#askdrkris - Perimenopause pt.2

Okay ladies..

Let's pick up where we left off last time.  We finished the last post with “do I need a blood test?” so we’ll start there. And then I want to give you some ideas on management options.

Do I need a blood test?

I really want to stress that you don't!  We just start by working out what symptoms are giving you the most grief and give you some options for management.

Everyone's hormone levels are different and being told your hormones are normal is pretty deflating when you've period irregularities or hot flushes or mood swings or any of the other 144 symptoms.

The only times I would consider doing blood tests are if you weren't responding to the treatment options or if I was worried there was something else going on other than just perimenopause.  While perimenopause is the most likely cause there's some other things we don't want to miss.

Night sweats always need to have lymphoma excluded (it's rare… really rare! And easily excluded with a blood test not looking at hormones).

Sometimes the symptoms can be thyroid related rather than perimenopause.. that's easy to exclude (and treat too).

If you're over 45.. certainly over 50 with a more recent onset of heavy periods then it's worth ruling out endometrial cancer.. but again rare.. very rare! Even rarer than lymphoma!

In General Practice we work on the mantra.. “what's the one thing we don't want to miss? What are the likely options? What's the one thing most likely?  Then we know you're safe, we've considered all the options.. and we start working our way through them.

So I'd offer you a blood test for a complete blood picture, kidney and liver health, and your thyroid.. but I wouldn't do hormones because they wouldn't guide us in any way.

Management Options..

Management options fall into 3 main categories.. mainstream hormonal.. bio-identical hormonal.. and non hormonal.

There's a lot of cross over between mainstream and bioidentical hormones but I've listed them that way because many Doctors don't agree with the concept of bio-identical. Truth be told, I like the rationale behind bio-identical hormones.

One of the founding doctors in the bio-identical field, Dr John Lee, attributes most perimenopause symptoms to too little progesterone while mainstream management contributes symptoms to too little oestrogen.  And the bio-identical movement talks a lot about Oestrogen dominance - so it seems a bit silly to add more oestrogen to someone who already has an imbalance.

I think there's a role for both.. and certainly if your symptoms didn't respond to one option we’d try the other.. simple!  At the end of the day they are all hormones.. and while some practitioners will tell you bio identical are safer, I'm not willing to do that. I think all hormones - mainstream or bioidentical - carry the same risk.. a very small one but still a risk. But then doesn't everything? Blood pressure tablets.. Antibiotics.. Even getting out of bed in the morning. We just need to balance the risks with the benefits. We're looking for quality of life here.. it's not worth living forever if it's like hell on earth!! (And that's another post in the series.. the risks with hormone therapy and the Nurses study and million women study.. we’ll come back to that another day)

So now let's look more closely at what I consider the three key symptom groups most women experience: period problems, hot flushes, and mood changes. These three tend to show up for most women, though everyone's experience will be unique - and they're a great way to highlight the different treatment options.

The Hormonal Rollercoaster - What's Really Happening?

For most of your adult life, you've likely had a fairly predictable cycle. Your body produces enough estrogen in the first half the cycle to trigger ovulation, then creates progesterone in the second half. Nice and orderly.

Then perimenopause arrives, and this well-orchestrated pattern goes off script. As Dr. John Lee pointed out, many perimenopausal symptoms stem from declining progesterone levels. When you don't produce enough estrogen to ovulate properly, you don't get that progesterone surge in the second half of your cycle.

In my experience, it's typically a combination of both hormones fluctuating in that erratic pattern I mentioned last time. Some days high, some days low - creating this perfect storm of symptoms.

Period Problems - When Your Cycle Loses Its Rhythm

Changes in menstrual patterns are often the first noticeable sign of perimenopause. Those previously regular periods might become heavier, lighter, longer, shorter, more frequent, or less frequent - or play a game of "no pattern at all." 

What's interesting is that conditions we typically associate with younger women, like PCOS and endometriosis, can actually emerge or worsen during perimenopause. Many women have spent decades with their natural cycles masked by pregnancy, breastfeeding, or contraception. When they finally return to their natural hormones, those hormones aren't behaving quite as expected.

For period problems, I'll be straightforward - hormonal treatments are often the most effective solution. After decades on contraception, many women understandably want to be "natural." But sometimes going back on the pill or opting for a Mirena IUD can be the most effective approach.

The Mirena IUD deserves special mention here - it's particularly helpful during perimenopause. It delivers progesterone locally to your uterus, controlling heavy bleeding and pain while allowing your background hormones to continue their natural patterns. It also provides a good foundation for future hormone therapy if needed.  And no, don't believe all the horror stories you hear.. the only people writing on social media are the ones who've got issues. The ones without issues who just keep cruising through.. they can't be bothered writing on SM.. I've put close up 700 Mirenas in.. taken out max 30 for problems!

