Introduction

Perimenopause refers to the period when the body slowly moves towards menopause, marking the end of reproductive capability. People assigned female at birth start perimenopause at different stages and progress toward menopause which usually starts in their 40’s.¹ Menopause is a time when periods permanently stop and it usually occurs between the age of 45 to 50.² Grasping the hormonal changes occurring during perimenopause and menopause is necessary for managing your physical, emotional and psychological health.

What is a hormone?

Hormones are the chemical messengers produced by glands which travel through the bloodstream to the tissue or organ. 

What is hormonal imbalance?

An imbalance in hormone levels, whether excessively high or low, impacts how our body functions as we age.

Key hormone affected

There are some key hormones affected in menopause:

1. Estrogen: It significantly decreases as it is produced by the ovaries; decrease in the level of ovaries function decreases the production of estrogen³
2. Progesterone: This hormone regulates the menstruation cycle. The levels of progesterone drop during menopause and can result in irregular menstrual cycles
3. Follicle-stimulating hormone: FSH supports ovaries to produce estrogen, in response to low estrogen, the production of FSH increases. Elevated FSH is a hallmark of menopause⁴
4. Luteinizing hormone: similar to FSH, the level of luteinizing hormone increases with the decrease feedback of estrogen.
5. Testosterone: this is a male hormone but also produced in a small amount by the ovaries and adrenal gland. It decreases in menopause, leading to many symptoms such as decreased sexual desire (libido)⁵

During perimenopause, the transition phase to menopause, there is an irregular fluctuation of progesterone and estrogen.

Menopause no menstruation for 12 consecutive months there is a drastic drop of progesterone and estrogen hormone. 

Common symptoms

Some symptoms are:

• Decreased libido (sexual desire)
• Hot flashes
• Night sweats
• Vaginal dryness
• Insomnia 
• Weight gain
• Fatigue
• Anxiety, depression, mood swing
• Irregular or skipped menstruation¹

Cause of this hormonal shift

Natural decrease in hormone

A natural decline in hormone levels happens as you near your late 30s, leading to decreased production of estrogen and progesterone by your ovaries, the hormones that control your menstrual cycle. In your 40s, you may observe changes in your menstrual cycle, including variations in the duration, heaviness and regularity of your periods. Eventually, your ovaries will stop releasing eggs, leading to the cessation of periods, which typically occurs around age 51.¹

Surgery

• Oophorectomy is a surgical procedure that involves the removal of one or both ovaries. The ovaries are responsible for producing eggs and hormones such as estrogen, progesterone and testosterone. The removal of both ovaries results in immediate onset of menopause
• Hysterectomy is the surgical removal of the uterus. Periods stop because of the removal of the uterus however, ovaries are present so menopause occurs later with the natural decrease in eggs
• Chemotherapy and radiation therapy may cause premature menopause.¹ Primary ovarian insufficiency usually occurs in 1% of the women who suffer with premature 
• Menopause (menopause before the age of 40) ovaries not making sufficient amounts of hormone; it may occur due to autoimmune diseases or gene changes¹
• Lifestyle like poor diet, smoking 

How is it diagnosed?

As you transition into perimenopause and menopause, doctors may assess your symptoms, taking into account your age, menstrual history and other bodily changes you are experiencing. Blood tests are generally not used to diagnose menopause; however, healthcare providers may sometimes utilize them to check hormone levels.

FSH (follicular stimulating hormone) levels go up and estrogen levels go down. 

TSH (thyroid stimulating hormone) is also checked to rule out the thyroid cause of amenorrhea.⁶

Treatment

Hormonal replacement therapy

Estrogen helps to manage the symptoms associated with menopause. The doctor may suggest a low dose of estrogen to balance symptoms like hot flashes, night sweating and mood swings. Estrogen also helps to prevent bone loss. Progesteron is also needed with estrogen if you have your uterus. Prolonged use of hormonal treatment could increase your chances of developing heart disease and the risk of breast cancer.

