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Lifting the lid on perimenopause


Let’s talk hormonal health, specifically the transition into perimenopause.


As a 47 year old woman in perimenopause (and quite frankly struggling with it at the moment) it is a subject very close to my heart. I have attended numerous webinars, lectures, have the books, listen regularly to the podcasts and am a huge fan of all the female hormonal health experts such as Lara Briden, Louise Newsome and Sara Gottfried (check them out if you haven’t already) yet my perimenopausal symptoms seemed to creep up on me and knock me for six.


In this blog, I want to cover the basics of perimenopause and bust a few myths along the way.


On that note, let’s get this one out of the way. There is no blood test to diagnose perimenopause as levels of various hormones can be different depending on the time of day, never mind where you are on your cycle.

Woman lying on bed in pain during menstrual cycle
Onset of heavier flows and increased cramping can be a feature of perimenopause

Perimenopause is diagnosed based on symptoms and context so if you are over the age of 35 (particularly if you are closer to 45) and experience 3 of the following symptoms, you are probably in perimenopause:

  • New onset of heavy and/or longer flow

  • Shorter menstrual cycles (25 days or less)

  • Sore, swollen or lumpy breasts

  • New onset waking in the middle of the night

  • Onset of night sweats particularly premenstrually

  • New or increased premenstrual mood swings

  • Increased period cramps

  • Weight gain without changes in food or exercise.


Perimenopause is a natural event that every single female on this planet will go through. However, nature is not always kind. Women’s hormonal health has been minimised, belittled and overlooked for many, many years. Did you know that it wasn’t until 1993 that it became law that women should be included in scientific studies?


Perimenopause/menopause is not just about the loss of fertility and the end of your periods, it is the beginning of a major shift in almost every aspect of a women's health.


You can have a totally regular cycle and still be in perimenopause.


Having said that, I think it’s important to note that some women sail through these changes, and it’s only in hindsight (in their post-meno years) that they may realise that they found life pretty difficult for a period of time. We are all very unique and individual and perimenopause and menopause will be different for all of us.


So what is perimenopause?

It is a sequence of events beginning with:

  • Declining progesterone

  • Paired with temporarily high oestrogen

  • Ending with declining and low oestrogen

  • Accompanied by quite significant changes to insulin metabolism or insulin resistance.

Perimenopause is temporary (hurrah), think of it as a second puberty. Ironically many of my clients enter this stage in life when they have teenagers at home dealing with their first puberty – the joys.


The perimenopause is a critical window for our health. Oestrogen and progesterone have such important and far-reaching roles in the body and producing less of these has an impact on so many systems in our body including:

  • Immune system

  • Cardiovascular health

  • Bones

  • Brain health

  • Gut health.

Perimenopause also increases our risk of metabolic disorders such as type 2 diabetes, declining bone density, mental health problems and autoimmune conditions such as Hashimoto’s thyroiditis and rheumatoid arthritis.


So what actually happens to our hormones during perimenopause?


There is a significant drop in levels of the primary female hormones oestrogen and progesterone.


The first hormone to begin to decline is progesterone.


In a healthy menstrual cycle we make 100 times more progesterone than oestrogen, so it’s a profound thing to lose progesterone. Oestrogen gets a lot of (deserved) attention but progesterone is important also.


Progesterone is produced in the luteal phase or the second half of your cycle after ovulation has occurred.


Remember, that the main event of your menstrual cycle isn’t your period, it’s ovulation.


In perimenopause, we have more anovulatory cycles which are cycles where we don’t ovulate, therefore we don’t produce progesterone.


Along with this quite steadily declining progesterone, we have our queen hormone oestrogen rising and falling unevenly and it’s this fluctuation which can contribute to many of the perimenopausal symptoms.


It might be helpful to refer to the work of Jerilynn Prior, a professor of endocrinology who describes the 4 stages of perimenopause as follows.


timeline of the 4 stages of perimenopause
Source: Jerilynn Prior 4 stages of perimenopause

Stage 1: Early Perimenopause

Our cycle is likely still regular but we could have some cycles where we might not ovulate and therefore lower progesterone levels can be lower. You can still have a bleed even if you don’t ovulate every month.


