What to expect when you’re expecting… menopause
For Janelle, it was massively heavy periods that lasted a fortnight and stopped her going to work. For Nicola, it was not being able to go for a run without crying. For Louise, it was sudden outbursts of unexplainable rage. For me, it was a bout of recurring UTIs (urinary tract infections) in my late forties.
These seemingly unrelated symptoms are just a few of the things that can start happening any time from our late thirties onwards, signalling the start of the transition that is perimenopause and menopause. It’s pretty common not to recognise these apparently random things for what they are. I know I didn’t, at the time.
And often our doctors don’t, either. Many women I’ve talked to have rocked up to their GP with random symptoms that can’t really be pinned on anything in particular, that — looking back — they can see were related to perimenopause. But at the time, nothing was really confirmed. What’s more, many women struggle for years to address these symptoms.
Part of the problem here is that menopause and perimenopause have many, many symptoms — as many as 40 by some counts (see page 24). Not surprising if we consider oestrogen has over 400 biological actions in the body, regulating everything from cognition to sleep. And though hot flushes are recognised as one of the most common symptoms, for many women the first sign of perimenopause might be something else; something that feels quite random.
Many of these random symptoms are unrelated, both to each other and to what we and doctors have understood to be the classic symptoms of menopause. Things like joint pain, for example — far more likely to be experienced by midlife women than anyone
else — and the array of mental health issues such as anxiety and depression that can often pop up for us in sudden and distressing ways.
WHAT DO MENOPAUSE AND PERIMENOPAUSE EVEN MEAN?
It’s probably worthwhile getting into the terminology here before we go any further. Menopause was identified by medical historians as far back as the ancient Greeks; it was written about by Aristotle, for example. The term ‘menopause’ wasn’t coined, though, until 1821 by a French doctor, Charles de Gardanne. It’s derived from the Greek words menos — meaning monthly — and pausis — cessation.
The term menopause, technically, refers to the final menstrual period. Menopause is confirmed once a woman has not had a period for one year. At that stage, we’re officially post-menopausal (though not necessarily free of symptoms).
Perimenopause is the time leading up to that one-year milestone, and that can last anything from one to 10 years. So really, when we are talking about a lot of the things that happen
to us at this time, we’re talking about perimenopause, which
can be a hugely turbulent time, hormone-wise. For many (but not all) women, once they’ve got a few years past their last period, things start to calm down a bit.
In this book, unless specified, I’m using the terms menopause and perimenopause similarly; menopause referring to this whole transition experience, pre- or post-cessation of periods; and perimenopause referring specifically to the hormone roller coaster before our periods shut up shop for good. Clear as mud? Right.
IT MIGHT NOT BE MENOPAUSE
It’s also really important before we go any further to note this: despite what I said above, not every random thing is related to menopause. Yes, it might be, but it’s super important to eliminate other causes first.
Don’t forget, also — there are some women who have very few, if any, symptoms. A lucky one in five or so of us sail on through menopause with no stories to tell.
So: if you’re experiencing something that is new or different for you, and it doesn’t feel right, get it checked out properly. Don’t self-diagnose; don’t assume just because it’s on the list of perimenopause symptoms that that’s what it is. Any change in the way your body is feeling or working needs to be investigated properly, and other, serious, causes ruled out. That goes for everything from headaches to bloating to skin irritation. Get it checked. Properly.
WHY DOES MENOPAUSE HAPPEN?
The answer to that, astonishingly, is: we don’t really know. In all the history of humanity, we’ve never figured it out. Human women and female killer whales are the only mammals that experience menopause, and it seems to me the whales might have been more researched.
Dr Beverley Lawton, who’s done a lot of research into women’s health and co-founded the Wellington Menopause Clinic, told me that scientists are really still making assumptions about why things happen the way they do at menopause: ‘We don’t really know why we’ve got this design.’
One theory — and this comes from the whale world; we don’t know if it really applies to human women — is that it’s to do with older females being able to care for younger females and their offspring, once they’re not too busy having more babies of their own. It’s been termed the ‘grandmother hypothesis’. In the killer whale community, the post-menopausal females protect and seek out food for the younger members of the family group, helping the survival of all.
As a consequence of the fact that we don’t really know the why of menopause, there are, as we will discover, quite a few gaps in the knowledge around the how of menopause. If you start to wonder, as I did while researching this book, whether this would be the case if menopause happened to men, I do not think you would be alone.
HOW DO I KNOW FOR SURE IF I’M PERIMENOPAUSAL?
Short answer: it’s not straightforward. There are no tests that can tell you, and anyone who says they can — I’m looking at you, online hormone-testing outfits — is probably trying to sell you something. And they’re also wrong.
No doctor-ordered hormone test can tell you that you’re in perimenopause or even menopause.
That’s because our hormones are fluctuating all the time, through most of our lives. They rise and fall throughout our menstrual cycle, depending on what stage of the month we’re at (see chapter 2). And in perimenopause, hormones — especially oestrogen — can be fluctuating wildly, from day to day and even hour to hour. So a blood test of oestrogen levels can only ever offer a snapshot — and depending on when it’s taken, it could give widely varying results, even in the same woman.
