This fertility rite of passage can be surprising, annoying, and sometimes painful. Since Judy Blume hasn’t written a book about it (yet), we’ve gone to the experts for the full details.
For many of us, our fertility ends as it began, with irregular periods. You might find yourself getting up from a chair in, say, your office conference room, and feel that familiar teenage horror and total certainty that you just bled right through your clothes. Afterward, once you’ve beelined to the nearest restroom to clean up as best you can, you’ll have one thought: “Why didn’t anyone warn me about this?”
Making the transition
Welcome to perimenopause. (Sorry we couldn’t warn you in time—but please share with friends so they’ll be prepared.) That’s the name for the transition a woman goes through as her ovaries start shutting down their baby-making operation, causing the hormones they produce—estrogen, progesterone, and testosterone—to fluctuate and decline. As they do, you might notice heavy bleeding and other symptoms like hot flashes, intense breast tenderness, longer/shorter menstrual cycles, acne, loss of libido and/or vaginal dryness, extreme PMS, anxiety, depression and trouble sleeping. (You see why no one wants to talk about it.)
“The hot flashes of menopause capture all the attention, but the perimenopause transition is much harder,” says JoAnn V. Pinkerton, MD, NCMP, executive director of the North American Menopause Society and Professor of Obstetrics and Gynecology at the University of Virginia. That heavy flow? “We call it opening the floodgates,” Pinkerton says. “As estrogen surges you bleed very heavy and often unpredictably—and unpreparedly—then it slows back down again.”
Women generally enter perimenopause around age 40 (give or take), and experience it for an average of four years but as little as a few months and as many as 10 years, says Pinkerton. There’s no medical test that determines if you’re in perimenopause; it’s diagnosed largely by its symptoms. (Your doctor may offer to check your hormone levels to see if you’ve entered perimenopause, but since they fluctuate during this time, Pinkerton says experts have agreed it’s not a reliable test.) Perimenopause ends 12 months after your last period, which is the sign that you have officially entered menopause.
Managing the symptoms: Seventy-five percent of women experience at least some perimenopause symptoms, says Pinkerton. If you fall into that group, be sure to talk to your practitioner about it. “You shouldn’t have to go through unpleasant symptoms like heavy bleeding and others that interfere with your life,” says Anne Moore, DNP, WHNP, the women’s health clinical trainer at the Tennessee Dept of Health and a clinical advisor for the Association of Reproductive Health Professionals. Heavy bleeding and other typical perimenopause symptoms are also sometimes a sign of an overactive or underactive thyroid. “Your clinician can test to make sure thyroid dysfunction isn’t a contributor, and make these episodes less frequent or prevent them from happening altogether.” Here’s what to expect, and how to ease the transition.
“This is the hallmark of perimenopause,” says Pinkerton. Your period is longer, it’s shorter, you don’t bleed one month, you bleed a lot the next—all of these are normal changes, if bothersome and hard to plan around.
Manage the symptoms: Hormonal strategies will help pace your period, says Moore. “If your periods are too spaced out, it’s more likely that your next period will be heavier, as there’s more time for uterine lining to build,” she says. “Hormone therapy like birth control pills, the vaginal ring or a progestin IUD, can modulate that and keep the uterine lining thin. And it has a double benefit of preventing pregnancy, since your body is still capable of achieving pregnancy.” For extremely heavy bleeding, your practitioner may advise taking non-steroidal anti-inflammatory drugs (NSAID) throughout your period, or even prescribe Lysteda, both of which can reduce blood loss.
“This is an estrogen withdrawal effect—a signal that you’re experiencing a decrease in estrogen supply,” says Moore. Hot flashes, which affect an estimated 60-80 percent of women, are best described as a sudden flush of heat across your upper body that can last as long as five minutes. If you experience them at night, it’s called night sweats. “They can disrupt sleep, which in turn influences your mood and performance the next day,” Moore says.
Manage the symptoms: “For women who are non-smokers, birth control pills can stop the ovaries from sputtering too much or too little estrogen,” Pinkerton says. “By the second or third month, perimenopause symptoms will go away and you’ll start to feel like you used to. You can use them for six months or longer, if needed.” There are also non-hormonal ways to ease the discomfort of hot flashes. “Cognitive behavioral therapy has been shown to help,” she says, “as well as antidepressants and medication for nerve pain.”
“Think of perimenopause as reverse puberty,” says Pinkerton. “As hormones start to shift, women can get acne, as well as dry skin and thinning skin.”
