What is Perimenopause?

Episode 1

Welcome to our inaugural episode - an in-depth look at the physiology of ovulation and how that changes during perimenopause.

Welcome to our inaugural episode - an in-depth look at the physiology of ovulation and how that changes during perimenopause.  In order to understand the hows and whys of perimenopause,  it can be helpful to understand what happens during a typical ovulatory cycle and then how that shifts over time.  This is likely our most technical episode - so feel free to listen a few times if the science of the ovulatory cycle is new to you!  

Learn more about the stages of perimenopause and lots of other relevant data here:  The Centre for Menstrual Cycle and Ovulation Research | (ubc.ca)

Full Text Transcript:

0:13

Welcome to The Change a podcast about perimenopause for people in their 30s and 40s. I'm your host, Caitlin O'Connor, naturopathic doctor with a practice in Denver, Colorado supporting patients with their health and hormones throughout the many phases of life. I'm happy you're here. Let's dive in. Today's episode is going to be an overview of perimenopause. What is it? How do you know what's happening and what to expect. So this is a lot of in depth information coming at you pretty fast. But it is a short episode. So feel free to take a few liste ns if you want to really deepen your understanding of what exactly is happening as we move through this transition. And if these details aren't important to you, feel free to just listen once and move on. There's definitely not going to be a quiz later. So before we start, I want to get some terms straight, because the terminology used around this time period is confusing and often incorrect. So we start with our ovulatory reproductive years, enter into the transitionary time called perimenopause. And most of what we think about our fear about menopause is actually what occurs during this perimenopausal period. Menopause is then a moment in time, it's the day you've gone 365 days without a menstrual cycle. And then it's over. The moment passes and we are officially postmenopausal, which is the time of hormonal stability that lasts for the rest of your life. And as luck would have it, I got a text message from a friend just this week that really exemplifies why I'm doing this project. So the text comes in and it says, Hey, I'm wondering if I should get some bloodwork. I'm having weird sleep stuff, weight gain breast tenderness, crazy bloating, blah, blah, blah. Could this be my hormones? My reply. Hmm, sounds very perimenopausal remind me how old you are again? Her: Noooooo! 43. Me: Everyone in their 40s is in perimenopause, smiley face. But it seems like you might be moving on to a new phase. Next message: Gee, this is depressing. Me: Aaaah, no, don't worry. This is just a transition with lots of stability and good living left at the other end. Don't worry, I'm making a podcast. So first off, this exchange really mirrors what I'm seeing in my clinic and my personal conversations all the time. First of all, folks are not realizing that their mystery symptoms are really pretty easily explained by where they are in their hormonal lifecycle. And then an immediate bummed out vibe when I tell them, Oh, no problem. You're just in perimenopause. So I'm making this podcast to help folks understand what is happening, and also what can be done to ease out the ride. It isn't always super fun or meaningful or easy, but the only way out is through and for me the more I can understand about a process the less out of control it feels. Perimenopause is a transition. It is a bridge that takes us from ovulatory menstrual cycles to no longer ovulating. From the potential reproductive years to the post reproductive years. And you graduate from perimenopause to menopause when you've had no menstrual cycles for 12 months. This transitionary period on average lasts anywhere from two to 12 years, but typically about seven to 10. And most folks will start to notice a shift around age 35 to 40. And then that's going to vary in intensity until the transition is complete. And what's wild to me and why I'm doing this podcast is that no one seems to know that this is a thing. Folks will come to me in their mid 40s with very typical perimenopause symptoms, and be totally shocked when I tell them they're likely in perimenopause. So perimenopause seems like this terribly scary thing, when in fact, it's just a phase of life, like many other phases of life, puberty, pregnancy, postpartum, it can be a whole mixed bag of experiences. Some might be good, some might be bad, but the fact is that it's happening and I think the more we know and understand the more prepared we can be. So this overview is going to describe what happens to folks with ovaries who aren't on hormonal birth control or hormone therapy, and have endocrine systems that are working pretty typically without disruption from other hormonal disorders. For example, this might look different for folks with PCOS or polycystic ovarian syndrome, or other conditions that disrupt regular ovulation. For many folks this start somewhere between 10 and 16 as part of the puberty process. In puberty, the brain and the ovaries are beginning their coordinated communication with the end result of a regular maturation and release of an egg. In perimenopause, the ovaries become resistant to this message from the brain. They stop listening. They are over it and ready to retire. In essence, perimenopause is like puberty in reverse, it is puberty, the remix. Both phases include fluctuating hormone levels, body changes, mood disruption, periods of intense dysregulation and ideally flashes of insight about the systemic bullshit that surrounds them, and an intense desire to fuck authority and throw off the ties that bind.

