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Dr. Gaudet: Understanding Perimenopause

Body+Soul, September 2006

Heather, a healthy 43-year-old woman, came to see me last spring because her menstrual cycle, which had always run like clockwork, was becoming irregular. She was worried that something was wrong. When I asked her more about her symptoms, she told me she occasionally woke up sweating in the middle of the night. "It's so strange; I've always been the one who piled on the blankets."

I told her I would do an exam and evaluation, but that her symptoms sounded like normal changes associated with the start of perimenopause. She almost jumped off the table. "Perimenopause? You've got to be kidding! I thought that wouldn't start for at least another 10 years! What if I want to have children?"

If there's one word that inspires more fear and confusion in the hearts of women, it's perimenopause. Women as young as their twenties and as late as their fifties ask me about it. It's one of those terms that never really gets defined, and yet is often used as a catchall to describe anything that might be related to fluctuating hormones. It takes some women, like Heather, by surprise. But for every Heather, there's an Ann, a 33-year-old patient who came to me terrified that two missed periods was the start of menopause, and a Dorian, 54, who has spent the last 20 years trying to outrun her body's changes with diets, antiaging potions, and plastic surgery.

Let's start by defining menopause. Technically, a woman is menopausal when she has gone a full year without menstruating at this time, symptoms associated with menopause are typically behind her, and she is no longer able to have children. Perimenopause, then, is the stretch of time anywhere from one to five years leading up to menopause, during which women begin to experience shifts in their menstrual cycle and symptoms such as temperature sensitivity, changes in libido, mood swings, vaginal dryness, and irritability. The average age for menopause in this country is 51; perimenopause most often starts in the mid-forties, though some of these changes can start as early as the late thirties.

Considering that all women go through perimenopause, it might seem surprising that so much confusion surrounds it. Part of the reason, I believe, is that unlike reproductive milestones like getting your period or having a child, perimenopause is not an event; it's a process, often without a clearly delineated beginning or end. More important, it raises deep-seated issues about childbearing, aging, and identity that cause many women to react with panic, denial, or some combination of the two. Faced consciously, however, it can prove to be a powerful opportunity.

What's causing the physical changes you notice? During perimenopause, women begin to have what are called "anovulatory cycles," in which the body does not produce an egg. (Ovulation, and the hormonal chain of events that surround it, regulate your cycle.) When ovulation doesn't occur, the length of the cycle is unpredictable, as are the amount of bleeding and the range of symptoms.

As I frequently remind my patients, every change in your cycle doesn't indicate perimenopause. The length and regularity of women's cycles change across our lifetime, with shorter, more consistent cycles from your mid-twenties to your mid-forties. For young women, irregular cycles may be caused by a number of things, including stress or significant changes in weight or exercise routine.

The ovulation gate doesn't come slamming down; it's a gradual transition. Though pregnancy becomes less likely during perimenopause, it is still possible. For women who are still trying to conceive, this is welcome news, but it catches some women unaware. One new patient with two high-schoolage children came to me to discuss integrative approaches to menopause; her periods had grown irregular and then stopped. After doing some tests, I told her that the reason she had stopped having periods was because she was pregnant. She was stunned.

As you have more and more anovulatory cycles, your levels of several important hormones estrogen, progesterone, and testosterone drop. This decline is believed to contribute to most of the symptoms and conditions associated with menopause, from hot flashes to heart disease; every part of your body that has "estrogen receptors" (such as breasts, heart, lungs, brain, and immune system) is affected by this hormonal shift. The changes are often subtle at first for example, many women notice a sensitivity to heat years before experiencing their first hot flash. I encourage women to stay attuned to their body's changes and use this time to prioritize their health.

Whether you've had children or not, moving into the stage of life where it is no longer possible to have them is a very significant change. When women allow themselves to reflect on this, it can lead to intense soul-searching and, for many women, a revisiting of their identity and sense of purpose. Menopause, in my view, is well named. It's as if the body and soul are programmed to pause, letting a woman reflect on the first half of her life and prepare for the second. Rarely, however, do women in our society view it this way anxiety and fear, stoked by our youth-worshipping culture, often get in the way. Women who pretend it isn't happening or try to "muscle through it" often find themselves really struggling. I see many women who have deep sorrows about their reproductive choices or regrets about their career choices or relationships. Those who bury their feelings experience a much harder transition they actually have more physical and emotional symptoms than women who are able to process what they're going through.

Time and again, I've worked with women on embracing perimenopause consciously, and I've seen that it can be a deeply rewarding time. One woman came to me with questions about hormone replacement therapy, and we ended up in a bigger discussion about her life. I gave her a series of exercises designed to help her reflect on her life thus far and envision her future. When I next saw her, she was beaming. She had reckoned with the fact that her job was unfulfilling and spent time thinking about what makes her feel alive and passionate. She quit her job so she could invest in a longheld dream: starting her own catering business.

Conscious transitions aren't always struggle-free, of course. Heather's office visit prompted some difficult soul-searching about whether she wanted to have a child. In the end, she and her partner agreed that they did not want to be parents and made peace with that decision. She's been happy and relaxed ever since; she and her partner have been traveling the world.

"Who is not afraid of pure space -- that breathtaking empty space of an open door?" asks Anne Morrow Lindbergh in Gift From the Sea. One way or the other, we all walk through it. But you get to choose how: eyes open or eyes closed. Above all, perimenopause is a perfect time to prioritize your whole self, not by trying to "outrun" aging, but by taking care of your body, listening to your soul, and creating a powerful vision for your future.

Text by Dr. Tracy Gaudet

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