No sweat: How to navigate the perimenopause

Perimenopause can last for up to 10 years yet there is a lack of awareness

No sweat: How to navigate the perimenopause

Perimenopause can last for up to 10 years yet there is a lack of awareness about the condition, says Áilín Quinlan

You're in a sweat and not because the kids are getting to you or work is very stressful lately — it’s because you’ve started the perimenopause.

“It’s the most challenging part of a woman’s life,” says hormone expert Dr Marion Gluck. “This is a time when the hormones fluctuate up and down and there’s no rhyme or reason to it.”

Perimenopause begins several years before menopause. This period, when the ovaries gradually begin to make less oestrogen, usually starts in a woman’s forties, but can begin earlier.

It lasts until menopause, a woman’s first anniversary of 12 months without a period.

Awareness of what’s happening to your body during this time is crucial to understanding perimenopause and to dealing with it, says Dr Gluck, who warns that perimenopause can last for anything between four and 10 years.

“These fluctuations can cause very severe physical symptoms like bleeding and emotional symptoms like anxiety, depression. They can also cause insomnia.

“Many women feel they’re going mad,” she says matter-of-factly.

They don’t understand what’s happening or why they have this feeling of anxiety or doom.

Yet, warns Gluck, author of It Must Be My Hormones, there is little awareness about this stage of life. “Many women sleepwalk into perimenopause because they’re not aware of what’s happening and they’re not aware of the sheer power of their fluctuating hormones in terms of their effect on body and mind.”

Calm to ‘psycho’

In fact, Angela (46) a Dublin businesswoman and mother of two young children aged seven and nine, assumed she must be pregnant when her perimenopause arrived about a year ago.

“I was wondering if I was pregnant because my period hadn’t come,” she recalls. “I went to the doctor and had blood tests and that showed I was in perimenopause.”

That gave her pause for thought she says, but on reflection she realised that she’d been experiencing significant anxiety since her early 40s. “I’d noticed that I was a bit hyper. I couldn’t calm myself. I’d get almost frantic about, for example, organising my daughter’s First Communion.

“I’d go from being quite calm to being ‘psycho’. I’d get frustrated with the kids if I was having to repeat things.

My empathy for the children in terms of them being young and not understanding what I wanted them to do, was less than normal.

“This was very unusual for me as I would normally have been far more patient,” she says.

It’s normal, observes Gluck, for many perimenopausal women to have a lot going on at this time in their lives, everything from the stress of trying to care for ageing parents, to managing adolescent children and the myriad complexities these life stages bring. This is why women need to know what to look for — because if she lacks awareness about the perimenopause, she may well attribute her symptoms to the wrong thing.

Intense upheaval

“Part of the problem is that perimenopause, a time of intense hormonal upheaval, is not well understood either by women or their doctors, says Dr Sara Gottfried MD, the three-time New York Times bestselling author of The Hormone Cure and The Hormone Reset Diet, and Younger. (Her latest book, Brain, Body Diet is out now.)

“The focus of discussion among women and the medical community is on menopause, which is the period of time that follows a woman’s final menstrual cycle,” says Gottfried. “At least up until recently, no-one was talking about the years preceding menopause, namely perimenopause.

This is much rockier and more difficult than menopause, made worse by the lack of sound information for a woman to access as well as a doctor who is not equipped to help her.

Why is perimenopause often more difficult for women than menopause?

“Compared with menopause, when a woman’s sex hormones (oestrogen and progesterone) are low but stable, hormones in perimenopause fluctuate greatly from month to month,” Gottfried explains.

“Our hormones affect everything from our mood, to our energy levels to our metabolism, so you can imagine how wildly fluctuating hormones can make a woman feel like she is going crazy as she struggles to understand her sudden mood swings, flashes of rage, exhaustion and weight gain that seemed to appear overnight.”

On top of that, she adds, the perimenopause can also severely affect a woman’s energy levels and concentration as well as her mood and libido.

“During perimenopause, the ovaries start to sputter and are no longer manufacturing the same, predictable, and consistent levels of the sex hormones — oestrogen and progesterone — that they used to.

“To make matters worse, the brain is less responsive to the hormones your ovaries still do produce. Scientifically, we’ve only recently discovered that the brain runs low on oestrogen first before the rest of the body in women over 40. This leads to low brain energy since oestrogen is involved in how your brain uses fuel.

