Multiples in Midlife: Could It Be Perimenopause?


One day shortly after my fortieth birthday, I noticed that nearly everything that my three young sons said or did irritated me beyond reproach. Now some compassionate readers may say, “Hey, kids will do that to you, especially if you have twins,” and on any other day I would agree. But on this particular day, it was different. I felt uncomfortable in my own skin. I couldn’t control the stern words spewing from my mouth; it felt as if someone else were speaking them.

I became antsy, searching for something on which to focus my attention. As I looked out the kitchen window, I realized that the big old elm tree hovering over the back of my house irritated me as well. “Come on, kids,” I yelled. “We’re going to cut down that tree!”

We marched into the garage and hauled out a ten-foot tree lopper, and dragged it to the backyard. I hoisted it into place—next to a 20-foot branch—and began sawing. The physical exercise, although immediately draining, gave me a much-needed outlet for my aggression. The boys looked on delighted as I zealously attacked the tree. And then suddenly, “CRACK!” The branch snapped off and crashed to the ground, taking a nearby telephone line with it. Panicked, I tried to pull the branch off the sagging line. “Give me a hand boys,” I yelled. They tried to help, but a one hundred pound tree branch is a bit much for a trio of munchkins to lift.

Then it hit me—I had completely lost my mind.

Just a bad case of PMS? Perhaps, but I had never experienced it (or as badly) before, and why would I now so late in my childbearing years? It wasn’t until I began to notice other subtle changes to my body—a shortening menstrual cycle, tender breasts, and periodic insomnia—coupled with my mood swings that I had my answer. Perimenopause.Asian woman with head in hand.

Not to be confused with menopause, a distinct stage in a woman’s life where she has stopped producing estrogen, progesterone, and no longer menstruates, or even early menopause defined by the cessation of a menstrual period for more than twelve consecutive months before age forty-five, perimenopause is a transitional phase—occurring up to a decade before menopause—defined by fluctuating hormone levels. With little or no progesterone (due to a non ovulating cycle, or anovulation) to balance the effect, unopposed estrogen—up one day, down the next—causes many women to experience a myriad of symptoms from irregular menstrual cycles to changes in memory and mood.

Is It All in Your Head?

“The biggest misconception about perimenopause is that what women are experiencing is all in their heads. Because in fact, it’s not,” says Dr. Steven R. Goldstein, professor at New York University School of Medicine, and author of Could It Be…Perimenopause?: How Women 35-50 Can Overcome Forgetfulness, Mood Swings, Insomnia, Weight Gain, Sexual Dysfunction and Other Telltale Signs of Hormonal Imbalance. Perimenopause, he says, is one of today’s most misdiagnosed conditions. “For a lot of women there’s a huge hormonal component to how they feel which has been blown off in the past by many physicians. But we’ve begun to realize that there is a definable entity prior to the onset of menopause. It needs some distinct attention.”

Since these perimenopause symptoms can subtly (or not so subtly) show up a decade before the onset of menopause, Dr. Goldstein stresses the importance of knowing the difference between the two. “The immediate forerunner of menopause is a set of symptoms that are not usually subtle, such as a dry vagina and hot flashes. These symptoms are caused by very low levels of estrogen as well as rising levels of FSH (follicle stimulating hormone),” he writes in his book. Women entering perimenopause, on the other hand, are still making estrogen, although the levels may fluctuate from day to day. “If a doctor misreads the signs and gives estrogen supplements to a woman whose problems are caused by unopposed estrogen, the symptoms may be compounded.”

Peri Who?

If you’ve never heard of perimenopause, you’re not alone. Although perimenopause has probably been around since the beginning of time (though most women just two hundred years ago didn’t live long enough to see a change in their midlife bodies), women in the past just accepted their symptoms, notes Dr. Darlene Lanka, associate professor at University of California San Francisco, and author of Perimenopause 2 Ed: Changes in Women’s Health After 35. “I’ve been treating perimenopause since the 1970s,” she says. “Many of us [physicians] have always used the term perimenopause, but back then the public wasn’t wildly interested in it. In fact, even today some patients aren’t given the right information.”

So why the sudden interest now? Lanka credits the baby-boomer generation with bringing it to the forefront of women’s health. “This is a well-educated group of women who read and who want to be at least a partner in their own health decisions. The interest rises from the fact that the women themselves wanted information.”

