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    Perimenopause

    The perimenopause transition is the stage of life that precedes menopause. People are officially in menopause after a 12 months without a menstrual period1. Perimenopause, is the 5-10 year transition time that proceeds menopause, where hormone levels begin to fluctuate and ovulation becomes less consistent as ovarian function declines2. During this perimenopause phase, the body has to work hard to ovulate, given the loss of ovarian reserve3. These subtle hormone changes are caused by the body having to work hard to ovulate and from the occasional missed ovulatory cycle. These changes can start to disrupt the consistent hormone production people are accustomed to in their earlier reproductive life.

    As people approach perimenopause, they may notice the following:

    • Irregular periods by more than 7 days longer or shorter than their usual (ie: if your cycle was 28 days previous it may now be 21 or 35)2.
    • Heavier periods due to anovulatory cycles
    • Symptoms of low hormone levels such as hot flashes, migraines and vaginal dryness, even if a period still happens regularly4.
    • Changes to mood and sleep that are independent of hot flashes1,5.
    • A worsening of PMS or feeling PMS symptoms longer though the month.

    Each of these symptoms are attributed to the hormone changes happening beneath the surface. As cycles become less regular, people may notice symptoms of low hormones. As the body tries very hard to recruit eggs each month, cycles may become stacked on top of one another bringing closer together bleeds as well as an increase in PMS symptoms2. Although the loss of ovarian reserve is a normal part of aging, not all women and people with ovaries experience symptoms of perimenopause. A person’s underlying health status can influence her progression though perimenopause and the symptoms they experience. 20% of women and people with ovaries are officially in perimenopause by the age of 40, and 1% are considered menopausal4,6. These numbers climb with every passing year. Many people are not aware that the hormone changes in perimenopause can begin in the early 40s and can feel confused about the changes they are experiencing in their body.

    Symptoms

    In addition to cycle changes, the most commonly cited symptoms of perimenopause include vasomotor symptoms (hot flashes and night sweats), changes to mood, weight gain and insomnia.4,7 People may also experience symptoms such as vaginal dryness, a worsening of headaches or migraines, an increase in joint pain or stiffness. These symptoms can feel frustrating when people are still menstruating regularly because the underlying hormonal cause is not obvious. Estrogen is the primary hormone responsible for appetite, mood regulation, temperature reregulation and vaginal health.2,4,8 Both the loss of estrogen and the widely fluctuating estrogen levels in the final few years of perimenopause can trigger symptoms. Progesterone is primarily responsible for regulating bleeding episodes, and the loss of progesterone may cause cycle length to change or an increase in heavy menstrual bleeding.9

    Weight and shape changes in perimenopause are complicated. Estrogen is responsible for keeping abdominal weight carrying low through the reproductive life, and weight that is gained by people under the influence of estrogen is carried in the “gluteal femoral” (meaning, hips and buttock area)9,10. When estrogen levels decline, people experience an increase in abdominal weight carrying, which changes the way people experience their body shape. Fluctuating hormone levels also impact how much a person is able to exercise due to fatigue or mood changes and affects appetite and cravings.8,12 This combination of body shape changes, and how people feel during perimenopause is the current theory on why people will experience both a change in weight and shape during this time.

    The risk factors that increase the likelihood of having depression during perimenopause include a higher body weight, social determinants of health such as income and education and stressful life events around the time of menopause11. Having other symptoms related to perimenopause such as hot flashes and insomnia also increase the risk of having low mood or depression11.

    Assessment and Testing in Perimenopause

    Assessing perimenopause is mostly through a detailed history taking and understanding a person’s symptoms and change to their cycle. There are lab tests that can be considered for perimenopause to help complete the picture of what a person is going through. However, because hormone levels fluctuate in perimenopause widely, lab work can occasionally be inconsistent with a person’s experience2. Perimenopausal blood work may show slightly elevated or elevated FSH levels, which signifies the brain working harder to ovulate. Estrogen levels may be lower than expected or higher than expected as cycles are stacked together or missed altogether. Progesterone levels will be low if ovulation is missed, but normal in a cycle that releases an egg.

