Perimenopause (and how to survive your midlife meltdown)

Women's Health
Sad looking woman sitting on floor with head leaning back on bed, looking up

The big surprise for many women in their 40s and the years leading up to menopause—a period of time also known as perimenopause—is that the symptoms usually associated with menopause can strike much sooner, wreaking physical, mental and emotional havoc on women’s lives.

Unfortunately, many women with perimenopausal symptoms are unaware of what’s happening in their bodies. This may be due to the fact we’ve traditionally been told that after the childbearing years comes menopause, or the end of menses, which is generally defined as 12 months since your last period. No one ever told us that in between we might have difficulty getting a good night’s sleep, lose interest in sex, or have such heavy periods we could barely leave the house. No one mentioned the “crazies” either—that feeling that we’re losing it on a regular basis.

“’I just don’t feel like myself. Sometimes I think I’m going crazy!’ We hear this all the time.” – Dr. Jocelyn Craparo

Most of us thought this kind of erratic life change would come with menopause, and in fact, many doctors thought so, too.

“When I first started working and seeing people still menstruating but having menopausal symptoms, I said to myself, this isn’t in the books,” says Jocelyn Craparo, MD, an OB/GYN at Bryn Mawr Hospital, part of Main Line Health.

As it turns out, perimenopausal patients often complain of irritability, loss of sexual desire, difficulty sleeping, hot flashes, night sweats, weight gain, depression, “brain fog,” and a host of problems all related to hormonal shifts happening in the years before menopause. Erratic periods and heavier flow patterns are disruptive, if not annoying, and easily translate into moodiness and difficulty concentrating. Perimenopausal women often go undiagnosed for anemia, due to excessive blood loss during menstruation, which can cause symptoms such as fatigue, headache and difficulty concentrating—all of which gets intertwined with other perimenopausal problems.

“It can be disturbing on many levels,” says Dr. Craparo, “as some women see it as a time when they’re losing their fertility. For others, it’s just quality of life, when a woman feels awful and can’t interact with her loved ones, coworkers and partner in a way that she feels fulfilled.”

What’s going on with hormones during perimenopause?

For what might be five to 10 years before you actually stop menstruating, your ovaries begin to produce fewer of the sex hormones estrogen, progesterone and testosterone. While estrogen decline usually comes closer to menopause itself, estrogen fluctuations are thought to cause perimenopausal plights such as hot flashes, vaginal dryness, urinary incontinence, even impacting motivation and ambition.

Declining progesterone may be a factor in irregular or heavy bleeding—one of the primary complaints of perimenopausal women—and can also contribute to problems with sleep, memory and concentration, not to mention tender breasts and bloat.

Testosterone, commonly associated with male reproductive and lifelong health, is in fact a key factor in women’s sexual health and general well-being throughout life. Low T or low testosterone can affect bone production and lean muscle mass, is a common culprit in lost libido (sex drive), and may be the missing ingredient when you’ve lost your mojo.

25 percent of women experience no symptoms of perimenopause at all.

For some women reading this, the symptoms are all too familiar. Yet one out of four women experiences no perimenopausal symptoms at all. Says Dr. Craparo, “I’ve been practicing for 30 years and there are women who never seem to perceive anything, never have moodiness in pregnancy, never a hint of depression or baby blues, and they go through menopause without a single hot flash. I’m not kidding—nothing!”

Dr. Craparo goes on to say that every woman is “like a snowflake in how we traverse,” and that perimenopause is a moving target. There is a full range of experiences as far as symptoms are concerned, and the presence of symptoms for some may be over the course of five to 10 years while others may get glimpses for a few short months.

Treatment for perimenopause symptoms

Perimenopause often coincides with other life changes and stressors, such as kids going off to college, caring for elderly parents, divorce and illness. Depression is common among women of this age group. So treating symptoms of perimenopause often depends on how bad the symptoms have gotten and how much it’s messing up your life. Dr. Craparo advises asking ourselves: Is this life-threatening to me? Should I be doing something about it right now? Is it affecting my quality of life? Do I want to do something?

Dr. Craparo admits, the physician in her wants to fix things, to make her patients better, “but people don’t always want it to be fixed.” Her approach begins with taking the time to educate her patients about this phase of their lives. She finds that many patients benefit from validation and education alone, simply understanding what’s going on, knowing they’re not crazy, and that there are legitimate reasons why they’re not feeling good. Some women prefer to make improvements in diet and exercise and just let this phase of life play out while others prefer to correct problems medically or surgically.

Women who are dealing with heavy blood flow, for example, may need to start with iron supplementation. They might then be introduced to options such as birth control pills, IUDs that contain progesterone to eliminate the bleeding patterns, or minimally invasive surgical options such as endometrial ablation, which can reduce bleeding. If a woman is bleeding heavily all the time, Dr. Craparo might also order lab work to check for blood clotting disorders or thyroid disorders. In rare cases, she may want to do endometrial sampling, taking a small biopsy of the lining of the uterus in order to rule out cancerous or precancerous conditions (such as uterine polyps). By simply addressing bleeding issues, she says, “Miraculously, a lot of the other symptoms improve.”

HRT for perimenopause symptoms

If traditional methods of treatment for perimenopausal symptoms don’t work, Dr. Craparo gets a bit more creative with estrogen and progesterone hormone replacement therapy (HRT), depending on the woman’s symptoms. While standard drug formulations work for about 80 percent of women, Dr. Craparo finds that more and more women are requesting bioidentical hormone therapy (exact same molecular structure as our own estrogen and progesterone) vs. synthetic options. For this group of women, she is open to sending patients to a compounding pharmacy that can produce the right formulation for the patient. Getting the dosage right on hormone patches, pills and creams can take some trial and error, but Dr. Craparo works with her patients to tailor how much or how little might be needed. While getting the hormone doses right is a bit of a “shotgun approach,” the relief for women who’ve struggled with quality of life in perimenopause can be life-altering.

“This is where I get the most satisfaction,” says Dr. Craparo, “guiding women through the difficult years when things start to get kooky. It’s rewarding to have someone come back and tell me they feel so much better.”

Looking for more information? Dr. Craparo recommends The Wisdom of Menopause, by Dr. Christiane Northrup, for women approaching menopause and beyond.

To schedule an appointment with a specialist at Main Line Health, call 1.866.CALL.MLH (225.5654).