Manage the symptoms: Maintaining an estrogen balance with hormonal therapy can help clear up your skin, says Moore. You can also talk to your dermatologist about a topical prescription treatment such as clindamycin for acne, and a retinoid to help stop skin from thinning.
Vaginal dryness and loss of libido
“Dryness occurs toward the end of perimenopause,” says Moore. As your skin stops producing as much oil (thanks to waning estrogen), it will get drier all over—including your vagina. Pair that with the sex drive dip that some women report, and intimacy can suffer.
Manage the symptoms: Pinkerton advises using lubricants during sex, as well as vaginal moisturizers. “A vaginal moisturizer is like one for your face,” she explains. “It gets absorbed into the skin, and should be used regularly.” If these remedies don’t work and sex is painful, talk to your practitioner about prescription low-dose vaginal estrogen products, which can restore moisture to the area.
Severe breast tenderness
Blame breast pain—which can range from bothersome to unbearable—on high levels of estrogen.
Manage the symptoms: This is another symptom that lessens with hormone therapy, but if you don’t want to go that route, Pinkerton says, taking vitamin E and evening primrose oil supplements can help to decrease the pain.
You know the signs: cramps, bloating, mood swings, headache in the days leading up to your period.
Manage the symptoms: Over-the-counter remedies include fluid pills and NSAIDs for cramping, and both magnesium and calcium have been linked to a reduction in PMS symptoms. “If it’s severe enough it might be premenstrual dysphoric disorder, or PMDD,” says Pinkerton. “To manage that, your doctor might prescribe birth control pills or low-dose antidepressants for either the seven to 10 days before cycle, or for the entire month.”
Pee a little when you sneeze or work out? That’s stress urinary incontinence (SUI). Feel like you need to go rightthisminute? That’s urge urinary incontinence (UUI). Both can develop as you transition to menopause. “Urine leakage and urgency is not uncommon,” says Pinkerton, as lower estrogen levels cause the lining of the urethra to thin. (If you’ve been pregnant and/or given birth, you might have already experienced leakage as a result of weakened pelvic floor muscles.)
Manage the symptoms: Emptying your bladder more frequently can help, and vaginal estrogen can help ease symptoms of an overactive bladder. Poise Impressa, a tampon-like device available at drugstores, puts pressure on the bladder wall to prevent SUI.
As hormones dip in the week before your period, you may feel exhausted. Likewise if you’re bleeding heavily, or experiencing hot flashes. “Sleep is a big issue—falling asleep, staying asleep,” says Pinkerton.
Manage the symptoms: “Practice smart sleep hygiene techniques,” advises Moore. “Take a warm bath before bed, no caffeine after 4 p.m., limit alcohol, read before bed instead of watching TV, and get to bed at the same time each night.”
“If you’ve had depression hormonally—during postpartum or puberty—you might be more likely to experience it during perimenopause,” says Pinkerton.
Manage the symptoms: If you feel depressed, speak with your practitioner to discuss treatment options.
“Some people get more tension headaches during perimenopause,” says Pinkerton. “And if you have a history of migraines they often become more frequent or severe.” The good news? “Once you get to menopause, they ease up,” she says.
Manage the symptoms: Treat your tension headaches as you normally do—by applying heat or ice, going for acupuncture or massage, or taking over-the-counter painkillers. With migraine, prevention is key, says Pinkerton. If your headaches come on at the same time every cycle, begin taking NSAIDS before the headache strikes. “Magnesium, acupuncture, triptans like Imitrex—use whatever works for you,” says Pinkerton.
Experts have found that hormonal shifts in perimenopause cause extra fat to accumulate around your middle. “Almost all women will struggle with some abdominal fat,” says Pinkerton.
Manage the symptoms: “Are you exercising? Sleeping? Eating healthy?” asks Pinkerton. “Stay on top of that as you go through this transition.” If you’ve gained more than 15 pounds, your practitioner might test your blood pressure as well as your blood sugar levels to make sure you aren’t pre-diabetic.
Whether you’ve experienced all, some or none of these symptoms, both Pinkerton and Moore emphasize the importance of taking care of yourself during perimenopause. “Typically, this is a moment where women don’t have to take care of others as much,” says Moore. “Treat yourself to exercise that you didn’t have time for before now. Make sure you get checkups that you’ve overlooked. This is a time when you can make yourself a priority.”