Most are familiar with menopause—which is when a woman ceases to have periods. But perimenopause—also called a menopausal transition—is the time when periods start to change and become less frequent. They may be heavier than they used to be, too.
Perimenopause lasts about four years and ends when a woman has her final period.
“Basically, menopause is when people stop having a period for a year, and perimenopause is when you don’t have regular ovulation anymore,” explains Walter Evans, M.D., OB/GYN and physician on the medical staff at Texas Health Presbyterian Hospital Dallas.
“As hormones fluctuate and change, women can experience hot flashes and even depression,” he continues. “Some women have severe symptoms, and some cruise through perimenopause and menopause with no problems at all.”
The average age of menopause is 51 years, although the age range can vary between approximately 45 and 55 years.
As they head into menopause, some women will experience a gamut of symptoms, including hot flashes, night sweats, sleep disruptions, vaginal dryness and depression.
“If a woman is having a tougher time with it, we can do hormone replacement—usually estrogen,” Evans said. Hormone therapy usually involves a combination of estrogen and progestin and can be taken in pill form, or by skin patch, vaginal ring, skin gel, cream or spray.
Hormone therapy has been shown to help alleviate symptoms like hot flashes, vaginal dryness and depression.
“We used to prescribe oral estrogen, but we found that it increased clotting,” Evans said. “Now we prefer non-oral routes like transdermal patches and gels that can last for four months for more sustained levels of hormone activity.”
Combinations of hormones formulated with the estrogen-like compounds estradiol and estriol, as well as progesterone and testosterone, can also be administered in pellet form and implanted in the hip. (The pellets are larger than a grain of rice, but smaller than a Tic Tac mint.) The hormones are then gradually released in the body over an extended period of time. The popular treatment BioTE is one such pellet-type formulation.
“BioTE can help with decreased libido and energy,” Evans said.
Low-dose oral contraceptives can help perimenopausal women regulate their periods as well, he said.
Evans says that many women are aware that, for a time, estrogen supplements were considered worrisome because of links to cancer, heart attack and stroke. But he says that newer research reveals that working with your doctor early can not only reduce the risk of those potential side effects but also provide relief for symptoms.
“With menopause, they tried to make estrogen out as a villain,” he explains, “but when they did the 2013 Women’s Health Initiative study and reanalyzed the data, the women who took estrogen alone had less cancer than the placebo.”
Evans says that research shows that women who start hormone replacement therapy within five years of the onset of their symptoms did not have increased risk of heart attack and stroke.
And not every woman will need the same kind of hormone replacement therapy.
“You can use site-specific hormones,” Evans said. “For instance, if you’re mainly experiencing vaginal dryness, uncomfortable sex, or problems with urine control, you can use vaginal estrogen creams.”
And while some women will still be wary of hormone replacement, and might even be tempted to try herbal supplements, Evans says he likes to remind patients that hormones are natural.
“None of the herbs have been proven to work like estrogen,” he says, “and estrogen is a naturally-occurring hormone.”
But not every woman will need hormone replacement therapy, either.
“If you go into menopause and feel great, there’s no compelling evidence that your life is going to be better with hormones,” Evans says. “But if you’re really suffering, you should talk to your doctor.”