Perimenopause is not a disease but a crucial and normal developmental process in a woman’s life.
During this rite of passage women experience physical, psychological and social changes.

Overview of conditions:
Perimenopause is an existence of life. It is part of a natural progression that involves a gradual change from the ability to conceive and birth a baby to the end of the normal reproductive phase of a woman’s life. It is associated with profound reproductive and hormonal changes. No comparable phenomenon takes place in a man’s body (although testosterone levels do decline). While it has a number of definitions experts generally agree that it begins with irregular menstrual cycles, as a result of declining ovarian function, and ends a year after the last menstrual period. After that a woman enters the postmenopausal stage so, technically, menopause is only one day in a woman’s life, which is exactly when she has not had
a period (amenorrhea) for 12 consecutive months.

Menopause is often referred to as the ‘change of life’ because it marks the end of a woman’s reproductive life. So, therefore perimenopause is the change before ‘the change’. For those interested in etymology ‘peri’ is Greeko for ‘around’ or ‘near’ so perimenopause literally means ‘around menopause’. The word menstruation comes from the Latin and Greek words for month and moon. ‘Mēn’ means month in Greek. “Pausis” means “to stop” in Latin. So, menopause means “to stop. menstruating”.

Perimenopause, therefore, is the natural transition to menopause and is also known as the ‘menopausal transition’. Although perimenopause is a universal phenomenon among women the timing of the onset, and the duration, of the menopausal transition and the timing of the final menstrual period are not. Most frequently it occurs in a woman’s forties, but some women enter perimenopause a decade earlier, especially during times of stress. In Australia the average female body hits menopause at 51. Perimenopause lasts an average of four to six years but can be as short as one year or as long as 10 years.

Traditionally perimenopause includes an early and a late stage. The early stage is defined by occasional skipped cycles. The second stage is characterized by greater menstrual irregularity with periods of amenorrhea lasting over 60 days and up to 12 months. Perimenopause is very similar to puberty and the years when the menstrual cycle starts to become established. It is a phase of self-discovery and identification which is not unlike a ‘second adolescence’. Both are characterized by hormonal and sometimes emotional fluctuations, and menstrual irregularity. In perimenopause the body’s natural secretion of these reproductive hormones (including oestrogen, progesterone, testosterone) is reduced due to the diminishment of the ovarian follicles, preventing the endometrium from proliferating, resulting in no shedding of the uterus.

These changing hormone levels manifest in varying symptoms. This period is characterized by
menstrual irregularities, prolonged and heavy menstruation intermixed with episodes of amenorrhoea,
decreased fertility, insomnia and vasomotor symptoms (symptoms that occur due to the constriction
or dilation of blood vessels) such as night sweats and hot flushes, the cardinal feature of perimenopause.
Despite decreased fertility it is still possible to get pregnant, so contraception is important if the woman is sexually active and is not intending to become pregnant. If a woman has had her ovaries surgically referered to as (full hystercomtomy) removed she will experience ‘sudden’ menopause.

When the changes in hormone production occur gradually fewer perimenopausal symptoms may be the result. This may be one reason why ‘naturally’ perimenopausal women tend to suffer fewer symptoms than women with premature menopause or women whose menopause is induced surgically or with drugs. Delving
into surgical and medically induced menopause is beyond the scope of this guide.

The experience of perimenopause has many variations, and the frequency, intensity and duration of symptoms will vary widely from woman to woman. Although most symptoms are not life-threatening, they may actually have a negative impact on the quality of life and the physical and mental health of perimenopausal women. However, all women can rest assured it will pass as it is merely the space of time between a normal menstrual cycle and the point when the periods stop. The symptoms associated with this phase will gradually ease during menopause and post menopause.

Perimenopause is more than a biological event and societal and cultural factors contribute greatly to how a woman will react. In the modern developed world, where other milestones for women such as puberty, menarche, menstruation and pregnancy are slowly being demystified, and are no longer taboo, the transition between the reproductive years and menopause is still baffling and puzzling with its unpredictability. Many women may suffer perimenopause in silence and shame because they are living in a society that worships youthfulness and people strive to maintain it at all costs. Within the silence there are whispers of it as a time of hormonal ‘chaos’ as they enter ‘old age’, ‘the end’ and become ‘a crone’. The doyenne of herbal medicine for women’s health in Australia, Ruth Trickey, says: “Far from becoming an old crone overnight, the perimenopausal woman… is energetic and ready for the challenges this new phase can bring. Being fifty-something isn’t old, but for all sorts of complex reasons women have somehow confused ageing and menopause.

