When is the onset of perimenopause

There are steps you can take to feel your best during this phase. Perimenopause occurs during the 40s for most women, but some notice changes as early as their mids. As estrogen hormones rise and fall, periods grow longer or shorter and women experience menopause-like symptoms.

Perimenopause is a natural part of the aging process, although some medications, cancer treatments and ovary surgery can speed up the process or cause menopause sooner. Perimenopause lasts for four years on average but sometimes only a few months.

In the last one or two years of perimenopause, the drop in estrogen speeds up, and women experience menopause symptoms while still having a period. Morris discusses this stage of life and how to deal with uncomfortable perimenopausal symptoms.

The average age of menopause is 51, and perimenopause symptoms typically begin about four years before your final period. Most women start to notice perimenopause symptoms in their 40s. But perimenopause can happen a little earlier or later, too. The best predictor of when your final period will be is the age at which your mother entered menopause if she didn't have a hysterectomy. The first perimenopause sign is typically a disruption of your menstrual cycle. For many women, your period starts earlier or later than normal.

For example, if your menstrual cycle has always been 28 days, during perimenopause, your period could come as early as 21 or as late as 35 days. Some women start skipping months entirely and then experience heavier-than-normal periods when they do have them. Hot flashes are the most common menopause-related discomfort.

They involve a sudden wave of heat or warmth often accompanied by sweating, reddening of the skin, and rapid heart beat. They usually last 1 to 5 minutes. Hot flashes frequently are followed by a cold chill. Night sweats are hot flashes at night that interfere with sleep. Treatments for night sweats and hot flashes include lifestyle changes, nonprescription remedies, hormone therapy with estrogen plus progestogen, or estrogen alone for women without a uterus , and nonhormonal prescription drugs.

The drop in estrogen around menopause leads to vaginal atrophy the drying and thinning of vaginal tissues in many women. It can cause a feeling of vaginal tightness during sex along with pain, burning, or soreness.

They include estradiol and conjugated estrogens. The term "progestogen" encompasses both progesterone and progestin. Progesterone is the name for the natural hormone that the body produces. Progestin refers to a synthetic hormone that has progesterone effects. Because estrogen alone can increase the risk for uterine endometrial cancer, progestogen is added to estrogen to protect the uterine lining endometrium and reduce this risk. Current guidelines support the use of HT for the treatment of severe hot flashes that do not respond to non-hormonal therapies.

General recommendations include:. Before starting HT, your doctor should give you a comprehensive physical exam and take your medical history to evaluate your risks for:. While taking HT, you should have regular mammograms and pelvic exams and Pap smears. Current guidelines recommend that if HT is needed, it should be initiated around the time of menopause. Studies indicate that the risk of serious side effects is lower for women who use HT while in their 50s.

Women who start HT past the age of 60 appear to have a higher risk for side effects such as heart attack, stroke, blood clots, or breast cancer. HT should be used with care in this age group. Women who experience premature menopause are usually prescribed HT or oral contraceptives to help prevent bone loss. These women should be reevaluated when they reach the age of natural menopause around age 51 to determine whether they should continue to take hormones.

When a woman stops taking HT, perimenopausal symptoms may recur. When a woman reaches full menopause, symptoms will eventually go away. Because HT offers protection against osteoporosis, when women stop taking HT their risks for bone thinning and fractures increases. For women who have used HT for several years, doctors should monitor their bone mineral density and prescribe bone-preserving medications if necessary.

Until , doctors used to routinely prescribe HT to reduce the risk of heart disease and other health risks in addition to treating menopausal symptoms. The WHI, started in , is an on-going health study of nearly , postmenopausal women. Part of the study focuses on the benefits and risks of hormone therapy. As new data are released and analyzed, there have been a number of changes in the way HT is prescribed and a better understanding of its risks.

HT pills and skin patches are considered "systemic" therapy because the medication delivered affects the entire body. The risk for blood clots, heart attacks, and certain types of cancers is higher with hormone pills than with skin patches or other transdermal forms. Vaginal forms of HT are called "local" therapy. Doctors generally prescribe vaginal applications of low-dose estrogen therapy to specifically treat menopausal symptoms such as vaginal dryness and pain during sex.

