PRIME TIME
All you need to know about the perimenopause
If you’re in your late 30s or 40s, no doubt Judy Blume’s Are You There, God? It’s Me, Margaret prepped you for the start of your periods; Just Seventeen and More magazines held your hand during puberty; while your friends warned you how haywire hormones go during pregnancy and after childbirth. But there’s one hormonal rollercoaster that’s traditionally been hushed up. Step forward the perimenopause, aka menopause’s younger sister, which many of us blindly and begrudgingly enter in our 40s, but sometimes as early as our late 30s.
‘The perimenopause is a time to reassess, reposition and reset aspects of your life that aren’t working for you. Out with the old, in with the new,’ says Emma Bardwell, a nutritionist who specialises in the peri- and menopausal years (emmabardwell.com). ‘While it’s a time that can be testing for many, it’s also one that encourages you to look inwards and redefine who you are. If you have kids, chances are they’re growing more independent, leaving you with more time to focus on yourself. Periods and contraception will eventually become a thing of the past. Your body is still very much open to change: you can build muscle, become more supple and learn new skills.’ Research by Women In Sport confirms this, finding that many women are using this time to reappraise what they want – to focus more on themselves, to take back control of their lives.
‘Seeing the perimenopause and menopause as a positive time for change – not pretending it’s not happening – can be an enormous help,’ says GP Dr Louise Newson (menopausedoctor.co.uk). ‘Your attitude and willingness to get help if you need it can make all the difference as to whether you sail through the perimenopause and menopause or if it feels like a dark and gloomy time.’
On top of this, understanding perimenopause can help you to have a better relationship with your body, boosting your confidence and countering creeping anxiety that physically and mentally things are changing. Plus, the health tweaks you make now can help future-proof your body. Getting enough calcium and finding heart-healthy exercise you love will help with the long-term effects of oestrogen deficiency, such as osteoporosis and cardiovascular disease.
The changes to make before the change
Let’s be frank, a rebranding of these years won’t magic away any unpleasant symptoms or make you ‘love’ your perimenopause – and that’s okay. But knowing what you’re facing, what might be making you feel off par (it may not be what you think), plus knowing what practical things can help, will put you in the driving seat. The first thing you need to know? That, for many, this transition time between the reproductive years and the menopause itself is no big deal, but for others there can be serious hormonal upheaval. We’re talking sleep disruption, a tanking libido, flushes, sweats, overwhelming emotions (moody, anxious and raging much?), and brain fog, as well as cycle changes, like much heavier periods, or a more frequent or painful cycle. These symptoms are triggered by hormonal changes, such as the ovaries gradually beginning to make less
oestrogen, and this rocky, yo-yoing road can go on for months, years, or even a drawn-out decade (or more) before you reach the menopause itself.
One thing is clear from this: a tradition of not talking openly about the perimenopause has made it harder to ID and address problems. In fact, recent research discovered that although 70% of 30- and 40-something women had experienced perimenopause symptoms, 90% failed to recognise the fluctuating hormone link and instead pointed the finger of blame at stress, ageing, anxiety and depression. Another problem? ‘Because you have symptoms but regular periods, doctors can sometimes misdiagnose depression, anxiety, unexplained fatigue and fibromyalgia,’ says Dr Newson. ‘The perimenopause is a normal life event, not an illness, but as a result it’s too often under-recognised, under-valued and not taken seriously. Ultimately, the more we talk and learn about the perimenopause, the more empowered we will be.’
It’s not you, it’s your hormones
A change of periods is an early tell-tale sign, but because numerous oestrogen receptors are in the brain, mood swings, anxiety, irritability, and having trouble concentrating or remembering can also be the first signs of plummeting oestrogen. ‘It’s common for the perimenopause to change your moods, your emotions and your levels of motivation,’ says Dr Newson. ‘And it’s these psychological symptoms, as well as a loss of self-confidence plus depressive symptoms, that bother women the most. Even those who’ve never felt anxious, now find themselves worrying about things for the first time.’
In fact, one new study found nearly half of all women experience depressive symptoms during the perimenopause due to the brain’s sensitivity to changing hormonal patterns. Nobody is immune, although some studies indicate those who’ve struggled with PMS or PND in the past, who might have a higher sensitivity to hormones, may be more predisposed. ‘If these symptoms are happening when you’re also busy with your career, have young children or ageing parents – and you’re not having the ‘classic’ symptoms of hot flushes – you may not know it’s the perimenopause,’ says Saska Graville, founder of Mpowered Women (mpoweredwomen.net), a community hub of doctors and wellbeing experts helping to break the taboo. ‘Awareness that it’s hormones causing problems – that it’s not you – is key. So too is arming yourself with a clear understanding of what this phase of life entails, and your options, because this will help you navigate it.’
Whatever stage you’re at, knowledge is power and tracking your cycle in your diary or on the health settings on your phone will help you get a fuller picture. ‘If you’re experiencing other problems, make regular notes so you can see how things are changing over time,’ says Dr Newson. The new Balance app (free), which tracks symptoms and shows emerging patterns can be helpful, while the Greene Climacteric Scale (find both at menopausedoctor.co.uk) can be an eye-opening symptom checker.
