Five things you didn’t realise you need to know about perimenopause

          Associate Professor Michelle Peate

In case you missed it, perimenopause is in the news.

It came about as a result of Pursuit’s editor Imogen Crump experiencing a perimenopausal hot flush live on ABC News Breakfast television while talking about the big news stories of the day with hosts Lisa Millar and Michael Rowland.

Instead of pretending it wasn’t happening – Imogen owned it. And that has started a national conversation.

“I’m so sorry, I could keep stumbling through, but I’m having such a perimenopausal hot flush right now, live on air, sorry,” Imogen said to the hosts, while fanning herself with her notes.

“I don’t think hormones respect national television.”

Lisa Millar stepped in. “We need to make it normal to have these kinds of conversations and I love you for even saying it, because we interview people, we talk to people about this and this is the reality.”

But is it weird that in 2023 perimenopause should still be so taboo that a woman having a hot flush on TV is a big deal?

Perimenopause is not a secret. All women go through it in some form or another. In fact, around 32 per cent of women in Australia are currently experiencing symptoms they attribute to menopause, which can severely affect the day-to-day life of at least one quarter of Australian women aged between 45 and 64.

So what do you need to know about perimenopause? Here are five simple answers to five basic questions to help demystify something that’s entirely normal.

Q. What’s the difference between perimenopause, menopause and postmenopause?

Menopause refers to a women’s final menstrual period. Natural menopause usually occurs between the ages of 45 and 55 years old, which marks the end of your reproductive age. You are considered postmenopausal if you’ve had no period at all for 12 months.

Around 32 per cent of women in Australia are currently experiencing symptoms they attribute to menopause. Picture: Getty Images

Perimenopause happens before menopause. It starts when menstrual cycles become very irregular (so the length of your cycle can vary by seven or more days in consecutive cycles) and continues until 12 months after you’ve had your final period. For some, perimenopause can begin five to 10 years before their final period.

But you can just use the term menopause as it’s divided into those three basic stages: perimenopause, menopause and postmenopause.

There are also other variables here – like surgical or treatment-induced menopause, early menopause (which can happen between the ages of 40 and 45) or premature menopause (which can occur below the age of 40).

Q. What’s actually happening and why?

Essentially, perimenopause, menopause and postmenopause are terms that all refer to the effect of declining circulating oestrogen (a group of hormones that play an important role in the normal sexual and reproductive development in women) in your body.

At birth, ovaries contain a certain number of cells (called follicles) which are involved in every menstrual cycle over a woman’s reproductive life.

As these follicles age and the number of follicles decline, there is a resulting impact on function and, consequently, circulating blood oestrogen levels drop. Menopause occurs because of this decline.

Perimenopause, menopause and postmenopause are terms that all refer to the effect of declining circulating oestrogen. Picture: Getty Images

Perimenopause, which includes the menopause transition, is typically characterised by fluctuating hormones and irregular cycles (shorter or longer).

And this is when you’ll start to experience typical (and occasionally weird) menopausal symptoms.

Q. Let’s talk symptoms, what can women expect?

There are so many perimenopausal symptoms linked to either an excess or loss of oestrogen. Women can experience both extremes as their hormones fluctuate.

Symptoms associated with excess oestrogen include heavy menstrual bleeding, sore breasts and headaches.

A recent global initiative has identified the symptoms associated with a loss of oestrogen – and it’s a long list.

It includes hot flushes and night sweats (known as vasomotor symptoms), sleep disturbances, and symptoms related to vaginal dryness (or genitourinary symptoms) – like vulval or urinary discomfort.

Other symptoms include mood changes, fatigue, cognitive concerns and a low libido, as well as joint and muscle pain or stiffness.

Another important consideration is that declining oestrogen also has implications for chronic disease risks. In particular, bone loss and heart health.

Symptoms for loss of oestrogen include hot flushes and night sweats and sleep disturbances. Picture: Getty Images

As our hormones bounce around, it can increase our osteoporotic and cardiovascular risk, which is associated with metabolism and body composition changes. There may also be increased risk of mood disorders for those who have a history of hormone-related issues.

And, to top it off, our cancer risk may also change – so making sure you’re up-to-date with bowel, breast and cervical cancer screening is very important.

Q. Then there’s mental wellbeing

The menopause transition phase can be a time where your mood and cognition are impacted – even in people with no prior history of mental health concerns.

And these mood changes can be quite unique and variable.

Some women report irritability or paranoia, while others experience increased anger, and then there are the women who report feeling less sad. Or it could be all of these at once.

These mood changes can last for varying amounts of time (from minutes to hours) and then just as suddenly, stop.

It does appear that the more physical symptoms (like vasomotor symptoms) or negative life events you have during this very changeable time can increase your risk of depressive symptoms. There is also a higher risk of a major depressive episode associated with perimenopause (compared with before your body starts to transition).

The current gold standard treatment for vasomotor symptoms is Menopausal Hormonal Therapy (MHT). Picture: Getty Images

Then there are the cognitive changes. Around two-thirds of women report memory problems or reduced processing speed during perimenopause – known by many as ‘brain fog’.

While we haven’t found a direct link between mood or cognition and menopause, oestrogen has been associated with changes in the brain. Hot flushes are also linked to changes in brain function and depression can be associated with cognitive decline.

The good news here is that most mood and cognition changes are thought to be temporary and do not continue in the postmenopausal period.

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