5:09

What happens hormonally in a typical ovulatory cycle is that a part of the brain called the pituitary gland, a walnut sized gland at the center of your brain starts to send messages to the ovary that it's time to recruit some eggs. And as a quick aside, if we go back in time a bit, and this is really amazing to me, folks with ovaries have all of their eggs tucked away inside of them in a state of hibernation at birth. And what is really cool is that the eggs that made you were actually present in your mother's ovaries when she was inside your grandmother. This is some serious matrilineal business. What this means is, things that your grandmother was exposed to during her pregnancy with your mother can actually impact your health today, but that's a podcast for another day. All of those millions of eggs that you have when you're born, are dormant. Again, I like to think of them as hibernating from when you are a fetus until the onset of puberty, when a coordinated cascade of hormonal events occur. The simple version is that the brain starts to send these chemical messages, the ovaries receive them, and it wakes up the eggs and begins a back and forth system of communication between the ovaries and the brain that lasts for the entirety of the ovulatory years. In an average cycle about five to 30 follicles will emerge. They come out of hibernation and each follicle contains an egg. During the first phase of the cycle, one of these follicles will become dominant. All of these other follicles are recruited and begin developing. But there can only be one. Although in some cases more than one, which is how we get twins. This one follicle takes over and becomes the dominant follicle which releases the egg. I think of it as like cheerleading tryouts, and only one can be the head cheerleader, or you're on the jobsite, and there's only one foreman. Whatever imagery fits here for you. The important thing to remember is that we start with many follicles at the beginning of the cycle, but only one will typically develop into the chosen one that releases the egg. This is one of the ways we burn through so many eggs over a lifespan. Many come out of hibernation per cycle, but only one is released. The rest get broken down and absorbed by the body. The brain sends out a messenger chemical called follicle stimulating hormone, or FSH for short. And the ovaries respond as they should by growing follicles. So as these follicles grow, they produce more and more estrogen. And this is a key fact here, the follicles of the ovary create estrogen. And as one follicle emerges as the dominant follicle, the one who rules them all, it makes more and more estrogen as the follicle gets bigger and juicier. So this is the follicular phase of the cycle, the time before ovulation. In an average 28 day cycle, this phase will be around 14 days. However, the follicular phase can be variable in length. So if somebody's having longer cycles, it's the follicular phase that extends, the phase before ovulation, not the phase after ovulation. This is important to know because during perimenopause, we're really likely to see variations in cycle length. And it's this pre ovulatory phase, the phase where we're producing more estrogens, that is likely to be extended. And this helps to explain a lot of the hormonal changes and fluctuations that we see during this time.

8:34

As a side note, estrogen stimulates the shift in cervical fluid that happens around ovulation. Many people will experience this as an increased lubricated sensation while wiping after going to the bathroom. Or they may notice increased vaginal mucus or discharge on their underwear. Paying attention to the shift and tracking cervical fluid can actually be a helpful way to monitor for ovulation, especially for folks with irregular cycles. So monitoring ovulation can be helpful when folks are having a regular cycle because it helps to make sense of the symptom picture. For example, if you're having headaches, are they before ovulation during ovulation or after ovulation? If you're having mood swings, or anxiety or sleep disturbance, is there an ovulatory pattern to those? Or are you experiencing them all the time? This can help you figure out what types of interventions might be helpful. Another wonderful thing estrogen does is to create a thickened uterine lining. So during the first phase of the cycle, we see a progressive increase in both cervical fluid as well as the lining of the uterus becoming more robust. A thicker uterine lining can often translate to heavier, more painful and cloudier menstrual cycles. So when people are experiencing those symptoms, it can often be because of an extended follicular phase or higher levels of estrogen production. So once the follicle reaches critical mass A specific threshold of estrogen production has been reached, the brain sends another chemical messenger in the form of luteinizing hormone, or LH. This is a hormone folks are testing when they're using ovulation test kits at home. LH triggers the release of the egg, which then will begin their 12 to 24 hour journey down the fallopian tube. This is not a gentle release. Rather, the egg is propelled forcefully from the follicle, and as a result, a little bit of fluid and tissue is released, which can then irritate the abdominal cavity and cause some mild to sometimes significant cramping for folks called middleschmertz. The leftover follicle the fluid filled sac that was housing the egg is then transformed magically into the corpus luteum. And its new job is to create progesterone. And the corpus luteum will continue to produce progesterone for about 10 to 14 days, unless it gets a message from a fertilized egg in which case it will continue to produce progesterone to support a pregnancy. If there's no fertilized egg sending messages back to the corpus luteum it shrivels up stops making progesterone and is reabsorbed by the body. Usually around 14 days post ovulation. The luteal phase is 14 days max unless the egg is fertilized. So this phase of the cycle, the luteal phase is fixed in comparison to the follicular phase which can be more varied. One main job of progesterone is to bring blood flow and nutrients to the uterine lining. I think of estrogen as laying down the bricks and progesterone is being the mortar. This is important as we begin to learn more about the menstrual flow changes that can occur during perimenopause when estrogen is typically higher and progesterone is lower. Once the corpus luteum stops producing progesterone, the drop in hormone triggers the uterine lining to shed. This is the menstrual flow. And those low levels of hormones also signal to the brain that no pregnancy has occurred and it's time to start again. And this cycle will continue until the onset of perimenopause when the eggs are less abundant and the follicles become less responsive to the messages from the brain. Quick recap. The follicular phase is prior to ovulation, dominated by estrogen and variable in length. The luteal phase is after ovulation, dominated by progesterone and fixed in length. Perimenopause is the transition away from these regular patterns of ovulation to menopause, which is the cessation of ovulation. As we begin perimenopause, we have both less eggs and eggs that are less responsive to the messages sent to the brain. The transition begins as the brain starts to notice that the ovaries are not responding as quickly as they used to and they're making less follicles and less hormone. As a result, the brain amps up the intensity of the messages, which will result in surges of estrogen that can actually be hired during perimenopause than the estrogen levels people experience in their younger years. This is contrary to many folks belief that perimenopause is a time that's dominated by lower estrogen levels.

