How to ease the symptoms of perimenopause

Every woman who lives long enough will go through the menopause. The perimenopause describes the transitional period into the menopause, and it is where most women first experience symptoms. There are a number of options to help manage and relieve these symptoms, both through clinical services and at home.

"Perimenopause means 'around menopause' and refers to the time during which your body makes the natural transition to menopause," explains Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists (RCOG).

Otherwise known as the 'menopause transition', perimenopause is the period of change from a woman's reproductive years to postmenopausal years, whereby her ovaries lose their productive function and ability to conceive children diminishes. This process usually comes about naturally with age, as the store of eggs in the ovaries decreases and less oestrogen is produced.

Women's Health Concern (WHC) describes this transition as gradual, pointing out that "the body does not stop producing oestrogen overnight, and the process can even take several years, during which symptoms arise gradually."

The average age at which women start the perimenopause is 46 years, with the menopause normally occurring between the ages of 45 and 55, according to official National Institute for Health and Care Excellence (NICE) guidance. Premature menopause describes women who start before 40 years.

There are also other factors that can trigger menopause besides ageing. These include premature ovarian insufficiency, chronic health conditions, and the removal of ovaries either to reduce risk of certain cancers or to remove the pain associated with endometriosis or other conditions.

Once the perimenopause begins, there are many possible symptoms. Every woman's experience with these is different, including the number of symptoms she has, how frequently they occur, and how much discomfort, pain, or disruption they bear on her life.

What symptoms may you experience?

The reason for experiencing symptoms during perimenopause is down to your hormones. Two hormones called oestrogen and progesterone have the task of regulating your menstrual cycle. Morris describes what happens:

"During perimenopause, hormone levels are gradually declining, resulting in changes to periods and menopausal symptoms. Hormone levels constantly fluctuate in the lead up to the menopause, which is why menopausal symptoms can be inconsistent, and change from one month to the next." 

Dr Paula Briggs, consultant in sexual and reproductive health, highlights that the symptoms of this process can be physical as well as cognitive:

"Low mood, anxiety, difficulty coping and decreased sex drive are some of the symptoms that might not be as much in people's minds when anticipating symptoms. This is why having access to the right knowledge and right sources is important."

With such a wide range of symptoms that could indicate the start of perimenopause, it's important to know what to look for and to consult your GP if you're struggling. Possible symptoms include the following:

  • Irregular periods.
  • Heavy bleeding during periods.
  • Hot flushes.
  • Night sweats.
  • Poor sleep.
  • Vaginal dryness and discomfort during sex (urogenital atrophy).
  • Bladder problems (eg constant urges to relieve bladder, pain and leakages).
  • Joint or muscle pain.
  • Headaches.
  • Racing heart (palpitations).
  • Changes in the hair or skin.
  • Loss of interest in sex (low libido).
  • Emotional instability (including mood swings involving irritation, anger and sadness).
  • Anxiety (including trouble coping in situations that were once fine, worsening phobias).
  • Depression (including lower moods than previously experienced, and lack of motivation).
  • Forgetfulness.
  • Poor concentration.

For some women these symptoms are short-lived. But for many, they can continue for many years.

The importance of quality information and support

In a survey by the British Menopause Society (BMS), 50% of women felt that the menopause - and perimenopause - had affected their home life and their sex life. On top of this, 36% believed their symptoms have impacted their social life, and over one third said it had affected their work life.

Despite the huge impact symptoms have, which for 42% of those surveyed were worse than expected, BMS found that 50% of women go through menopause without consulting a healthcare professional. Yet, accessing the support available can drastically improve your quality of life during this period.

Briggs believes that accessing good-quality information, ideally before perimenopausal symptoms progress, is an important step in preparing yourself. There are a number of trustworthy online resources including WHC and Menopause Matters. Briggs also has a useful booklet on Fast Facts for Patients: Menopause, which also allows women to monitor their symptoms.

Alongside self-education, it is important to consult a healthcare professional if your life is disrupted. They can talk you through all treatment and management options, from the available clinical treatments to the lifestyle changes at home.

Lifestyle changes to ease your symptoms

"Some women find that these early symptoms can be eased through changes to their lifestyle and diet," advises Morris. "These changes can also help some women manage the longer-term effects of declining oestrogen."

The following symptoms may be either improved or more easily managed at home:

Heavy bleeding

  • Wearing panty liners or protective underwear if periods are unpredictable.
  • Using high-absorbency tampons or pads during your period change.
  • Taking ibuprofen, which may reduce flow by up to 30%.