This type of ET is available in a cream, tablet, or ring that is inserted into the vagina. Bioidentical hormones are typically compounded in a pharmacy. Some compounding pharmacies claim that they can customize these formulations based on saliva tests that show a woman's individual hormone levels.

The FDA and many professional medical associations warn patients that "bioidentical" is a marketing term that has no scientific validity. Formulations sold in these pharmacies have not undergone FDA regulatory scrutiny. Some of these compounds contain estriol, a weak form of estrogen, which has not been approved by the FDA for use in any drug.

In addition, saliva tests do not give accurate or realistic results, as a woman's hormone levels fluctuate throughout the day. FDA-approved hormones available by prescription come from different synthetic and natural sources, including plant-based. For example, Prometrium is a progesterone derived from yam plants. Systemic HT is mainly recommended for relieving menopausal symptoms such as hot flashes, night sweats, and sleep problems, as well as vaginal dryness.

Local HT delivered vaginally is used specifically for treating vaginal dryness and atrophy; and accompanying pain during sexual intercourse. HT does not prevent certain other problems associated with menopausal changes, such as thinning hair or weight gain. It is unclear whether HT helps improve mood. Estrogen increases and helps maintain bone density. HT may be useful for some women at high risk for osteoporosis, but for most women the risks do not outweigh the benefits.

Other drugs, such as bisphosphonates, should be considered first-line treatment for osteoporosis. Duavee is a drug that contains a combination of conjugated equine estrogen and the selective estrogen receptor modulator SERM bazedoxifene.

It is approved to treat hot flashes and prevent osteoporosis in women with a uterus. Although HT may have some benefits in addition to menopausal symptoms, results from the Women's Health Initiative WHI studies strongly indicate that HT should be used only for relief of menopausal symptoms, not for prevention of chronic disease. HT may increase the risk of heart disease and heart attack in older women, or in women who began estrogen use more than 10 years after their last period.

HT is probably safest in healthy women under age 60 who begin taking it within 10 years after the start of menopause. Taking HT in order to prevent heart disease is not recommended.

Women who have a history of heart disease or heart attack should not take HT. HT may increase the risk of stroke. HT increases the risk for formation of blood clots in the veins deep venous thrombosis or in the lungs pulmonary embolism.

The risk for blood clots is higher with oral forms of HT than with transdermal forms skin patches, creams. There appears to be little, if any, increase in the risk of blood clots when transdermal forms of HT are used. Estrogen- progestogen therapy EPT increases the risk for breast cancer if used for more than 3 to 5 years.

This risk appears to decline within 3 years of stopping combination HT. Estrogen-only therapy ET does not significantly increase the risk of developing breast cancer if it is used for less than 7 years. If used for more than 7 years, it may increase the risk of breast and ovarian cancers, especially for women already at increased risk for breast cancer. The North American Menopause Society does not recommend ET use in breast cancer survivors as it has not been proven safe and may raise the risk of recurrence.

Both estrogen-only and combination HT increase breast cancer density, making mammograms more difficult to read. This can cause cancer to be diagnosed at a later stage. Women who take HT should be aware of the need for regular mammogram screenings. The North American Menopause Society recommends that women who are at risk for breast cancer avoid hormone therapy and try other options to manage menopausal symptoms.

Long-term use more than 5 to 10 years of estrogen-only therapy ET may increase the risk of developing and dying from ovarian cancer. The risk is less clear for combination estrogen-progesterone therapy EPT. Taking estrogen-only therapy ET for more than 3 years significantly increases the risk of endometrial cancer.

If taken for 10 years, the risk is even greater. Adding progesterone to estrogen EPT helps to reduce this risk. Women who take ET should anticipate uterine bleeding, especially if they are obese, and may need endometrial biopsies and other gynecologic tests.

No type of hormone therapy is recommended for women with a history of endometrial cancer. It is not clear if HT use is associated with an increased risk of lung cancer, women who smoke and who are past or current users of HT should be aware that that EPT may possibly promote the growth of lung cancers. The Women's Health Initiative Memory Study and other studies suggest that combined HT does not reduce the risk of cognitive impairment or dementia and may actually increase the risk of cognitive decline.