In this early stage we might not even be aware of the hormonal changes in our body. Some women might not experience any symptoms yet some will be getting symptoms that are typically associated with low progesterone.

Symptoms of low progesterone

Woman scratching at skin on neck
Itchng and new allergies are not uncommon during perimenopause
  • Migraines/headaches

  • Sleep disturbance

  • Heavy and painful periods

  • Mood changes

  • Breast pain

  • Irritable mood

  • Histamine-related symptoms (new allergies, itching).




Stage 2: Early Menopause Transition

This is when our cycles are starting to become more irregular and can vary in length, sometimes by more than 6 or 7 days. We are likely to have low progesterone and high, fluctuating oestrogen. This means that when oestrogen drops, it not only has further to fall but it can also drop to lower than what we’re used to. Such a drop in oestrogen can trigger symptoms such as hot flushes and night sweats or if we already have them they can get worse.


Woman rubbing brow with damp cloth trying to cool down
Night sweats and hot flushes are very common during the 2nd stage of perimenopause

Symptoms of high, fluctuating oestrogen

  • Heavy and painful periods

  • Breast pain

  • Irritable mood

  • Histamine-related symptoms

  • Hot flushes and night sweats

  • Mood issues

  • Vaginal dryness

  • Aches and pains

  • Abdominal weight gain

  • Increased irritability

  • Poor sleep.

Stage 3: Late Menopause Transition

This is when we start missing periods and we have our first cycle that’s longer than 60 days. Symptoms of high oestrogen can start to ease because we’re starting to lose oestrogen – even though it might still be fluctuating. As a result, breast pain could ease but night sweats and hot flushes could get worse.


Woman trying to button jeans
Insulin resistance increases during menopause and perimenopause resulting in weight gain

Symptoms of low oestrogen

  • Hot flushes and night sweats

  • Mood and sleep issues

  • Vaginal dryness

  • Aches and pains

  • Abdominal weight gain – one of the reasons for this is we naturally become more insulin resistant and as we lose progesterone and oestrogen.


Stage 4: Late Perimenopause (or you might call this Menopause)

This is when our periods are likely over and we’ve stopped ovulating, but 12 months without a period haven’t gone by yet so we haven’t officially reached menopause. We likely have low oestrogen and therefore symptoms of high and fluctuating oestrogen are easing – so our mood and sleep might be stabilising, although hot flushes can last for another while for some and some can have symptoms into their late 50’s.


You are officially in full menopause 12 months after your last period. The lead up to that is perimenopause or the menopause transition.


Now, at the risk of sounding like a Negative Nelly let’s look at this in a more positive light. There is so much more knowledge and information in the public sphere nowadays about the menopause transition.


HRT and the increasing knowledge and availability of HRT is helping so many women and it’s about time. Badly designed studies, false and alarmist headlines around HRT did women a disservice for so long. While HRT can prove to be a lifeline for many women, it isn’t a magic bullet.


This is also a time where it becomes imperative for women to really look after their health in the many ways that we can.


Nutrition and lifestyle play a huge role in helping to manage symptoms during perimenopause and support our bodies through this transition. For instance sugar and processed foods have been shown to negatively impact hormonal systems while eating more essential fatty acids helps to support joint care and reduce inflammation.


There is so much that we can do to help such as prioritising our sleep, working on our stress or our perceived stress, learning to say ‘no’, making time to move our body regularly, sorting out any gut and digestive issues and keeping up with regular health checks, tests and so on.


If you’re interested in learning more check out some of my other articles including Nutrition Advice for Perimenopause, What are Phytoestrogens and why do you need them? and managing stress part 1 and part 2.


This topic is so close to my heart. As I mentioned I have been going through perimenopause for a few years now and I am passionate about helping others navigate this time and make it as smooth as possible. I am opening the doors of my Happy Healthy Hormones online group programme again very soon. If you are experiencing any of the symptoms of perimenopause, menopause or hormonal fluctuation this is your chance learn how to manage those changes and start to feel like yourself once again.


Email us if you have any questions about whether Happy Healthy Hormones is right for you!

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