The years before you finally hit menopause are called perimenopause, and consist of the changes we associate with ‘menopausal symptoms’ – hot flashes, night sweats, a dry vagina, periods all over the place with long gaps in between. Perimenopause appears two or three years before ovulation actually grinds to a halt, with first progesterone declining, and then oestrogen dropping off.
Your ovulation and periods may become less frequent, or stop and start unpredictably.
How you end up pregnant in your late 40s or early 50s
Oddly timed ovulation can result in sort-of-menopausal women ending up pregnant. You think you’ve been cut loose from it all, only to find yourself having a final hurrah ovulation that has resulted in a pregnancy. While a surprise pregnancy as you enter menopause is not that common, it does happen.
Getting into menopause – the easy way and the hard way
There are two ways to enter menopause, with the first being naturally with age, and the other being through surgical or medical interventions (removal of ovaries or hormone-blocking treatments). What age you hit menopause will vary, with the best indicator being genetic – ask your mother and any of her sisters.
The slower perimenopause is, the fewer symptoms are experienced, but it’s very difficult to predict what will happen to you as an individual. Your whole body, health, genetics and environmental factors all come into play.
Signs and symptoms of perimenopause
First phase – changes in progesterone and oestrogen levels
- Periods become less frequent
- Cycle length may shorten initially and then increases
- Vaginal dryness
- Hot flushes
- Night sweats
- Weight gain
- Mood symptoms
Second phase – menopause arrives
- Period doesn’t come for a year
- Very sparse periods may lead up to this time
- ‘Flooding’ period, usually right before they stop altogether
- The first phase symptoms may or may not continue past this point
- Joint pain
- Lowered libido
- Mood symptoms
- Vaginal dryness
- Change in body shape (more abdominal weight, less muscle)
- Significant event for the body
Menopause refers to the last menstrual period a woman will get. This is only identifiable in hindsight with a woman being considered “postmenopausal” when she hasn’t had a period for 12 months. Some women will stop getting symptoms after their final period, while others will continue to get hormonal and physical symptoms beyond this.
Hormones – oestrogen, progesterone, testosterone, follicle-stimulating hormone (FSH) and luteinising hormone (LH)
Oestrogen normally inhibits follicle-stimulating hormone (FSH), but as oestrogen decreases, elevated blood levels of FSH become clear on a blood test – this is one of the indicator tests for menopause. FSH and luteinising hormone (LH) are released about every 60-90 minutes in small bursts, with the burst of LH understood to coincide with hot flashes.
LH also stimulates the ovaries to produce an androgen that is converted into a form of oestrogen (oestrone), which is the most dominant type of oestrogen in postmenopausal women. The majority of oestrone production in postmenopausal women, however, is the job of the adrenal glands.
The adrenal glands produce the most of the androgen that is converted to oestrone, which fat cells then turn into oestrone. The more oestrone you have in menopause will correlate with greater bone density and fewer menopausal symptoms, and this varies from person to person.
Oestrone is about 12 times weaker than your usual oestrogen from the ovaries, oestradiol. The oestrogen effect in menopause is heavily reduced. Without as much oestrogen, androgens behave differently too, but only drop by about 15 per cent.
This means that overall, androgens are dominant. The ‘androgen body type’ is that of a man’s, with skinny legs and a bigger midsection – the classic older lady body. The loss of androgens is also believed to contribute to menopausal symptoms. This is understood to be because half of our testosterone is produced in the ovaries, with just 10 per cent from the adrenals, and the rest converted in our fat cells.
The testosterone levels of a woman in her forties are half that of a woman in her twenties. Low levels of testosterone are thought to contribute to low mood, less stamina, lowered libido, and other symptoms. Some women, on the other hand, will see male-pattern hair loss or facial hair growth, caused by the effect of the androgen DHEA on hair follicles, indicating more androgen effect.
Progesterone is produced unpredictably in perimenopause. Progesterone is produced by ovulation, so the less ovulation, the less progesterone is being produced. Progesterone declining can cause mood changes and heavier periods.
All these changes together cause the physical and chemical changes that characterise menopause, bringing with them hot flushes, mood changes, and menstrual cycle changes.
Tests for menopause
The FSH test is not always very accurate, since your FSH levels can fluctuate during the day or day to day during perimenopause. This can be misleading. Once you have become menopausal, however, FSH levels will stay high, but you won’t need a test to tell you that – you will know.
The best time to take the FSH test is three days after your period starts – if your result is >10 IU/L, it indicates a perimenopausal state. Oestradiol levels should also be taken at the same time, with a reading of <150 pmol/l suggestive of perimenopause.
If you have had a hysterectomy and there is doubt regarding your test due to no periods, FSH alone may be useful in determining what is going on. Progesterone and oestrogen tests are even less reliable due to fluctuations, and are typically a waste of time and money. If you are on oral hormone replacement therapy, results will be inaccurate.
The look of your vaginal walls is a good indicator of where you’re at, with thinner, drier, easily-disturbed tissue a good indicator of lowered oestrogen levels.
How can I tell if I am menopausal?
If you haven’t had a period for a year, and there is no other obvious cause (i.e. you are too young, there is unusual bleeding or other symptoms), then you can suppose that menopause has arrived.