Many bind together the years between menopause and 80 with the tag ‘postmenopausal woman’; and it’s not the energetic 50-year-old, it’s the 80-year-old they visualize.” Many women embrace this period
of their lives when the fear of pregnancy is gone and monthly bleeding is over. In some cultures
women look forward to menopause because it brings higher status, respect and it is seen as a sign
of great wisdom. Studies of menopausal women in traditional cultures demonstrate that most will
pass through menopause without hot flushes and other symptoms common to menopausal women in
developed countries. In this context perimenopause can be viewed as a beginning not an ending. It is a time for renewal rather than buying into the cultural stereotype of aging and fearing the change. It is a good opportunity for a woman to literally pause, rest, re-examine values, enjoy accomplishments and love and appreciate the female processes.

Common Symptoms :
Many women go through perimenopause without experiencing any difficulties. For a small number of women the symptoms may be incapacitating. Missed or irregular periods In addition to a reduction in the
number of ovarian follicles there is a marked reduction in the sensitivity of the central nervous system to
both the positive and negative feedback effects of oestrogen. These changes in sensitivity explain
menstrual irregularities.

Periods that are heavier or lighter than normal:

Heavy periods can cause episodic flooding (periods so heavy they bleed through tampons and pads).
With less progesterone to regulate the growth of the endometrium the uterine lining may become thicker
before it is shed resulting in very heavy periods. Also, fibroids (benign tumours of the uterine wall) and
endometriosis (the migration of endometrial tissue to other pelvic structures), both of which are
fueled by oestrogen, may become more troublesome. Heavy or unusual bleeding at any age should
always be checked by a doctor, but especially for women over 50. Hot flushes (hot flashes) These and night sweats, they are the most commonly reported symptom of perimenopause and are considered to be a hallmark symptom of the menopausal transition. They are defined as transient periods of intense heat in the upper arms and face, which often are followed by flushing of the skin and profuse sweating.
Many hot flushes are followed by chills and can be accompanied by palpitations and a sense of anxiety. Approximately 60% to 80% of menopausal women experience hot flushes at some point during perimenopause. Despite their high prevalence surprisingly little is understood about their exact pathophysiology. Although the origin of hot flushes is not entirely clear studies have suggested that changes in core body temperature regulation, or changes in endogenous hormone levels or both, are associated with the onset of hot flushes. Because hot flushes accompany the decline of oestrogens in the vast majority of naturally and surgically menopausal women there is little doubt that oestrogens play a role in the genesis of hot flushes. However, oestrogens alone do not appear responsible for hot flushes because there is no correlation between the presence of this symptom and plasma, urinary or vaginal concentrations. Flushing may contribute to broken sleep leading to fatigue, forgetfulness and even mood swings. Lately, there has been speculation that hot flushes are not just a nuisance and that they may serve a positive role. One theory is that the increase in body temperature sets the stage for a healthier old age by burning up toxins and stimulating the immune response (similar to the increase in immune activity when there is a temperature caused by a cold or the flu). One common Chinese formula for sweating
associated with weakness contains astragalus, codonopsis, dong quai, black cohosh, atractylodes and
bupleurum. Mood changes including low or swinging mood, irritability, depression and anxiety Existing premenstrual syndrome can get worse. Women with an optimistic attitude towards menopause tend to have a more positive body image and their depression level is lower. Studies of mood during menopause
have generally revealed an increased risk of depression during perimenopause with a decrease
in risk during postmenopausal years. The strongest predictor of depressed mood is a prior history of depression and is likely due to fluctuating and declining oestrogen levels in part. Although the precise mechanisms are yet unknown regulation of serotonin and norepinephrine may change as oestrogen levels fluctuate and thus contribute to depression. Some women may be more vulnerable than others to hormone-related mood changes. The unpredictability of perimenopause can be stressful and provoke some episodes of irritability. The best predictors of mood symptoms at midlife are life stress, poor overall health and a history of depression. Together with all the changes associated with perimenopause many middle-aged women are often occupied with other challenges. These include physical disease affecting them or their husband, the death of their spouse or parents, caring for ill family members, marital difficulties and grown children leaving home. The departure of children into leading their own independent lives may trigger depression in women.

