This week’s blog explores the three stages of menopause and how we accurately establish what life stage we’re in. Dr Vera Martins, our consultant naturopath and herbalist, gives her expert view on the terminology and the best route to getting honest answers. We hope you enjoy the read.
PERIMENOPAUSE, MENOPAUSE, POST-MENOPAUSE.
We may be familiar with these terms as women actively navigating the life-stage. But do we really know what they mean?
The truth is that the language that surrounds the menopause is not always clear. We sometimes see these terms being used interchangeably.
Do you find it confusing?
If you do, you are not alone, and that is why, as we look at how to establish what life-stage you are in right now, I want to start by demystifying these terms.
Peri-menopause, menopause and post-menopause describe the three different stages of the menopause, each of them characterised by biochemical changes in the body.
As we enter the peri-menopause, known as Bio-Stage No.1, our ovaries start to produce less sex hormones as a result of the decline in eggs, which reduce in number as we age. Production of oestrogen declines, which, in turn, increases the levels of a hormone called Follicle Stimulating Hormone (FSH). Luteinising Hormone (LH) increases during menopause too. Alongside these changes, other key hormones such as progesterone and testosterone decrease in the body.
You may find yourself experiencing common symptoms such as irregular cycles, low mood, anxiety, insomnia, fatigue, weight gain, low sex drive, hot flushes and sweats, dry skin, vaginal dryness, painful joints, brain fog, migraines, heart palpitations and sluggish digestion.
Although certain symptoms are more likely to be present at a particular stage of the menopause, every woman is different so the type of symptoms and their intensity can vary greatly from woman to woman. Genetics and lifestyle can also significantly contribute to the differences observed amongst women.
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THE THREE STAGES OF MENOPAUSE. STEP–BY–STEP
Perimenopause (Bio-Stage No.1) is the time preceding menopause, which usually happens in your 40s and 50s, but can be earlier for some. Due to sex hormones starting to decline, your cycles of menstruation and ovulation may become irregular. You may notice mood swings, your sleep becoming more disturbed, weight gain out of the blue - particularly around the waist area, your sex drive going down, and your skin becoming drier.
These symptoms can come unannounced, and slowly start to be more present to the point when you reach menopause (Bio-Stage No.2). At this stage, all your sex hormones will have gradually decreased, and symptoms such as hot flushes and night sweats become more common. This is also the time to start thinking about your bone and heart health more seriously.
When you have had more than 12 consecutive months without a period (without bleeding), your menopause is complete. This is the point when you enter post-menopause (Bio-Stage No.3) .
At this period of life your sex hormones will become pretty flat. Some symptoms, particularly hot flushes, may ease, although some women can experience them for several years. Urogenital symptoms such as vaginal dryness, urgency and frequency to urinate, and urinary tract infections are more common in post-menopause due to low levels of oestrogen. The risk of osteoporosis, cardiovascular disease and mental health issues (including depression and dementia) also increases. It is important to be monitored and assess your individual risk for these conditions with your doctor.
The transition from peri-menopause into menopause and post-menopause is a gradual process, and very individual. Some women can stay in peri-menopause for several years while others have a quicker transition through menopause. The average age of women reaching menopause in the UK is 51.
IDENTIFYING PERIMENOPAUSE
The perimenopause is a time of heightened hormone instability. It is like your hormones are on a rollercoaster - think of it as a reverse puberty.
Although both progesterone and oestrogen start declining with age, the trend is that progesterone levels can start decreasing more rapidly than oestrogen during peri-menopause. Oestrogen instead, is more likely to suffer fluctuations with high and low peaks being common during this stage.
A typical scenario in perimenopause is low progesterone associated with high or low fluctuating oestrogen, which is related to low mood, anxiety and insomnia - some of the first and most troubling peri-menopause signs.
Low progesterone may also result in longer cycles and heavier periods. You make progesterone after ovulation so when you do not ovulate (which becomes more common in perimenopause) you produce little or no progesterone. Since progesterone balances out the role of oestrogen in endometrium thickening, if levels start to reduce, your endometrium grows thicker. So, when you have a period, you bleed more. You may also experience both the effects of high and low levels of hormones. This is particularly true of oestrogen, and the reason why you may also have typical PMS symptoms such as sugar cravings during peri-menopause.
DIAGNOSING PERIMENOPAUSE – WHAT ARE THE OPTIONS?
