Dr. Maggie Ney is a licensed, board-certified naturopathic doctor and co-director of the Women’s Clinic at Akasha. She specializes in female hormone balancing and healthy aging.
Yep, it’s Perimenopause
Every woman is pretty familiar with the signs of menopause—unbearable hot flashes, thickening waists, moods that fluctuate wildly—but what about all those other signs of “aging,” like thinning hair, flighty cycles, brittle nails, and weird sleep disturbances? We’ve learned it’s likely perimenopause, a drawn-out period of time when your body’s reproductive system slows down until you hit menopause, which is actually the technical term for the full year anniversary of not having a period. We asked Dr. Maggie Ney, the co-director of the Women’s Clinic at the Akasha Center in Santa Monica, to explain exactly what’s happening, and whether there’s anything to be done to make the process a little less disruptive.
Q: So is perimenopause just an inevitable part of aging?
A: Funny you should ask. Most women know that hot flashes, night sweats, and menstrual irregularities are part of the hormonal changes of perimenopause. But I find that many women associate weight gain, fatigue, insomnia, forgetfulness, and even “abnormal labs” (like increased cholesterol, insulin, and blood sugar levels) with the normal aging process. Or, women experience depression and anxiety for the first time and do not know why but find that their quality of life has diminished and just believe it is going to be that way. So often these changes are associated with hormonal changes—by addressing hormones and supporting healthy lifestyle factors, these signs and symptoms—so often associated with “aging”—are reduced and optimal health is restored.
Q: At what age can perimenopause start?
A: The level and consistency of estrogen and progesterone generally starts to become more irregular starting in a woman’s early to mid-30s. She may not have any symptoms yet, but hormonal changes are happening. Most women start to report symptomatic changes of perimenopause during their ’40s.
I always tell my patients that they can continue to age with the same (or even better) level of energy and vitality as they had when they were younger—but how we treat our bodies becomes much more important. Women in their ’30s and ’40s can’t get away with staying up all night or eating poorly. While women of all ages should take the best care of their health, it is vital for women in their ’30s to make healthy lifestyle and dietary changes so that symptoms associated with perimenopause are reduced.
Q: Can a woman in perimenopause still get pregnant?
A: Yes! If a woman has not gone a full year without a period, she can still get pregnant. Is it more difficult? Yes. A woman does not always ovulate regularly, and egg quality diminishes which reduces chances of a healthy conception. Some stats: A 30-year-old has about a 20% chance of getting pregnant every cycle, a 45-year-old has about a 1% change of conceiving using her own eggs.
Q: What are the most common symptoms?
A: Besides the cycle and mood issues mentioned above, other symptoms include:
- hot flashes
- night sweats
- lower libido
- vaginal dryness
- weight gain (especially around the middle)
- hair loss or thinning
- worsening PMS
- breast tenderness
- urinary incontinence and change in frequency
- mood swings
- coming to tears easily
- skin issues (not as toned as well as episodes of feeling electric shocks and tingling)
- changes in nails
- memory lapses
- more difficulty recovering after exercise
- increased gas and bloating
- bleeding gums
Q: Sounds pretty awesome! What can be done to mitigate some of these symptoms?
A: The hormonal fluctuations in perimenopause can cause a metabolic imbalance in our body. The most important thing a woman can do during perimenopause is optimize her health by:
- eating a clean, whole foods diet, with lots of dark leafy green vegetables and healthy sources of protein and fat
- staying well-hydrated
- maximizing sleep before midnight and never sacrificing a good nights rest to get something else done
- managing stress
When I work with women going through perimenopause, I first look at the whole person and address those areas that need attention whether it’s diet, lifestyle, gastrointestinal issues, thyroid issues, nutrient deficiencies, or any lab abnormalities. Then, I make recommendations based on overall health and symptom presentation that are a mix of elements below. Consult with your doctor or health care professional about the appropriate mix for you.
PROBIOTIC: This helps balance the intestinal flora, support gastrointestinal and immune health functions, and enhance digestion.
DIGESTIVE ENZYMES: Helps digest food and support gut health.
ADRENAL SUPPORT: Herbs such as rhodiola, eleuthro, ashwaganda, american ginseng, scizandra, and vitamins and minerals such as B vitamins, magnesium, and vitamin C all support the adrenals.
OTHER HERBAL SUPPORT: I have found that these herbs (and often a combination of herbs) are most successful in addressing perimenopausal symptoms: Maca; black cohosh; dong quai; a blend of Angelica gigas (root); phlomis umbrosa (root); and Cyanacum wilfordii (root); rhapontic rhubarb.
