Perimenopause and hormonal health. Many women expect menopause to announce itself with hot flushes. For many, the first signs are quieter, and they are frequently put down to stress or a busy life.
median duration of hot flushes and night sweats in women with frequent symptoms.
higher risk of major depression during perimenopause and early postmenopause.
rise in spine bone density after eight months of supervised heavy strength training.
The first signs are often waking at three in the morning, a shorter fuse, forgetting words mid-sentence, aching joints, or a waistline that changes without any change in habits. Many women explain it away: I’m just getting older, I’m just stressed, I’m just exhausted. Very often it is none of those. Oestrogen begins to swing and fall in the mid-forties, often during the most demanding years of work and family life, which makes for a perfect storm.
Perimenopause is the transition from regular ovulation to the final period, and menopause is the point twelve months after that final period. The transition usually starts in the mid-forties and lasts four to eight years. Hormone levels do not fall smoothly. They swing unpredictably, and the swings cause as many symptoms as the eventual fall.
Hot flushes are only one of many possible signs, and often not the first.
Sleep is often the first thing to change, and hot flushes and night sweats last longer than most women are told. In a study of more than 3,000 women, those with frequent symptoms had them for a median of 7.4 years.
For women with frequent symptoms, flushes and sweats lasted a median of 7.4 years, 4.5 of them after the final period.
Honest arithmetic matters too: going to bed at eleven with an alarm at half past five cannot give seven hours of sleep. Sleep apnoea also becomes more common after 50, and in women it more often shows up as insomnia, fatigue and low mood than as snoring.
Mood changes are real and are not a matter of willpower. Women are two to four times more likely to have an episode of major depression during perimenopause than before it, and a previous history of depression is the strongest predictor. Brain fog is real too, and usually temporary. In 2,362 women followed for four years, the normal improvement with practice on memory tests paused during perimenopause and returned after menopause.
Scans of women through the transition showed that the rate of fat gain doubled at its start while muscle began to decline, with little change in total weight. More fat settles around the waist and organs, LDL cholesterol rises and bone loss speeds up, which is why midlife is the time to measure heart and bone risk as well as treat symptoms.
Body composition through the transition, to about two years after the final period. Fat gain speeds up and muscle declines while total weight barely changes.
Strength training is one of the best responses. In an Australian trial, eight months of brief, twice-weekly heavy resistance and impact training raised spine bone density by 2.9 per cent in women with low bone density, with no significant injuries. That means not walking, and not only yoga or Pilates, but picking up something heavy and moving it with good form.
For women over 45 with typical symptoms, perimenopause is diagnosed on age, the pattern of periods and symptoms, without a hormone test. FSH and oestradiol swing so widely that a normal result on the wrong day can lead to a woman being told she is not menopausal and leaving without help, which is why NICE advises against using them after 45. Under 40, testing is essential, because early menopause needs treatment to protect the bones and heart. The useful midlife tests look for overlapping conditions and future risk: iron studies, thyroid function, HbA1c, cholesterol and up-to-date screening.
When hormone blood tests help, by age.
The principle is base first, then we can get fancy. When the story clearly points to the transition, it makes sense to treat that before working through a long list of supplements and diets. The North American Menopause Society concludes that hormone therapy remains the most effective treatment for flushes and sweats, and that for women under 60 or within ten years of their final period without contraindications, the benefits generally outweigh the risks. The type, dose and route matter. In more than 80,000 women, hormone therapy absorbed through the skin was not linked to a higher risk of blood clots, unlike tablets. Oestrogen is not a foreign substance: a woman’s body has made it all her life. A history of breast cancer or blood clots changes the discussion, and effective non-hormonal options and cognitive behavioural therapy are available. Some women want to start treatment quickly and others prefer to try other measures first, and both are reasonable choices once the facts are clear.
A 46-year-old woman has been waking at three every morning for six months. She feels anxious in a way she has not before, is struggling to find words at work and has gained five centimetres around her waist. Her periods are slightly irregular, and after a normal FSH she was told she is too young for menopause. Her age, her cycle and her symptoms are enough to make the diagnosis, and the normal FSH does not exclude it. The useful tests are iron studies, thyroid function, HbA1c and cholesterol, with a check for sleep apnoea. The plan treats her sleep, mood and thinking together, with a strength programme to protect her muscle and bone.
At My Performance Doctor, your doctor looks at your symptoms, your sleep, your body composition and your long-term heart and bone risk together, treats the main driver first, and stays with you through the transition. If you recognise yourself in this, a call with Robyn is a good place to start.
This article is general information and is not a substitute for individual medical advice. From the doctors at My Performance Doctor.