Perimenopause- The Untold Story

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 her 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. 

Perimenopause Facts:

-There are currently 59 ½ million women in the United States in the perimenopausal period between the ages of 39 and 53.

– Typically, perimenopause begins when a woman is in her forties, but may begin as early as the mid-thirties. 

-The average age for menopause occurs at 51.3 years. 

The mechanics of perimenopause are changes in the regular cycling of a woman’s hormones that she has been accustomed to since puberty.  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 creates physiological and emotional havoc.

A large majority of these women will endure significant emotional and psychological upheaval during their changes — such as depression, anxiety, issues with sexuality and body image, insomnia, job dissatisfaction, marital difficulties and frustration in other relationships-often leaving women with a diminished sense of contentment with life, in general.

Not all women experience perimenopause the same way.  For some women, perimenopause is relatively uneventful, bringing change but not to a disruptive level.  For other women, the strength of the perimenopausal changes can be of an intensity that brings significant distress. The good news is that the instability does stabilize over time.

Most women will pass through four psychological stages of perimenopause. I identify and define these as:

  1. Stage I Perimenopausal Initiation
  2. Stage II Emotional Disruption
  3. Stage III Turbulence
  4. Stage IV Quietude.

There is an increasing sense of internal distress and outward emotional unpredictability in Stages I through III.  Stage IV, Quietude, is when emotional lability begins to level out-leaving women as calm or calmer than before they entered perimenopause.

Many women in the menopausal transition also experience changes in their thyroid functioning, resulting in a decrease in their thyroid hormone levels. This adds to the challenging hormonal effects on mood and energy since hypothyroidism (low thyroid function) creates many of the same depressive and mood changing effects as perimenopause.

The relationship between changing female hormone levels and the body’s requirement for thyroid hormone is important to understand. When women’s estrogen levels are high, their bodies require more thyroid hormone. Conversely, when women’s estrogen levels are low, their bodies require less thyroid hormone. In women with healthy, well-functioning thyroids, this is not a problem since the thyroid secrets the appropriate amount of thyroid hormone to fit the body’s requirements. When the thyroid is not adequately functioning, as is common in the 40s and 50s, problems are likely to arise.

As women progress through perimenopause, their estrogen levels are changing frequently and drastically. This places a huge demand on the thyroid to manage the appropriate levels of thyroid hormone. When the thyroid is ailing, the level of thyroid hormone will be inadequate for the needs of the body. A visit to the doctor, even when blood work is done, may yield misleading results. If at the hour of the visit, your estrogen levels dip, the thyroid hormone level may appear adequate even though the thyroid may be grossly inadequate for those times that estrogen levels are high. At that time, the thyroid will not be able to keep up with the demand. Unless your doctor is familiar with the changing hormonal levels during perimenopause and how that interacts with your thyroid, he or she will likely miss the source of your symptoms.

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 and 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.

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.  A wonderful example of the frustrations that so many men experience is Frank, who was happily married for twenty eight years to his forty eight year-old wife.  In the throes of hormonal and emotional changes, his wife was miserable and Frank was distraught.   In a moment of utter helplessness, Frank implored  ‘help me to understand, Doc, I am just a laborer.  I don’t know what’s happening to my wife’. 

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.

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