Perimenopause is the phase between a woman’s reproductive years and menopause, marking the end of monthly bleeding cycles. During this transition, hormone levels change significantly. There are fluctuations in progesterone, but mainly a decline in estrogen. This drop in estrogen can cause both physical and emotional symptoms.

Understanding how estrogen levels play a key role in perimenopause is crucial for managing symptoms. It can also help improve the quality of life for women experiencing this transition.

What is Perimenopause?

Perimenopause typically begins when women are in their 40s but some may begin to experience symptoms in their mid-30s. This early onset is considered premature menopause. During this time the ovaries gradually produce less estrogen until menstrual periods completely stop, signaling the arrival of menopause. 

The common duration of perimenopause is about four years, but can vary for each person (1). However, women who experience premature menopause, or undergo surgical menopause (the removal of the uterus and one or both ovaries), are suddenly menopausal, and may experience symptoms of low estrogen (2). In these cases, some providers prescribe hormone replacement therapy (HRT) containing estrogen to help with menopausal symptoms.

Estrogen’s Role in the Body

Estrogen is a key hormone in the female reproductive system that regulates the menstrual cycle and maintains pregnancy. Beyond its reproductive functions, estrogen also plays a vital role in various body systems, including the cardiovascular, skeletal, and central nervous system (3). 

In 2016, the Early Versus Late Intervention Trial (ELITE) was conducted. This study introduced a term called, “the timing hypothesis” (4). This hypothesis suggests that starting menopause hormone therapy (MHT) within 5 to 10 years of menopause is key. It helps estrogen protect the heart and support brain function.

1. Cardiovascular System: Estrogen helps maintain healthy blood vessels and promotes good cholesterol levels, reducing the risk of heart disease.
2. Skeletal System: Estrogen helps keep bones strong and protects against osteoporosis.
3. Central Nervous System: Estrogen influences mood, cognitive function, and overall mental health.

Hormonal Changes During Perimenopause

During perimenopause, the rise and fall of estrogen levels is unpredictable. These fluctuations lead to a range of symptoms, including mood swings, and irregular menstrual cycles (1). The drop in estrogen also affects the hypothalamic thermoregulatory center, which regulates the body temperature (1). This can cause symptoms like hot flashes and night sweats (1).

Symptoms of Estrogen Fluctuations:

1. Vasomotor Symptoms: Hot flashes and night sweats are among the most common symptoms experienced during perimenopause. These are directly linked to the fluctuating levels of estrogen and their impact on the body’s temperature regulation (1).
2. Mood Swings and Depression: Changes in estrogen levels can affect neurotransmitter systems in the brain, leading to mood swings, anxiety, and depression (1).
3. Sleep Disturbances: Many women report difficulties in sleeping, which can be attributed to night sweats and hormonal changes (1).
4. Cognitive Changes: Some women experience memory lapses and difficulty concentrating, often referred to as "brain fog" (1).
5. Physical Changes: Weight gain, particularly around the abdomen, and changes in skin firmness and hair texture are also common.

Estrogen Therapy in Perimenopause

Hormone Replacement Therapy (HRT) is a common treatment for reducing perimenopausal symptoms. HRT involves the administration of estrogen or a combination of estrogen and progesterone/progestin to stabilize hormone levels.

1. Benefits of HRT: HRT can significantly reduce vasomotor symptoms, improve mood sleep quality, and protect against bone loss.
2. Risks of HRT: While HRT is effective, it is not without risks. Potential side effects include an increased risk of blood clots, stroke, and certain types of cancer. It is essential for women to discuss the benefits and risks with their healthcare provider to make an informed decision.

Non-Hormonal Treatments

For women who cannot or choose not to use HRT, there are non-hormonal options available. These include lifestyle changes, maintaining a healthy diet, regular exercise, and stress management techniques. Additionally, certain medications, like selective serotonin reuptake inhibitors (SSRIs), can help manage mood swings and hot flashes.

Emerging Research

Recent studies have highlighted the complex role of estrogen in perimenopause (4). For example, research suggests that estrogen’s impact on brain pathways involved in inflammation may contribute to mood disorders during this transition. Another study found that the change in estrogen, rather than the actual levels, might be more strongly linked to perimenopausal symptoms.

Views on Menopause Throughout History 

Historically, menopause was viewed as a disease. It was seen as needing medical and sometimes psychiatric help, and not as a natural part of a woman's life. In some cultures, or societies, menopause was kept secret, creating a sense of shame and isolation for women. By the mid-20th century attitudes were showing signs of change. 

The development and introduction of HRT in the 1960s marked a significant turning point for women. However, it also led to the belief that perimenopause and menopause were due to a deficiency that needed fixing. This further framed a natural female life transition as a medical problem.