Endocrinologist Dr Anna Fenton — a menopause expert — told me: ‘[Perimenopause] can actually begin in the mid to late thirties, so things actually start to change quite a lot earlier than people are aware. And you see the hormones begin to swing more wildly than they have before. Women will go through periods when hormone levels are higher than they’ve ever been before, and lower than they’ve ever been before, and everything in between.
‘And then as women get into their forties — particularly beyond, say, the early forties — probably somewhere between a third and half of their cycles will be ones where no ovulation has occurred, so you get bigger swings again in hormones. And that’s often when symptoms start to occur.’
Blood tests for hormones are unreliable, she says, because of these big hormone swings. Blood test results ‘may be completely normal while a woman is drenched with sweat,’ she says, and they ‘can be completely abnormal while she has no symptoms’.
There are a couple of other tests you might have heard of being done. One is the FSH (follicle-stimulating hormone) test. This is a hormone that comes from the brain and stimulates egg development; it’s produced to get the eggs developing over the first half of the menstrual cycle. As we near menopause, and the brain senses the ovaries are struggling,
it will push FSH levels up to try to stimulate the ovary into producing an egg, so FSH levels are sometimes used to confirm menopause. Even then, though, this can be misleading. Just like oestrogen, FSH levels can vary greatly during perimenopause. One elevated FSH level is not enough to confirm menopause. And the other way around, too: a low FSH level doesn’t rule out perimenopause.
‘We hear this story all the time,’ says Fenton. ‘That snapshot test has just been taken at a time when the level looks normal. But it doesn’t exclude menopause.’
The other test that can be used is for something called anti- Müllerian hormone (AMH). This
is more commonly tested during fertility assessment. It’s a hormone that’s considered a useful guide to how many eggs a woman still has.
‘We’re still learning how to use this test at menopause,’ says Fenton. ‘The AMH level does start coming down fairly dramatically from about 37 or 38 onwards, and it will normally reach zero about 3–5 years, we think, before periods stop. So that’s probably a slightly better guide than doing normal hormone levels.’
The AMH test is an expensive, specialist test; it’s not something your GP is likely to offer. And again, it won’t and shouldn’t be used on its own to confirm menopause.
So, unless it’s recommended by your doctor or specialist — usually to look at issues around fertility, cancer treatment or hormone-therapy treatment post- menopause — forget about tests of hormone levels.
And definitely skip the online quizzes and ad hoc hormone testing from other providers. You might see tests for oestrogen levels promoted by supplement companies or natural health websites, pitched at diagnosing ‘oestrogen dominance’, which for the record is not a recognised medical term. They’re at best unhelpful, and at worst, misleading. They’re almost always expensive.
WHAT TO DO
If you’re having symptoms you think might be hormone-related, talk frankly and thoroughly to your doctor, who’ll hopefully be able to put all the pieces together. They will look at your whole health, so make sure you cover it all, even the embarrassing bits.
‘Diagnosis is very much about listening to the patient,’ says Fenton.
Ask your doctor if a symptom could be related to perimenopause. And don’t necessarily accept an answer of ‘No, you’re too young for that‘. You might be too young, but it pays to be prepared. And persistent. This could, after all, affect other life decisions, not the least of which are those around having (or having more) children.
Fenton says: ‘Women are actually very good at telling you what they think’s going on, and I’ve learned over the years that if you ignore women, you do so at your peril. They’re usually right.’
Even experts can have a blind spot about their own perimenopause. Melissa Gilbert, a GP with a special interest in menopause, didn’t realise at first that her own chronic insomnia, starting in her early forties, was the first calling card of perimenopause.
‘I was a nurse first, and I’ve always been a feminist and always been pretty pro-women. So it was kind of shocking that I missed my own first menopausal symptoms,’ she recalls.
‘My GP even said to me, “Do you think it’s early menopause?” Because it was just insomnia. It was only insomnia for about four years. And I was like, “No, no, it’s not that yet.”’
It took her another four years to finally connect the dots and get the diagnosis and hormone treatment that, for her, made a huge difference.
As at the time of writing, at 50, I’m yet to experience a hot flush. But I am definitely experiencing other things related to perimenopause. My cycle — after decades of being a clockwork-like 29 days — has now become extremely unreliable, ranging from 22 days to 58 days (what?) and my periods are constantly taking me by surprise as if it were the first time, not the thousandth.
I’ve also developed osteoarthritis in my fingers and knees, something which is twice as likely in women compared with men and is associated with dropping oestrogen levels. I now creak and click like an un-oiled hinge when I go down stairs. And I seem to more frequently have that thing where I can’t for the life of me remember the name of that . . . thing. Yes, the dreaded brain fog has clicked in.
All of this is to say: menopause and perimenopause are different for every woman. What you experience might not be the same as your friends, or your sister, or your mother. Every woman is different.
Don’t forget also that this is a natural, normal transition that all women go through. Though it might not feel like it sometimes, you’re not the only one.
Lawton has words of wisdom for us here. ‘It’s a natural thing. And it shouldn’t be a negative,’ she says. ‘This is normal. This is what happens. And for most women it will settle. That’s really powerful; knowing that it’s all about your hormones being altered.’
Natural or not, menopause can be daunting, overwhelming and for some of us, pretty life-altering. If you feel like that’s you, you’re not alone.
So let’s get into this together.
Extract from This Changes Everything: the honest guide to menopause and perimenopause, by Niki Bezzant. Click here for more info.