One of the reasons behind mood changes in perimenopause is the sometimes precipitous drop in oestrogen, which fills your tank with serotonin, the feel-good transmitter. When oestrogen starts to fade in perimenopause, serotonin levels drop and can sometimes lead to depression.

“This is not well understood by mainstream doctors, which is why women may be handed a prescription for an anti-anxiety medication or an antidepressant by their well-meaning GP, instead of opting to run a full hormone panel.

“This happens to many women when they go to see their doctor, especially if they are still getting a period, albeit more irregular.”

Low oestrogen also shows up as poor memory, emotional fragility, depression, anxiety or persistent mild depression (dysthymia), night sweats or hot flashes and vaginal dryness as well as low libido, among other things she explains.

Meanwhile, low progesterone often manifests as anxiety, sleep disruption, night sweats, and shortened menstrual cycles.

“Thyroid hormones, which control how we burn calories and keep our metabolism from getting too sluggish, often get out of balance as we get older.

“This is a trend that has been labelled ‘thyropause.’ Your metabolism slows. Your weight climbs even if you eat less and exercise more. You start to feel depleted, and your mood becomes erratic.

“Then the adrenal glands (where the stress hormone, cortisol is produced) get into the act. “With all these hormonal changes, your stress response becomes heightened. You just can’t roll with the punches the way you used to. You can’t focus or concentrate.”

It’s a good idea to have tests done to measure which hormones are out of balance, says Gottfried. “It may not necessarily be oestrogen that is the main problem. It could be your stress hormones or your thyroid or even low progesterone knocking everything else out of whack.”

The growing acceptance that this is a very challenging time for many women is reflected in the establishment of The Menopause Hub, Ireland’s first and only dedicated menopause clinic.

HRT concerns

So what can women do? A popular solution for many is Hormone Replacement Therapy (HRT) — a tried-and-tested medication containing female hormones to replace the ones the body no longer makes as a result of perimenopause and menopause — which is an effective treatment, according to doctors. However, a study published in The Lancet recently raises concerns about the longterm use of HRT.

Women taking hormone replacement therapy for more than five years were found to have twice the risk of developing breast cancer than menopausal women who have never taken HRT, with a heightened risk remaining 10 years after women have stopped taking the therapies.

On foot of the study, the British Medicines and Healthcare products Regulatory Authority (MHRA) has recommended that HRT only be prescribed where menopause affects the quality of life for the patient and prescribed at the lowest dose and for the shortest time possible.

Gluck, who is based in Britain, says she has experienced significant success with the use of her bio-identical hormone balancing treatment, which involves the use of hormones which are identical to the individual woman’s and are “a perfect fit for what your body needs”.

This is a bespoke therapy — a treatment where every prescription is tailored to the needs of the patients. We are only giving back what nature intended, and replacing like with like and giving the patients what they need.

To learn about your perimenopause, and how to manage it, Gluck advocates keeping a symptoms diary, so that you can track what is happening and, crucially, when it happens over the month.

“This is very important for helping you understand your symptoms and in discussions with your doctor,” she says, adding that once they have a good idea of their own personal pattern, they should consult their doctor to discuss the symptoms. If the doctor tries to diagnose depression, she says, the woman should have the confidence to debate the issue. The next step is to have your hormone levels checked.

“This is very important and a lot of doctors don’t believe in having your hormones checked in the part of your cycle when you have the most significant symptoms such as heavy bleeding or very high anxiety. But you need to see what the imbalance is,” she says.

Bioidentical hormone replacement therapy is available in Ireland, but can be expensive — one clinic charges around €350 for a first consultation and €225 for each follow-up consultation.

Regulating periods

When Angela noticed that she was starting to “really overheat” during the night, along with needing to go frequently to the toilet, she decided to take a natural approach.

She found maca, a supplement made from the root of the maca plant, which grows in central Peru, helpful. It helped to regulate her periods, which were still coming, but intermittently, and the mood swings which accompanied them.

She needed it — when one of these intermittent periods did arrive, the pre-menstrual tension she suffered was extreme.

I can reach severe lows just before one of these intermittent periods arrived.

