Perimenopause, the 2 to 10 years preceding the cessation of menses, challenges forty to fifty year old women with the most turbulent hormonal changes since puberty. Such hormonal changes have an enormous impact, not only on her body and how it functions, but on a woman's emotional state, as well.
Far too many women think of events related to menopause as being a concern only for those in their middle to late forties or early fifties. More enlightened women, who are familiar with ‘Perimenopause’ too often think of it only in terms of hot flashes, night sweats, menstrual changes and some occasional mood swings. The majority of women, including those who are very well informed, are frequently shocked to learn how global the effect hormonal changes can make on depression, anxiety and overall life satisfaction. Even more important, are the interactive effects of how life challenges and hormonal events can combine to create additional misery, not just for women, themselves, but for their loved ones.

The physiology of perimenopause

The mechanics of Perimenopause are changes in the regular cycling of a woman’s hormones that she has been accustomed to since puberty. Before women notice changes in their menstrual cycles, the hormones, estrogen and progesterone are shifting. Because their menstrual cycles appear unchanged, women often do not realize they are in Perimenopause. Most women do not know that even though they are menstruating, they may not be ovulating, throwing their hormones, and subsequently their moods, out of balance.

When women are in their late thirties, their ovaries begin to rid themselves of their eggs by releasing more and more eggs each month. Eventually, as women progress through their forties, there are a diminished number of follicles available for ovulation each month, until there are no egg follicles left at all. When Perimenopause begins, women begin having annovulatory cycles (cycles in which no ovulation takes place).

These changes in the menstrual cycle do not follow a linear pattern. A woman may have months of normal cycles followed by a stretch of irregular cycles. There may be cycles in which she does ovulate followed by any number in which she does not. There may be cycles in which she feels she is ovulating, but there is actually no egg follicle maturing. Some women have a pattern of one month normal, and the next irregular. Any type of pattern is possible. Regardless of whether or not she ovulates, she may still menstruate.

An irregular pattern of hormonal fluctuations, beginning with a significant rise in levels of estrogen and ending with a gradual overall decrease in estrogen and progesterone is activated. The most troublesome aspect of this change is that the decrease in hormones is neither linear nor predictable. It is the erratic rise and fall of the hormones throughout Perimenopause that create physiological and emotional havoc.

The Psychology of Perimenopause

Progesterone and estrogen, while responsible for female sex characteristics (the female body and procreation), are also highly influential in our moods. Progesterone is the 'feel good' hormone; it is the calming, soothing antidote to the very energizing (and sometimes stress-inducing) estrogen. It is during ovulation that calming progesterone is produced and released. When there is no ovulation, there is no production of progesterone, leaving women without one of their most calming hormones. This may result in women feeling stressed, high-strung or very much on edge.

Simultaneously, “estrogen”, which is actually comprised of three different types of estrogen, begins to shift radically. Estradiol, one of the estrogens, which evokes nurturing and maternal behaviors rises sharply during the follicular phase of a woman’s menstrual cycle then drops. Estriol, important in facilitating sexual activity through the maintenance of vaginal tissues, is highly responsive to stress, decreasing as stress increases. This is even more of a problem with Estrone levels, the third estrogen. Estrogen levels decrease over the course of Perimenopause but vacillate wildly on their way down, sometimes spiking to very high levels. In a given day, estrogen levels may be high and low… a number of times.

The overall pattern of progesterone dropping and estrogen vacillating un predictably, leaves women very vulnerable to emotional distress. This shifting of the female hormones has a global effect on our feelings-including calmness, anxiety, depression, the desire to nurture, our romantic and sexual desires, and how productive we feel. It also affects sleep, job satisfaction and can create marital difficulties and frustration in other relationships. Consequently, when the hormones shift, so will women's moods, leaving a large majority of women with significant emotional and psychological upheaval during their changes and a diminished sense of contentment with life, in general (Table 1).

Psychological stages of perimenopause

Most women will pass through four psychological stages of Perimenopause. There is an increasing sense of internal distress and outward emotional unpredictability in Stages I through III. Stage IV, Quietude, is when emotional liability begins to level out-leaving women as calm or calmer than before they entered Perimenopause. I identify and define these as:

Stage I: Perimenopausal Initiation is characterized by minimal changes in the menstrual cycle, a slight worsening of PMS, a lower threshold for tolerating unpleasantness, heightened emotional reactivity, increased distractibility and forgetfulness and the first signs of a declining libido.

Stage II: Emotional Disruption brings heavier but still regular periods with worsening PMS and mid-cycle cramping. Symptoms of anxiety, sadness and depression increase and women begin to feel a need to “escape”. The degrees of distractibility and forgetfulness become intrusive and disruptive. Interest in sex decreases while there is an increased need for non-sexual contact.

Stage III: Turbulence is when the menstrual cycle becomes quite irregular in flow and frequency. PMS may be quite severe. There is intense and unpredictable mood liability with a significant increase in anxiety and depression. Some women become explosive and there is a sense of over-reacting both internally and to those around them. There is also an increased risk of panic attacks, OCD and other mood disorders, leaving women feeling as if they are in an emotional tornado. During Turbulence, many women suffer from insomnia and disturbing dreams, and libido is at an all time low. This is the most difficult and challenging stage of Perimenopause.

Stage IV: Quietude defines the end of Perimenopause and the entry into menopause. Menstruation ceases and moods begin to stabilize. Anxiety and depression return to pre-menopausal levels or lower. Concentration rebounds and libido returns but is more sensually as opposed to sexually driven. While vasomotor symptoms (hot flashes and night sweats) are increasing, most women feel an increasing sense of tranquility and empowerment.

Environmental challenges

If this isn’t enough… simultaneous to these vast hormonal changes, the typical 40 to 50-something year old woman is coping with some hefty emotional events. These include: the loss of her fertility, changing sexuality, aging parents, the emptying of her nest with the resulting significant changes in her perspective on herself, her spouse and her self-defined meaningfulness. She is vulnerable to suffering an identity crisis equivalent in magnitude to one experienced in the teenage years. In addition, she will likely have stressful and challenging financial struggles as she manages both college tuitions and preparation for retirement. She is in the process of developing an entire new self as she evolves and redefines herself both physiologically and psychologically.

Treatment and support

There is much that can be done to help women manage the storm of Perimenopause, from balancing their hormones to changing their diet and activity levels. Two popular methods used in helping women balance their shifting hormone levels, are supplementing their diets with estrogen-rich foods such as soy, legumes, lignans and coumestans. These phytoestrogens have estrogenic properties that are effective in reducing some of the unpleasantness of perimenopausal symptoms. The second commonly used method is adding bioidentical hormones, which are derived from plants and mimic the body’s natural hormones, but in smaller amounts.

Exercise, energy therapies, for example acupuncture, mind-body therapies which include yoga, meditation, psychotherapy, relaxation therapy and psychotropic medications have all been successfully used to help women pass through this very difficult stage of life a bit more easily.
While women struggle through this difficult transition, their loved ones are struggling, too. Husbands and children have even less of an understanding of what is going on than the women, themselves. Because of the hardship suffered by the women and the hardship imposed on the loved ones of the women making this transition, it is important for the whole family to speak openly, share informational materials and find ways to mutually support one another. With this type of approach, rather than becoming a destructive force that strains a family’s strength and well being, a family can discover new strength and methods of mutual support, allowing all to transition to a happier, stronger place.

None.

None.