To relieve vaginal dryness, estrogen is used in the form of cream, gel or tablets to directly absorb with vaginal tissue, and also prevent discomfort during intercourse and other urinary issues.⁶ 

Non-hormonal treatment

1. Small amount of antidepressants such as Selective Serotonin Reuptake Inhibitor (SSRI) or Serotonin Norepinephrine Reuptake Inhibitor (SNRI) are used to reduce the symptoms of hot flashes in people who can't take estrogen. It also helps with mood disorder
2. Vaginal moisture and lubricant is used for vaginal dryness⁷
3. Fezolinetant: this medicine is used to treat hot flashes by blocking pathways in the brain to manage body temperature.The medication has received FDA approval for the management of menopausal symptoms^6.
4. Some other medication, such as gabapentin or clonidine, is used to treat the symptoms when recommended by a doctor⁶
5. Take medicine to prevent or treat bone thinning conditions

Complementary and alternative medicine

These medicine has been characterised as:

1. Mind body practice:
   1. hypnosis helps to change how you feel and act⁹
   2. Cognitive behaviour therapy (CBT) is used to treat hot flashes, mood changes and other symptoms of menopause by educating, interviewing, relaxation, paced breathing and other strategies⁹
   3. Mindfulness-based stress release⁹
   4. Aromatherapy uses essential oil to relieve stressful symptoms of menopause^9.
2. Natural product:
   1. Black cohosh (actaea racemosa) used for the management of menopausal symptoms¹⁰
   2. Dong quai (angelica sinensis) Chinese medicine to treat women reproductive health¹⁰
   3. Red clover (trifolium pratense) manages the level of estrogen used for managing menopausal symptoms¹⁰
   4. Vitamin E is a fat-soluble vitamin that functions as an antioxidant and is utilised to relieve symptoms associated with menopause⁹
3. Whole system approach
   1. Homeopathy medicine based on the concept of cure using highly diluted remedies such as pulsatilla and sepia lachesis commonly used to treat mood swings and hot flashes⁹
   2. Acupuncture technique involves inserting needles used to treat menopause symptoms and hormonal imbalance⁹

Prevention and management tip

• Avoid spicy food, alcohol, hot drink 
• Exercise regularly
• Practice yoga, meditation 
• Take a calcium rich diet, to manage bone health
• Don't smoke⁸

When to see the doctor?

• If you are experiencing intense symptoms that greatly impact your everyday life
• When u have heavy and unusual bleeding
• A doctor's concern is needed when you are considering hormonal replacement therapy

FAQs

What age does menopause start?

Menopause generally occurs between the ages of 45 and 55, with an average onset age of 51. However, symptoms of perimenopause may start several years before.

Is weight gain during menopause normal?

Yes, hormonal fluctuations often lead to weight gain in many women, particularly in the abdominal area. A balanced diet and consistent physical activity can assist in controlling it.

Are herbal treatments safe for menopause?

Certain herbal treatments may provide relief, but it's advisable to speak with a healthcare professional since not all are verified or safe for everyone—particularly if you are taking other medicines.

How long does menopause last?

The transition period, encompassing perimenopause and postmenopause, can extend over a number of years. For some women, symptoms such as hot flashes may persist for as long as 5 to 10 years.

Summary

The perimenopausal phase leading to menopause signifies the end of reproductive capability. Women usually start their perimenopausal periods in their 40s and menopause where periods permanently stop start between 45 to 50. The hormonal imbalance is the key feature, in premenopausal the hormone progesterone and estrogen fluctuate which leads to many symptoms of mood swings, hot flash, irregular periods and sleep disturbance. In menopause, these hormones drop significantly and lead to more symptoms like periods stopping completely, libido, vaginal dryness. 

Hormonal imbalance also affects bone, heart health, mood and cognitive thinking. Diagnosis is typically evaluated through symptoms and blood tests. These symptoms are managed through hormonal replacement therapy, lifestyle modification and antidepressant. Some alternative medicine or aromatherapy, acupuncture, cognitive behaviour therapy (CBT) are also to be considered for mindfulness, relieve stress and mood stability. Early recognition, proper treatment, and emotional support can greatly improve quality of life during this natural stage of ageing.