Perimenopause: The Ovary’s Frustrating Grand Finale

Women in midlife increasingly hear the words “estrogen deficiency” spoken as the ultimate in bad news. Everyone knows that low estrogen levels cause heart disease, osteoporosis, Alzheimer’s and frigidity. But as Dr. Susan Love, the influential breast surgeon, feminist advocate and now deceased author of Dr.

Susan Love’s Hormone Book asserts, “If estrogen deficiency’s a disease, all men have it!”(1) Also, it is hard to see how “estrogen deficiency” even exists. Why? Because, progesterone deficiency would always occur before “estrogen deficiency” since an estrogen peak is required before the ovary can release an egg and produce progesterone during the menstrual cycle. https://www.scientificamerican.com/article/is-estrogen-deficiency-really-a-thing/

Our purpose here is, first, to put women’s midlife concerns into a new and more accurate hormonal picture. Specifically, I’d like to present information about high estrogen levels in perimenopause. Estrogen levels in perimenopause, in contrast to expectation, are not low, nor are they even normal. Rather they are higher than in the (sexiest) 20-something female!

Secondly, I’ll discuss how a woman can tell when her estrogen levels are high and out of balance with progesterone, the other important hormone for women.

Finally, we’ll review the many ways a woman can help herself through perimenopause, “Estrogen’s storm season” http://www.cemcor.ca/resources/estrogen%E2%80%99s-storm-season.

What is perimenopause?

Women (and experts) have often called “menopause” everything they experience during the changing times of midlife and beyond. “Menopause” may also be used in the same way as “postmenopause”; this happens when the word “menopause” is inappropriately used to mean the last menstruation.

Menopause, defined accurately, means that a year has passed since a woman’s last menstrual period.

Now, we know that perimenopause is different than menopause, but how are they different? These normal life phases differ because perimenopausal women have had a period or some uterine bleeding within the last year. Perimenopausal hormones are also variable and often high compared with the normally low, and more steady levels in menopause.

Figure 1 shows line drawings of about a month of estrogen levels during the menstruating years (premenopause), when cycles and experiences are changing in perimenopause, and during menopause that starts a year after the final menstrual flow.

Although things like hot flushes and night sweats (vasomotor symptoms, VMS) and sleep problems occur in both perimenopause and menopause, some experiences, such as heavy flow, premenstrual symptoms and sore breasts, are very different. The Centre for Menstrual Cycle and Ovulation Research and many women and experts believe that it is important to use accurate names in describing midlife women’s reproductive phases.

Perimenopause refers to the long and changing time until it has been a year since the last flow. The first changes may be more heavy flow, night sweats, and waking the middle of the night or increased premenstrual symptoms. On average, perimenopause starts in the mid-40s and ends from ages 40-59 or at the average age in the early 50s. Perimenopause may last a couple, to more than 10 years. It also may start in women with predictable month-apart cycles (“very early perimenopause”) in women who have night sweats, sleep troubles and another typical change http://www.cemcor.ca/resources/how-can-i-tell-i-am-perimenopause.

The good news is that perimenopause ends! https://www.tandfonline.com/doi/abs/10.1080/02646830600974071. I survived a rough perimenopause. When I was in that difficult time, I learned, from my experiences that the experts had it all wrong about low perimenopausal estrogen levels! Despite all the evidence, that wrong concept persists.

What’s the evidence that perimenopausal estrogen levels are high?

A dozen or so studies in the last 20 years have set out to measure estrogen hormone levels in perimenopausal women. When all of the studies are put together in what is called a meta-analysis that compares average perimenopausal estrogen levels with those in young women, it is clear that perimenopausal estrogen levels are higher, and significantly so(2).

Figure 2 illustrates that average, within-study-centre estrogen levels are significantly higher in perimenopause (red), than in premenopause (yellow), especially in the latter portion of the menstrual cycle when women are ideally normally ovulating. These data were graphed from a Table in Prior JC, Endocrine Reviews 1998;19:397.

“Perimenopause is characterized by dropping estrogen. . . levels”(4). They couldn’t “see” what they didn’t expect!

Figure 3 shows as bands of colour the levels of estrogen measured on cycle days 3-8 in 380 women who were ages 45-55 years. Menstrual Status Category 1 means regular periods, II and III changes in flow and cycle lengths, respectively, IV includes changes in both cycle lengths and flow, and V includes women 3 to less than 12 months without a period. Redrawn from(3).

