The perimenopause can be a challenging and confusing time for women. Historically it has been poorly understood, under-diagnosed and often mis-labelled as anxiety. Thankfully, knowledge and awareness around the perimenopause and menopause has improved over the last few years but there is still a lot of confusion and misconceptions out there.
GP and co-founder of BiOrigin, health and hormone clinic, Dr Tanya Patrick, covers the basics in this article to help you navigate the Perimenopause, including some information on hormone therapy, nutrition and lifestyle recommendations.
What actually IS the perimenopause?
The perimenopause is defined as the time leading up to the menopause when symptoms of hormone deficiency might start as ovaries begin to lose function. It can start anytime between late 30s’ and mid to late 40s and often lasts between 2 to 10 years. It often occurs around the busiest time of a woman’s life with multiple responsibilities including caring for children/elders, managing a career, and being the home maker. The menopause is defined as 1 year after your last period, so this is diagnosed retrospectively.
What are the symptoms?
- Heavy irregular periods
- Mood swings
- Worsening PMS or PMDD
- Insomnia
- Irritability
- Anxiety and reduced ability to cope with stress
- Memory problems
- Headaches
- Weight gain
- Joint pains
As periods may still be regular, some doctors may not realise that a woman’s symptoms are due to hormone fluctuations in the perimenopause. Seeking medical advice from a doctor who is trained in menopause care can ensure you are given the best treatment.
What is happening?
The perimenopause is a sequence of events that starts with losing progesterone. Many women will start to have anovulatory cycles in the perimenopause, which means they are still cycling but without ovulating. When your body does not ovulate, it does not make any progesterone, so progesterone levels go down. Oestrogen levels tend to fluctuate wildly and can be very high (as surges in ovarian activity can occur) or very low. Wildly fluctuating oestrogen is often responsible for a woman’s symptoms in the perimenopause. Progesterone acts as the body’s natural calming hormone, by upregulating the neurotransmitter GABA. It balances the stimulating effects of oestrogen and reduces thickening of the lining of the womb. When progesterone levels are low, and oestrogen high or normal, a woman may experience prolonged heavy periods, worsening PMS, breast tenderness, headaches, irritability, insomnia, mood swings and anxiety.
Diagnosing the perimenopause
This can often be done by symptoms alone, and blood testing is not always necessary. It can be useful to test blood levels if you want to rule out other medical conditions such as thyroid problems or anaemia. For some women, it can be useful to do bloods to check whether ovulation has occurred or to assess oestrogen and testosterone levels. However, there is no single blood test to diagnose the perimenopause.
What can I do?
Every woman’s experience of the perimenopause is different, with some experiencing only mild symptoms and others struggling to function normally day to day. Whatever your symptoms, it’s helpful to consider the perimenopause as a critical window for you to take extra care of your health.
Some top tips include:
- Speak to a health professional
- Talk about it with friends- sharing stories and experiences
- Address lifestyle factors (see below)
- Adapt your exercise regime according to your needs
- Focus on nutrition and balanced diet
- Adopt healthy sleep habits
- Bioidentical hormone therapy can help in this phase
- Herbal therapy can also offer relief from symptoms
Lifestyle
Eat to nourish
We are the food we eat. Choosing a nutritionally dense, varied high quality diet full of colourful veggies, iron, protein and healthy fats will help you achieve optimal health and energy in the perimenopause. Dark, leafy, green vegetables are especially good in the perimenopause as they support detoxification and a healthy oestrogen metabolism. Sugar is not our friend, as it drives symptoms of the perimenopause, such as irritability, anxiety and weight gain. It is also a big driver of chronic disease. Insulin resistance and prediabetes are more common in perimenopause and menopause so reducing sugar and simple carbohydrates will help improve insulin sensitivity. Alcohol also often becomes problematic during the perimenopause as many women find they are suddenly unable to tolerate it, or develop insomnia and headaches after just a few glasses of wine. It can also drive hot flushes, night sweats and anxiety. There are a number of reasons why this may be, including lower levels of the enzyme that breaks down alcohol, and slower liver metabolism.
Nurture to flourish
Stress has a negative impact on our hormone production, sleep, immune system and wellbeing. It is not possible to eliminate stress from modern life, but we can change the way we react to it and the way we perceive it. Adopting techniques such as breathwork, meditation, yoga, being in nature and grounding can all help lower the stress hormone cortisol. We know that stress hormones (adrenaline and cortisol) will exacerbate symptoms of the perimenopause, especially anxiety, flushes, and poor sleep. So, tackling stress is really crucial for health and wellbeing in the perimenopause. Working with a breathwork coach or health coach can be helpful too. Try some simple breathwork exercises e.g. 4:6 (inhale for 4, exhale for 6) or box breathing (inhale for 4, hold for 4, exhale for 4, hold for 4) to relax and promote sleep at bedtime.
