Three in the morning, and you are awake again. The blanket is kicked down to your feet and the back of your neck is damp with sweat, even though the fan is running as it does every night. Then you lie there tossing and turning until it starts to get light. The period tracker on your phone says your period came five days early this month, and three days early last month. In the afternoon you open the fridge and just stand there, unable to remember what you came for.
Women over 35, and especially over 40, often put these things down to a heavy workload, young children and aging parents. Those reasons are usually real. But they can also be early signs of perimenopause (also called the menopause transition), when the ovaries start to work differently than before.
How hormones change after 35
The ovaries carry a set number of follicles (the small sacs that hold eggs) from birth. That number falls over time and is never replaced. When few follicles are left, the pituitary gland in the brain has to send a stronger signal to push the ovaries (the hormone FSH), and the ovaries no longer respond as evenly as before.
So hormone levels rise and fall unpredictably from one month to the next. In some months estrogen runs higher than usual, and you may have tender breasts, a heavy period and a short temper. In other months no egg is released, and the body lacks progesterone, the hormone made after ovulation that helps keep the cycle regular and sleep settled. Periods then drift easily, sometimes early, sometimes late.
Early signs that are easy to miss
Symptoms at this stage are very common. Santoro (2016) reports that nearly 90% of women around menopause have gone to a health professional to ask how to cope. The catch is that the first signs are often small and easy to mix up with everyday life.
Your cycle
- Your cycle is a few days shorter than it was for many years;
- Cycle length varies by 7 days or more, and this keeps happening (the marker for the early menopause transition in the STRAW+10 staging system, Harlow and colleagues, 2012);
- The amount of bleeding changes, heavy one month, light the next;
- Breast tenderness before your period is more noticeable than before.
Once you have gone 60 days or more without a period, this system places you in the late stage of the transition.
Sleep, mood and memory
- Waking often in the night and finding it hard to get back to sleep;
- Getting irritable or hurt easily, or feeling anxious for no clear reason;
- Forgetting things and finding it hard to concentrate, even on familiar tasks.
Your body
- Hot flashes, a feeling of heat rushing up to the chest, neck and face, with sweating;
- Night sweats that soak your collar or pillow;
- Vaginal dryness, pain during sex, lower sex drive;
- Drier skin than before.
Most women have hot flashes at this stage, and about one in three find them moderately to severely bothersome. Vaginal dryness and pain during sex affect about one in three women in the late stage and do not go away on their own without treatment (Santoro, 2016). Many people feel shy about bringing this up, even with a doctor.
Why symptoms tend to come together and can last a long time
These symptoms feed into each other. People who are feeling low tend to have worse hot flashes and sleep less well (Santoro, 2016). A hot flash in the middle of the night wakes you up, so you are tired in the morning, irritable and forgetful by the afternoon. Many nights of poor sleep pull your mood down, and a heavy mood in turn makes sleep harder.
In the SWAN study of 3,302 women, Avis and colleagues (2015) found that frequent hot flashes and night sweats lasted a median of 7.4 years, meaning half of the women had them for less time and half for longer; counted from the final menstrual period, the median was 4.5 years. They usually lasted longer in women whose hot flashes began while their periods were still regular, and in women who were stressed, low or anxious when the symptoms started.
A median cannot tell you how long it will last for you in particular, and research has not shown that reducing stress will shorten hot flashes.
Conditions that look like perimenopause
Some other conditions also cause tiredness, poor sleep, palpitations and period changes:
- Thyroid disease, both an overactive and an underactive thyroid;
- Anemia, common in people with heavy periods;
- Depression, with lasting low mood and loss of interest.
The doctor will usually order tests to tell these apart. Long-term stress can also cause tiredness and sleeplessness (read more about stress).
When to see a doctor sooner
Don’t wait for your routine check-up if you have:
- Bleeding between periods or after sex;
- Bleeding after menopause, however light, even just once;
- Very heavy periods, or periods lasting more than 7 days;
- Low mood lasting several weeks, with loss of interest in almost everything.
Heavy periods and the iron deficiency that often comes with them are covered in detail in our article why periods can be heavy. If you have thoughts of harming yourself, tell someone close to you right away and go to the nearest medical facility.
How traditional medicine sees this stage
The classic text Su Wen (素问 / 素問, Sù Wèn, Basic Questions), in its chapter Shang Gu Tian Zhen Lun (上古天真论 / 上古天真論, Shàng Gǔ Tiān Zhēn Lùn, “Ancient Natural Truth”), divides a woman’s life into stages of seven years. At “five sevens” (五七, wǔ qī), age thirty-five, the Yangming channels (yáng míng mài) begin to weaken, the face loses its freshness and the hair starts to fall. At “seven sevens” (七七, qī qī), age forty-nine, the Conception vessel (rèn mài) becomes deficient, the Chong vessel (chōng mài) declines, tian gui (天癸, tiān guǐ) runs dry and menstruation stops. Tian gui is an essence nourished by Kidney qi that governs having periods and having children.
As Kidney qi gradually declines, some women lean toward yin deficiency and others toward yang deficiency. Three patterns are common at this stage:
- Kidney yin deficiency (肾阴虚 / 腎陰虛, shèn yīn xū): hot flashes, night sweats, hot palms and soles, dry mouth, ringing in the ears, aching lower back and knees;
- Heart and Kidney failing to communicate (心肾不交 / 心腎不交, xīn shèn bù jiāo): trouble sleeping, vivid dreams, palpitations, forgetfulness, an inner restlessness;
- Spleen–Kidney yang deficiency (脾肾阳虚 / 脾腎陽虛, pí shèn yáng xū): dislike of cold, cold hands and feet, tiredness, poor appetite, loose stools.