Smart tweaks
In general, anything that makes you feel perkier now, be it a daily swim, more sleep, switching to decaf or having the tonic without the gin, may help regulate your mood and ease symptoms. ‘With less oestrogen in your diet, bones need extra nourishment to stay strong,’ says Dr Newson. If your diet lacks calcium-rich foods such as dairy, green leafy vegetables, nuts, seeds and tinned fish with the bones in, mainline a daily calcium and vitamin D supplement (FYI vitamin D is key for calcium absorption). Heavy periods and nada energy? Many women have low iron levels, so ask your GP for a test.
Studies have found that women who eat a lot of phytoestrogens (naturally occurring plant compounds that are structurally similar to oestrogen) have fewer menopausal symptoms. ‘Add a few portions of soy, flax seeds, chickpeas and oats to your diet every day, which have been shown to help with hot flushes and night sweats in the early stages of perimenopause,’ says Emma. ‘But I advise sticking to minimally processed and fermented sources where possible, such as tofu, tempeh and edamame beans.’
There’s also research into the gut microbiome and how it relates to hormonal health, which may place nutritional interventions centre stage in the future. The key to better gut health? ‘Diet diversity is good for your gut, and for your estrobolome, the bacteria responsible for modulating oestrogen levels,’ says Emma. ‘Aim for 30 different plant types a week and include fermented food such as kefir, live yogurt, sauerkraut, miso and kimchi. Studies have found a plant-focused diet is linked with fewer symptoms.’
Get peri-savvy
As for herbal supplements, some women swear by them, but there’s little large-scale evidence to support their use. A few studies have shown that black cohosh could reduce night sweats and hot flushes, and there’s also some (limited) evidence for red clover for flushes, sage for sweating, and agnus castus for Pms-like mood swings. Some women find CBD helps with stress, sleep and anxiety, but there are no large research studies supporting its use for perimenopausal symptoms. Now there are also supplements tailored to this time, such as Mpowder’s Peri-boost Bio-stage (£69 for a 30-day supply, Mpowder.store), a plant-based food supplement specifically for the perimenopausal years.
Dealing with stress, or at least making time to de-stress, needs to become a priority. This is because when you’re tense, your cortisol (stress hormones) levels shoot up, which has a knock-on impact on the balance of oestrogen and progesterone in your body. Mindfulness is proven to ease anxiety (we like the Calm app), while regular mind-body exercises such as yoga can help reduce that frazzled feeling. Exercise also counteracts the future fall in muscle and bone mass so try a weight bearing or resistance workout such as lifting weights, Pilates, or push-ups and squats. In fact, research by Women In Sport found that the active women they interviewed said exercise played a role in managing their symptoms – and therefore gave them a sense of control. We also can’t stress this enough: prioritise sleep. There’s no system in your body or aspect of wellness that gets away unscathed by a lack of zeds.
Take back control
Feel ruled by your hormones and having a really rough time of it? Although, generally speaking, you don’t need to get your perimenopause diagnosed – and blood tests can be unreliable because hormone levels vary from day to day – you should speak to your GP. ‘A low dose HRT, to ‘top up’ falling levels of hormones might be something to consider as it is by far the most effective treatment and can drastically improve symptoms and quality of life,’ says Dr Newson. ‘You don’t have to wait for your periods to stop before starting HRT, and it also reduces the risk of heart disease and osteoporosis.’
Nowadays, there’s no ‘one size fits all’ approach to HRT and there are multiple brands, strengths and formats to choose from, including tablets, skin patches or gels. For example, there is a natural ‘body identical’ oestrogen (which has the same molecular structure as oestrogen) derived from yams in a patch or gel, plus micronised progesterone as a pill or Mirena coil. According to Dr Newson, some women benefit from testosterone, but as it’s not currently licensed as a treatment for menopausal symptoms in the UK, it needs to be prescribed ‘off prescription’ by menopause specialist doctors. But what about those scary HRT headlines? Although the latest NICE guidelines say it can increase breast cancer risk, its benefits are generally thought to outweigh the risks and your GP can weigh up your own personal risk factors. Not getting the help you need? ‘Don’t be fobbed off, keep pushing – see another GP in your practice, or ask to be referred to a specialist menopause clinic,’ suggests Saska.
As for expensive ‘bioidentical’ hormones (not to be confused with ‘body identical’ hormones a GP can prescribe), be wary. There are implications these are better than NHS standard HRT because they’re prescribed by some private doctors, but the British Menopause Society and Royal College Of Obstetricians and Gynaecologists advise women not to take them because they’re unregulated, unlicensed and it’s unclear how safe or effective they are.
But we need to talk and learn about perimenopause more. ‘While it’s a time that can be testing for many, with the right tools, it can also be incredibly liberating,’ says Emma. So as she suggests, let’s get to it and try a new approach. ‘We need to reframe midlife and perimenopause as a time when women – with the right approach – can feel more relevant, more curious and more fearless than at any other time in their lives.’
‘WOMEN CAN FEEL MORE FEARLESS THAN AT ANY OTHER TIME’