Poor sleep, brain fog, mood swings? Perimenopause, explained: A clinical refresher for busy physicians
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We need to be thinking [about] anticipatory guidance. Clinicians shouldn’t wait until symptoms appear to start explaining what changes might be coming.
—Karen Adams, MD
Perimenopause can have a significant impact on patients who menstruate, yet research into this phase of life is lacking.
Here’s a refresher on everything you need to know about perimenopause.
Overlooked symptoms
It all starts with accurately identifying symptoms of perimenopause—something experts say is often missed.
“Because perimenopause symptoms are so unpredictable and can last for 7 years on average, providers and patients both need to understand that symptoms are also unpredictable. Mood, sleep, or cognitive symptoms can occur prior to changes in periods. Hot flashes may also appear prior to cycle irregularity. This means that patients’ symptoms are often dismissed as not being related to perimenopause,” Karen Adams, MD, clinical professor of OB/GYN at Stanford University and Director of the Stanford Program in Menopause & Healthy Aging, tells MDLinx.
We need to validate our patients’ experiences, first and foremost. Women often have to see several clinicians before their symptoms are recognized and treated as perimenopause. We should not be just telling them, ‘Oh, you’re getting older, what do you expect?'
—Karen Adams, MD
How to prepare patients
Research suggests that many women feel unprepared for perimenopause, as well as menopause.[] They report not feeling adequately supported by their workplaces or their healthcare systems during this phase of life.
Dr. Adams says one of the key ways clinicians can help is to get ahead and have discussions with patients before symptoms even begin.
Related: 2 major misconceptions about menopause—from the experts, for the experts“We need to be thinking [about] anticipatory guidance. Clinicians shouldn’t wait until symptoms appear to start explaining what changes might be coming. We also need to reassure our patients that everything is treatable. Also, many women have an IUD or are on birth control or have had a hysterectomy. Lab values don’t diagnose perimenopause, so women need to be on the lookout for the symptoms that herald the onset of perimenopause,” she says.
The most significant factors
Up to 90% of women seek help for symptoms of perimenopause. The range of symptoms can be vast and include vasomotor symptoms like night sweats or hot flashes, vaginal dryness, and reduced libido. Sleep and mood changes are also common, as are cognitive issues.[]
“We need to let patients know that mood symptoms are especially common. It’s our responsibility to sort out whether mood changes are related to perimenopause or if it’s true major depression or generalized anxiety disorder,” Dr. Adams says.
“Although hormones can stabilize mood, true depression needs to be treated primarily with antidepressants. We need to always remember that although mood disturbances can happen in women with no past history … those who had postpartum depression or major depression earlier in life are especially at risk,” she adds.
Related: Docs react to FDA’s removal of HRT black box warning: ‘An incredible mistake was made 25 years ago’—but not all agreeWhen it comes to helping patients experiencing sleep disturbances, Dr. Adams turns to the “3P model.”
“There are predisposing factors, like the person [does] shift work, or they naturally have some anxiety that makes it harder to sleep, or they live in a noisy apartment building, etc. Then, in perimenopause, new precipitating factors can arise, such as night sweats or a bump in anxiety, that push the person into a true insomnia category. Finally, perpetuating factors can make sleep problems persist even after the precipitating factors are treated,” she says.
“This is why cognitive behavioral therapy (CBT) for insomnia is so effective, because the behaviors people do in response to sleep disturbance can actually make the problem worse rather than better (perpetuating), and CBT helps break that cycle. People who already have predisposing factors are more at risk for sleep upset in perimenopause than others,” Dr. Adams adds.
Why you shouldn't take a one-size-fits-all approach
Perimenopause can last between 5 to 10 years on average, but it is highly variable in terms of onset, length, symptom severity, and impact on functioning.
Given this, Dr. Adams says treatment options will also vary significantly among patients.
“We should consider the whole gamut of possible treatment options: hormonal, nonhormonal, and behavioral/lifestyle interventions. We need to set shared treatment goals and come up with a plan together,” she says. “This is never, never, never one-size-fits-all medicine.”
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