In her 40s, Karen Cummings started to notice a shift in her menstrual cycle. The New Yorker’s typically mild and consistent symptoms had been replaced by bloating, emotional swings and overwhelm before she entered menopause five years ago, at 52.
She thought she might need to switch up her birth control. Her doctor suggested an antidepressant. But the symptoms seemed tied to her menstrual cycle. “I’m not depressed,” she remembers thinking. “I’m on the wrong birth control.”
Dr Brittanny Keeler, an OBGYN in Buffalo, New York, often has patients show up with menopausal symptoms feeling hopeless. It can feel like “falling off the cliff”, she said. “They don’t understand what’s happening to them.” Often, they are told they need to wait until their period stops to start treatment.
In the US, the average age of menopause, or the period of one’s life where reproductive hormones decline and menstruation ceases, is 51. Perimenopause can start seven to 10 years beforehand. People who menstruate may start to notice symptoms like insomnia, hot flashes and mood changes in their late 30s and early 40s. These add to other life pressures, including a career in full swing and family commitments. “The divorce rate spikes for this group,” Keeler said. Perimenopause “is absolutely a contributing factor”.
Many doctors do not fully diagnose the cause of these symptoms. Keeler, who was just awarded the credential of certified menopause practitioner by the North American Menopause Society, said: “We see a massive increase in the amount of antidepressants that are prescribed around the mid 40s. A lot of women are not getting the treatment that they really need.”
Plenty of people benefit from mental health medication. But it is not the full story when it comes to treating perimenopausal symptoms, nor does it sufficiently address hormonal fluctuations. It is extremely common to be met with a dismissive diagnosis and subsequent SSRI prescription for depression and anxiety without any acknowledgment of perimenopause.
Cummings found a new doctor and shared the same information: symptoms and her curiosity about other birth control options. Her doctor said: “You need another birth control. You’re on the wrong one.” Her doctor reassured her they would keep trying until they found the right birth control for her current needs. Cummings said: “It was just such a simple thing.”
What are the common symptoms of perimenopause?
Menopausal symptoms can occur much earlier than people think. “Perimenopausal women are actually some of the most symptomatic people because of the wild fluctuations in their hormones,” Keeler said.
“When someone is in perimenopause, the ovaries are still working, but not in that nice, very predictable fashion that they did before, where you’d have your monthly cycles,” she said. “They’re sending out some estrogen and not getting the response they want, so they’re sending out even more.” This can result in no ovulation at all some months or twice in others; the latter is known as experiencing an out-of-phase cycle.
Symptoms are different for everyone but can include mood changes and erratic bleeding like shorter, lighter cycles or heavier, longer cycles. Hot flashes and night sweats may also occur closer to the period. Insomnia is very common as well. It may not be hard to fall asleep, but staying asleep through the night is challenging.
Perimenopause is clinically defined by a seven-day variance in menstrual cycle and typically lasts four years. “It’s a gradual shift,” said Dr Katie Unverferth, director of UCLA’s Women’s Life Clinic and a psychiatrist focusing on reproductive psychiatry and women’s mental health. But fluctuations in ovary function can start well before that level of variance.
“This hormonal dysregulation can lead to a lot of mood symptoms,” Unverferth said. It’s fairly common to experience mood changes, popularly referred to as premenstrual symptoms, or PMS, during the luteal phase, which lasts longer as women age.
Patients may feel “all over the place”. Anxiety, depression, insomnia and cognitive complaints like memory issues might occur. “Many say that they don’t feel like themselves, and it’s really hard to pinpoint why,” Unverferth said.
“The greater the hormonal changes, the greater the risk of depression,” Unverferth said. These severe fluctuations in hormones also show up in premenstrual dysphoric disorder (PMDD) and during pregnancy and postpartum. “But once you hit menopause and that change is done, the depression risk goes back down.”
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How do you treat symptoms during perimenopause?
“Menopause is more straightforward to treat than perimenopause, because with menopause, we just give you back what you’re not making,” Keeler said. Menopausal hormone therapy (MHT), formerly referred to as hormone replacement therapy (HRT), replaces the progesterone and estrogen that declines during menopause. This can help alleviate symptoms like hot flashes, night sweats, brain fog, vaginal dryness and mood swings. It also lowers the risk of heart disease, osteoporosis, diabetes and dementia.
But, in some circumstances, MHT is not sufficient treatment for those in perimenopause. “Not only do we need to manage symptoms, but we also have to support the uterine lining to prevent erratic bleeding caused by fluctuating hormones, which can sometimes happen with menopausal dosing because it’s too low, and then, some women also still need contraception,” Keeler said.
“Birth control pills are actually awesome for people who are experiencing [perimenopause symptoms], especially mood fluctuations, because birth control pills will suppress ovulation,” she said, and the ovaries will no longer try to take the body through the menstrual cycle.
But not everyone is a candidate for hormonal treatments, such as those who have had a heart attack or experienced blood clots. Treatment should be individualized and developed through a consultation with a healthcare provider.
Additionally, people who have existing mental health issues or a low tolerance for subtle health changes can really struggle with perimenopausal symptoms like having hot flashes in public or sleep issues, and may believe they are “embarrassing and shameful”, Unverferth said. “Cognitive behavioral therapy specifically for perimenopausal symptoms can be really helpful.”
Research has shown that antidepressants can be effective when it comes to emotional symptoms. According to Unverferth, one 2011 study found that, for instance, the antianxiety and antidepressant medication Lexapro and hormone therapy together helped with hot flashes, night sweats, sleep and quality of life. “Typically, antidepressants are still first line for depression and perimenopause, but for someone who’s having treatment-resistant depression or very severe depression, or someone who’s also having insomnia or night sweats, we would definitely consider hormone therapy,” she said.
Awareness and access to treatment options are essential, but MHT, birth control and non-hormonal options like antidepressants are not cure-alls. “If you’re not taking good care of yourself – eating well, prioritizing your sleep, exercising – you’re not going to get as much benefit out of this as you’re hoping for,” Keeler said. She emphasized strength training for those in their 30s and those experiencing perimenopause and menopause since it can counteract muscle mass loss and bone health decline during menopause.
Reproductive health, particularly in terms of perimenopause and menopause, is not solely the responsibility of OB-GYNs. “The entire healthcare system is flawed. We’re just not allotted enough time to focus on prevention with patients,” Keeler said. Not all doctors can specialize in everything, but they should recognize perimenopausal symptoms and know where to send patients for care. Those entering this transition should consult their primary care doctor, and consider talking to an endocrinologist and even an orthopedist. “This [transition] affects all organ systems, and so all physicians have a responsibility to whatever specialty they’re in to at least recognize the symptoms, even if they aren’t equipped to manage them,” Keeler said.