“When I get a period I’m floored. It leaves me very physically and mentally drained and I cannot plan for anything; in fact, I’ve had to cancel plans because it takes over my life completely. But if I took the supplement Maca it helped to regulate them.

Freezing ovarian tissue

A cutting-edge procedure which has just become available in Britain involves the removal and freezing of women’s ovarian tissue with a view to delaying menopause when the woman becomes older. Under the procedure, when the woman enters the menopause, potentially decades from now, the frozen tissue can be thawed out and grafted back into the body.

Limerick-based consultant endocrinologist Mary Ryan says this looks promising but more research needs to be carried out to ensure it is safe

“Studies will have to be done to ensure this is safe and if it is safe, I would welcome it,” she says, adding that she believes many women can manage the perimenopause through education and a knowledge about the need for a healthy and appropriate diet, an emphasis on rest and pacing themselves.

“It is very much about educating women about the symptoms — a lot of women do not need treatment — they need rest and an understanding of the need to pace themselves. I am very much in favour of healthy eating, resting and pace,” says Dr Ryan, a headline speaker at Ireland’s first Menopause Conference, in October.

She prescribes medication for issues such as peripheral nerve pain or irritable bowel which can accompany the advent of perimenopause. In fact, she says, she prescribes traditional hormone replacement therapy to only about 20% of patients who would have severe problems with symptoms. While some of her colleagues use bio-identical hormone therapy, she says, she does not use it herself.

What to do

  • Educate yourself, advises perimenopause coach Catherine O’Keeffe. “Prepare for it and empower yourself with knowledge.”Visit websites like or, she says. “The more you know, the more empowered you will be.”
  • Develop your personal tool kit, says O’Keeffe.Whether it’s a Rescue Remedy for anxiety or a walk to lift your mood, get to know what works for you.
  • Maintain and expand your social network. “It’s really important to make time with a friend for coffee, for example,” says O’Keeffe.
  • Manage your diet, particularly your sugar intake, advises Dr Gottfried. As women get older, their blood sugar becomes more unstable, she says. This not only affects your weight but can have a longer-term impact on your brain health. Reduce sugar intake and removed processed foods. Eat one pound (0.5 kg) of vegetables a day and two pounds for a bonus.
  • Drink water. “If you’re dehydrated, your brain won’t function optimally,” says O’Keeffe. “Many people don’t seem to understand that coffee consumption impacts on hydration levels. She recommends at least eight glasses a day, more if you’re having a lot of night sweats and hot flushes.
  • Breathe deeply. Easier said than done when you are in a period of your life when you can get stressed over the most minor thing, Gottfried acknowledges but managing stress is more important now than ever.“You’ve heard of meditation, but did you know deep abdominal breathing can reduce hot flushes by more than 40%?“If you need support there are many wonderful meditation guides or apps to help you make meditation part of your daily routine,” she says.“One example is Headspace, which is an app that helps you learn mindfulness meditation in just 10 minutes a day.”
  • Reduce alcohol intake and, if you can, give it up altogether, says Gottfried. “As we get older, alcohol negatively impacts most things from sleep to the weight around the waist. Alcohol shrinks the brain. It’s a neurotoxin.”
  • Exercise. Introduce high-intensity interval training which means short duration done at a high intensity with variability. This type of training is effective at targeting belly fat, the ‘menopot’ that many women complain of. High-intensity interval training exercises make your muscles hungry for glucose, which helps to regulate insulin levels and improve insulin resistance as well as build muscle.High-intensity interval training exercise could involve walking briskly for two minutes alternating with jogging for two minutes, for a 20 minute total or cycle fast for bursts of one minute alternating with a slower pace for one minute for a total of 30 minutes. However, you don’t have to hit the gym every day, she says. Walking in nature can be great exercise too.
  • Have plenty good-quality sleep, advises Gottfried. She warns that poor quality sleep wreaks havoc on your hormonal balance.

- The M Word, Ireland’s first major conference on menopause brings nine expert speakers to the Raddison St Helen’s in Stillorgan, Dublin, on October 11th. Headline speakers include Meg Matthews, menopause advocate and founder of MegsMenopause, Dr Mary Ryan, expert on mid-life women’s health and Emily Power Smith, sexologist. For tickets and further information on the event, see

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