Signs And Symptoms of Perimenopause

So you’re over age 35 and you’re beginning to notice something out of the ordinary happening to your body. Maybe it’s persistent absentmindedness, difficulty sleeping, mood swings, constant fatigue, weight gain, or a decreased libido. Perhaps your menstrual cycle, always on target at 28 days, has suddenly shortened to 26 days. Or, your bleeding pattern during the past several months has changed, and now you bleed for eight days instead of four, or you find it’s much heavier than normal, or lighter. Hey, you even skipped a period, and you’re not pregnant! Could this be a sign of perimenopause? Obviously excess stress due to a recent job change, divorce, buying a new home, or recently going off the birth control pill could be to blame for some symptoms, but if a woman has ruled them out and her symptoms continue, should she see a doctor?

For women with mild symptoms, opening a dialogue with their health-care providers during routine visits may be all they need. “For many women, just the knowledge of what’s going on in their bodies is enough to help significantly,” Dr. Goldstein says. “Many of my patients are coming to me periodically at this stage regardless of whether or not they’re having symptoms, and it’s an excellent time to discuss issues that relate to perimenopause and overall health-care strategies.”

For women with more severe symptoms, however, a hormone imbalance (the “unopposed estrogen” mentioned above) may be to blame, warranting a visit to their physicians to discuss treatment options. [Although 75 percent of heavy bleeding is due to hormone imbalance, if you experience extremely heavy, ongoing bleeding, it may be due to a polyp, pelvic infection, or other problem, and you should seek immediate medical attention to rule them out.]

What’s a Midlife Mom to Do?

So how can estrogen be at the root of perimenopausal problems? According to Dr. Lanka, during perimenopause, the hormone reaches its highest levels than at any other time except during pregnancy, and it also reaches its lowest levels than at any other time except during menopause. And, she adds, this fluctuation happens almost daily. “Your ovaries are failing, and they’re trying their best to keep up your estrogen production,” she explains. “Some days they over shoot it, and on other days they can’t produce enough.”

Many doctors rely on blood tests—one to measure your FSH (follicle stimulating hormone); the other to measure estradiol, one of three hormones found in estrogen—to determine whether or not a woman is perimenopausal, but Lanka cautions that they aren’t very accurate. “It depends on when that needle was put in your vein,” she laughs. “You could have had a hot flash last night, and then in the morning had the test and your estrogen level is high because your hormones have come back up again.” (The only test that Lanka does recommend, however, is a thyroid test, since thyroid disease often mimics many of the symptoms of perimenopause.)

Instead doctors should look deeper, asking patients about their menstrual histories (so start keeping those menstruation diaries now) and other more subtle signs including mood swings, anxiety, forgetfulness, and so on, before making a diagnoses.

According to both Lanka and Goldstein, low-dose birth-control pills (such as Loestrin 1/20 or Ortho-Cyclen) are the most effective treatment option for an otherwise healthy woman experiencing perimenopausal symptoms, regulating not only her menstrual cycle, but her mood as well. Not to be confused with HRT (Hormone Replacement Therapy), which is used for women who have completely stopped making hormones, or even the birth control pills of the 1970s where the pills had four to six times more estrogen, these low-dose birth-control pills are specifically designed for women in their forties.

Because of this confusion, Goldstein likes to refer to these low-dose pills as cycle regulators. “Many patients are misinformed about the birth-control pill, and how it works,” he explains. “The concept here is to suppress a woman’s own ovarian function. The Pill will turn off her ovaries and substitute with what’s in the pill. It’s not on top of, it’s instead of.” But since the Pill contains both estrogen and progesterone, many women are incorrectly comparing the hormone replacement issues that have been so loudly debated in the media with the Pill. But according to Goldstein, there is no comparison. “Some women look at the Pill and think, ‘This pill has estrogen. Estrogen causes cancer, so why would I take this pill?’ They don’t realize that in perimenopause, they’re already making a sizable amount of estrogen, and that is part of the culprit for their symptoms, and that the Pill is going to turn that off.” And he adds, “For some women what’s in the low-dose pill, or now the birth-control patch, may in fact be less than what they were capable of making themselves.”

Talking About Lifestyle

Still, there are a number of women who may not feel comfortable taking the Pill regardless of the positive information surrounding its effectiveness. For some, simple lifestyle changes can help elevate symptoms, and may prove to be just what the doctor ordered.