    Cycle tracking is one of the most crucial steps a person can take to understand their hormones and perimenopause. Tacking the cycle should include:

    • The total length of the cycle. Track from day 1 of your period to day 1 of the next menstrual period.
    • Cervical mucous changes that indicate ovulation (egg white consistency discharge signals ovulation)
    • The total number of days of bleeding and the number of menstrual products or millilitres of blood lost.
    • PMS symptoms such as mood changes, bloating and breast tenderness.
    • The severity of cramps and the number of painkillers needed each month.
    • Symptoms that coincide with stages of your cycle such as hot flashes, headaches, sleep challenges, mood changes, vaginal itching or dryness.

    Tracking for a minimum of 3 cycles can help your practitioner diagnose PMS, perimenopause and help identify any additional lab work that needs to be completed. It’s challenging to remember cycles that happened inn thee past. People who track their cycle have an easier time reporting to their practitioner what has changed, because they understand their baseline cycle health.

    In addition to hormone testing, people in perimenopause benefit from other testing including iron, glucose, liver enzymes, cholesterol and vitamin D. Testing is crucial to see if deficiencies are contributing to symptoms such as heavy bleeding or mood changes.

    Test  Perimenopause Menopause
    FSH (Follicle Stimulating Hormone) May be normal, may be slightly elevated Very elevated
    LH (Luteinizing Hormone) May be normal, may be slightly elevated Very elevated
    Estrogen Often elevated in the early stages of perimenopause. May be low during the menstrual cycle Low
    Progesterone May be low during anovulatory cycles. May be normal if an egg happens to be released Low

    Nutrition During Perimenopause

    Women and people with ovaries can support themselves during the perimenopause transition by focusing on nutrition.Studies that have examined nutrition during the perimenopause transition to focus on satiety, protein adequacy and the impact of motivational interviewing on helping people overcome the challenges they face day to day with their nutrition and weight loss12–14. Nutrition choices that focus on satiety, meaning how satisfied or full someone feels from meals, play a significant role in how easily a person can follow a nutrition plan. If a plan for nutrition creates hunger, doesn’t follow a person’s cultural preferences or feels highly restrictive, it’s less likely to be successful in the long run15,16. Focusing on building satiety through fibre and protein can help people in perimenopause manage their nutrition choices more easily. Protein needs for aging women are approximately 1.5 grams of protein per kilogram of body weight17

    Dietary choices that follow a Mediterranean pattern of eating have been shown to reduce the symptoms associated with perimenopause18,19. Women who eat more fruit20 and who include soy in their diet have lower risks of depression21,22. Choosing olive oil, nuts, berries and fish can help people move their diet towards a healthier pattern of eating. It’s also important to note that people also increase their alcohol intake during perimenopause, which may have a negative impact on mood, sleep and overall health23.


    Exercise, Lifestyle Changes and Perimenopause

    The menopause transition is accompanied by changes to body composition with people experiencing increases in body fat and a loss of lean tissue24. These changes begin in the perimenopause stage of life and highlight the need for exercise and nutrition support for this population as a way to prevent future health risks associated with weight gain. Exercise also has additional benefits beyond weight management, with the research on people in menopause experiencing fewer hot flashes and better mental health when they engage in regular exercise25.  Guidelines that make recommendations for exercise in depression include women in the perimenopause transition as people who may benefit from regular exercise in combination with other supports to treat mood symptoms26.

    One of the challenges to daily movement in this phase of life is the impact of how people feel during perimenopause eon their ability to exercise regularly. Activities of daily living, step counts and non-exercise activity decreases during perimenopause, life because people struggle with sleep, mood changes and generally not feeling themselves27,28.

    Exercise that includes sweating and being breathless a few times per week has been shown to improve overall mood and wellbeing25. Studies also show that the combination of nutrition, lifestyle and resistance exercise supports body composition better than any treatment avenue alone29.