Hot Flushes - When Your Internal Thermostat Misbehaves

Hot flushes - perhaps the most well-known perimenopause symptom, yet no less challenging when they're happening to you in the middle of the night or during an important meeting!

These sudden waves of heat occur because fluctuating hormone levels affect your body's temperature regulation. Your brain's thermostat gets confused by the changing estrogen levels and triggers a cooling response - hence the sudden heat and sweating.

For managing hot flushes, we have several approaches:

1. Mainstream hormonal options - hormone replacement therapy remains one of the most effective treatments for severe hot flushes.

 2. Bio-identical hormonal options - for those who prefer this route.  It's often worth a trial of bioidentical progesterone to see if that's of benefit.. often the simplest and most minimalist treatment..

 3. Non-hormonal medications - interestingly, certain blood pressure medications and some antidepressants can reduce hot flushes by 60-70%! This crossover effect shows how interconnected these symptoms really are.

 4. Practical approaches - layering clothes, using fans, keeping cool water handy, separate bed covers for you and your partner (relationship saver!), and identifying triggers like alcohol, spicy foods, or caffeine.. but we're talking quality of life here and chucking our coffee, curry and champagne is not my idea of quality!!

Mood Changes - Your Emotions on a Hormonal Seesaw 

The emotional aspects of perimenopause can be some of the most distressing. Irritability, anxiety, tearfulness, mood swings, brain fog - these aren't character flaws or signs of weakness. They're legitimate symptoms caused by hormonal fluctuations affecting your brain chemistry.

Remember premenstrual syndrome? Many women experience mood changes in the week before their period due to the withdrawal of progesterone. Now imagine your body not producing consistent progesterone at all - your mood might feel quite unpredictable! 

If you've had mood issues before perimenopause, you may be more likely to experience them during this transition. But even women with no previous history can find themselves experiencing new mood symptoms.

Treatment options include:

1. Hormonal regulation through contraceptives - sometimes just stabilizing those hormone fluctuations makes a significant difference.

 2. Bio-identical progesterone - options like troches (small dissolvable tablets that sit in your cheek) or progesterone creams can help, particularly in the days before your period.

 3. Non-hormonal approaches - including antidepressants, anti-anxiety medications, and counseling. There's absolutely no shame in seeking this kind of support.

The Connected Web of Symptoms

 One of the most interesting aspects of perimenopause is how treating one symptom often improves others. I recently treated a patient with endometriosis who was pleasantly surprised when her mood improved significantly too. This connection makes sense when you realize it's all part of the same hormonal system.

When you address one symptom, you're often addressing the underlying hormonal imbalance that affects multiple aspects of your health.

When to Seek Help

 As I mentioned in our first chat, these symptoms are normal but you don't have to suffer through them. If hot flushes are disrupting your sleep, if mood changes are affecting your relationships, if heavy periods are interfering with your life - please talk to your doctor.

 There are mainstream medical options, bio-identical options, and non-hormonal approaches. Finding the right combination often requires some adjustment, which is why it's important to have a healthcare provider who listens and partners with you.

Remember, perimenopause isn't a disease to be cured - it's a natural transition to be managed. With the right support and tools, this period can be navigated successfully and even become a gateway to a new phase of life. 

Again, we've probably generated more questions than we've answered. If there's something we haven't covered go DM us via SM or send us an email - aislinn@bostonbaycollective.com.au.. we’ll cue them for future posts..  and please, please read the disclaimer below (again 😎)

Dr Kris xx

DISCLAIMER 

We've been planning to write some health discussions for a while now. There's a need for good, unbiased information that shows both/all sides of the story - but that's just what this is.. information. Please don't think it's medical advice. Please do not stop any medications or change your treatment plan without discussing it with your own doctor first. We are just helping you find the right questions to ask to get greater control and understanding of your own health and wellbeing.  Please feel free to ask us anything of a general nature - we’ll endeavour to get a post up on that topic.. whatever you want to know, we're pretty sure there's 100 others want to know it also! But we can not answer specific personal questions for you and we can not give you specific medical advice.. that's for your own doctor.

Please be aware that any negative or argumentative comments will be removed. We are aware that some people have totally opposite views to what we discuss here.  Everyone has their own opinions - heck we've seen that emerge in bucket loads since the pandemic.  This is simply a general education chat where we present a broad brush picture - you are free to research further as much as you like.