Perimenopause/Menopause
As women age, the number of eggs in their ovaries decrease.
Decline in ovarian function leads to a gradual reduction in the production of the hormones oestrogen and progesterone and is irregular initially. Oestrogen can in fact rise 3x normal levels during perimenopause.
Can begin up to 10 years before menopause, which is when periods stop.
Symptoms typically start in the late 30s or 40s but can occur at any age after periods begin.
Testosterone also drops – can be crucial for women's health.
Menopause is when periods have stopped for 12 consecutive months.
Average age of menopause is 51.
Bloods not helpful during perimenopause - diagnose based on symptoms.
Future Health
In addition to causing symptoms, the hormonal decline during perimenopause and menopause significantly impacts womens’ long-term health.
It raises the risk of conditions such as heart attacks, strokes, and dementia.
Women are also more susceptible to osteoporosis, fractures, type 2 diabetes, bowel cancer, osteoarthritis, and depression.
Common Symptoms
Poor sleep, mood, and memory.
Headaches and changes in temperature regulation, causing hot flushes and night sweats (called vasomotor symptoms).
Other symptoms can include fatigue, muscle and joint pain, low libido, recurrent UTIs, vaginal dryness, and painful intercourse.
During perimenopause - still have periods, but they often change; becoming heavier, lighter or irregular.
Everyone’s experience is unique!
Treatment overview
Optimise nutrient levels – do bloods
Optimise gut health
Consider hormone testing, adrenal testing
Vitamins, supplements
Lifestyle modifications – healthy diet; reducing alcohol intake; engaging in regular exercise; avoid smoking
Good sleep hygiene, mindfulness/meditation, connect with nature, reduce stress.
Other treatments – acupuncture, yoga, reiki, massage, ayurveda, tai chi, hypnotherapy, CBT…
Hormone Treatment (HT), also known as HRT and MHT - can be safely used in almost ALL women
Other prescribed medications - antidepressants (SSRI’s), gabapentin, pregabalin, clonidine, oxybutynin and metformin
Tibolone – synthetic steroid hormone
New med – Fezolinetant (Veozah), NK3 receptor antagonist – treats vasomotor symptoms by modulating neuronal activity in the brains thermoregulatory zone
Optimise bloods
Iron
•Aim Ferritin level 60-90
•Rx: ferrous sulphate or liver capsules
B12
•Aim Blood level >450 (>600 even better)
•Rx: B12 injections or sublingual (i.e. spray or melts)
Vitamin D
•Aim 100-120
•Ie level 50 – use 4000-6000iu daily
Thyroid function
•Aim TSH <2.5
(preferably closer to 1.0)
Rx: Thyroxine, zinc, selenium, gluten free diet
Magnesium
•Aim mid-range (0.8-0.9)
•Rx: magnesium glycinate
Vitamins and supplements
Inflammation, mental support, energy:
Fish oils 1g daily
•Revesetrol, Quercetin
•Turmeric (Curcumin)
•COQ10 150-300mg daily
•Magnesium 400mg elemental daily
•Taurine 500-3000mg daily
•B vitamins
•Chromium
•Adrenal support – ginko, ginseng, ashwagandha (withania), rhodiola
Gut health:
•Probiotics
Hair, skin, nails:
•Silica
•Zinc 25-50mg daily
Vasomotor, anxiety and depression, joint pain, bone health, sleep:
•Herbs – chaste tree (vitex agnus), black cohosh, evening primose, red clover, maca, valerian
•Saffron extract
•Phytoestrogens – isoflavones, hops extract
•PEA – Palmitoylethanolamide 600mg bd
•Boron, Vitamin K2, Vitamin D
•Calcium – Algaecal
Supplements - top 5 :)
Omega 3’s
Vitamin D
B vitamins inc B12
Magnesium
Curcumin (concentrated form of Turmeric)
Hormone replacement therapy (HRT)
Safe for almost ALL women.
Can be started at any age and used indefinitely (5 year rule is out the window!).
Most use body-identical ingredients - derived from yam.
Overwhelming data that starting within 10 years of menopause reduces risk of future major disease including cardiovascular disease.
Oestrogen - given as Estradiol - gel or patch - start with 2 pumps gel Estrogel or 1 sachet Sandena daily or 50mcg patch twice weekly - day or night.
Progesterone - given as Prometrium - 100-300mg at night. 2 weeks of cycle (second half) if perimenopause, continuously if menopause. Needed if taking oestrogen, to protect the uterus lining or if have had hysterectomy for severe endometriosis. I often use it regardless due to its benefit of helping with sleep. Can be used on its own which I often do during perimenopause, in second half of cycle (can help with PMS symptoms)
Vaginal hormones - Ovestin (estriol) cream or pessary or Vagifem pessary or Intrarosa (DHEA) pessary. Safe to take with other HRT. 30% women will need both.
Testosterone - Australia has the only body-identical testosterone (Androfeme). Approved for use in Hypoactive Sexual Desire Dysfunction (HSDD). Trial after using HRT for a few months if ongoing symptoms of fatigue, brain fog and low libido.
Main Concerns of HRT
Breast cancer biggest concern.
Womens Health Initiative (WHI) studies in 2002 was flawed! – synthetic hormones used and older cohort, study data was misinterpreted and overstated the risks.
Oestrogen alone = reduced risk!
No link between breast cancer and body-identical progesterone (ie Prometrium).
Even women who carry BRCA 1/2 can have HRT, it does not increase their elevated risk further.
More risk of developing breast cancer if drink 2 or more standard alcoholic drinks a night.
For almost all women, the benefits of HRT far outweigh the potential risks, especially when body-identical forms are used.
Do annual screening if concerned including up to date mammogram prior to starting.
Blood clots
Some forms of oral oestrogen can increase the risk of clots or stroke
Body-identical oestrogen, given through the skin as a patch or gel – no increased risk
Resources
Websites
Australasian Menopause Society - menopause.org.au
Jean Hailes – jeanhailes.org
Menopause Friendly – menopausefriendly.au
Dr Ceri Cashell
Podcasts
Real Health and Weight loss - Dr Lucy Burns
You are not broken – Dr Kelly Casperson
The Dr Louise Newson Podcast
Books
Oestrogen Matters – Dr Avrum Blooming
Lara Briden – Hormone Repair Manual
The Menopause Brain – Dr Lisa Mosconi