    Stress and mindset have also been linked to symptoms in perimenopause, with women and people with ovaries experiencing worse symptoms when they have significant stress or dread the changes happening to their bodies25. People who embrace their aging and have high self-compassion have fewer hot flashes, and overall rate their experience of perimenopause better30,31.

    Nutraceuticals and Supplements

    The use of nutraceuticals and supplements during the perimenopause experience cannot change the underlying hormones shifts or consequences of aging, but they can support the symptoms people experience during this phase of life. Changes to hormone levels are a natural part of aging, but the symptoms of perimenopause are not something that people have to suffer with.

    Melatonin is a nutrient that may support the symptoms of perimenopause, especially if there is an overlap between low mood and disturbed sleep. Melatonin secretion during perimenopause is different than in other times of a woman’s life32, and this disruption may be contributing to both the mood and sleep challenges women face at this time. Research suggests that the addition of melatonin in poor sleepers may support their ability to sleep, and may support symptoms overall in perimenopause, including mood33

    Saffron is a herb gaining interest for its use for mental health symptoms from depression to ADHD34–36. Saffron has been studied in women in post menopause for depression and hot flashes and was found to be a safe and effective herbal treatment for these symptoms37,38.

    Sage is a herb that has been studied in people with menopause and hot flashes and shows that sage decreases the frequency and intensity of hot flashes over a 4 week period of time39,40. Sage has also been shown to improve joint pain and sleep in people in menopause as well41.

    Two herbs that have been researched for supporting people in perimenopause include Rhodiola and Ashwagandha. Rhodiola improves energy and an overall sense of wellbeing in all people, and has been studied to support the stress response in people in perimenopause42,43. Ashwagandha improves anxiety and stress in people during the menopause transition44,45 and has been shown to improve physical  and emotional symptoms of people in perimenopause when used for 8 weeks or more46.

    Chaste tree has also been traditionally used to support PMS and may play a role in alleviating symptoms of breast tenderness and mood fluctuations in people in the perimenopause transition47,48.

    Menosmart+ is a combination of research backed herbs like Chaste tree and Sage – to help reduce the symptoms of menopause like hot flashes and night sweats and to ease nervous tension.  Imagine taking back control of your hormonal health, and celebrating the woman you are now and forever!

