You may have seen chatter on social media about “hormonal imbalance.” In many cases, what people are describing is the hormonal fluctuation that naturally occurs during the period leading up to menopause, known as perimenopause.
Perimenopause is a time of significant hormonal variation. “Hormonal imbalance” is a term that doesn’t hold much clinical meaning when talking about perimenopause and menopause. In fact, hormonal fluctuations are an expected part of this transition, according to Elizabeth L. Howland, DNP, FNP-BC, APRN, MSCP, and Alexandra H. Woolley, CNM, WHNP-BC, MSCP, of Dartmouth Hitchcock Medical Center’s Menopause and Midlife Clinic. Below are their answers to common questions about perimenopause.
What are the signs of perimenopause?
The most common symptoms that our patients tell us about during the menopause transition are hot flashes, night sweats, sleep disturbance, brain fog, mood changes, vaginal dryness, and painful sex.
People often ask us how they’ll know they’re in perimenopause. Changes in the timing of your menstrual cycle can be an early sign, but even if you’re still cycling predictably and monthly, you may experience other symptoms. Perimenopausal symptoms can begin three to seven years before the final menstrual period and can persist for 10 years or more afterward.
Should I get my hormones tested?
Except in unique cases, having “hormone panel” lab work is not informative and doesn’t help patients and providers make decisions regarding menopause care. We would have to draw labs every day or even a few times per day to follow hormone trends or understand where someone was in their cycle. Doing so would not change our clinical recommendations, which are based on what symptoms are bothersome to our patients and whether treatment is working to relieve them.
Is there anything I can do for relief?
Among all the hormone variability of the menopause transition, there is an overarching trend of a long-term decrease in estrogen because the ovaries are making less of it as menopause unfolds. Adding back a low, consistent dose of estrogen as part of someone’s menopause hormone therapy is an evidence-based treatment for hot flashes and night sweats, also called vasomotor symptoms. It may also help with brain fog, mood changes, and other symptoms, though these are not as well studied.
Local, topically applied estrogen, such as a vaginal cream or suppository, is well-studied and helps improve vulvovaginal tissue changes that cause things such as dryness, discomfort during intercourse, and even recurrent UTIs. There are also nonhormonal medications for many of these concerns.
Systemic estrogen is also an excellent way to prevent age-related bone loss, though it’s not a treatment for osteoporosis if someone already has it. There is also some exciting research underway about the long-term cardiovascular and neurological benefits of menopause hormone therapy, but more data are needed.
There is a low but important risk of blood clots with systemic estrogen, and we seek to mitigate this risk when estrogen is prescribed in a form that is absorbed through the skin (i.e. a patch or gel), rather than orally. For symptomatic patients, the benefits often outweigh the risks, especially if treatment is started before age 60 or within 10 years of (or before) their last period. There will always be people for whom the benefits do not outweigh the risks. That should come down to an individualized conversation between a patient and their provider.
When someone still has a uterus and is on systemic estrogen, it is important to also be on progesterone to protect the uterine lining.
Testosterone is used to treat low libido in postmenopausal women and sometimes in perimenopause. A person’s testosterone level declines with aging. When someone is on testosterone therapy, we monitor lab values because too much can come with permanent side effects, like a deepened voice or enlarged clitoris. There are also nonhormonal medications for bothersome low libido.
Who should I see for help?
It’s important that, like any other aspect of your healthcare, your menopause care is tailored to you as an individual. Meeting with a Menopause Society Certified Practitioner or another provider who is knowledgeable in this field can be incredibly valuable and empowering.
Be wary of anyone offering too much testing for too much money or selling their own products. Your hormones are changing as you go through menopause, and may be wreaking some havoc, but you likely don’t need “hormone testing” in order to feel better. What you need is someone knowledgeable in this field to listen and work with you to make a plan for getting back to feeling like yourself.