13:10

perimenopause is a transition. This process on average takes about 10 years and can be broken down into four semi distinct stages. This framework was created by Dr. Geralyn Pryor, the founder of the Canadian organization, Center for Menstrual Cycle and Ovulation Research. This is a really fabulous organization dedicated to the study of the menstrual cycle, perimenopause and menopause. Highly recommended you check them out for further reading. They named these stages very early perimenopause, early menopause transition, late menopause transition, and then somehow you're back to late perimenopause. I find that framework a little bit confusing. So I've simplified it a bit and I refer to the stages as very early, early, middle and finally, late perimenopause. So very early, perimenopause is likely the stage that's going to be tricky for most folks. Oftentimes, because they're in their late 30s or early 40s. And they're still having regular menstrual cycles. They might not be aware that their reproductive hormones are changing, which might lead them to believe that these are symptoms related to another condition or that something must be going wrong with their body. However, the truth of the matter is, as we get older, our eggs will naturally produce more estrogen and less progesterone. And this is the hallmark of the majority of perimenopause, more estrogen, less progesterone. So even though folks are having regular cycles, these cycles could be heavier and more painful. Remember, estrogen lays down the lining of the uterus, while progesterone nourishes and organizes it. So when estrogen is higher and not as well balanced by progesterone, we'll see some more of these issues with spotting, longer bleeding, heavier cycles, more clots and more cramps. Additionally, higher estrogen levels can cause a constellation of symptoms like migraines, mood issues, breast tenderness and sleep disruption. And this phase will last around two to five years. The next phase, early perimenopause is when we start to see cycle irregularity from cycle to cycle you'll typically have a greater than seven day difference. So one month could be 21 days, the next month could be 30. The next month could be 40. The next month 23. So often I have women come to my practice and their only complaint or concern is that they're having irregular menstrual cycles. But outside of that they actually feel pretty good. They're not having any of the other symptoms we associate with perimenopause. However, the cycle irregularity really concerns them and they think something might be wrong. So again, one of the main reasons I'm doing this podcast is to provide this education that cycle irregularity is super normal during perimenopause and usually isn't a cause for concern. However, with this cycle variability comes a variability in the production of estrogen, some months, we might have higher levels, other months, it might be lower, and it's this variation of estrogen that starts to trigger some additional symptoms. Symptoms like hot flashes and night sweats. We also might see an intensification both in the duration and frequency of some of those symptoms that started in the earlier phase. Now we move on to the middle transition. This is defined as the first time you go longer than 60 days with no menstrual cycle. So we're moving from a time of higher and more variable levels of estrogen, to a time that has consistently lower levels of estrogen and progesterone. This is where we see some of those more typical, quote unquote, menopausal symptoms, such as vaginal dryness issues with the pelvic floor, urinary tract infections, yeast infections, and I know this sounds a little scary, but we're gonna have a whole episode on managing your vagina during perimenopause. And I promise you, it's going to be okay. So usually this phase is going to last about four years until you graduate to your final cycle. So that brings us to the last phase late perimenopause. It's the time between your last period to your official graduation day, 12 months of no periods. You don't really know when this is happening until it's over, as you may go six months with no period, and then have a cycle, in which case you have to restart the clock.