    References

    1. Avis, N. E. et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med 175, 531–539 (2015).
    2. Santoro, N. Perimenopause: From Research to Practice. J Womens Health (Larchmt) 25, 332–339 (2016).
    3. Willi, J. & Ehlert, U. Assessment of perimenopausal depression: A review. J Affect Disord 249, 216–222 (2019).
    4. Peacock, K. & Ketvertis, K. M. Menopause. in StatPearls (StatPearls Publishing, 2021).
    5. de Kruif, M., Spijker, A. T. & Molendijk, M. L. Depression during the perimenopause: A meta-analysis. J Affect Disord 206, 174–180 (2016).
    6. McLeod, G. F. H. et al. Menopause status and climacteric symptoms in a birth cohort of mid-life New Zealand women. Climacteric 1–7 (2021) doi:10.1080/13697137.2021.1948005.
    7. Lizcano, F. & Guzmán, G. Estrogen Deficiency and the Origin of Obesity during Menopause. Biomed Res Int 2014, (2014).
    8. Leeners, B., Geary, N., Tobler, P. N. & Asarian, L. Ovarian hormones and obesity. Hum. Reprod. Update 23, 300–321 (2017).
    9. Brown, L. & Clegg, D. Central Effects of Estradiol in the Regulation of Adiposity. J Steroid Biochem Mol Biol 122, 65–73 (2010).
    10. Greendale, G. A. et al. Changes in body composition and weight during the menopause transition. JCI Insight 4,.
    11. Willi, J., Süss, H., Grub, J. & Ehlert, U. Biopsychosocial predictors of depressive symptoms in the perimenopause-findings from the Swiss Perimenopause Study. Menopause Publish Ahead of Print, (2021).
    12. Armstrong, M. J. et al. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev 12, 709–723 (2011).
    13. Barnes, R. D. & Ivezaj, V. A systematic review of motivational interviewing for weight loss among adults in primary care. Obes Rev 16, 304–318 (2015).
    14. Chopra, S. et al. Weight Management Module for Perimenopausal Women: A Practical Guide for Gynecologists. J Midlife Health 10, 165–172 (2019).
    15. Westenhoefer, J., von Falck, B., Stellfeldt, A. & Fintelmann, S. Behavioural correlates of successful weight reduction over 3 y. Results from the Lean Habits Study. Int J Obes Relat Metab Disord 28, 334–335 (2004).
    16. Wing, R. R. & Phelan, S. Long-term weight loss maintenance. Am J Clin Nutr 82, 222S-225S (2005).
    17. Deutz, N. E. P. et al. Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group. Clin Nutr 33, 929–936 (2014).
    18. Sayón-Orea, C. et al. Adherence to Mediterranean dietary pattern and menopausal symptoms in relation to overweight/obesity in Spanish perimenopausal and postmenopausal women. Menopause 22, 750–757 (2015).
    19. Barrea, L. et al. Mediterranean diet as medical prescription in menopausal women with obesity: a practical guide for nutritionists. Crit Rev Food Sci Nutr 61, 1201–1211 (2021).
    20. Wu, T. et al. Association Between Self-Reported Food Preferences and Psychological Well-Being During Perimenopausal Period Among Chinese Women. Front Psychol 11, 1196 (2020).
    21. Li, N. et al. Soy and Isoflavone Consumption and Multiple Health Outcomes: Umbrella Review of Systematic Reviews and Meta-Analyses of Observational Studies and Randomized Trials in Humans. Mol Nutr Food Res 64, e1900751 (2020).
    22. Hanachi, P. & S, G. Assessment of Soy Phytoestrogens and Exercise on Lipid Profiles and Menopause Symptoms in Menopausal Women. journal Biological Science 8, (2008).
    23. Hyvärinen, M. et al. Predicting the age at natural menopause in middle-aged women. Menopause 28, 792–799 (2021).
    24. Gould, L. M. et al. Metabolic effects of menopause: a cross-sectional characterization of body composition and exercise metabolism. Menopause (2022) doi:10.1097/GME.0000000000001932.
    25. Bondarev, D. et al. The role of physical activity in the link between menopausal status and mental well-being. Menopause 27, 398–409 (2020).
    26. Maki, P. M. et al. Guidelines for the Evaluation and Treatment of Perimenopausal Depression: Summary and Recommendations. J Womens Health (Larchmt) 28, 117–134 (2019).
    27. McNeil, J., Liepert, M., Brenner, D. R., Courneya, K. S. & Friedenreich, C. M. Behavioral Predictors of Weight Regain in Postmenopausal Women: Exploratory Results From the Breast Cancer and Exercise Trial in Alberta. Obesity (Silver Spring) 27, 1451–1463 (2019).
    28. Wong, J. C. H., O’Neill, S., Beck, B. R., Forwood, M. R. & Khoo, S. K. A 5-year longitudinal study of changes in body composition in women in the perimenopause and beyond. Maturitas 132, 49–56 (2020).
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    31. Tobin, R. & Dunkley, D. M. Self-critical perfectionism and lower mindfulness and self-compassion predict anxious and depressive symptoms over two years. Behav Res Ther 136, 103780 (2020).
    32. Brown, L., Bryant, C., Brown, V., Bei, B. & Judd, F. Investigating how menopausal factors and self-compassion shape well-being: An exploratory path analysis. Maturitas 81, 293–299 (2015).
    33. Toffol, E. et al. Nighttime melatonin secretion and sleep architecture: different associations in perimenopausal and postmenopausal women. Sleep Med 81, 52–61 (2021).
    34. Treister-Goltzman, Y. & Peleg, R. Melatonin and the health of menopausal women: A systematic review. J Pineal Res e12743 (2021) doi:10.1111/jpi.12743.
