the dose and your estrogen levels. It is ideal to take it cycle days 14 to 27 after the first day of flow (Figure 4). If your cycles are shorter (flows less than 25 days apart), start the progesterone on day 12 and continue through day 25.
Each time you start it finish the full 14 days of progesterone. Full doses (3 capsules of progesterone =300 mg/d or 1 10-mg tablet of medroxyprogesterone) are absolutely necessary because we are trying to balance very high estrogen levels. It may be necessary to take high doses for a number of months. If you have migraine headaches, ask your doctor to prescribe it every daily because often hormone changes can trigger migraines.
In most cases of heavy/frequent flow there is no need for a referral to a gynecologist, an endometrial biopsy, a D & C or a pelvic ultrasound. Keep in close contact with your family doctor. Unless both you and your doctor decide that at least six months of full or high dose cyclic progesterone hasn't helped don't see a surgeon whose common "choices" are oral contraceptives, uterine lining ablation (killing the endometrium) or hysterectomy. I suggest you decline the oral contraceptives your doctor may offer because even "low dose" pills contain high estrogen that won't suppress the estrogen your ovaries are already making in abundance! If at all possible, refuse the hysterectomy or endometrial ablation (killing the uterine lining) surgery that gynecologists often offer. Either surgery takes away flow that provides one of the few clues we have to the ovary's mysterious antics during perimenopause and helps us to know when we are menopausal. Like the rest of perimenopause-this heavy flow will get better!
So, let's review. We have talked about the perimenopausal puzzle of high rather than low estrogen levels and the paradox that many doctors believe estrogen treatment will help. Now you will be able to recognize when your estrogen levels are too high and will know that, although life may be miserable right now, this is likely quite normal and will pass. You can now figure out that you are perimenopausal, even though flow is regular, when you start getting night sweats and or premenstrual symptoms increase. Most importantly, when flow is abnormal and persists in being so, you can ask for cyclic full-dose progesterone treatment to help balance your high estrogen effect in the brain and bone and uterus. And, if you are taking good care of yourself and find you still can't cope with premenstrual symptoms, waking in the wee hours of the morning and night sweats, you could ask your doctor for cyclic progesterone therapy for those reasons also.
Most important-understand that you, like me, can survive perimenopause!
As Ursula LeGuin, the science fiction writer says "The woman who is willing to make that change must become pregnant with herself, at last" [LeGuin 1991].
Jerilynn Prior is an internationally known expert on progesterone and an active researcher and educator.
- Love S: Doctor Susan Love's Hormone Book. San Francisco: Random House, New York, 1997; 1-348.
- Burger HG, Dudley EC, Hopper JL, et al: The endocrinology of the menopausal transition: a cross-sectional study of a population-based sample. J.Clin.Endocr.Metab. 1995; 80: 3537-3545.
- Prior JC: Perimenopause: The complex endocrinology of the menopausal transition. Endocr.Rev. 1998; 19: 397-428.
- Prior J. C. Perimenopause-- the ovary's frustrating grand finale. A Friend Indeed 15(7), 1-4. 1998.
- Prior JC: Ovulatory changes with perimenopause Endocrine Ageing in Women. In: Endocrine Facets of Ageing in the Human and Experimental Animal. Veldhuis JD, Laron Z, eds. London: Wiley Publishers (in press), 2001.
- Santoro N, Rosenberg J, Adel T, Skurnick JH: Characterization of reproductive hormonal dynamics in the perimenopause. J Clin Endocrinol Metab 1996; 81:4, 1495-1501.
- Prior JC, Vigna YM, Schechter MT, Burgess AE: Spinal bone loss an ovulatory disturbances. NEJM 1990; 323: 1221-1227.
- Kaufert PA, Gilbert P, Tate R: Defining menopausal status: the impact of longitudinal data. Maturitas 1987; 9: 217-226.
- Kirschbaum C, Schommer N, Federenko I, et al: Short-term estradiol treatment enhances pituitary-adrenal axis and sympathetic responses to psyhosocial stress in healthy young men. J Clin Endocrinol Metab 1996; 81: 3639-3643.
- Kelsea M: Beyond the stethoscope: a nurse practitioner looks at menopause and midlife. In: Women of the 14th Moon: writings on menopause. Sumrall AC, Taylor D, eds. Freedom, California: The Crossing Press, 1991; 268-279.
- Guthrie JR, Dennerstein L, Hopper JL, Burger HG: Hot flushes, menstrual status, and hormone levels in a population-based sample of midlife women. Obstetrics and Gynecology 1996; 88: 437-442.
- Page L: Menopause and emotions: making sense of your feelings when your feelings make no sense. Vancouver: Primavera Press, 1994; 1-241.
- Thys-Jacobs S, Starkey P, Bernstein D, Tian J, The Premenstrual Synrome Study Group: Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Am.J.Obstet.Gynecol. 1998; 179: 444-452.
- Swartzman LC, Edelberg R, Kemmann E: Impact of stress on objectively recorded menopausal hot flushes and on flush report bias. Health Psychology 1990; 9: 529-545.
- Murkies AL, Lombard C, Strauss BJG, Wilcox G, Burger HG, Morton MS: Dietary flour supplementation decreases post-menopausal hot flushes: effect of soy and wheat. Maturitas 1995; 21: 189-195.
- LeGuin UK: The Space Crone. In: Women of the 14th Moon: writings on menopause. Sumrall AC, Taylor D, eds. Freedom, California: The Crossing Press, 1991; 3-6. Copyright Jerilynn C. Prior October, 2002