Exercising regularly not only helps to maintain body weight, but also increases endorphins, helping to lower blood pressure and calm your emotions. In addition, exercising helps lower heart rate, increases lung capacity, and helps to relieve joint pain.

  • Quit smoking (Nicotine is a horrible toxin and a leading cause of cancer and heart disease).
  • Reduce your stress through meditation, yoga, massage therapy, or other relaxation techniques.
  • Monitor your diet by reducing fat and increasing complex carbohydrates that some research has shown to raise serotonin levels, a mood stabilizer. Watch salt (which raises blood pressure) and caffeine intake (known to deplete calcium levels).
  • Take a multi-vitamin daily, making sure you get the following as well:
  • 150 – 200 mg of time-released vitamin B6 (a mood stabilizer).
  • 1,000 mg of calcium and 400 IU of vitamin D (helps prevent osteoporosis).
  • 600 – 800 IU of vitamin E (an antioxidant helpful with PMS symptoms).
  • And here’s a bit of interesting news—a healthy sex life can actually offset mild perimenopausal symptoms. How you ask? When you don’t have sex for a while, your vaginal tissues tend to shrink and narrow, and they won’t bounce back even if you begin having sex years later. Women who are sexually stimulated (you can go it alone, you know) on a regular basis (about twice a week) do not lose their vaginal secretions. So follow the advice of Masters and Johnson and, “Use it or lose it.”

What About Natural Products for Perimenopause?

Before you head to the health-food store to inspect the countless natural remedies for perimenopause symptoms, both Lanka and Goldstein stress caution. “It concerns me that too many patients equate natural with risk-free,” Goldstein says. “All medicinal agents have their origins in botanicals. The fact that something comes from nature, or the health-food store, doesn’t mean it’s safe. There are some very potent estrogens found in nature, and can be found in the health-food store.”

And, notes Lanka, some over-the-counter products from India and China contain heavy metal poisoning and could do extensive damage to your liver. “There’s no FDA [Food and Drug Administration] monitoring of them,” she says. “You have to be very careful.”

With that said, are there any natural products that work? Black cohash root has shown to supply estogenic sterols, a building block of estrogen, and thus relieve hot flashes in some women. But once again, Goldstein urges caution stressing that a diagnoses of your condition is imperative. “Are you truly menopausal and thus lacking estrogen? Or are you perimenopausal and dealing with fluctuating levels of unopposed estrogen as your cycle goes awry?” he writes. If that’s the case, your symptoms may become exasperated rather than diminished. [The herb should be avoided if you are trying to get pregnant or may become pregnant.] There’s also a lot of anecdotal evidence from women using evening primrose oil suggesting it helps relieve PMS-type symptoms, but Lanka cites a study where the effects were similar to that of a placebo group. Saint-John’s-wort has been shown to help promote a feeling of well being, and is widely used throughout Europe to fight depression.

Both doctors urge that if you’re going to take the natural route, to first educate yourself as much as possible and not just accept the advice of someone working in the health-food store that probably hasn’t had much training and knowledge in natural remedies. Goldstein suggests women analyze each product as they would a prescription, and to start with just one, not a handful, to better evaluate what it’s doing to their bodies. And always seek a diagnosis to your problem first from a professional physician.

And what about other alternatives? Lanka believes that Chinese medicine—acupuncture and acupressure—and homeopathy have not been fully appreciated by Western medicine. “Some of these things have a significant benefit,” she notes. But, she adds, it’s important to seek out a licensed and respected acupuncturist or homeopathic practitioner to get the best results.

Midlife and Marvelous

The more you know, the better decisions you’ll make about your healthcare. “Knowledge is power,” says Goldstein. Educate yourself as much as you can about this transition in your life. “At the end of the day, as my mother-in-law once wisely said, one of the nice things about getting older is that every year you get to know yourself a little better. And if people can adopt that attitude about being comfortable in their own skin, they’ll do much better.”

Developing a positive attitude goes a long way, too. “Wellness is your whole outlook on life. Your whole being,” Lanka says. “Making yourself as good as you can be. Keeping yourself in shape, eating properly, and having a good attitude.”

That’s good advice, regardless of what age you are.

A copy of the book Double Duty.