Perimenopause And Menopause

Introduction

The relentless elapsing of time comes along with inevitable changes in the human body, leaving its footprint on the reproductive system The reproductive life of people assigned female at birth (AFAB) is characterised by menstruation during fertile years, progressing through perimenopause and menopause. Perimenopause signifies the transitional phase preceding menopause, when reproductive and hormonal alterations begin to appear, accompanied by irregularities in the menstruation cycle.¹ The end of perimenopause is marked by the final menstrual period, indicating the onset of menopause. Menopause itself is defined as a period of twelve consecutive months without menstruation, establishing the end of reproductive function and fertility. Following menopause, individuals enter postmenopause, the final stage of reproductive ageing.²

Perimenopause and menopause are represented by numerous symptom manifestations that can last up to several years. Many people with AFAB have described experiencing emotional and mental changes, like mood swings, brain fog, and fatigue.³ Physical symptoms, including body composition variations and loss of bone density, are also significant aspects of these stages. Furthermore, the cardiovascular risk calculator drastically changes for people AFAB entering perimenopause and menopause, as they lose the previous hormonal protection to cardiovascular diseases.⁴

Perimenopause and menopause may remain taboo topics in certain communities, leaving individuals under-informed of the symptoms, risks, and management methods. A rigorous understanding of the matter would empower people AFAB, enhancing their knowledge and encouraging them to seek medical advice for managing troublesome symptoms.⁴

Understanding perimenopause

Perimenopause, also known as the menopausal transition, can last up to several years, with an average duration of four years. The mean age at which individuals AFAB enter this stage is 47 years, although early or late menopausal transitions have also been reported.⁵

Symptoms and hormonal changes

A wide range of signs and symptoms have been described, varying from one individual to another, including:¹

• Hot flashes

The perception of hot flashes has been declared by 30%-70% of people AFAB in this reproductive stage, notably impacting their quality of sleep and overall well-being, often causing distress. The duration of hot flashes may either be brief or persist for as long as 10 years, particularly observed among people AFAB experiencing this symptom at an early perimenopausal stage or with a high body mass index (BMI).

• Sleep irregularities

Poor sleep, difficulty falling asleep, and insomnia, often associated with hot flashes, have been described by a great number of adults in this stage. According to a specific survey of 3243 people AFAB, 56.6% reported insomnia linked to night sweats. The intensity of these sleep disturbances tends to worsen as individuals progress into late perimenopause.

• Vaginal dryness

Different symptoms, such as vaginal dryness, irritation, pain, or increased frequency of urination, are prevalent among postmenopausal people, encompassing the genitourinary syndrome of menopause (GSM). However, GSM may initially manifest in perimenopausal individuals with a tendency to exacerbate over time without proper treatment.

• Adverse mood

Depressive symptoms, major depressive disorder, mood swings, and anxiety are all common mental health challenges, of varying severity, seen in individuals with AFAB during menopause.

Most of these symptoms are associated with hormonal imbalances present in this stage. Levels of sex steroid hormones oestrogen and progesterone begin to fluctuate significantly during perimenopause, eventually declining to very low production. The unpredictable patterns of these hormones, with increases and decreases beyond normal levels, result in irregular ovulation and menstruation, often with heavy or frequent flow.⁵ This hormonal dysregulation also affects the cardiovascular and neurological health of individuals, contributing to an inflammatory state and increasing the risk of cardiovascular comorbidities and neurological conditions during this stage.⁶

Analysing menopause

The period of twelve consecutive months without a menstruation cycle (amenorrhoea) is defined as menopause. The mean age of people AFAB entering this stage is 51 years, although this age may vary globally.⁷ Apart from menopause occurring naturally with age, premature menopause may also be induced, particularly after chemotherapy, endometriosis treatment, and radiation. Additionally, it can also occur after surgical interventions involving the removal of one or both ovaries (oophorectomy).⁸

Symptoms and long-term health considerations

Under natural circumstances, the depletion of ovarian follicles upon reproductive ageing eventually brings the cessation of ovulation, causing a decrease in oestrogen levels and ultimately the end of menstruation.⁸ These events, characteristic of menopause, give rise to specific symptoms, similar to those experienced during the perimenopausal period with variations in their severity. Other reported symptoms include memory problems, panic attacks, decreased libido, migraines, and dizziness.⁹

