Perimenopause & Menopause – Separating fact from fiction

Isla Oliver, DNP, CNM, ARNP

Menopause is having a moment these days – and rightfully so! But with so much information online, and so many conflicting narratives, it’s hard to know what’s real and what is made up for “clicks”. That is where board certified providers & participating members of The Menopause Society (- that's me! -) can step in.

Let’s take a look at some of the top questions patients bring to their visits, and what the evidence says about what we do, and do not, know about hormones and hormone therapy.

1.      How do I know if I’m menopausal?

First let’s define perimenopause, menopause, and post-menopause. For most individuals with ovaries, perimenopause typically begins between the ages of 45 and 50. It is often marked by changes in menstrual cycles and, for some, symptoms like hot flashes and night sweats (commonly referred to as vasomotor symptoms of menopause). Perimenopause continues until 1 year after your final menstrual period. When perimenopause occurs between ages 40 and 45, it is generally considered early, and before age 40, it is classified as premature. 1 , 3

There are other symptoms that are common in this phase, including joint aches, weight gain, sleep disturbances, dry skin, and mood changes. There are also many other common conditions in this age range that can cause the latter symptoms, which should be screened for and ruled out before treating them as perimenopausal. This phase usually lasts around 4 to 6 years before menstrual periods cease entirely. 2, 3

Menopause is defined as the day that you have been without a period for 12 months. By medical definition, menopause is a single point in time, but we often use “menopause” to describe the entire transition from peri- through post-menopause. 1 , 3

The postmenopausal phase starts the following day after Menopause. From here out, we do not expect you to have any vaginal bleeding, and if you do, a workup is necessary to rule out things like cancers, amongst other causes. For most people, the vasomotor and other symptoms of the menopausal transition last anywhere from 1-10 years into post-menopause. After that point, most of the symptoms people experience are related to aging rather than hormone fluctuations. That said, some people do experience symptoms for longer than this. 3

2.      Is hormone therapy safe?

Generally speaking, yes! There are certain conditions which could make hormone therapy not safe for you & we always screen for those before starting a new medication.

In 2001, the Women’s Health Initiative (WHI) conducted a study on the use of oral Conjugated Equine Estrogen (a medication we rarely use today) and oral medroxyprogesterone (another medication now sparingly used in menopause care) to evaluate their benefits and risks as hormone therapy. The study reported an increased risk of breast cancer and blood clots among participants. It was stopped early due to these risks, leading to widespread reporting that caused many doctors and providers to stop prescribing hormone therapy. 4

So, what has changed in the last 25 years?

• Number 1 – we learned that synthetic estradiol, especially topical estradiol in the form of patches and gels, had a much better safety profile.

• Number 2 – the average age of women initiating hormone therapy in the WHI was 63.3 years old. These days, we do not initiate hormone therapy after age 60 due to the diminishing benefits and increased risks of heart attack, stroke & dementia. We now know it is safest and most effective to start hormone therapy in the years leading up to menopause, and within 10 years of your last period.

• Number 3 – we recommend micronized progesterone instead of medroxyprogesterone (a progestin), which based on current evidence, we believe carries a lower risk of blood clots.

The risk of breast cancer is real and does go up when you are using both estradiol and progesterone. One very important consideration is that this increase translates to 1 additional person out of 1000 being diagnosed each year. This means that the absolute risk of breast cancer is still low, and we have seen through longer term studies that the risk of dying from breast cancer is reduced in those receiving hormone therapy. We don’t know the exact cause of this reduction, but it’s believed it might be related to consistent breast cancer screening for these patients.  4 , 5

3.      Can I start hormone therapy now?

Let’s talk about it! You’ll notice I don’t have “hormone therapy” visit type on my website. That’s because as providers we don’t assess for medication use, we assess and treat symptoms. We know that hormone therapy can help with certain symptoms like hot flashes, night sweats, and sleep. By stopping these pervasive symptoms, it can help your body recover, reduce wasted energy from hot flashes, and reduce fatigue, mood changes, brain fog, and aches and pains as a result.

Hormone therapy does not directly address weight gain. However, it can boost your energy levels, enabling you to engage in physical activities like weightlifting, building muscle, and nourishing your body in ways that may positively impact your body composition. I am a strong proponent of understanding why your body is changing, accepting the changes we can’t control, and setting you up with lifestyle modifications that will help you live a long, healthy and strong life.

If you are someone for whom hormone therapy isn’t appropriate or isn’t safe, we do have other options to manage your symptoms. I always ask that you keep an open mind as there is so much information and so many options available to us, and sometimes it takes thinking outside the box to find the right solution for you as an individual.

The menopause transition has historically been underserved, under-researched, and rarely discussed, despite being an inevitable part of life for half the population. Fortunately, we are now in an era where research is advancing, and providers are beginning to take these symptoms seriously. If you have questions about this period and what to expect, or if you're suffering from symptoms, please reach out!