Hot flushes

  • Wearing several thin layers that you can remove quickly.
  • Carrying a fan.
  • Splashing your face with cold water.
  • Avoiding triggers like spicy food, alcohol and caffeine.
  • Checking whether any of your existing medications increase the risk.
  • Adopting relaxation and breathing techniques to avoid stress and anxiety.

Night sweats

  • Wearing fewer clothes at night.
  • Using two single duvets for you and partner, and buying cooling pillows.
  • Avoiding spicy food, alcohol and caffeine.
  • Checking existing medications for increased risk.

Vaginal dryness

Bladder problems

Constant urges to relieve urine, leakages, or pain when you pee.

  • Practising pelvic floor strengthening exercises such as Kegel, yoga and Pilates.
  • Having your last drink at least one hour before bed.
  • Avoiding spicy food, alcohol and caffeine.

Mood and mind

  • Maintaining an physically active lifestyle.
  • Following a healthy diet.
  • Spending time outdoors.
  • Adopting relaxation and breathing exercises.
  • Telling loved ones if you're struggling.

Low sex drive

  • Exploring other types of intimacy.
  • Using alternative ways to show affection and connect with your partner.
  • Following advice for vaginal dryness.

Poor sleep

  • Avoiding alcohol and caffeine from early evening (or possibly even earlier in the day).
  • Adopting relaxation and breathing exercises if you're stressed.

It may also be a good idea to speak to your employer about any adjustments that can be made at work to make you feel more comfortable. These could include more flexible working hours if you need more sleep, taking regular breaks, good ventilation, moving your desk to have better toilet access, or changes to your work clothes or uniform.

Treatments through your GP

While making adjustments at home can make a large impact, they may not be enough. It's important to talk to your GP if you have any concerns or if your symptoms are negatively impacting your home, social, or work life. Some of the treatments they can provide include:

Ruling out other health complications

  • For heavy bleeding.
  • For feeling more tired than usual, which could be due to anaemia.

Prescribing medication

  • For hot flushes, prescription medications called SSRIs, SNRIs, or pregabalin, gabapentin and clonidine are sometimes recommended. However, these can have significant side effects and your doctor will want to discuss the risks and benefits for you.
  • For your mood and mind, SSRIs, SNRIs, or antidepressants.
  • For an overactive bladder.
  • For vaginal dryness, prescription moisturisers, hormone pessaries, creams, or a vaginal ring that delivers low doses of oestrogen.

Referrals to health specialists

  • For bladder issues you may be referred to a specialist physiotherapist for exercises to improve your urogenital tissue quality.
  • For mood and mind it may help to see a cognitive behavioural therapist.
  • You could be referred to a gynaecologist who specialises in women's reproductive health.

Hormone replacement therapy

For the more severe cases, hormone replacement therapy (HRT) is considered to be the most effective treatment for alleviating perimenopausal symptoms. The BMS and WHC 2020 recommendations on HRT advise: "A holistic and individualised approach in assessing menopausal women, with particular reference to lifestyle advice, [and] diet modification, as well as discussion of the role of HRT."

Morris explains how the treatment works: "It aims to top up the declining levels of hormones. Topping up oestrogen levels can help to manage symptoms related to an oestrogen deficiency, including hot flushes, mood changes and night sweats. The progestogen that is contained in HRT can also be helpful to manage period problems."

Another benefit is that HRT also reduces the long-term consequences of the menopause. This said, you should discuss both the benefits and the risks of the therapy with a healthcare professional. The main health concerns are the increased risk of breast cancer and heart disease. While both the 2020 Women's Health Initiative trials and the 2012 Denmark trials have shown more promising results for the links with breast cancer and heart disease retrospectively, a major review of other studies in 2019 shows the risk of breast cancer need to be weighed up against the benefits.

As WCH advises: "If your family doctor does not have sufficient knowledge of the current situation concerning the benefits and risks of HRT, and many have lost confidence in prescribing because of the recent scares, then it is your right to request advice from a local menopause clinic or a specialist."

Your age will also be a factor in your GP consultations. If you are under 60 years of age and in good health, BMS believes that the benefits of HRT far outweigh the risks, and that if you are going through early menopause you should be encouraged to use the therapy at least until the average age of the menopause.

The fact that HRT can be administered in tablets, patches, gels, spray or implants means that the treatment can be tailored to your needs. For example, a patch, gel or spray may be more suitable if you have a higher risk of blood clots or have any underlying health issues.

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