What is Perimenopause, Menopause & Postmenopause?
A woman's body generally goes through a physiological transition over the course of several years as menopause approaches. Often this transpires unbeknownst to most women; however, they may begin to experience irregularities in the symptoms, duration, and frequency of their monthly menstrual cycles.
Perimenopause describes the period prior to complete amenorrhoea and extends over several years. Hormonal changes signalling the beginning of the perimenopausal period often begin when a woman is in her mid-forties. The length of this hormonal transition can vary because each woman's physiology and fertility pattern is different. Such variables to this progression include race, heredity, health status, diet and level of physical activity. These factors influence the way a woman experiences menopause in the same way they affect menarche, the menstrual cycle, and fertility in general.
A quick overview of the female monthly rhythm needs to be outlined in order to understand the physiological changes which take place during menopause. All the hormones released during the menstrual cycle are secreted not in a constant, steady manner but at dramatically different rates over the specific phases of the 28-day cycle.
For the first eight days, the ovaries produce lots of oestrogen to prepare the follicles for the release of one of the eggs. Oestrogen secretion begins to fall around Day 13, one day before ovulation occurs. Progesterone begins to rise at this time, stimulating very rapid growth of the follicles. Ovulation then takes place.
After the egg is released (known as the luteal stage), the follicle begins to change, enlarging and becoming the corpus luteum. Progesterone is secreted from the corpus luteum, a tiny organ with a huge capacity for hormone production. The surge of progesterone at the time of ovulation is the source of libido.
After 10 to 12 days, ovarian production of progesterone falls dramatically if fertilisation does not occur. It is this sudden decline in progesterone levels that triggers the shedding of the secretory endometrium (the menses), leading to a renewal of the entire menstrual cycle. This cycle continues month after month for at least 40 years of a woman's life. It’s no wonder that by the time a woman makes it to this 'change of life' and the hormonal rollercoaster ride stops, it is always a welcome thing!
The total number of follicles and eggs in the female body decreases throughout a woman’s lifetime due to ovulation. As she approaches menopause, the number of follicles drops further, causing a significant reduction in ovarian oestrogen production. These lowered oestrogen levels are not sufficient to signal the brain to stop producing FSH (follicle stimulating hormone) and so FSH continues to be released at high levels, causing rapid but inadequate follicular development. With fewer follicles remaining, oestrogen production continues to drop. Insufficient oestrogen is produced to regularly induce the LH (luteinising hormone) surge necessary for ovulation. As ovulation ceases completely, the levels of both FSH and LH rise significantly.
Ovarian failure associated with reduced oestrogen production can start triggering menopausal symptoms such as hot flushes, night sweats, insomnia, headaches, mood swings and incontinence. There is also an increased risk of osteoporosis, increased bone turnover, high cholesterol levels, dry skin and reduced vaginal lubrication.
Changes such as lighter menstrual bleeding begin as a woman enters the perimenopausal phase. Most women observe that this happens around the same time their own mothers experienced changes in their menstrual cycles (often around the ages of 45 to 55).
As early as the age of 35 however (and leading up to 50), it is critical for women to be aware of the changes that are starting to occur in their bodies. That way, they can find means to support the endocrine control centres to lessen or avoid unpleasant symptoms and ensure healthy menopause.
The frequency and severity of symptoms associated with perimenopause can be improved with the right lifestyle and diet. By lightening the load on digestion and the liver, uncomfortable symptoms can often be appeased. Desensitisation, detoxification and regulation of the hypothalamic-pituitary-adrenal (HPA) axis can be the "missing link" in the successful treatment of hormonal disorders.
If menopausal symptoms are ignored or suppressed with hormonal treatments, the underlying attempt of the body to try and manage this transition naturally is sabotaged. This can lead to a range of other issues such as:
- Weight gain
- Thyroid reduction
- Skin breakouts
- Mood swings
- Premature ageing
- Early menopause
Menopause is the time in a woman’s life when menstrual cycles permanently cease (amenorrhoea) due to the physiological changes in ovarian function. Most women would like this process to occur naturally with the least amount of problematic symptoms.
Natural menopause is diagnosed after the cessation of menses for 12 months. This phenomenon is caused by the reduced secretion of the ovarian hormones (oestrogen and progesterone) which takes place as the finite store of ovarian follicles is depleted. Women are born with a certain number of eggs which are released with each monthly cycle at the time of ovulation. Menopause occurs when the supply of eggs from the ovaries runs out. It signals both the end of menstruation and the end of the fertile years of a woman’s life.
