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G is for “Getting Through Perimenopause”

December 11, 2011
From the WebMD Archives

I decided to write about perimenopause not only because it’s my favorite subject, but also because a patient of mine has had an extremely rough time going through this period in her life. I wanted to share her struggles and her relief once we were able to get her to feel normal again.

Perimenopause is the four to seven years prior to menopause. It is a time in a woman’s life when her hormones are fluctuating and sometimes causing symptoms such as hot flashes, night sweats, insomnia, mood swings, anxiety and depression, joint pain, migraines, palpitations, decreased libido, vaginal dryness, weight gain, memory glitches and fatigue. There are other less common symptoms as well. Patients have come to me after they have been told by their doctors that they need to see a psychiatrist. Or they have come to me because their doctors have told them there is nothing they can to do until they’ve gone a full year without a period. This isn’t true. It is during the perimenopausal years that intervention is necessary and possible. Hormone replacement therapy is safe and effective during this time.

My patient is a 45-year-old who came to see me two years ago. During her periods she was experiencing heavy bleeding that frequently lasted two weeks at a time. Her previous gynecologist wanted her to undergo a dilation and curettage to clean her uterus. I disagreed. I felt that her issues were hormonal, that she was in perimenopause, and I asked about her other symptoms. She was experiencing anxiety, insomnia and emotional issues. She had a history of OCD (obsessive compulsive disorder), and all of her symptoms were much worse now. This is an important point. We know that women who have psychiatric disorders have a much worse perimenopausal transition.

The first thing I did was a timed uterine biopsy four days before her expected period. I wanted to make sure she did not have uterine cancer, and I also wanted to see if she was still making progesterone. I also did hormone studies on the second or third day of her cycle to see if she was close to menopause, and I did a transvaginal sonogram from day five through nine of her menstrual cycle. Everything pointed to perimenopause and I started her on progesterone oral bioidentical pills. She took them starting day 12 for 10 days to straighten out her cycle. It worked. But her other symptoms, such as anxiety and crying spells needed to be addressed as well. That’s where the psychopharmacologist came in to help. Together, we worked with antidepressants along with the progesterone.

The hot flashes followed about a year later. At this point, we decided she needed estrogen. I compounded bioidentical biEst cream, which worked for a short time, but eventually she needed pure estradiol. I switched her off the progesterone, which seemed to be making her depressed, and place her on a patch of estradiol. I followed her blood levels until we reached a good hormone level. She stayed on the estrogen patch without progesterone and her depression lifted and her moods improved. It was all right to stay on pure estrogen as long as she was getting periods at least every two months; but this was the difficult part because she would go long stretches without her period and I would add back progesterone and then she would feel terrible.

As time went on, it looked like menopause was getting closer. Her bloodwork proved that but also the fact that when we gave her a round of progesterone, she would not bleed. Finally, I put her on the estradiol patch and she is just taking estrogen. She feels great. But every three months I have to give her a round of progesterone, and that really affects her in a bad way. I am hoping that as time goes on she will get further from perimenopause and become a menopausal woman, and her symptoms will improve. We are still working with the psychopharmacologist and he has been extremely helpful.

There is no reason for a woman to suffer. It is in the perimenopausal stage that woman need to be treated. Once she goes a full year without a period, things tend to improve. Symptoms get better, there is no more bleeding, and you begin to feel like yourself again. Remember, if you see s gynecologist and he or she says there is nothing they can do, or they do not acknowledge there is something going on with you hormonally, you need to seek a new doctor.

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