Perimenopause: An Important Transition In Women's Life.

Perimenopause is a clinical diagnosis, based on the characteristic symptoms of abnormal uterine bleeding, hot flashes, and night sweats, which occur as a result of declining ovarian function. Perimenopausal symptoms may occur up to 8 years before the final menstrual period. These symptoms related to the hormonal fluctuations typical of perimenopause significantly affect women’s quality of life. 

A pivotal transition in a woman's life. 

Perimenopause marks a transition between the reproductive years and menopause. Awareness of the hormonal changes associated with perimenopause helps with the recognition and management of some unpleasant symptoms, including menstrual cycle irregularity, VMS (Vasomotor symptoms) , mood and sleep disorders, and sexual dysfunction. The mean duration of perimenopause is 5 years, but symptoms may begin 8 years or more before the FMP (Final Menstrual Period). 

This represents a transitional phase in which emerging symptoms may pose challenges in making complex management decisions. In the period leading up to menopause, there is a reduction in the supply of mature eggs in a woman's ovaries, leading to irregular ovulation. Simultaneously, the production of oestrogen and progesterone declines. The significant decrease in oestrogen levels is primarily responsible for the majority of menopausal and peri-menopausal symptoms. 

Hormonal Changes and Symptomatology 

Perimenopause symptoms commonly encompass heavy or frequent menstrual flow, sore breasts, migraine headaches, anxiety, low mood, memory and concentration issues, low energy, motivation challenges, panic attacks, mood swings, low self-esteem, or the development of new fears and phobias. These symptoms are likely connected to hormonal changes. It's crucial to bear in mind that menopause experiences vary among individuals, not only in terms of symptoms but also in the duration of the transition. 

Understanding Some of the Symptoms:  

 Cognitive Symptoms: 

  - Memory loss 

  - Difficulty staying focused 

  - Word-finding difficulties 

  - Losing train of thought 

  - Easy confusion 

Abnormal Uterine Bleeding (AUB), associated with anovulatory cycles (declining ovarian function): 

- Light and infrequent bleeding 

- Unpredictable and heavy menstrual bleeding 

Vasomotor Symptoms (VMS): 

  - Commonly known as hot flashes or flushes, and night sweats 

  - Affects approximately 60%–80% of women during late perimenopause and early post- menopause years 

  - Many perimenopausal women experience moderate to severe VMS frequency and intensity, negatively impacting sleep, mood, and quality of life 

Vulvovaginal Atrophy: during perimenopause, lower oestrogen levels may lead to: 

- Thinner, drier, and less elastic tissues in the vulva and lining of the vagina 

- Condition known as "vulvovaginal atrophy" 

    - Reduced vaginal secretions, resulting in decreased lubrication 

Hormonal Changes and Indicators 

The physiological alterations during the menopausal transition primarily arise from a decline in ovarian function. To identify shifts within the perimenopausal period, various indicators of ovarian ageing have been recognised. Traditionally, follicle-stimulating hormone (FSH) has been employed to measure ovarian ageing, yet its application is restricted due to its indirect association with the functional decline of the ovaries. While assessing perimenopausal status typically includes considering the individual's age, menstrual history, and encounter with vasomotor symptoms (VMS), supplementary assessment in the menopausal transition might involve laboratory data such as estradiol (potent oestrogen) and anti-mullerian hormone (AMH to assess a woman's ovarian reserve or egg count).  

Treatment Strategies 

For women, these symptoms may lead to social impairment and work-related difficulties, significantly decreasing overall quality of life. Effective medical therapies, whether hormonal or nonhormonal, are designed to alleviate the dysfunction caused by perimenopausal symptoms, which affect up to 70% of all women. 

Administering oestrogen therapy is most effective for perimenopausal women through low-dose combination contraceptive methods such as the pill, patch, or ring. These methods provide relief from hot flashes, regulate menstrual cycles, and offer contraceptive benefits. It's crucial to note that oestrogen therapy is a topic of controversy (see sources at the end of article). For those who prefer not to use hormonal methods for personal reasons, alternative holistic approaches are available. It's essential to emphasise that individual responses to treatment vary and scientific research is advancing every day. 