LIVER SUPPORTIVE HERBS: Milk thistle, burdock, dandelion root, DIM or I3C (the latter two support estrogen metabolization and decrease estrogen dominance which can occur during the early perimenopausal transition).
HEART SUPPORT: COQ10, Magnesium
BONE SUPPORT: Calcium, Magnesium, Vitamin D
BRAIN HEALTH: fish oil, NAC, Vinpocetine, B Vitamins
VAGINAL DRYNESS: Vitamin E oil can be helpful.
THYROID: zinc, selenium, B Vitamins
SLEEP SUPPORT: Melatonin, Chamomile, Hops, Glycine, Phenibut, and, if cortisol is elevated at night time (which can happen with stress and low estrogen), hosphatidylserine
HAIR: biotin, silica, copper, zinc, manganese
If a woman is still ovulating, hormones may not be necessary. The first line of defense is nutrition and lifestyle habits, followed by herbal and nutritional therapies. Lifestyle changes should be made as soon as possible. If diet and lifestyle changes do not improve symptoms then hormones can be considered.
If ovulation is no longer regular, the body’s exposure to progesterone is reduced and symptoms of estrogen dominance can present (more water retention, bloating, breast tenderness). In this situation, supplemental progesterone may be helpful. Progesterone can be taken in cream or pill form. Potential side effects are short-term exacerbation of symptoms, fatigue and/or weepiness. Oral progesterone is particularly effective at addressing insomnia.
Birth control pills are also commonly prescribed for women going through perimenopause since they suppress ovulation and provide a stable, non-fluctuating level of hormones throughout the month. I rarely choose this option since it is a band-aid approach and uses synthetic hormones; however, it may be the right decision for some woman. I have seen birth control pills profoundly improve a woman’s quality of life.
Symptoms such as hot flashes, night sweats, and vaginal dryness tend to be more prominent as estrogen production diminishes. Again, if lifestyle changes do not improve the situation, estrogen and progesterone can be considered. There are many different types of estrogen. The form of estrogen that has the greatest effect in addressing symptoms of perimenopause and menopause, and the one most commonly prescribed, is estradiol. Estradiol can be given orally or transdermally (patch or cream). Estradiol cream or patch (rather than pill form) is the safest route to go since oral estrogen can increase inflammation and risk of clot formation. Estriol is a weaker form of estrogen that is very effective at addressing vaginal dryness when applied locally. Progesterone must be prescribed along side estradiol in order to protect the uterus from uterine cancer.
Women need to see their physician to see if hormones are an appropriate treatment option. Women with a strong breast cancer history or women with an increased risk of clotting should avoid hormones. Prior to starting hormones, I recommend getting a mammogram (to rule out breast mass) and pelvic ultrasound (to rule out a thickened endometrial lining and assess whether there are fibroids).
How to Evaluate Hormones
1. You will need to do a comprehensive hormonal panel on day 21 of your cycle (or 1-week before you expect to get your period). This is when hormones should be at their peak and is the best time to assess adequate progesterone levels. This will also determine whether you ovulated during the cycle. This is just a baseline and needs to be evaluated knowing that hormone levels in the blood fluctuate throughout the day and do not represent the free hormones in the body. I do find that it gives a good baseline and is easy to obtain and often covered by insurance. To do a fertility assessment of hormones, you will need to do an evaluation on day 2 or 3 of your cycle.
2. A saliva and urine test can evaluate the free hormones, which are available to bind to cells to have an affect in the body. Hormones also come bound to proteins, which are essentially not active in the body. To more closely evaluate adrenal health, do a saliva test at four different times of the day.
3. Every women should also get a comprehensive panel to assess cholesterol levels (especially LDL and HDL), blood sugar levels (glucose and HgA1C), fasting insulin, hsCRP (measures inflammation, ideally this number should be <1), thyroid panel (TSH, free T3, free T4, and reverse T3), liver enzymes, kidney function, and a CBC (to rule out anemia and look at immune system). These labs are essential to get a comprehensive, holistic picture of a woman. Treatment plans are specific to each individual’s health history, current symptoms, and health goals. (See above for examples to address possible lab abnormalities.)
Q: How do hormones influence our metabolism?
A: Fluctuating levels of hormones (mostly estrogen and progesterone) can cause a metabolic imbalance in the body. As hormones decline, neurotransmitters, cortisol, and insulin change in such a way that lowers our metabolism and contributes to weight gain (and difficulty loosing weight unless lifestyle and hormones are addressed).
For example, as estrogen levels decline, cortisol levels increase. Cortisol is a stress hormone that contributes to midsection weight gain. To counter this, eat clean, whole foods—limited processed foods (if any at all), limited sugar—and focus on exercise, sleep, hydrating, stress management, and supporting gut, liver, and the adrenals.