What’s in a Name: menopause, perimenopause, post menopause…
Menopause; a term used so frequently, yet still most women (understandably) are confused about its definition and many women also genuinely feel fearful of approaching or being in this life stage. The trouble is, menopause, post menopause , menopause transition, perimenopause are all used interchangeably and as a result it’s created a great deal of confusion.
Couple this with trying to decide if you take HRT, if so, when should you start on HRT? In perimenopause, menopause or post menopause? Is HRT going to prevent cardiovascular risk and cognitive decline? And how long should you be taking it for? It’s little wonder women are left feeling somewhat out on a limb, frustrated, upset and overwhelmed.
Ok, so let’s start with unraveling the terminology, beginning with menopause. Menopause is a normal physiological process. It is the evolutionary planned end of a “season” in a womans’ lifespan where she no longer matures and releases follicles (eggs) from her ovaries. It is these follicles that produce the vast majority of oestrogen, which among it’s multiple actions; stimulates growth of breast tissue, maintains vaginal blood flow and lubrication, causes lining of the uterus to thicken during the menstrual cycle, keeps vaginal lining elastic and many other functions, including preserving bone for women from her first menstrual cycle until her graduation into menopause.
Menopause inevitably brings about a woman’s final menstrual period, occurring between the ages 45 - 55 (providing an average of 51 years old, the age often used as the time of menopause). In other words, when periods decline and cease from the age of 45+ this is a completely normal evolutionary planned process.
Worldwide Menopause Societies Definitions
The British Menopause Society definition: “Menopause is the time in a woman's life when her periods stop as a result of the reduction and loss of 'ovarian reproductive function'.”
North American Menopause Society definition: “The final menstrual period, which can be confirmed after 12 consecutive months without a period. This time marks the permanent end of menstruation and fertility. It is a normal, natural event associated with reduced functioning of the ovaries, resulting in lower levels of ovarian hormones (primarily oestrogen).”
So to summarise, menopause is deemed to have occurred after 12 consecutive months without a period for which there is no other obvious physiological or pathological cause and in the absence of clinical intervention (see note below). It is a normal, and natural evolutionary planned process.
{An important note ] Premature menopause occurs when the ovaries cease maturing and releasing follicles before the age 40 and may be the result of genetics, autoimmune disorders, or medical procedures or treatment.
When this happens, the ovaries don't make the “typical” levels of oestrogen or release eggs regularly, and therefore no progesterone is made either. This often leads to infertility, bone density loss, night sweats and many debilitating symptoms. Do head over to my Podcast - The Best of Health Series 4 | Episode 7 with Dr Mandy Leonhardt - where we discussed understanding POI (Premature Ovarian Insufficiency) in detail.
Early menopause occurs between the ages of 40 and 45 years and we include Induced menopause that results from surgical removal of both of the ovaries (bilateral oophorectomy) for medical reasons. and cancer treatment here. Again, if you have experienced this as a result of cancer, you may well enjoy this extremely powerful interview on The Best of Health Series 4 | Episode 5 with Dawn Waldron.
What is Perimenopause
The time when ovarian function starts to change is known as the menopause transition, which in the UK is more commonly termed, perimenopause. These changes begin subtly and increase gradually over a number of years. This is why it’s called “transitionary”. Perimenopause can be a decade in length (but remember it begins with subtle, incremental changes) that develop as ovarian functionality changes. I’ll break it down some more here for you:-
Very early perimenopause (38- early 40’s); very mild changes in mood, subtle changes in confidence and more fleeting anxiousness. Overall, just very subtle changes are more related to the nervous system and mood. Menstrual cycles remain unchanged..
Early perimenopause (early-mid 40’s); Menstrual cycles will start to change in length by 7 days or so, often initially shorter. Flow is heavier and often with flooding (as progesterone is dropping, while oestrogen remains high).
Mid > Late Perimenopause (mid-late 40’s) - Now cycles extend in length, as a result of less regular ovulation of follicles. Missed periods, so cycles can be 60 days +. Now oestrogen levels are erratic, spiking typically 20-30% higher than during before perimenopause and as a result fluctuate much more widely which contributes significantly to the neurological symptoms; hot flushes, night sweats and brain fog as a direct result of the fluctuating disruptive hormonal equilibrium.
Late perimenopause > approaching final menstruation >>> graduation to menopause; oestrogen is now consistently lower. The turbulent fluctuations are over. Professor Jerilynn Prior describes it as the more stable phase that begins one year after the final period.
This @CeMCOR diagram illustrating these midlife names
I personally far prefer this language from Professor Jerilynn C Prior; referring to the last period onwards as the time of graduation into menopause and the time before the last period as the menopause transition or perimenopause.
So, back to my question - what‘s in name?
Although names are just labels, as a society we have become somewhat obsessed with them, and they often carry unconscious meaning and bias that can diminish the worth or detract from the attention that the thing may deserve. My belief is this is the nub of where we have become unstuck. Any phase or label with the word menopause involved has come to represent; hot flushes, brian fog, weight gain, aging, alzheimer's, pain and with that, comes understandable fear, denial and a rejection of this label.
If, on the other hand we took a broader more evolutionary view of what is occurring, simply entering into a new life stage, we can build a deeper understanding and respect for this process rather than use the same medical model used for disease; of evaluate, diagnose and prescribe .We have to ask is this appropriate for a lifestage?
The Lancet published a series earlier this month which set out to address this very point, it was entitled “Time for a balanced conversation about menopause” a quote directly from this series:
“The framing of this natural period of transition as a disease of oestrogen deficiency that can be eased only by replacing the missing hormones fuels negative attitudes to menopause and exacerbates stigma”
And goes on to say “ women's experience of menopause varies hugely and there is no one-size-fits-all approach to management. Many women transition this stage of life uneventfully, whereas some experience prolonged or severe symptoms and need information, support, or medical treatment. The most common symptoms associated with menopause include vasomotor symptoms such as hot flushes and night sweats, sleep disturbances, vaginal dryness, and muscle and joint pain”.
Interventions to help alleviate the most common symptoms can include HRT (I am not anti HRT per say) but it is not the only, nor indeed without risk, intervention. We also must consider what actual hormone levels are at different stages of the transition i.e. when oestrogen levels are erratic and spiking typically 20-30% higher than during perimenopause. Is this a time to be adding in more oestrogen? Personally speaking, I would be cautious with oestrogen therapy at this particular stage. For more details on HRT head over to my blog posts here and here.
The body comprises of multiple systems (nervous, neuro-endocrine, gastrointestinal, immune to name a few) that all operate within a dynamic support network of each other. As we transition into the lifestage of menopause, and the natural decline of some hormones, the body indeed has a back up plan, it will draw on these other systems within its network to compensate. Taking this more 360 holistic view provides us with a far broader terrain and tool kit in providing support and as The authors of the Lancet state “ It is time for a sensible conversation about menopause to enable informed, individualised decision making on optimal management of this transition”.
In health, Tanya x