Breast tenderness (mastalgia):

Rises and falls in hormone levels can affect breast tissue. Sore and swollen breasts is a common complaint in patients with breast pain associated with perimenopause. While the causes of mastalgia are
overwhelmingly benign, concern for malignancy is often a source of anxiety in those with mastalgia.
This has contributed to breast pain becoming the most common breast-related symptom for which a
woman will seek consultation from her doctor.

Fatigue and memory problems:

Majority of women complain of short term memory problems and difficulty concentrating during
perimenopause. Although oestrogen and progesterone are players in maintaining brain function
there’s too little information to separate the effects of aging and psychosocial factors from those
related to hormone changes.

Decreased libido:

The physiologic changes of perimenopause affecting sexual response are largely mediated
by oestrogen. Diminished sexual intercourse and libido changes can be caused by structural and
physiological changes associated with perimenopause, depression, marital discord, illness, medications
or by a combination of all these factors. The ideal treatment for women in midlife is complete
evaluation of the factors affecting sexuality and use of a combined treatment approach to improve
these factors. Use of such an individualised approach can enable women in midlife to continue to
have a satisfying sexual life, should they choose to do so.

Vaginal dryness (which can cause pain on intercourse) and dry skin:

Vaginal dryness is associated with oestrogen loss. Hormonal skin ageing co-exists with chronologic
and photo ageing.

Urinary tract infections, increased urgency or frequency of urination,
stress urinary incontinence:

The abundance of oestrogen receptors in the urogenital tract explains why the natural reduction
of endogenous oestrogen, the benchmark of menopause, can cause or potentiate pelvic floor
disorders and recurrent urinary tract infections.

Insomnia, sleep disturbance:

Sleep disturbances have been associated with hot flushes. The problem is too complex to blame
on hormone oscillations alone. Sleep cycles change with aging and insomnia is a common age-related
complaint in both sexes. Headaches, migraines or making existing migraines worse Oestrogen withdrawal can have a secondary impact on headache patterns.

Joint and muscle aches, worsening of existing fibromyalgia:

Entering menopause may for some be like constantly being in the ‘low oestrogen’ part of the cycle,
heightening the pain experience for any given pathology.

Weight gain:

The hormonal changes across perimenopause substantially contribute to increased abdominal
obesity which leads to additional physical and psychological disease.

Hair changes and increased facial hair:

The reduction in ovarian hormones and increased androgen levels can manifest as hair and skin
disorders. Although hirsutism, unwanted facial hair, alopecia, skin atrophy and slackness of
facial skin are common issues encountered by postmenopausal women, these problems receive
very little attention relative to other menopausal symptoms. The visibility of these disorders has been shown to cause significant anxiety and may impact on patients’ self-esteem and quality of life, particularly given the strong association of hair and skin with a woman’s femininity and beauty, which is demonstrated by extensive marketing by the cosmetic industry targeting this population and the large expenditure on these products by menopausal women.

Increase in cholesterol levels:
This puts women at a higher risk for heart disease.

Risk Factors:

The severity of symptoms, and age of perimenopause onset is related to genetic, behavioural and environmental factors:

Exercise:
Physical activity is a potent tool for health promotion and disease prevention in perimenopausal
women as well as in the population as a whole. It has a positive effect on hot flushes, night sweats, weight
and body fat, bone density and changes in mood.

Smoking:
A number of studies have linked smoking to risk of early menopause and it has been suggested to cause
destruction of the ovarian follicles.

Obesity:
Midlife obesity is associated with a different menopausal experience including associations with menstrual cycle length prior to the final menstrual period, age at the final menstrual period and
higher prevalence of vasomotor symptoms. High body mass index (BMI) has been associated with
late menopause in some studies but not all. Women with a higher BMI may experience a lower level
of perimenopause symptoms due to the production of oestrogen by aromatase in adipose tissue.