The market for home test kits to diagnose perimenopause/menopause is flourishing, with an array of options on the menu for private purchase globally. Although at first sight the possibility of testing for perimenopause from the comfort of your own home may sound attractive and cost-effective, there are a number of considerations to be aware of.
A number of menopause home test kits promoted are urine tests that rely on one single hormone, FSH. Since FSH levels oscillate during perimenopause, if you diagnose perimenopause based on FSH only, you may be getting a false negative or false positive result. If you do perform this test, it is a good idea to repeat 6 months later to double-check. FSH levels become consistently higher during menopause and post-menopause, however it is still not recommended to self-diagnose for those stages based on one hormone only.
Other home tests analyse a broader range of hormones in the blood based on a finger prick and, although they may be helpful in a different context, they have limitations in menopause as progesterone is not assessed as part of their hormone profile.
There are home test kits which can be useful in assessing hormone balance. Although these tests are not specifically for menopause, they offer a more comprehensive and helpful view of your hormone profile. And because they are prescribed by a health practitioner who will interpret the results and support you with your symptoms, you won’t be relying on self-diagnosis. These companies will test for adrenal hormones such as cortisol (a stress hormone) too, which can be valuable to track. Stress can make your peri-menopause symptoms worse. This is because once your ovaries start producing less sex hormones, you rely more on the adrenals. But if they are over busy producing the stress hormone cortisol…you get the picture.
Interestingly, a recent medical study described a new highly-sensitive blood test claiming it can predict the final menstrual period of a woman. This test is based on a hormone called Anti-Mullerian Hormone (AMH) which represents an indirect measure of the amount and quality of your eggs. Theoretically, the lower the levels of AMH, the lower your egg reserve and therefore the closer you may be to menopause. This is the principle but it does not mean that AMH levels can precisely predict the timing of menopause. Although this is an interesting study, more research is needed before AMH can be reliably used as a test for menopause. In fact, menopause guidelines from NICE (The National Institute for Health and Clinical Excellence) specify not to use AMH for menopause diagnosis. The truth is that currently, there is no test scientifically proven to tell you with precision when you will reach menopause.
My view is that, if you are experiencing potential perimenopausal/menopausal symptoms, the best first step is to visit your doctor with a list of symptoms and concerns. If you feel brushed off or ignored, ask to see a doctor within the NHS that specialises in menopausal health. There are too few specialist clinics (currently 74 in the UK for 13 million women!) but they are free. The alternative is to go to a private healthcare professional with expertise in menopause. They will be able to provide you with full hormone profile testing which may include oestrogen, progesterone, FSH, LH, and testosterone. Testing at the right timing, especially when menstrual cycles are irregular, is critical and something they will manage. The doctor will be able to interpret your results in the context of both your symptoms and age and follow it up with the right support. You may even find that you are not perimenopausal but your hormones are still out of balance. Further investigation, such as checking your thyroid hormones, may be then recommended.
My final message is that, when it comes to menopause, there is no magic bullet for diagnosis because women and their hormones are a fine delicate affair. Whatever your story or your menopausal stage, the most important thing is to seek professional help, practice self-care and self-love.
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References:
Au, A. et al. Estrogens, inflammation and cognition. Frontiers in Neuroendocrinology (2016).
Finkelstein, J.S., Lee H., Karlamangla A., Neer R.M., Sluss P.M., Burnett-Bowie, S.M., Darakananda, K., Donahoe, P.K., Harlow, S.D., and Prizand, S.H. Anti-Mullerian Hormone and Impeding
Menopause in Late Reproductive Age: The Study of Women's Health Across the Nation. The Journal of Clinical Endocrinology & Metabolism (2020).
Greendale, G. A. et al. Changes in body composition and weight during the menopause transition. JCI Insight (2019).
Hantsoo, L. & Epperson, C. N. Anxiety Disorders Among Women: A Female Lifespan Approach. Focus (Madison). (2017).
MacGregor, E. A. Menstrual migraine: Therapeutic approaches. Therapeutic Advances in Neurological Disorders (2009).
Menopause: diagnosis and management. The National Institute for Health and Clinical Excellence (NICE) guideline [NG23]. Published date: November 2015, Last updated: November 2019.
Sherman, B. M., West, J. H. & Korenman, S. G. The menopausal transition: Analysis of LH, FSH, estradiol, and progesterone concentrations during menstrual cycles of older women. J. Clin. Endocrinol. Metab. (1976).
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