November 20, 2023
By Nielufar Varjavand, MD

Menopause is defined as not having a period for 12 months continuously, without any other reason. Perimenopause is the transition period before one is fully menopausal. This generally lasts about four years and involves hormonal fluctuations and irregular periods. In general, the interval between periods is 25-35 days. During the transition period, the time between menses may increase, and then gradually, one may skip cycles. During perimenopause, there’s generally a decrease in bleeding, although some people experience heavy or longer bleeding.

All women experience menstrual irregularity and hormonal changes as part of menses, as well as changes in lipids and bones. Many women experience symptoms called hot flashes. Some report vaginal dryness and breast tenderness. These all relate to hormonal changes. In turn, these symptoms may impact one’s function, with interference of sleep, concentration, mood, energy, daily and sexual activities.

Independent of the effect of hot flashes, some women experience sleep changes, depression and anxiety, as well as joint pain. As low estrogen persists, genitourinary symptoms (i.e., vaginal dryness) develop and occur later than other symptoms of menopause. Low estrogen leads to a decrease in blood flow to the vagina and vulva, which leads to symptoms of vaginal dryness and sexual dysfunction; these may be remedied with vaginal estrogen therapy.

While everyone experiences menopausal changes (hormonal fluctuations, irregular menses) resulting in lipid and bone change, not everyone experiences the other symptoms of menopause (hot flashes, sleep changes, mood, vaginal dryness).

When Does Perimenopause Start?

While the average age of menopause is 51, this is not the same for everyone. Anyone who starts having irregular cycles around the ages of 40 to 45 is said to be experiencing early menopause; if irregular cycles occur before 40 years of age, other issues with the ovary need to be investigated.

There are variations among women who experience symptoms and their attitudes. In a 2021 sample of 3,460 postmenopausal women (age 40-65) in Europe (five countries), the U.S. and Japan, “the prevalence of moderate to severe vasomotor symptoms (hot flashes and/or night sweats) was 40% in Europe, 34% in the U.S., and 16% in Japan. Prevalence of symptoms in Europe ranged from 31% in France to 52% in Italy. A large proportion of women were hormone therapy averse, albeit eligible (Europe 56%, U.S. 54%, Japan 79%.).” ¹

Here is more evidence for variation. The SWAN study (Study of Women’s Health Across the Nation, swanstudy.org) began in 1994 in the U.S. and is ongoing, with research locations across the U.S., representing five racial/ethnic groups (Caucasian, African-American, Chinese, Japanese and Hispanic women). The study examines changes in women during their transition period. One study notes the variation of symptoms by ethnicity: “among Hispanic women, symptoms varied by country of origin.”² Another study, which noted variation of self-reported menopausal symptoms in an ethnically diverse population of 5,634 women in the Pacific Northwest of the U.S., sought to attribute the differences to soy intake and concluded that there was little evidence of this.³ Could there be genetic variations predicting symptoms? Another part of the SWAN study notes genetic, syndrome and symptom variability among these different groups.⁴

Treating Perimenopausal Symptoms

For those with perimenopausal symptoms, management depends on their choice and their other health issues. The North American Menopause Society issued their position statement about treatment of symptoms in 2023.5 They note that hormonal therapy is the most effective treatment. Non-hormonal choices are cognitive-behavior therapy, hypnosis, antidepressant medications (in the categories of SSRI and SNRI), weight loss and stellate ganglion block (injection into a collection of nerves). They do not recommend supplements/herbal therapies, cooling techniques, avoiding triggers, exercise, yoga, mindfulness interventions, relaxation, soy, acupuncture, chiropractic interventions or the medication clonidine.

Let’s delve into the role of these complementary / alternative therapies some more. According to the American Cancer Society, up to one-third of people experience the effect of placebo. Further, carefully controlled randomized trials to demonstrate efficacy of each method may be challenging. Even though evidence may be lacking, complementary treatments are tempting to pursue. If hot flashes are significant, talk to your doctor about possible hormonal or non-hormonal therapies. If you are having mild symptoms, perhaps complementary or alternative therapies could be helpful, even though evidence has not been found for them.

Patients have lipid and bone changes because of menopause, even though they may not experience these as symptoms. Bone loss is typically highest during the one year before and two years after menopause. Thus, adopting healthy behaviors to specifically target these changes is ideal. For bone health, engage in regular daily physical activity, achieve normal body weight, attend to appropriate nutrition intake (protein, calcium and vitamin D), avoid tobacco and alcohol, and prevent falls (perhaps by doing balance exercises.) Some medicines, like steroids or antiseizure medicines, contribute to bone loss (talk to your doctor if you are taking these before you make any changes.)

Calcium and vitamin D are necessary for bone health. Goal intake should be about 800 units of vitamin D and 1200 mg calcium daily. Ideally, this should be from food sources, as there is controversy around calcium supplements and cardiovascular disease. However, if dietary sources are not possible, the National Osteoporosis Foundation considers supplemental in this dose range safe. 6 Some examples of daily physical activity to improve muscle tone and bone strength are: 30 minutes of brisk walking (such that the person is sweating and has an increased heart rate but can still talk) or dancing. Adding resistance training (with weights or resistance bands) improves muscle tone, too.

To recap, here’s what to expect based on a person’s age:

• If you begin to have irregular periods and are younger than 40, before you think about menopause, reasons for premature ovary insufficiency must be evaluated.
• If you suspect you are peri/menopausal and are between 40 and 45 years, talk to your doctor to assure there are no other reasons for menstrual changes. Some reasons could be pregnancy, thyroid issues or high prolactin production.
• For those older than age 45, the diagnosis of menopause is set as 12 months without a period, if there are no other causes. Lab work is not required for diagnosis.

Resources

• Nappi, RE et al. Global cross-sectional survey of women with vasomotor symptoms associated with menopause: prevalence and quality of life burden. Menopause. 2021 Aug; 28(8): 875–882. doi: 10.1097/GME.0000000000001793
• Green and Santoro. Menopausal symptoms and ethnicity: the Study of Women's Health Across the Nation Womens Health (Lond). 2009 Mar;5(2):127-33. doi: 10.2217/17455057.5.2.127
• Reed et al. Self-reported menopausal symptoms in a racially diverse population and soy food consumption. Maturitas. 2013 Jun;75(2):152-8. doi: 10.1016/j.maturitas.2013.03.003. Epub 2013 Apr 3
• Sowers et al. Sex steroid hormone pathway genes and health-related measures in women of 4 races/ethnicities: the Study of Women's Health Across the Nation (SWAN) Am J Med. 2006 Sep;119(9 Suppl 1):S103-10. doi: 10.1016/j.amjmed.2006.07.012
• NAMS Position Statement. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 30 (6) 573-590. MENO_230215 573..590 (menopause.org)
• Kopecky et al. Lack of Evidence Linking Calcium With or Without Vitamin D Supplementation to Cardiovascular Disease in Generally Healthy Adults: A Clinical Guideline From the National Osteoporosis Foundation and the American Society for Preventive Cardiology. Ann Intern Med. 2016;165(12):867. Epub 2016 Oct 25