Nonpharmacologic therapies can help improve sleep disrupted by Vasomotor Symptoms (VMS). Activities such as exercise, yoga, and cognitive behavioural therapy have shown effectiveness. A recent study indicated that maintaining consistently high levels of recreational physical activity enhances the quality and depth of sleep in perimenopausal women. Furthermore, hypnotic treatments could be effective in alleviating insomnia for women encountering both sleep disruptions and Vasomotor Symptoms (VMS). 

Vaginal moisturisers and lubricants can ease discomfort associated with vaginal atrophy or insufficient lubrication. While vaginal oestrogen treatment is typically reserved for postmenopausal women, there are various alternatives available, such as vaginal gels with natural formulations, on the market. 

To address the psychological and emotional changes that may occur during perimenopause and menopause, you can explore various approaches, including: 

1. Cognitive Behavioural Therapy (CBT): a type of talking therapy, an effective treatment to bring a sense of balance to your thoughts and feelings, aiding in the psychological and emotional changes during perimenopause and menopause. 
2. Non-Hormonal Medication: certain types of antidepressants, the high blood pressure medication clonidine, and the epilepsy medication gabapentin may assist with symptoms like hot flushes, night sweats, low mood, anxiety, and vaginal dryness. However, it's important to note that these medications might not be suitable for everyone, and they can have serious side effects. 
3. Alternative Remedies: exploring natural remedies, especially isoflavones, can be an alternative approach. 

4. Complementary Therapies: massage, acupuncture, aromatherapy, yoga, and meditation can really support your overall well-being during this phase. 

Perimenopause as a Transitional Phase 

This transitional period is influenced by biological, psychological, and socio-cultural factors within the ageing process involving both physical and emotional changes. The perimenopause is considered a vulnerable phase, underscoring the importance for women to comprehend the transformations occurring in their bodies and discover effective approaches to alleviate symptoms. It's crucial to recognise that the physical, emotional, and cognitive difficulties related to the menopause transition are typically temporary. Emphasising the transitional nature of these symptoms can empower women to become stronger and more resilient. 

 Ethnic Disparities in Perimenopausal Experiences 

It's important to note that research, particularly in the United States, has highlighted the variation in peri and menopausal symptoms among different ethnicities. For instance, a study indicated a higher prevalence of vasomotor symptoms in African-American and Hispanic women. Additionally, M. Putman's research suggests that African American women face a lower risk of fracture compared to Caucasian women, possibly due to differences in "bone microarchitecture and density." 

Despite the UK being a multi-ethnic country, with 13.8% of the population having an ethnic minority background (2018 data), there is still limited research evidence on the experiences of peri- and menopause in British ethnic minority women. A substantial portion of the available information is derived from overseas research. 

Embracing Knowledge for Empowerment 

The greater the amount of information that women can access regarding various aspects of experiencing menopause at a younger age, the less intimidating it becomes, and the more support their families can provide. Equipped with a deeper understanding of potential symptoms, women can concentrate on adapting to the changes in their bodies and overcoming the associated feelings of sadness and loss that accompany this new biological stage. 

Furthermore, research suggests that finding meaning in life and embracing spirituality can provide strength and comfort. Both these concepts are associated with an improved health-related quality of life and reduced menopausal symptoms, particularly in comparison to women with lower spirituality or a diminished sense of meaning in life. Maintaining a role or having goals has been linked to experiencing life as more meaningful. Consequently, some studies indicate that self-efficacy plays a crucial role as a resilience factor during the perimenopausal phase. Additionally, research shows that higher levels of optimism are correlated with fewer reported symptoms in perimenopausal women. 

In conclusion knowledge emerges as a potent tool, transforming the experience from an enigma to a journey of self-awareness and empowerment. By dismantling stereotypes, fostering open dialogue, and embracing the wealth of information available, women and their families can move through this journey hand in hand, embracing the beauty and strength that comes with each stage of life. 

Sources on hormone replacement therapy: 

https://www.breastcancer.org/risk/risk-factors/using-hormone-replacement-therapy 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6780820/