17:32

Okay, take a deep breath. That sounded a little scary, right? The good news is we have so many tools to modify and ease these different phases. I promise we will get to that. But the take home message I want folks to get is that this is a process that comes in phases. And all of the phases are temporary. Most folks will experience peaks, valleys and plateaus. You might have months or years where you feel pretty stable. And you might have months or years where things are very much in flux. My goal with this podcast is to provide you the listener with number one an understanding of the process. So when you experience a shift or a change, it makes sense, versus feeling as if it's out of control or coming from nowhere. And two to build a robust toolkit that helps you surf these waves versus feeling like you're getting pulled down in the undertow. So if you're still wondering, hmm, am I in perimenopause? Here's a checklist from Dr. Geralyn price. So anyone who's over 35 that has three of the following symptoms that can't be accounted for by other medical conditions is likely to be starting pre menopause. So a new onset of heavier or longer periods, cycles that occur more frequently than every 25 days. breast tenderness, waking at night, increasing cramps, night sweats, especially in the week before the period starts. New or more frequent migraines, new or increased mood swings, weight gain that's not explained by habit changes, or an increase in joint pain and or general achiness. And remember, almost everyone over 40 is in perimenopause to some degree. So if you don't have a uterus or you're on hormonal birth control or aren't able to otherwise, track or monitor what's happening with your menstrual flow, and you even have one or two of these symptoms, it's pretty likely that you're in perimenopause. There are no specific blood tests that can absolutely confirm perimenopause. And it can be tricky as hormone levels will fluctuate a lot from cycle to cycle. That being said, I do think it's important to look at general labs as well as a thorough health workup with your provider to make sure there's not underlying issues such as thyroid or nutrient deficiencies that might be amplifying, worsening, or creating a similar symptom picture to what you see with perimenopause. One downfall I see in medicine for this age group is everything is blamed on hormones, and often other health issues are overlooked. This is especially important if symptoms are severe bothersome and are not responding to typical intervention. One of my pet peeves in medicine is when women don't get adequate medical care, because providers assume that midlife is meant to be terrible, and you just have to suck it up a deal. I wholeheartedly disagree. And although I've presented these phases as if they're straightforward and linear process, they're actually much more flexible and circular folks might actually move back and forth from Phase to Phase depending on life circumstance. Often in my patients I observe when life is more stressful, the process becomes accelerated, they might move from one phase to the next, or they might experience an intensification of symptoms. And then as things calmed down again, we might actually move back to a time where cycles are more regular again, and symptoms are more manageable. So just because you're experiencing specific symptom at this phase of time, doesn't mean you'll have it for your whole perimenopause or that it's not modifiable.

20:54

So after years of hormonal fluctuations, transitions and tribulations you finally graduate to menopause once you've gone 12 months without any menstrual bleeding, you made it up the mountain, you swam through the river. Now take a moment to celebrate. I really want menopause parties to become a regular thing. I'm gonna plan my party on the beach with the BFFs wearing caftans drinking cocktails, big bonfires in the moonlight. Maybe you're gonna go to Vegas, maybe you're gonna hike the Appalachian Trail. Whatever it is, I really encourage you to take some time to plan something fabulous. Once you graduate things settle down again. And I think this is really important to remember. Perimenopause is a transition with stability on the other side. Postmenopausal folks will usually enjoy a calm new normal, free of most of the symptoms that they experienced during perimenopause. And I think that this period is more rich and rewarding than we give it credit for. The patriarchy has created this story of post menopause being this dried out unproductive and terrifying time. In practice, this can be a time of increased freedom, creativity and an opportunity to explore. Research in hunter gatherer societies have even found that postmenopausal women contribute more calories to their community than any other age group. They know where all the best stuff is, and they have time to go find it. And studies of folks in the UK show that people in their 70s experienced the same level of happiness, or even higher levels of happiness than they did in their 20s. All of this to say is I think the reason we fear aging is complex. And in a culture that values youth above all else, it's no wonder we're freaked out. But I believe most of what we think about old age is a myth. And it's a myth used to sell us stuff in an attempted to delay the process. I think we can do much better than that. Thanks so much for listening to this episode of the change a podcast about perimenopause for folks in their 30s and 40s. I'm Dr. Caitlin O'Connor and our executive producer and audio engineer is Janece Matsko of Empowerment Ventures. Theme song created by Lady Gang music from Denver, Colorado. You can check out show notes and find and share episodes at Drcaitlin.com/podcast. And while you're there, you can sign up for my newsletter. This podcast is a labor of love and if you like it, please tell your friends and subscribe rate and review on Apple podcast Spotify or wherever else you listen. Now for the legally appropriate disclaimers. This podcast is for general informational purposes only. This does not constitute the practice of medicine and this podcast does not give medical advice. No doctor patient relationship has been formed. listeners should not delay or disregard medical advice for any condition they have. And if you aren't getting good care advocate for yourself, explore your options and try the best you can. Until next time, I love you and you're doing a great job.