Anxious? Low? Angry? Exhausted? It might just be the perimenopause.
A decade before your body goes through the menopause, you can already feel its impact. But despite the 13 million women in the UK experiencing perimenopause, we're still not talking about it says Brigid Moss.
‘I can feel the hormonal shifts happening - the sweating, the moods. You’re just like all of a sudden furious for no reason,’ revealed Gwyneth Paltrow recently, instantly volunteering herself as the new face of the perimenopause.
I for one, want to thank her for that, not only because it’s happening for so many of us in our 40s and even late 30s (the average age for the perimenopause to start is 45, Gwyneth is 46), but it’s good to hear that even she, insanely privileged and with doctors on tap, can be felled by hormones, too. ‘I think when you get into perimenopause, you notice a lot of changes,’ she announced on a video she filmed for her wellness company Goop.
Forever, the menopause has been seen as the beginning of the end, embarrassing, unsexy, a horrible experience. But there’s a sense this is are changing. Menopause is now prime time: Mariella Frostrup has shared her experiences in The Truth About Menopause on the BBC. The previous year, it was Kirsty Wark and Jennifer Saunders.
Let’s not pretend, perimenopause needs attention. It currently affects 13 million women in the UK - women maybe like you, or you will become. Symptoms can be way worse than Paltrow’s experience; Meg Mathews tells how she was plunged into anxiety, other women feel flat, depressed, hopeless. According to research from Nuffield Health, up to one in ten women consider quitting their jobs because the symptoms are so debilitating.
We need good information: before you get to the perimenopause, the details of this life stage are a mystery. Everyone is taught about puberty but there’s no schooling about the other bookend of our fertile lives.
As you may or may not know, during perimenopause, as your store of eggs starts to run out, your levels of sex hormones – oestrogen, progesterone and testosterone - fluctuate wildly, though the general trend is downwards. You will still have periods, although they may get heavier or lighter, closer together or further apart, longer or shorter. Confusingly, symptoms may not start with the obvious ones, such as hot flashes. Or they may be hard to talk; vaginal dryness or pain, for example. Or they may not be at all gynaecological.
But if you’ve got period changes and any of the following list, it could be hormonal: sleeplessness, emotional upheaval, joint pain, loss of libido, weight gain, anger, irritability, low mood, poor concentration, memory problems, anxiety, dizziness, irritability, mood swings, disturbed sleep and fatigue. In one study, as many as a quarter to a third of women reported symptoms of depression.
The reason for such huge variety of symptoms is, you have hormone receptors in nearly every tissue in the body, so everywhere is affected. Often, progesterone levels will start to go down before oestrogen does - that can mean extended bouts of PMS and period flooding. Symptoms often interact for extra misery: my near-constant PMS with mind fog and sleeplessness, being one example. And a 2015 study suggests your oestrogen ups and downs actually increase your sensitivity to everyday stress. So what you could cope with last year now feels like too bloody much.
The fact symptoms are so non-specific combined with a lack of compulsory training for GPs, means often, they don’t join the dots.
‘Women struggle to access GPs and appointments. Some women take years to get a diagnosis. One woman saw three neurologists for her brain fog and memory problems before finding out it was the menopause,’ says Maria who runs The Menopause Collective, a support group on Instagram. Dr Louise Newson, who runs a menopause clinic in Stratford-upon-Avon admits even she missed hers: ‘I was getting more tired, irritable, had night sweats, low mood, couldn’t find the car keys. Knowing as much as I know, I thought I was working too hard! If I couldn’t put it all together, I can see why other people don’t.’
So you think you may be perimenopausal?
The first thing to do, is see your GP; if you are in a bigger practice, ask if there’s a doctor who specialises in it. And if you don’t get the help you need, ask to be referred to a specialist menopause clinic.
1. HRT and medication
The one treatment that treats all menopausal symptoms, by topping up the falling levels of hormones: HRT. It also protects your cardiovascular health and bones, cutting the increased risk of heart disease and osteoporosis in postmenopausal women.
Despite this, only one in five eligible women in the UK currently take HRT. This is because of the breast cancer-HRT scare in the 2010s. However, this evidence is now fully discredited; in 2017, some of the doctors involved actually apologised. These are the facts we now know: out of 1000 women, 23 will get breast cancer.
With HRT, there will be four extra cases. Drinking more than two units of alcohol a day carries more risk than HRT, and being obese doubles the risk. Most women can take HRT safely, even some women with a family history of breast cancer.
The current NICE guidelines say: if you have symptoms, you are over 45, have changes in your period and have no contra indications, you can be prescribed HRT. Dr Louise Newson, prefers to prescribe ‘body identical’ forms of the hormones, and monitors patients to get the dosage right. (NB: ‘Body identical’ hormones are not the same thing as the ‘bioidentical’ hormones given by some private doctors, which are not regulated). She says the best way to give oestrogen is via the skin, as a patch or gel (17 beta-oestradiol). For the progesterone part (essential if you have a womb), she prescribes the Mirena coil, ideal during the perimenopause, when you can still get pregnant. Or micronised progesterone in the form of an oral capsule, Utrogestan. For vulvovaginal symptoms (at least half of women have these), there is topical vaginal oestrogen as well as moisturisers and lubricants. Unlike most GPs, Dr Newson also often prescribes testosterone, for loss of libido, although this is ‘off label’ in the UK - ie there is no specific female preparation available.