Many women have hot flashes and also dislike the cold, which means both yin and yang are deficient. The doctor identifies the pattern through the four examinations: looking, listening, asking and taking the pulse.
What a visit with Dr. Tam includes
Dr. Pham Tran Dan Tam (MD, Specialist Level I in Traditional Medicine) asks about your cycle over the past few months, your sleep, your mood, and the waves of heat by day and by night. Your intimate life, if you are willing to share it, is also worth talking about, because vaginal dryness can be treated. Then comes a clinical examination by modern medicine and the four examinations of traditional medicine. Depending on what she finds, the doctor may suggest:
- Reproductive hormone tests, read together with your period record, because hormones at this stage swing from month to month;
- Thyroid function tests;
- A complete blood count if anemia is suspected;
- A pelvic ultrasound to look at the uterus, its lining and the ovaries.
Dr. Tam also uses Applied Kinesiology (AK) muscle testing to check for stress in the frontal lobe, the limbic system and the cingulate gyrus. To choose the herbs and minerals that suit you, the doctor has you hold a very small amount of each against your body, then retests the muscle to compare. Muscle testing is an addition; it does not replace lab tests or ultrasound, and the doctor reads all the results together when planning treatment.
Care during the transition
Lifestyle
Stuenkel and colleagues (2020) see perimenopause as a chance to start changing your lifestyle and protect your health for the years ahead. A few practical steps:
- Move regularly, such as brisk walking, swimming or yoga, plus a few exercises to keep your muscles strong; eat enough protein, vegetables and fruit, and cut back on alcohol and afternoon coffee;
- Go to bed and get up at the same time, keep the bedroom cool and airy, and keep a towel and a glass of water by the bed;
- Make time to rest, and talk with someone you trust when things feel heavy.
Herbal decoctions, acupuncture and moxibustion
An herbal decoction is prescribed according to the pattern: nourishing Kidney yin when yin is deficient, restoring communication between the Heart and Kidney when poor sleep and palpitations stand out, and warming and tonifying the Spleen and Kidney when yang is deficient, then modified after each follow-up visit. Acupuncture is used in the hope of supporting sleep and easing tension; evidence specific to perimenopause is still limited, so Dr. Tam monitors your response at each follow-up visit. Moxibustion (warming points with burning mugwort) suits the yang-deficient pattern better, and for people with a lot of internal heat the doctor weighs it carefully.
If you are taking conventional medicines or hormones for another condition, give the list to the doctor, because some herbs can change how they work (Ulbricht and colleagues, 2008).
When hormone therapy is worth considering
Santoro (2016) describes two approaches: short-term hormone therapy, and non-hormonal options, including behavioral changes. When symptoms affect your life a great deal, Dr. Tam works with gynecologists and endocrinologists to help you weigh the benefits and risks based on your own and your family’s medical history.
Frequently asked questions
At what age does perimenopause start?
There is no single age. Many women begin to notice changes in their 40s, but it can come earlier or later for each person. If your periods become less frequent or stop while you are still fairly young, see a doctor early.
If my periods are still regular, could I already be in perimenopause?
Yes, you could. In the SWAN study, some women began having hot flashes while their periods were still regular (Avis and colleagues, 2015). At this stage you may still ovulate in some cycles, so if you don’t want to become pregnant again, you still need contraception, and should ask the doctor when it is safe to stop.
Should I buy hormone pills or “hormone-boosting” products on my own?
No. Abnormal bleeding, thyroid disease, and conditions of the uterus or breast need to be examined first, and products that act like hormones are not suitable for people with certain medical histories. Bring the product box with you to your visit so the doctor can check the ingredients.
Worth keeping
- Keep a record of your periods for at least three months: start date, number of bleeding days, and how heavy;
- Also note the number of hot flashes and how many times you wake in the night;
- See a doctor early if you bleed between periods, after sex or after menopause;
- Tell the doctor about vaginal dryness and about the low days, too;
- Walk briskly or do an activity you enjoy, regularly every week;
- Don’t take hormone pills or “hormone-boosting” products on your own before being examined.
When your cycle starts to change and your sleep is no longer as settled as it was, you can bring your period record to Dr. Pham Tran Dan Tam for an examination and a care plan that suits you.
References
- Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. J Clin Endocrinol Metab. 2012;97(4):1159-1168. https://doi.org/10.1210/jc.2011-3362
- Santoro N. Perimenopause: from research to practice. J Womens Health. 2016;25(4):332-339. https://doi.org/10.1089/jwh.2015.5556
- Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-539. https://doi.org/10.1001/jamainternmed.2014.8063
- Stuenkel CA, Santoro NF, Laughlin-Tommaso SK, et al. NAMS 2019 Pre-Meeting Symposium: The Perimenopause. Menopause. 2020;27(7):735-745. https://doi.org/10.1097/GME.0000000000001571
- Ulbricht C, et al. Clinical evidence of herb-drug interactions: a systematic review by the Natural Standard Research Collaboration. Curr Drug Metab. 2008;9(10):1063-1120. https://doi.org/10.2174/138920008786927785