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    69. Avis, N. E. et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med 175, 531–539 (2015).
    70. Santoro, N. Perimenopause: From Research to Practice. J Womens Health (Larchmt) 25, 332–339 (2016).
    71. Willi, J. & Ehlert, U. Assessment of perimenopausal depression: A review. J Affect Disord 249, 216–222 (2019).
    72. Peacock, K. & Ketvertis, K. M. Menopause. in StatPearls (StatPearls Publishing, 2021).
    73. de Kruif, M., Spijker, A. T. & Molendijk, M. L. Depression during the perimenopause: A meta-analysis. J Affect Disord 206, 174–180 (2016).
    74. McLeod, G. F. H. et al. Menopause status and climacteric symptoms in a birth cohort of mid-life New Zealand women. Climacteric 1–7 (2021) doi:10.1080/13697137.2021.1948005.
    75. Lizcano, F. & Guzmán, G. Estrogen Deficiency and the Origin of Obesity during Menopause. Biomed Res Int 2014, (2014).
    76. Leeners, B., Geary, N., Tobler, P. N. & Asarian, L. Ovarian hormones and obesity. Hum. Reprod. Update 23, 300–321 (2017).
    77. Brown, L. & Clegg, D. Central Effects of Estradiol in the Regulation of Adiposity. J Steroid Biochem Mol Biol 122, 65–73 (2010).
    78. Greendale, G. A. et al. Changes in body composition and weight during the menopause transition. JCI Insight 4,.
    79. Willi, J., Süss, H., Grub, J. & Ehlert, U. Biopsychosocial predictors of depressive symptoms in the perimenopause-findings from the Swiss Perimenopause Study. Menopause Publish Ahead of Print, (2021).
    80. Armstrong, M. J. et al. Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials. Obes Rev 12, 709–723 (2011).
    81. Barnes, R. D. & Ivezaj, V. A systematic review of motivational interviewing for weight loss among adults in primary care. Obes Rev 16, 304–318 (2015).
    82. Chopra, S. et al. Weight Management Module for Perimenopausal Women: A Practical Guide for Gynecologists. J Midlife Health 10, 165–172 (2019).
    83. Westenhoefer, J., von Falck, B., Stellfeldt, A. & Fintelmann, S. Behavioural correlates of successful weight reduction over 3 y. Results from the Lean Habits Study. Int J Obes Relat Metab Disord 28, 334–335 (2004).
    84. Wing, R. R. & Phelan, S. Long-term weight loss maintenance. Am J Clin Nutr 82, 222S-225S (2005).
    85. Deutz, N. E. P. et al. Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group. Clin Nutr 33, 929–936 (2014).
    86. Sayón-Orea, C. et al. Adherence to Mediterranean dietary pattern and menopausal symptoms in relation to overweight/obesity in Spanish perimenopausal and postmenopausal women. Menopause 22, 750–757 (2015).
    87. Barrea, L. et al. Mediterranean diet as medical prescription in menopausal women with obesity: a practical guide for nutritionists. Crit Rev Food Sci Nutr 61, 1201–1211 (2021).
    88. Wu, T. et al. Association Between Self-Reported Food Preferences and Psychological Well-Being During Perimenopausal Period Among Chinese Women. Front Psychol 11, 1196 (2020).
    89. Li, N. et al. Soy and Isoflavone Consumption and Multiple Health Outcomes: Umbrella Review of Systematic Reviews and Meta-Analyses of Observational Studies and Randomized Trials in Humans. Mol Nutr Food Res 64, e1900751 (2020).
    90. Hanachi, P. & S, G. Assessment of Soy Phytoestrogens and Exercise on Lipid Profiles and Menopause Symptoms in Menopausal Women. journal Biological Science 8, (2008).
    91. Hyvärinen, M. et al. Predicting the age at natural menopause in middle-aged women. Menopause 28, 792–799 (2021).
    92. Gould, L. M. et al. Metabolic effects of menopause: a cross-sectional characterization of body composition and exercise metabolism. Menopause (2022) doi:10.1097/GME.0000000000001932.
    93. Bondarev, D. et al. The role of physical activity in the link between menopausal status and mental well-being. Menopause 27, 398–409 (2020).
    94. Maki, P. M. et al. Guidelines for the Evaluation and Treatment of Perimenopausal Depression: Summary and Recommendations. J Womens Health (Larchmt) 28, 117–134 (2019).
    95. McNeil, J., Liepert, M., Brenner, D. R., Courneya, K. S. & Friedenreich, C. M. Behavioral Predictors of Weight Regain in Postmenopausal Women: Exploratory Results From the Breast Cancer and Exercise Trial in Alberta. Obesity (Silver Spring) 27, 1451–1463 (2019).
    96. Wong, J. C. H., O’Neill, S., Beck, B. R., Forwood, M. R. & Khoo, S. K. A 5-year longitudinal study of changes in body composition in women in the perimenopause and beyond. Maturitas 132, 49–56 (2020).
    97. Hao, S. et al. Dietary and Exercise Interventions for Perimenopausal Women: A Health Status Impact Study. Front Nutr 8, 752500 (2022).
    98. Tobin, R. & Dunkley, D. M. Self-critical perfectionism and lower mindfulness and self-compassion predict anxious and depressive symptoms over two years. Behav Res Ther 136, 103780 (2020).
    99. Brown, L., Bryant, C., Brown, V., Bei, B. & Judd, F. Investigating how menopausal factors and self-compassion shape well-being: An exploratory path analysis. Maturitas 81, 293–299 (2015).
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    101. Treister-Goltzman, Y. & Peleg, R. Melatonin and the health of menopausal women: A systematic review. J Pineal Res e12743 (2021) doi:10.1111/jpi.12743.
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    Assessment and Testing in Perimenopause