For the women for whom HRT isn’t recommended, or who prefer not to take it, there are drugs for specific symptoms too; ask your GP for advice or, again, to be referred to a menopause clinic.
2. Herbs for hormones
If you’d prefer to use herbal remedies, there is some (limited) evidence they work. In clinic, Marilyn Glenville author of Natural Solutions To Menopause, uses combinations of red clover and black cohosh - ‘what works for one woman often won’t work for another,’ she says. There’s also some evidence for St John’s Wort for hot flushes, and agnus castus for PMS-like mood swings and irritability. Check with your GP: herbs can interact with medication.
3. Mind treatments
Cognitive behavioural therapy and HRT are recommended by NICE for low mood and anxiety. ‘We do know that if woman are stressed, the symptoms are more extreme,’ says Glenville. One reason is, our adrenal glands are supposed to produce a form of oestrogen that can cushion the drop from the ovaries, but if you’re stressed, this doesn’t happen. And if you're producing the stress hormone cortisol, you will have less capacity to manufacture sex hormones.
How to look after yourself during the perimenopause.
Lifestyle changes do make noticeable difference to symptoms. ‘I’ve seen women who have transformed the way they feel,’ says nutritionist Emma Ellice-Flint, author of The Happy Hormone Cookbook, who works at Dr Newson’s clinic.
1. Look at gut health
At the VivaMayr clinics in Austria, a heathy menopause starts with the gut, because your gut health affects hormone production including levels of serotonin, the mood hormone. These are their golden gut rules: try not to overeat or to eat when stressed fast, to eat junk or late at night. And chew your food properly. Dr Newson is a fan of probiotic supplements, too.
2. Tailor your exercise
Weight bearing exercise and strength training are both a good idea: not only to keep your skeleton strong, but your muscles too. ‘We need to make demands on the skeleton to keep up bone density,’ says Glenville. The right exercise will also reduce stress hormones, and is good for the heart. All exercise is worth doing; research shows less exercise equals worse symptoms.
3. Watch your alcohol and caffeine
‘Often women find they can’t tolerate alcohol as well at this time,’ says Glenville. ‘Your liver is busy metabolising hormones.’ Her advice is: cut down, have alcohol free days and don’t binge drink. She prescribes milk thistle, a herb for liver function. NB: Alcohol, caffeine, spicy foods and smoking can trigger hot flushes. And, Glenville says, sadly too much caffeine may worsen other symptoms, too.
4. How to eat well
A diet rich in oily fish (mackerel, salmon, sardines) and legumes (lentils, chickpeas, beans) has been shown to delay the menopause, according to a 2018 study, while a high intake of refined carbs - specifically pasta and rice - may make it earlier. ‘Eating high GI foods (fibre-rich such as whole grains and vegetables) will keep your blood sugar levels even,’ says Ellice-Flint. Blood sugar fluctuations put stress on the body and affect hormones. ‘And eat a few portions of foods containing phyto-oestrogens daily for their balancing effect on oestrogen levels,’ she says. That means: one heaped teaspoon flaxseed a day, a small handful of nuts and a handful of cooked legumes or lentils.
5. The right supplements
Your nutrient needs are individual. However, there’s research to show B vitamins are supportive during the perimenopause. ‘And magnesium can work very well for sleep quality and help with anxiety for some women,’ says Ellice-Flint. Taking omega 3 - in oily fish and flax seed - is good as it is anti-inflammatory. You may also need vitamin D: over 90 per cent of the women who attend Glenville’s clinic are deficient.
For more information from Dr Newson including on HRT safety and dosage, as well as other drugs: menopausedoctor.co.uk.
For information on perimenopause and menopause visit the NHS website or visit your GP if you're struggling any of the issues mentioned in this feature.
Could early perimenopause affect you?
There's no real way to predict when you'll go through the change, although family history is generally a good indicator.
For those hoping to get pregnant in future; perimenopause may make it harder to conceive - but it isn't impossible, Hamoda explained.
'Premature ovarian insufficiency (POI) refers to a significant decline in ovarian function before the age of 40, and can be short-term menopausal,' he said.
'Women with POI can have intermittent ovarian activity and have a chance of natural conception, although this is likely to decrease the more infrequent their menstrual cycles are.
'The likelihood of natural conception in women with POI is low and is estimated to be in the region of 5%–10%.'
Chances are you won't start noticing the effects of perimenopause until you hit mid forties. However, if you're unsure of what to expect or concerned about the age your mother or grandmother began the change, book an appointment with your doctor for peace of mind.
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