Sleep to recover
Sleep has to be the number one pillar of health, without which everything else falls apart. We are more likely to make poor lifestyle choices after a bad night’s sleep, ingest more calories, struggle to make decisions and generally feel a lot moodier. Adopting a healthy sleep routine, with a regular bedtime, avoiding screens/blue light before bed, including a relaxing activity in the evening and avoiding stimulants late in the day all helps. Remember caffeine has a half-life of seven hours, so limit caffeine intake to before 1pm. Getting natural light on your face first thing in the morning is a fantastic way to set your circadian rhythm for the day, and optimise melatonin (our sleepy hormone) later in the evening.
Move to support health & wellbeing
Exercise regularly but diversely, meaning not all HIIT or cardio which can increase levels of the stress hormone cortisol in the perimenopause. For women in whom central weight gain is a problem, increasing levels of cortisol further can make it harder to lose weight. Weight bearing exercise is important to maintain bone density and joint strength; adding in resistance/weight training 2-3 times weekly is also very important to support muscle mass, which naturally declines in women over 40 years. Muscle acts as a “sink” for glucose, helping to maintain healthy glucose levels at rest, which is important for your metabolism and promotes longevity.
Bio and body identical HRT
Replacing progesterone alone in the perimenopause will often provide significant relief of symptoms in the perimenopause. Progesterone can be given orally, as a cream, or a vaginal pessary. It can reduce symptoms of anxiety, mood swings, PMS, headaches, insomnia and heavy bleeding.
Transdermal bio identical progesterone is very well tolerated with very few experiencing side effects. This form of progesterone is off-license as it has a variable dose and is not regulated by the MHRA. Oral body identical progesterone (Utrogestan) is a licensed form of progesterone that is regulated by the MHRA and is available on the NHS. Some women struggle to tolerate oral progesterone, and will do better with a lower dose, or transvaginal progesterone (both of which are off-license). Synthetic progestins such as those found in conventional HRT patches or in the Mirena coil will not have the same beneficial effect. Body identical oestrogen includes Oestrogel, Lenzetto spray and Oestradiol patches. Bioidentical oestrogen is usually in the form of a cream that has been compounded by a pharmacy to suit your needs, it can sometimes be combined with testosterone or progesterone so that you only need to use one cream. Bioidentical hormone therapy such as this is off license due to the variable doses that are involved.
Herbal therapy
Certain herbs may help relieve symptoms of the perimenopause including: Sage, red clover, black cohosh, agnus castus, and ashwagandha. We advise speaking to a qualified herbal therapist or nutritionist.
Supplements
Some women find a benefit in taking nutritional supplements during the perimenopause. Magnesium glycinate or magnesium threonate can have a calming effect on the body and support sleep. A quality omega 3 supplement is cardio-protective and supports brain health. Supplementing with Vitamin D is especially important in the winter months for optimal bone health and immunity. Every one of us is unique so we recommend consulting with a health practitioner for advice.
Summary
The perimenopause can be a challenging time, but it is also a great opportunity to address lifestyle and nutrition, and focus on achieving optimal health and wellbeing. Many women find they enter the perimenopause feeling stressed, tired and burned-out but come out the other end feeling stronger, happier and healthier. We believe this is possible for all women.
Author
Dr Tanya Patrick
MBChB MSc nMRCGP DRCOG DFSRH AFMCP
Dr Tanya Patrick is co-founder of BiOrign the GP-led integrative Health and Hormone Clinic. She has 12 years of experience as an NHS GP, with a special interest in Women’s Health and Hormones. Her personal experience of Long Covid, hormonal migraines, and POTs in 2020 triggered her interest in functional medicine, addressing nutrition, gut health, mitochondrial function, the immune system, and hormone imbalance. She has a Diploma from the Royal College of Obstetricians and Gynaecologists and the Faculty of Sexual and Reproductive Healthcare. She is also a member of the British Menopause Society, the International Menopause Society, and the prestigious Institute for Functional Medicine in the US. She is fully trained in bioidentical and body-identical HRT to treat hormone disorders.
Previously a big runner and cyclist, now a yoga convert and cold-water enthusiast. She is a firm believer in lifestyle medicine, nutritional health and root cause medicine.
About BiOrigin (www.BiOrigin.co.uk)
BiOrigin is a GP-led integrated health and hormone clinic that was set up by Dr. Liz Leek and Dr Tanya Patrick, who met through a mutual interest in root cause medicine and have personal experience in overcoming health challenges. They head up a team of highly qualified team of health care practitioners, which include Specialists GPs, Nutritional Therapists, a Health and a Breathwork Coach.
Using an integrative whole-person approach to identify the root causes of a person’s health concerns, BiOrigin focuses on the foundations of health. This includes examining lifestyle factors, emotional wellbeing, and a systems-based approach looking at gut health, immune function, hormone balance, bioenergetics, and detoxification pathways.
BiOrigin, specialises in treating the following range of conditions: Perimenopause, Menopause, PCOS, Endometriosis, PMS & PMDD, Fatigue, Thyroid dysfunction, Fertility support, and Long Covid. Virtual and face-to-face consultations are available. To find out more about the clinic visit www.biorigin.co.uk, or follow them on Facebook, Instagram or email in**@*********co.uk.