Menarche (initial period), menstruation and menopause are normal phases in a woman’s life. In some cultures, spiritual ceremonies are even held to honour each passage. Menopause takes place when there is a shift from high hormone production that initiates and sustains hormonal development of the fertile menstrual cycle to a more passive cycle when the hormones produced are used to sustain secondary sex characteristics, skin health, bone density and energy levels. These are all positive changes; however, many people associate menopause as a time of disorders and ailments or even a time of despair. This negative connotation may have stemmed from not fully understanding or supporting the physiological changes that naturally occur in the life of a woman.
On the physiological level, menopause occurs due to a drop in oestrogen/progesterone and significantly decreased ovarian function. Hence, menstruation stops and reproductive ability ceases. With age, the ovaries become less responsive to pituitary gonadotrophins resulting in:
- A shorter follicular phase (therefore shorter menstrual cycles)
- Fewer ovulations
- Decreased progesterone production
- Irregularities in cycles
- Increased levels of LH and FSH
The timeframe for menopause is varied and it may be natural (approximately around 50 years of age), artificial (following radiation or surgery of the ovaries), or premature (before 40 years of age).
Menopause may be classified into four types:
- Natural menopause (occurring around the age of 47 and lasting for 4-5 years) which occurs as a healthy, normal and natural process from childbearing years to the mature years of post-menopause
- Medically-induced menopause which occurs due to a chemical or trauma-induced intervention. These include oophorectomy, chemotherapy, radiation of pelvis or impaired ovarian blood supply. Menopause can also occur after radiation therapy for cancer, particularly radiation of the pelvic region. Ovarian tissue is damaged and fails to produce follicles in the usual reproductive way, so menopause is an inevitable effect. Also, some drugs used in the treatment of cancer can cause menopausal symptoms, premature ovarian failure or early menopause.
- Premature menopause occurs before age 40 and may be due to an ovarian failure of unknown cause (may be associated with smoking, living at high altitudes, or poor nutritional status).
- Surgically-induced menopause which involves the removal of the ovaries is actually less common these days due to the effectiveness of anti-oestrogen drugs such as Tamoxifen. A complete hysterectomy, bi-lateral hysterectomy (both the ovaries and uterus are removed), or removal of the ovaries will immediately shift a woman into menopause. These types of surgery are commonly performed on women suffering from endometriosis, oestrogen-respondent breast cancer, ovarian tumours or ovarian cancer.
After her menstrual period has ceased for 12 consecutive months, a woman is said to have entered postmenopause. This means that there have been no bleeds or spotting during this time. Technically, a woman is postmenopausal from the day menopause occurs until the end of her life. Ideally, it should be a symptom-free period wherein she can easily transition into midlife and beyond. Unfortunately, that is not the case for most women and there are some health considerations which still need to be addressed.
Menopausal symptoms such as hot flushes, anxiety and irritability should ease up during postmenopause. Depending on how their symptoms were managed, some women may continue to experience the negative side effects associated with hormonal imbalance well into their later life.
The symptoms most women experience during their postmenopausal years can be very similar to those they had during perimenopause. These include:
- Vaginal dryness and itching
- Vaginal discharge
- Weight gain
- Stress incontinence
- Urinary tract infections
In postmenopausal women, the drop in oestrogen production is sometimes not enough to sustain the health of the skeletal and cardiovascular systems. Oestrogen exhibits a protective effect on both of these systems. Postmenopausal women should, therefore, be aware of the heightened risk of developing osteoporosis, hypertension, and heart disease once they enter postmenopause.
One more thing to be vigilant about during this period is postmenopausal bleeding. For practical purposes, postmenopausal bleeding is defined as vaginal bleeding occurring after twelve months of amenorrhoea (the last menstrual cycle). Although post-menopausal bleeding is common, it is not normal to bleed at this time, even if it is just light spotting. The cause is usually something minor; however, other causes need to be ruled out such as:
- atrophic vaginitis (inflammation and thinning of the vaginal lining)
- endometrial cancer
- cervical polyps
- endometrial hyperplasia (thickening of the womb lining)
For these reasons, postmenopausal women should continue to have themselves regularly checked. They must be aware of the implications of a loss of bone density as they age. A bone density screening test helps to determine the level of the mineral calcium present in the bones and is essential in the prevention of osteoporosis. Blood pressure levels should also be kept within the normal range and regular visits to a doctor can help ensure optimum heart health.