Alcohol consumption:
Low and moderate alcohol intake may be associated with later onset of menopause although the
magnitude of the association is low.

Genetics:
Numerous studies have confirmed the role of genetics in determining a woman’s age at menopause. A
new study not only reconfirms this association but additionally suggests a link to familial longevity.

Race/ethnicity:
Racial and ethnic differences exist with respect to how a woman approaches perimenopause.

Climate:
Women living in countries with higher temperatures and lower altitudes reported more frequent
and problematic hot flushes. On the other hand, high altitude, which can significantly affect oxygen
availability with consequent shorthand/or long‐term body adjustments, may affect perimenopause.
Compared to lowlander native women living at sea level, high-altitude native women living
at high altitude have a shorter reproductive life span because of delayed menarche and earlier
menopause. A recent study said it is well known that chronic exposure to altitude causes reversible fertility impairments in humans who are not well adapted.

Age of menarche:
Having early menarche increased the risk of premature and early menopause by 80%, while the
risk doubled for women without children. Furthermore, the combination of early menarche
and having no children resulted in a five-fold increased risk of premature menopause and twice the risk of
early menopause compared with women having later menarche and two or more children.

Parity:

(number of viable pregnancies) and breastfeeding Both increasing parity and increasing duration of breastfeeding were associated with a decreasing risk of early natural menopause. The lowest risk of early menopause was observed among women reporting exclusive breastfeeding for seven to 12 months in each level of parity. Results of a 2020 epidemiological analysis of more than 108,000 women observed
a lower risk of early menopause among women who had at least one pregnancy lasting at least six months and among those who had breastfed their infants. The risk was lowest among those who breastfed exclusively. Age at last pregnancy In one recent study women with older age at last delivery were associated with younger age at menopause. Increased number of pregnancies was related to older
age at menopause. Use of oral contraceptives the results of one study suggest that long term use of high dose oral contraceptives accelerates menopause and that use of lower dose oral contraceptives has
no effect on age at menopause, although possible bias by residual confounding factors could not be excluded.

At menarche you meet your wisdom; with monthly bleeding you practice your wisdom.
and, at menopause, you become your wisdom.
North American Indian saying

Natural therapies for treatment & prevention:

There are two main issues for perimenopausal women. The first is the need for a safe and effective way to manage the symptoms of the transition phase of menopause and the second is the need to reduce risk of chronic degenerative diseases. Women should be guided towards a general health program as soon as possible as this will ultimately improve their symptoms and lessen their duration. Ensuring optimal health and improving health parameters more generally will not only improve symptoms during the
transition phase when hormones first start to decline but also reduce the risk of osteoporosis, heart
disease and other chronic diseases. As JRR Tolkein, author of Lord of the Rings, said “The old that is strong does not wither.

Many women turn to practitioners /naturopaths for explanation and reassurance. Because perimenopause is a natural process naturopaths focus on supportive care, empathy and education throughout the
process rather than ‘treatment’.

Natural medicines have a long history of going way back of this method being used to improve the transition through menopause into the next phase of life although results will not be instantaneous.
Herbal treatments, for example, black cohosh, will require two weeks to observe its effect and three
months before optimal benefit can be observed. There are many herbal medicines in particular that are very effective in not only relieving the symptoms of perimenopause but also in managing the underlying
cause of the symptoms, the hormonal fluctuations and depleted adrenal function. The adrenal glands
play an essential role in managing the stress response, energy maintenance and in the production
of sex hormones when the ovaries begin winding down production in the perimenopausal years.
A therapeutic approach could include these factors.

Diet:
Diet has a direct influence on perimenopausal symptoms and is believed to contribute to the
marked differences in symptoms experienced by women from other cultures, especially hot flushes.
• Adopt a general wholefoods diet high in fruit, vegetables, wholegrains, protein, nuts, seeds
and legumes.
• Stabilize and maintain an ideal weight. • Optimize digestion and nutrient absorption for bone health,
prevention of cardiovascular disease and cancer. Encourage optimal digestive processes with
fiber rich foods.
• Eat more phytoestrogen rich foods. Most plant foods contain beneficial compounds known
as phyto-oestrogens. When broken down in the body they have a weak oestrogen-like effect which has been proven to reduce hot flushes and vaginal dryness. Phyto-oestrogens are abundant in soy products (tofu or miso combined with soy sauce), legumes, seeds (flaxseed or linseed), sprouts, nuts and
whole grains. They also contain vitamins and minerals. • Optimize hydration.