Hormonal changes during menopause and afterwards have been associated with long-term health risks, particularly in heart and bone health. Premenopausal individuals with AFAB exhibit a lower cardiovascular risk compared to postmenopausal people with AFAB and those assigned male at birth, connoting the significant effects of oestrogen in the heart. Besides its cardioprotective mechanism, oestrogen plays a pivotal role in bone growth and metabolism, preserving bone health. The natural decline of oestrogen levels heightens the risk of decreased bone mineral density, osteoporosis, and fractures observed in postmenopausal individuals AFAB.¹⁰

Managing perimenopausal and menopausal symptoms

Lifestyle modifications

People AFAB who have transitioned through perimenopause and menopause can consider implementing valuable lifestyle changes to help them cope with associated symptoms. While symptomatology and intensity may vary among individuals, self-care, and embracement with the idea of ageing are fundamental views when going through these stages, as affirmed by those who have experienced them. However, when symptoms become bothersome or when environmental or genetic risks come into play, seeking medical help is highly recommended.¹¹

More practical non-pharmacological techniques such as smoking cessation, regular exercise regimens, and stress reduction have been reported to show positive effects in the management of menopausal symptoms.⁹

Diet and nutrition are important factors to consider in perimenopause and menopause, which assist in reducing the symptoms and risk of diseases affiliated with these periods. Maintaining a normal BMI and consuming a well-balanced diet rich in minerals, vitamins, fibres, and antioxidants are highly recommended. Specifically, intake of foods rich in omega-3 fatty acids, legumes, fruits, low-fat protein products, whole-grain cereals, dairy products, seeds, unsalted nuts, and smaller quantities of sugar, saturated fats, processed foods, red meat, and alcohol are all essential recommendations for promoting overall health during these stages of life.¹²

Pharmacological treatment

Hormone therapy

People with AFAB with more troublesome symptoms usually undergo hormone replacement therapy, which involves the use of oestrogens alone or in combination with progesterone. Oestrogen is effective in reducing symptoms such as hot flashes and night sweats and is available in various forms, including oral medications, patches, gels, creams, or vaginal formulations. Oestrogen therapy is primarily administered to individuals who have surgically removed the uterus (hysterectomy). For those with a uterus, combination therapy with progesterone or progestin, a synthetic form of progesterone, is recommended as it protects against endometrial hyperplasia and cancer.⁷

The decision to undergo hormonal therapy and the choice of therapy type are made by healthcare providers, upon analysing your family history and individual risk markers for various diseases. This happens because hormone therapy may be contraindicated in certain cases due to its association with increased risks of breast cancer, ischemic stroke, and venous thromboembolism.⁷

Non-hormonal therapy

Individuals ineligible for hormonal therapy have additional options for managing severe symptoms through different herbal remedies and other pharmacological agents. For instance, supplements, such as black cohosh, evening primrose oil, ginseng, and maca, among others, are believed to provide relief from hot flashes. Prescribed antidepressants, including selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, gabapentin, and clonidine may also alleviate mood swings and hot flashes.¹³

Summary

In conclusion, perimenopause and menopause are normal physiologic processes that every person AFAB will experience at some point in their life. The natural occurrence of these periods, though varying considerably, typically after the age of 45, signalling the end of the reproductive years.

Perimenopause, preceding menopause, is characterised by irregular menstruation cycles and ample fluctuations in sex steroid hormones, especially oestrogen and progesterone, alongside a gradual descent in these hormone levels. These changes provoke the hallmark symptoms of this stage. Menopause is defined as the period of twelve consecutive months without menstruation, accompanied by low oestrogen levels, further influencing these symptoms and indicating the cessation of ovarian function.

The symptoms experienced in these stages, including hot flashes, sleep disturbances, mood changes, and GSM, can cause distress to varying degrees, as individuals progress through reproductive ageing. Diverse management approaches have been identified to mitigate troublesome symptoms, ranging from lifestyle modifications to hormonal and other pharmacological therapies. Given the diversity in symptom manifestations and the associated risks of each treatment approach, people with AFAB should discuss their unique case with a healthcare provider. Adhering to a tailored treatment plan that addresses your exact symptoms at each specific stage, and anticipating potential progress is more likely to enhance your well-being and quality of life.