Volume 3, Number 3: Fall Equinox, 2001

Perimenopause: The Ovary's Frustrating Grand Finale - BC Endocrine Research Foundation

Jerilynn C. Prior MD, FRCPC

University of British Columbia, Vancouver, B.C.

(Revised 10/2001. Adapted from telehealth conference script originally as a video, 10/1998 sponsored by the B.C. Women’s Hospital Foundation)

Introduction

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. Right? 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!” [Love 1997]

Our purpose here first is to put women’s midlife experiences and 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 woman! Secondly, I’ll discuss how you can tell when your 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. However, now that we know about perimenopause, a hormonally distinct time in midlife, it is important to use the right names. Menopause means that a year has passed since a woman’s final period. Perimenopause refers to the long and changing time until a woman “graduates” into menopause. The newest name for perimenopause is “menopausal transition”.

The first perimenopausal change commonly masquerades as increased premenstrual symptoms (sometimes called PMS). A regularly menstruating woman may have her first migraine, start waking after two or three hours of sleep and toss and turn. Finally she may suddenly flood during what was a normal period or start having night sweats. On average the perimenopause lasts at least four and commonly eight to 10 years. The good news is that perimenopause ends! I am an expert on the perimenopause primarily because I have now graduated! I survived a rough 10-yr perimenopause and my own experiences told me that the experts had it all wrong about dropping or deficient estrogen levels!

High and swinging, not dropping estrogen levels in perimenopause!

Many studies in the last 20 years have measured estrogen levels in perimenopausal compared with premenopausal women. Each study, however reports by summarizing that estrogen levels are dropping.

Surprisingly, they don’t bother to mention the high levels they also found [Burger, Dudley, et al. 1995].

When all of the studies are put together (Figure 1, above), and the average perimenopausal estrogen levels are compared with average levels in young women, it is clear that estrogen levels are about 30% higher than normal during perimenopause [Prior 1998].

Let’s consider estrogen levels from a population-based study of over 300 Australian perimenopausal women (Burger, Dudley, et al. 1995). Each woman had a blood test 3-8 days after the start of flow-each woman’s level is a dot in Figure 2.

This shows lots of estrogen variation and high levels occurring not only in the regularly menstruating women (group 1) but also in women who were between 3 and 11 months since their last period.

Not only are most of the levels higher than the average end-of-flow estrogen levels for 20-35 year olds (dotted line) but many are even higher than the highest point at the middle of the cycle for 20-35 year olds (solid line). But what did these very good scientists say in summary? “Perimenopause is characterized by dropping estrogen . . .levels” [Burger, Dudley, et al. 1995].

The study we just discussed [Burger, Dudley, et al. 1995] also measured a strange new hormone called “inhibin”. I believe it is because inhibin, the ovary’s 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 [Prior 1998]. Lower inhibin levels allow FSH to increase and to stimulate several rather than just one follicle (the nest of estrogen-producing cells surrounding an egg). As a consequence estrogen levels rise and become unpredictable [Prior 1998].

The other big hormonal change of perimenopause is that progesterone levels are too low [Prior 2001]. Progesterone, the important ovarian counterbalancing hormone to estrogen which is made after an egg is released, is produced in lower levels even when cycles are still regular [Santoro, Rosenberg, et al. 1996]. We know that normal progesterone levels are needed to prevent bone loss in young women [Prior, Vigna, et al. 1990]. We also know that too much estrogen with too little progesterone makes for heavy periods or frequent flow.

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!

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!

Summary

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.

References

  1. Love S: Doctor Susan Love’s Hormone Book. San Francisco: Random House, New York, 1997; 1-348.
  2. 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.
  3. Prior JC: Perimenopause: The complex endocrinology of the menopausal transition. Endocr.Rev. 1998; 19: 397-428.
  4. Prior J. C. Perimenopause– the ovary’s frustrating grand finale. A Friend Indeed 15(7), 1-4. 1998.
  5. 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.
  6. 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.
  7. Prior JC, Vigna YM, Schechter MT, Burgess AE: Spinal bone loss an ovulatory disturbances. NEJM 1990; 323: 1221-1227.
  8. Kaufert PA, Gilbert P, Tate R: Defining menopausal status: the impact of longitudinal data. Maturitas 1987; 9: 217-226.
  9. 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.
  10. 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.
  11. 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.
  12. Page L: Menopause and emotions: making sense of your feelings when your feelings make no sense. Vancouver: Primavera Press, 1994; 1-241.
  13. 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.
  14. 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.
  15. 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.
  16. 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

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Board Members: Dr. Keith Dawson, Dr. Jason Kong, Dr. Ehud Ur, Dr. Jerilynn Prior, Dr. Tom Elliott, Dr. Breay Paty, Dr. Sandra Sirrs

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