What to avoid
• Reduce known triggers. The impact of hot flushes can be reduced if triggers can be identified and avoided. For example, hot drinks, hot weather, stressful circumstances, excessively spicy foods. Caffeine,
alcohol and smoking can trigger flushes. • Saturated, trans and hydrogenated fats, simple and
refined carbohydrates, sugar and processed foods.
• Avoid large meals

Lifestyle:

Exercise:
Regular exercise can help improve mood, weight gain issues and hot flushes. With the loss of oestrogen
both bone strength and heart health are more vulnerable. Exercise can counteract this.
Clothing:
Some women find it helpful to dress in layers to help them cool down more quickly during hot flushes.
Light and loose-fitting clothing, made from natural fibres such as cotton, is much less likely to
aggravate sweating. Avoid synthetic materials. Wearing light breathable nightwear, or sleeping naked,
might help ease hot flushing. Some women sleep on a towel, or folded sheet, so they can take it out of the bed if it becomes wet rather than changing the sheets. A bedroom fan may also help.
Rest and relaxation. Address sleep hygiene.
Manage stress:
Stress reduction techniques such as mindfulness or meditation.
Address sexual health Encouraging circulation and tone in the genital area through pelvic floor
exercises or more general regimens such as exercise, yoga or Tai chi. A water-based vaginal lubricant
can help make intercourse more comfortable. A vaginal moisturizer can help keep needed moisture in
vaginal tissues.

Herbal actions and potential herbs include:
Hormonal modulators, phytoestrogens, female and uterine
tonics, bladder tonics. To assist in regulating and supporting hormonal cascades and
to improve bone mineral density. To improve bladder tonicity. Herbs such as alfalfa, black cohosh, chaste tree, crateva, dong quai, false unicorn root, fennel, hops, Korean ginseng, ladies mantle, paeonia, red clover, shatavari, tribulus, wild yam.

Adaptogens and adrenal restoratives:
To support women through the transition, hypothalamic pituitary/adrenal axis modulation and reduction of cortisol secretion in cases of fatigue and overwork. To support stress recovery. Herbs such as astragalus, codonopsis, Korean ginseng, liquorice, rehmannia, rhodiola, schizandra, shatavari, Siberian ginseng, withania. Antihydrotic, cardiovascular herbs Alleviate hot flushes and associated perspiration. To regulate and support cardiac function. Herbs such as hawthorn, motherwort, sage. Nervine, sedative, hypnotic, antidepressant, anxiolytic, cognitive enhancer to support mood and sleep, address anxiety and depression and improve cognition. To assist in regulating the circadian rhythm. Herbs such as chamomile, ginkgo, hops, Korean ginseng, lavender, maritime pine, liquorice, motherwort, oats,
pulsatilla, rehmannia, St. John’s wort, Siberian ginseng, valerian, vervain, withania.

Emollient, demulcent, astringent, vulnerary:
To address mucous membrane dryness and menorrhagia. Herbs such as chastetree, chickweed,
fenugreek, golden seal, Korean ginseng, ladies mantle, marshmallow, shatavari, shepherd’s purse.

Hepatoprotective, hepatic, cholagogue, bitters, antioxidant, digestive:
To improve nutrient absorption, lipid profile le and assist with clearance of oestrogen metabolites, reduce
oxidation. Herbs such as alfalfa, astragalus, burdock, dandelion root, fennel, globe artichoke, glossy
privet, Korean ginseng, shatavari, St. Mary’s thistle, blue flag.

Final thoughts:
Perimenopause is inevitable natural process in a woman’s lifecycle and symptoms are not
necessarily indicative of disease. Instead of being viewed with trepidation it can be approached
with a sense of excitement and joy at the prospect of entering a new phase of life. Hollywood
screen legend, actress Lauren Bacall, famously summed it up during her midlife: “I am not a
has-been, I’m a will-be”.

Rosemarie

Naturopath, Herbalist, Iridologist, Equine herbalist and Iridologist.

References;

Herbal extract company Australia.