How to recognize perimenopause
April 1, 1998 4 minutes read
How to recognize perimenopause
By Penelope Morrison Bosarge, RNC, CRNP, MSN
Women's Health Nurse Practitioner
Teaching Faculty, Graduate Programs
University of Alabama School of Nursing
Birmingham
How many times have clinicians been asked, "Am I going through the change?" That question arises at any point in a woman's life when she experiences signs historically associated with menopause.
Menopause doesn't happen spontaneously. Rather, it is a much more complex sequence of events that transcends several years, resulting ultimately in total cessation of menses. Caught up in this maze of somatic, physiological, and psychological events is a mysterious, ill-defined period we refer to as perimenopause.
The diagnosis is complex, with seemingly unrelated signs and inconclusive laboratory results. Patients may go from provider to provider to find answers, but instead they get a new prescription at each stop with little explanation other than, "It's just your nerves. Keep busy; do volunteer work."
Perimenopause is defined as a period of menstrual irregularity, possibly with increasing episodes of amenorrhea, culminating in natural menopause.1,2 This period is said to begin when there has been a change in cycle pattern from the premenopausal pattern. This change can be shorter, longer, or variable.
One estimate is that perimenopause begins at 47.5 years and lasts 3.8 years - about four years before permanent cessation of menses. During that time, the woman will experience more than just menstrual changes, which may pale in comparison to the myriad other symptoms she will encounter.
The age of natural menopause has remained fairly consistent from medieval times, when literature reported the age as 50,3 to the present, with reliable estimates at 50.1 to 51.5 years.4 Smokers begin perimenopause earlier and will have a shorter transition period, from 18 months to two years.5
Most changes associated with perimenopause are normal. Providers should refrain from calling these changes "symptoms," since the term suggests a disease process. A healthy attitude will result from proper education and attention to helping women understand the changing menstrual function as entirely normal. Pathology, however, must be ruled out.
· History: This is the most important diagnostic tool; for if providers listen to patients, they will tell them what's wrong. The history should include basic medical and surgical information and focus on menstrual history, medications, and signs experienced. Somatic signs include night sweats, insomnia, headaches, muscle pain, and palpitations. Physiological ones include tension, mood swings, fatigue, and concentration problems.
· Physical: This should be within normal limits.
· Laboratory: There are fluctuating levels of follicle stimulating hormone (FSH) and lutenizing hormone. You can measure postmenopausal levels of FSH and still see evidence of normal ovulation and luteal function.6 These levels also can accompany hot flushes, followed by spontaneous disappearance of the flushes with gonadotropin and urinary estradiol levels returning to that of regular cycling women. There seems to be no way to distinguish between menopausal and this transient amenorrhea; therefore, hormonal status cannot be truly diagnostic of menopause until menses have been absent for one year.7
How can providers tell if a patient is going through "the change"? Since there seem to be no reliable tests or remarkable physical findings, they must rely on the history. The hallmarks of perimenopause are the menstrual changes as described in the definition. While 10% of women stop their menses abruptly, the remainder experience various irregularities. Urogenital changes, such as atrophic changes leading to loss of lubrication, usually occur later in the transition and should be addressed before they become a problem.7
Vasomotor instability, the "hot flash," is characterized by an aura signaling an abrupt change in core temperature, peripheral dilation, and a transient increase in heart rate. This state lasts for several minutes wherein the skin becomes red and there is profuse perspiration. There is no correlation between levels of estrogen or gonadotropin and this sign. The mechanism is unknown but is thought to be related to the rapid decline in estradiol rather than a prolonged low level. The catecholamines, when altered, modulate mood and may play a role in vasomotor instability.
Sleep disturbances are common in perimenopause and seem to be correlated with hot flashes and disturbed rapid eye movement sleep.8 Frequent awakenings may lead to fatigue, irritability, and mood changes.
The idea of perimenopause as a specific psychiatric disorder (involutional melancholia) has been abandoned. Many studies have failed to link depression with perimenopause. In fact, there is less depression in women in their middle years. Loss of sleep can result in any of the psychological changes. The Seattle midlife women's health study found dysphoric moods are not related to vasomotor instability or insomnia but may be the result of stress, overwork, an ongoing emotional illness, or a chronic disease process.9
Perimenopause can be a time of positive energy and personal growth, even while experiencing multiple discomforts. Being aware of the normalcy of perimenopause can make the progress toward natural menopause an easier road.
References
1. Speroff L, Glass RH, Klase NG. Clinical Gynecologic Endocrinology and Infertility. Baltimore: Williams and Wilkins; 1994.
2. McKinlay SM, Brambilla DJ, Posner JG. The normal menopause transition. Maturitas 1992; 14:103-115.
3. Amundsen DW, Diers CJ. The age of menopause in classical Greece and Rome. Hum Biol 1970; 42:79-86.
4. Bengtsson C, Lindquist O, Redvall L. Is the menopause age rapidly changing? Maturitas 1979; 1:159-164.
5. McKinlay SM, Bifano NL, McKinlay JB. Smoking and age at menopause in women. Ann Intern Med 1985; 103:350-356.
6. Burger HG. The endocrinology of menopause. Maturitas 1996; 23:129-136.
7. Metcalf MG. The approach of menopause: a New Zealand study. NZ Med J 1988; 101:103-106.
8. Ware J, Wooten V. Sleep dysfunction in postmenopausal women. Menopausal Med 1995; 3:9.
9. Mitchell ES, Woods, NF. Symptom experiences of midlife women: observations from the Seattle Midlife Women's Health Study. Maturitas 1996; 25:1-10.
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