Researchers are continuing to study the effects of HT on Alzheimer disease risk. Despite its risks, hormone therapy appears to be the most effective treatment for hot flashes. There are, however, nonhormonal treatments for hot flashes and other menopausal symptoms. The antidepressants known as selective serotonin-reuptake inhibitors SSRIs are sometimes used for managing mood changes and hot flashes.

A low-dose formulation of paroxetine Brisdelle is approved to treat moderate-to-severe hot flashes associated with menopause. Other SSRIs and similar antidepressant medicines are used "off-label" and may have some benefit too. They include fluoxetine Prozac, generic , sertraline Zoloft, generic , venlafaxine Effexor , desvenlafaxine Pristiq , paroxetine Paxil, generic , and escitalopram Lexapro, generic.

Several small studies have suggested that gabapentin Neurontin , a drug used for seizures and nerve pain, may relieve hot flashes. This drug is sometimes prescribed "off-label" for treating hot flash symptoms. However, in the FDA decided against approving gabapentin for this indication because the drug demonstrated only modest benefit. Gabapentin may cause:. Clonidine Catapres, generic is a drug used to treat high blood pressure.

Studies show it may help manage hot flashes. Side effects include dizziness, drowsiness, dry mouth, and constipation. Some doctors prescribe combinations of estrogen and small amounts of the male hormone testosterone to improve sexual function and increase bone density.

Side effects of testosterone therapy include:. Testosterone also adversely affects cholesterol and lipid levels, and combined estrogen and testosterone may increase the risk of breast cancer. Many experts do not consider testosterone safe or effective for treatment of menopausal symptoms.

Vaginal lubricants such as KY Jelly and Astroglide and moisturizers such as Replens can be purchased without a prescription and are safe and helpful for treating vaginal dryness and dyspareunia painful sexual intercourse. Dyspareunia is a result of thinning vaginal tissues vaginal atrophy due to low estrogen levels. The North American Menopause Society recommends lubricants and long-acting moisturizers as first-line treatments for vaginal atrophy.

For women who still experience discomfort, low-dose vaginal local estrogen is the next option. Ospemifene Osphena is approved as a non-hormonal prescription drug for treating menopausal-associated vaginal dryness and dyspareunia. Ospemifene is an oral drug pill that acts like an estrogen on vaginal tissues to make them thicker and less fragile.

However, this drug may cause the lining of the uterus endometrium to thicken, which can increase the risk for uterine endometrial cancer.

Because of this and other risks, ospemifene should only be taken for a short amount of time. Common side effects of ospemifene include hot flashes, vaginal discharge, and excessive sweating. North American Menopause Society -- www.

American College of Obstetricians and Gynecologists. ACOG committee opinion no. Obstet Gynecol. PMID: www. Committee opinion no. Acupuncture for menopausal hot flushes. Cochrane Database Syst Rev. Hormone therapy and other treatments for symptoms of menopause. Am Fam Physician. Vascular effects of early versus late postmenopausal treatment with estradiol. N Engl J Med. Postmenopausal years do bring some new symptoms with them, however. Some things to expect include:. Estrogen plays a role in collagen production.

Collagen makes up your skin, hair, bones and many other tissues around your body. Because your estrogen levels are lower after menopause, your skin or hair may become dryer or thinner. Lower estrogen levels can also cause vaginal tissue to become dryer and thinner. This may result in discomfort or pain during sex.

A moisturizer or lubricant can often relieve these symptoms and help you feel more comfortable. Did you know that estrogen also helps support the sides of your bladder? Less estrogen can lead to weaker pelvic floor muscles. The way you experience each stage of menopause will be unique. For example, hot flashes may never affect you, but insomnia leaves you feeling exhausted and irritable. Or perhaps the first sign of change is vaginal dryness.

Menopause symptoms can often be managed by maintaining a healthy diet, exercising regularly, and taking advantage of home remedies or over-the-counter medications. But if your symptoms are intense enough to affect daily activities or keep you from doing the things you love, it may be time to seek advice and care for menopause symptoms.

Care options might include hormone replacement therapy HRT , and supplements or medications to help with depression, high blood pressure or other conditions.

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