For most women, menopause doesn’t abruptly come out of the blue. It begins with an interim phase called perimenopause when the body begins its transition into menopause. Lasting anywhere from months to years, it signals that a woman’s reproductive years are drawing to a close. At this time, women experience symptoms similar to menopause, although they tend to be milder. These include: hot flashes, mood changes, insomnia, depression, fatigue, acne, memory problems, headaches and night sweats.
I’ve seen several perimenopausal women who get debilitating headaches with each monthly menstrual cycle. They are referred to as “menstrual migraines” and are usually treated with pain medications, beta blockers or Imitrex. Migraines typically occur right before or during the first days of a menstrual cycle. They can also occur mid-cycle, at the time of ovulation. These times in the menstrual cycle are associated with a sharp rise or fall in estradiol that may trigger a migraine. The headaches can often be prevented with a small dose of topical estradiol applied one day before the anticipated migraine. Topical estradiol can be taken as a cream, gel, spray or patch applied to the skin.
Perimenopause is characterized by fluctuations in estrogen and progesterone. While both hormones drop, there’s usually more decline in progesterone than estrogen leading to heavy menstrual bleeding. Women in perimenopause often have a normal follicle stimulating hormone (FSH) because they are still producing estrogen. Perimenopausal women are often told “everything is normal” when their FSH is normal. A normal FSH simply means you are not menopausal. It’s disconcerting to a woman suffering significant perimenopausal symptoms to be told “nothing is wrong.” It makes her feel that somehow she is imagining her symptoms. These patients are often prescribed antidepressants or tranquilizers. When the heavy bleeding is caused by a relative deficiency of progesterone, in the early stages, it can often be controlled with cyclic progesterone. If progesterone alone does not control bleeding, oral contraceptives (OCs) may be prescribed through menopause until the periods stop.
Women who don’t respond to progesterone or OCs should be considered for an endometrial ablation. This is a procedure performed by gynecologists that destroys the endometrium, the lining of the uterus. Various types of endometrial ablations, some office-based, are available and should be discussed with the gynecologist. If the bleeding goes on untreated without the benefit of progesterone, OCs or ablation, it may worsen, leading to anemia. At that point, most women are worn down and opt for relieving their symptoms by undergoing a hysterectomy. Perimenopause can be a turbulent time for a woman. Learning about your body can enable you to smooth out this transition and avoid unnecessary surgery.
Marina Johnson, M.D., F.A.C.E., a UCLA-USC trained physician has no ties to any pharmaceutical company. She is the author of “Outliving Your Ovaries: An Endocrinologist Reviews the Risks and Rewards of Treating Menopause With Hormone Replacement Therapy.” She’s the medical director of the Institute of Endocrinology and Preventive Medicine in Dallas, Texas. In 2011, she spoke at the Cleveland HeartLab symposium at the Cleveland Clinic. She’s appeared on Joni’s Table Talk on Daystar Television Network, The Balancing Act on Lifetime Television, Daybreak USA radio show and written articles for numerous magazines.
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