The study we discussed above(3) also showed that a strange hormone called ‘inhibin’ was lower than normal. Inhibin is made by ovarian follicles (nests of estrogen-making cells surrounding an egg). Inhibin may decrease in midlife because the follicles have been in the ovary for longer. I believe the high estrogens in perimenopause occur largely because inhibin, the normal brake-type hormone, slacks off in its job of keeping the pituitary’s Follicle Stimulating Hormone (FSH) in line. FSH increases, stimulating many, rather than just a few, follicles at a time. The result is increased estrogen levels, lower progesterone and increased cycle unpredictability(3). All of the perimenopausal changes are because the “big plan” is to get rid of all the follicles left in our ovaries so that we don’t have periods in a nursing home.

How can a women know when her estrogen levels are high or out of balance with progesterone?

There are many clues and they differ between women, and in one woman over time. Early in the process of my perimenopause, I dreamed I was going to have a baby and woke thinking I had really lost it! At fifty, with my two children grown, the last thing in the world I wanted was to be pregnant. But after some thought, I began to understand that it was my subconscious self’s way of saying goodbye to the fertile part of my life.

Many of the things I felt in that dream, however, are also high estrogen signs: swollen and tender (sometimes lumpy) breasts, increased, stretchy vaginal mucus and a heavy pelvic feeling almost like cramps. High estrogen and progesterone levels in pregnancy are normal and necessary, but in the perimenopause, estrogen is high but progesterone is not. It is this imbalance that causes significant difficulties for many women.

Dr. Patricia Kaufert, a scientist from Winnipeg who decades ago did one of the best studies about what women experience during perimenopause, found that women were likely to have a flooding menstruation just before their periods changed from regular to skipping(4). But heavy flow, bleeding at shorter intervals than 3-weeks, continual spotting or flow with clotting and cramping are all signs that estrogen is too high and progesterone is too low. Any period is too heavy if you soak more than 16 pads or tampons.

It is sometimes normal to feel breast tenderness in the front or nipple area when estrogen hits its high midcycle peak. But swollen breasts most of the time, or front-of-the-breast soreness for more than a couple of days of a month, means high estrogen.

During perimenopause many women occasionally become forgetful and sometimes can’t remember what they were saying. We now know that stress makes for memory problems. And the high estrogen levels of perimenopause (on top of the stressors of this major life transition) make cortisol and other stress levels higher. No wonder it feels like PMS-city! One nurse said it very well, “At (peri)menopause life can turn into one long pre-menstrual experience. Hormones slap you up against the doors of your unfinished business”(5). (italics added)

Are hot flushes/flashes and night sweats (vasomotor symptoms) from low estrogen?

If monthly periods tell a woman that her estrogen levels are normal, and if vasomotor symptoms (VMS) are caused by low estrogen levels, how come so many perimenopausal women start having night sweats when periods are perfect? The answer is that the brain has become used to the young normal or higher perimenopausal estrogen levels; when estrogen drops, the brain rebels. What happens with a hot flush is like what a drug addict goes through during withdrawal — a major brain discharge of stress and other hormones. It is this stress hormone discharge that causes the anxious feelings, nausea and chest pain as well as the feeling of heat/sweating that go with VMS. Also, randomized controlled trial evidence shows that life stress also triggers hot flushes. So, if someone tells you your night sweats are all in your head, just tell them, “you’re darn tootin they are”!

I first twigged that I was perimenopausal when I woke abruptly one dark November morning feeling MAD! I looked for a cause — my dog and my partner were sleeping soundly, all was quiet in the house and the neighborhood. But my heart was pounding, my legs wouldn’t lie still and I was ready to do battle. Then I felt a weak and woozy wave of heat and began to sweat. A day later my period started, and I had no more night sweats until the day before my next period. I had learned an important thing — in the “very early perimenopause” when periods are still regular, night sweats are a clue that your period is coming.

Another new observation is that women who have increased premenstrual symptoms early in perimenopause are more likely to have a difficult time with VMS later. That information came from information discovered in the same Australian study we talked about earlier(6). We also have recently learned that downward estrogen swings trigger the negative moods that perimenopausal women sometimes experience.