Interesting insights come from writer, and oral historian, Dr. Helen Foster (6). She presents the history of menopause, bringing to light the confusion and superstition about menstruation and menopause. Dr. Foster uses audio clips from interviews with modern women to explore the difficult and sometimes violent history of menopause (6). She also dives into the mythology, and taboos around periods and the onset of menopause. 

In a podcast episode of The Happy Menopause, Dr. Foster talks about her project, “The Silent Archive Project.” She notes, “I found there was a real gap around women’s stories at midlife, particularly at the mention of menopause… What I couldn’t find was women sharing what their symptoms were and how they felt about them.” “(Menopause), doesn’t really feature in any historical accounts, or very, very few. When there is, they are from the roots of taboo” (6).

Advocating for Change

Right now, there is political legislation that aims to address women’s midlife health issues that are often overlooked (5). The legislation, backed by celebrity support, is set to increase federal funding over a five-year period. This will also provide professional training and resources for healthcare providers on early detection, diagnosis, and treatment of perimenopausal and menopausal symptoms. This initiative is a crucial step toward ensuring that women receive the specific care and attention they deserve.

Perimenopause and menopause are natural biological phases marking the changes toward the conclusion of a woman's reproductive years. Like the onset of menstruation, perimenopause and menopause as an individual feminine experience is culturally acknowledged and celebrated differently throughout the world. 

In this article from The Women’s Journal, author Carmen Rodriguez Gonzales discusses how menopause is viewed around the world. She writes, “In many cultures, menopause is seen as a significant milestone in a woman’s life. It is often associated with wisdom, maturity, and the attainment of a new level of spiritual and emotional growth. Understanding the cultural nuances surrounding menopause is crucial to providing appropriate support and empowerment for women during this transformative phase” (7) 

How we, as women, see the physical and emotional changes in our bodies is important. It is helpful to explore these feelings with female friends, family, or support groups. Talking about our fears and discussing changes in our bodies with other women can be healing. It benefits both ourselves and all women. 

The unique experience of biological changes can be seen in light of a person's religious, cultural, and family background. This context can greatly impact how each of us anticipate the experience and navigate the changes for ourselves.

Were you able to experience your mother going through the perimenopause or menopause transition? If you were fortunate enough to have your mother during this time in her life, how did her experience shape your views? How did it affect how you want to go through your own transition? 

Conclusion

Perimenopause is a challenging phase marked by significant hormonal changes, particularly in estrogen levels. Understanding the role of estrogen can help women and healthcare providers better manage the symptoms associated with this transition. While HRT remains a cornerstone of treatment, non-hormonal options and emerging research offer additional avenues for relief. As always, personalized care and informed decision-making are central in navigating perimenopause effectively.

Convenient at-home tests using saliva or dried blood spots can check ovarian hormone levels. These hormones include estrogen and progesterone. This testing can provide meaningful insights for supporting a woman's health as symptoms are being anticipated and experienced. Hormone testing can also help women feel more empowered in their bodies during this transitional stage of life.

References:

1. Dhalwani, N. N., Williams, D., McManus, R. J., & Gokhale, K. M. (2023). Mortality and cardiovascular outcomes with different classes of antihypertensive drugs: A population-based cohort study using electronic health records linked to the UK Biobank. BMJ, 382, e072612. https://doi.org/10.1136/bmj-2022-072612

2. Sohn, E. (2023). Surgical menopause: Estrogen after hysterectomy. WebMD. https://www.webmd.com/menopause/surgical-menopause-estrogen-after-hysterectomy

3. Mehta, M., Jaya, Chester, C., Rebecca, & Kling, M., Juliana. (2019). The Timing Hypothesis: Hormone Therapy Treating Symptomatic Women During Menopause and Its Relationship to Cardiovascular Disease. Journal of the American College of Cardiology, 74(17), 2167–2175. https://doi.org/10.1016/j.jacc.2019.08.1037

4. Russell, K., Jason, Jones, K., Carrie, & Newhouse, A., Paul. (2019). The Role of Estrogen in Brain and Cognitive Aging. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC6694379/

5. Murkowski, L. (2023, September 21). Senator Murkowski introduces historic new bipartisan legislation to boost menopause research, expand training and awareness around menopause. Senator Lisa Murkowski. https://www.murkowski.senate.gov/press/release/senator-murkowski-introduces-historic-new-bipartisan-legislation-to-boost-menopause-research-expand-training-and-awareness-around-menopause

6. Wellcome Collection. (n.d.). A bloody history of menopause. https://wellcomecollection.org/series/a-bloody-history-of-menopause

7. Rodriguez Gonzalez, C. (n.d.). Menopause in different cultures around the world. The Women’s Journal. https://www.thewomensjournal.co.uk/womens-life/health-wellness/menopause-in-different-cultures-around-the-world/