    Assessing perimenopause is mostly through a detailed history taking and understanding a person’s symptoms and change to their cycle. There are lab tests that can be considered for perimenopause to help complete the picture of what a person is going through. However, because hormone levels fluctuate in perimenopause widely, lab work can occasionally be inconsistent with a person’s experience2. Perimenopausal blood work may show slightly elevated or elevated FSH levels, which signifies the brain working harder to ovulate. Estrogen levels may be lower than expected or higher than expected as cycles are stacked together or missed altogether. Progesterone levels will be low if ovulation is missed, but normal in a cycle that releases an egg.

    Cycle tracking is one of the most crucial steps a person can take to understand their hormones and perimenopause. Tacking the cycle should include:

    • The total length of the cycle. Track from day 1 of your period to day 1 of the next menstrual period.
    • Cervical mucous changes that indicate ovulation (egg white consistency discharge signals ovulation)
    • The total number of days of bleeding and the number of menstrual products or millilitres of blood lost.
    • PMS symptoms such as mood changes, bloating and breast tenderness.
    • The severity of cramps and the number of painkillers needed each month.
    • Symptoms that coincide with stages of your cycle such as hot flashes, headaches, sleep challenges, mood changes, vaginal itching or dryness.

    Tracking for a minimum of 3 cycles can help your practitioner diagnose PMS, perimenopause and help identify any additional lab work that needs to be completed. It’s challenging to remember cycles that happened inn thee past. People who track their cycle have an easier time reporting to their practitioner what has changed, because they understand their baseline cycle health.

    In addition to hormone testing, people in perimenopause benefit from other testing including iron, glucose, liver enzymes, cholesterol and vitamin D. Testing is crucial to see if deficiencies are contributing to symptoms such as heavy bleeding or mood changes.

    Test  Perimenopause Menopause
    FSH (Follicle Stimulating Hormone) May be normal, may be slightly elevated Very elevated
    LH (Luteinizing Hormone) May be normal, may be slightly elevated Very elevated
    Estrogen Often elevated in the early stages of perimenopause. May be low during the menstrual cycle Low
    Progesterone May be low during anovulatory cycles. May be normal if an egg happens to be released Low
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