The changes women undergo during perimenopause needn’t be debilitating. Dr Sly Nedic unpacks the symptoms and signs of perimenopause, as well as a few key interventions that can minimise the effects.
Perimenopause refers to a transitional period that finally leads to menopause – a permanent absence of menstruation. Perimenopause takes place while women still have their periods, which often causes confusion as they aren’t expecting to have any ‘menopausal symptoms’.
Before their early forties, many women haven’t even heard of perimenopause. Not to mention that symptoms such as hot flashes and night sweats are supposedly reserved for much older women!
But the facts actually paint quite a different picture.
A timeline
According to the North American Menopause Society, perimenopause can last anywhere from two to ten years.
It usually starts in the mid-40s but can begin as early as your 30s!
Perimenopause, however, shows considerable variation in duration – for some women, it lasts just a few months, while for others, it can last many years.
The severity and presentation of symptoms can also vary significantly. As the ovaries start to run out of ripe eggs, a fluctuation of hormones become prominent, and women begin to experience various symptoms (*see Perimenopausal symptoms sidebar).
Not-so-innocent hot flashes
Hot flashes are among the most frequently reported symptoms during perimenopause. Hot flashes (vasomotor symptoms) occur in more than 75% of women during the transition into menopause.
Recent research demonstrates that they may last anywhere from 6 months to 14 years, with an average duration of 7.4 years. Hot flashes are also present in all women with induced and premature menopause.
This bothersome symptom is mostly caused by the dropping levels of oestrogen and progesterone. The decreasing levels of these hormones have a direct effect on the hypothalamus – the part of the brain responsible for controlling appetite, sleep and body temperature. 
A recent study showed that women who had frequent hot flashes had double the risk of having a cardiovascular disease event, such as a heart attack or stroke, during the study period compared with women who did not have them with great frequency.
This research has led to new progressive thinking that other hormones could actually be involved in this process – primarily insulin. Women with insulin resistance and polycystic ovarian syndrome (PCOS) frequently suffer from hot flashes. Similarly, a high adrenalin state (e.g. fight or flight response) or affected catecholamines clearing (affected by slow COMT genes, alcohol use, birth control pills etc.) can produce hot flashes even with normal oestrogen and progesterone levels. Quite simply, our body prefers to be in hormonal homeostasis, a state of equilibrium, and any hormone that is out of sync can affect sex hormones and worsen perimenopausal symptoms.
Furthermore, poor lifestyle choices, a lack of sleeping, nutritional depletion and toxicities all affect the ‘hormonal symphony’. So, hot flashes must never be taken as a simple perimenopausal symptom, but rather as a sophisticated message from the body (suggesting that numerous hormones could be out of sync). It must also not be taken lightly, as it suggests there is a heightened cardiovascular risk.
Perimenopausal symptoms
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Hot flashes
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Night sweats
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Anxiety and depression
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Mood swings and irritability
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Heavy and prolonged periods
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Fatigue
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Other symptoms that can be present simultaneously and range from mild to severe include decreased libido, vaginal dryness, breast tenderness, bloating, increased PMS, aches and pains in muscles and joints, loss of confidence, etc. Onset can range from gradual to dramatic.
Perimenopause and anxiety
Unfortunately, anxiety and depression related to hormonal fluctuations are frequently underdiagnosed in the perimenopausal period. Some 25% of women over the age of 40 are prescribed antidepressants when, in fact, their hormones should be balanced.
A recent survey published in the peer-reviewed journal Menopause (Raglan, Jan 2020) showed that gynaecologists’ screening during perimenopause was insufficient, as 34% of doctors did not regularly screen perimenopausal patients for depression. And half of those that they did screen were not confident in how to treat these patients. 
To adequately treat anxiety and depression that starts in the perimenopausal period, hormonal levels and their metabolites need to be checked. With the ovaries producing fewer ripe eggs in perimenopause, progesterone drops.
A decrease of this calming hormone means that the body becomes less resilient to stress. And in chronic stress situations, we experience cortisol diversion (AKA pregnenolone steal), which contributes to a further drop in progesterone.
Without the soothing effect of progesterone and its opposition to oestrogen activity, we start experiencing anxiety, heavy bleeding, insomnia and symptoms of oestrogen dominance. This represents the usual situation in which perimenopausal women are offered a hysterectomy and antidepressants when, in fact, rebalancing the hormones should be the preferred solution. 
To make matters worse in this situation, many women suffering from these symptoms start consuming more alcohol to temporarily relieve anxiety – without understanding that alcohol actually perpetuates anxiety and oestrogen dominance by affecting methylation.
Furthermore, the study shows that ingesting more than two servings of alcohol per week significantly increases the risk of breast cancer. 
Every symptom in the perimenopausal period needs a proper investigation of hormonal levels. This extends beyond oestrogen and progesterone to include thyroid, insulin, cortisol, among others, and the circumstances behind the hormonal fluctuation.
Perimenopause and fertility
During perimenopause, despite a decline in fertility, women can still become pregnant, as ovulation continues irregularly. And, these days, many women also only consider becoming pregnant around the age of 40 and more.
Besides a natural drop in ovarian capacity to produce eggs at this age, many women hoping to become pregnant suffer from underlaying hormonal imbalances, insulin resistance, PCOS, oestrogen dominance due to environmental toxicities, detoxification problems, sleep deprivation and nutritional depletion, which all contribute to infertility.
In perimenopausal women, checking anti-Müllerian hormone levels as a predictor of the occurrence of the menopausal transition can be helpful. Adopting a healthy lifestyle, seeking help to treat underlying problems (with understanding the timing of ‘going into menopause’) could help perimenopausal women to make better decisions about pregnancy in this period of their life.
Treatment
For the vast majority of women in perimenopause, symptoms can be managed and reversed through lifestyle changes such as adapting to a correct diet and nutrition, incorporating exercise, getting proper sleep, avoiding toxins, and learning how to relieve stress.
Additionally, in using a functional medicine approach, all hormones need to be checked and balanced, and the underlying causes that contribute to hormonal fluctuations during perimenopause should be determined.
Resources www.8thsense.co.za. References available on request.
Written by Dr Sly Nedic – MBChB (Bel)
Dr Sly Nedic
- Founder of 8th Sense Medi-Spa, Sandton www.8thsense.co.za
- Board-certified doctor of WOSAAM (World Organisation of Society of Anti-Ageing Medicine)
- Member of IHS (International Hormone Society)
- Member of A4M (American Academy of Anti-Ageing Medicine)
- Faculty member of Preventive Genetics- Laboratories Reunis, Luxembourg
A2 Disclaimer: This article is published for information purposes only, nor should it be regarded as a replacement for sound medical advice.
This article was written by Dr Sly Nedic and edited by the A2 team EXCLUSIVELY for the A2 Aesthetic & Anti-Ageing Magazine Mar/Jun 2020 Edition (Issue 33).
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