Perimenopause: The signs, symptoms and what the brain has to do with this life stage

If you are a woman in your forties, you may wake up sweaty in the middle of the night, unable to return to sleep. Or maybe you’re suffering from erratic menstrual cycles, weight gain and severe skincare issues. This is the beginning of your body’s transition stage called perimenopause.

Perimenopause is the long, hard and confusing stage before menopause. Most know that menopause marks the end of a woman’s reproductive years, but getting there can be a long process, starting with perimenopause.

It’s not easy to distinguish perimenopause symptoms from other health and middle-age events; however, knowing what they are can provide clarity. For example, a Harvard Medical School article estimates that 35 to 50 per cent of menopausal women suffer from hot flashes and night sweats, but the location and intensity of the heat can vary.

Common perimenopause symptoms include:

• Hot flashes: Sudden moments of heat causing one to become hot and sweaty, lasting from one to several minutes
• Night sweats: Hot flashes during the night
• Irregular periods: Inconsistent timing and flow
• Sleep disturbances: Insomnia or difficulty getting to or returning to sleep
• Sore breasts
• Bloating
• Mood symptoms: Irritability, increased anxiety, or even depression
• Skin issues: Acne, or skin dryness
• Vaginal dryness: Discomfort during the day and during sexual intercourse
• Other symptoms: Losing concentration or memory issues

A PERIMENOPAUSE SYMPTOM WOMEN MAY NOT BE AWARE OF

Two recent Singapore studies on women aged 45 to 69 under the Integrated Women’s Health Programme (IWHP) by National University Hospital (NUH) and the Yong Loo Lin School of Medicine at the National University of Singapore, found that another symptom plagued women in this age group – joint pain.

The first study found that of the 1,054 Singapore women studied, one-third (32.9 per cent) reported muscular and joint discomfort or arthralgia, which is joint pain from overuse or injury but without inflammation. Hot flashes ranked fifth in this study.

The second study of 1,120 middle-aged Singapore women reinforced that arthralgia is more prevalent among women in menopause. Close to 75 per cent of women reported differing degrees of joint and muscle aches, and pain, accompanied by poor muscle strength and vaginal dryness.  

PERIMENOPAUSE AND THE BRAIN: IT’S NOT JUST YOUR OVARIES

Perimenopause can also affect the brain, challenging a woman’s concentration and memory. According to American neurologist Dr Lisa Mosconi, a woman’s brain and her hormone-making glands change during menopause. “From a biological perspective, menopause affects far more than fertility,” she said.

Dr Mosconi, an associate professor of Neuroscience in Neurology and Radiology and director of the Alzheimer’s Prevention Programme at Weill Cornell Medicine and the NewYork-Presbyterian Hospital, studied the brains of women in perimenopause and post-menopause.

Her research, outlined in her book The Menopause Brain, found that perimenopause symptoms like hot flashes and night sweats, do not originate from the ovaries but in the brain.

The reduction in oestrogen causes the loss of a key protective element in the female brain, leaving the woman vulnerable to cognitive decline and neuro-degenerative diseases like Alzheimer’s.

Dr Susan Logan, a senior consultant at the NUH Department of Obstetrics and Gynaecology who was involved in the IWHP study, said more needs to be done to understand Asian women’s perimenopause and menopause symptoms and their respective treatments.

She added that with Singapore’s ageing population, it is worth noting that by 2050, women facing perimenopause and menopause will form the majority of the population, and more conversations and research are needed to support women during this time.

IS IT PERIMENOPAUSE OR SOMETHING ELSE?

While many perimenopause symptoms are easy to spot, others are not as obvious, noted Associate Professor Rukshini Puvanendran, co-director of the KK Menopause Centre, and head of Family Medicine Service at KK Women’s and Children’s Hospital (KKH).

In a qualitative study co-authored by KKH of perimenopausal and menopausal women aged between 47 and 54 years, the women reported experiencing hot flashes, mood changes, vaginal dryness, insomnia, joint and muscle pains.

“This study also found that these perimenopausal women … were uncertain whether their symptoms were related to menopause or other health problems,” she said. Seventy per cent of participants did not seek treatment for their symptoms, and only 5 per cent sought menopause hormone therapy (MHT).

Adding to this confusion, there are no specific perimenopause and menopause tests. “For women in their late forties and fifties, tests are not required to determine if they are going through this transition,” Assoc Prof Puvanendran added.

The study also found that women felt lost, and lonely, faced a sense of loss for their womanhood, and an awareness of ageing and even death.

HOW TO MANAGE PERIMENOPAUSE SYMPTOMS  

Because symptoms vary between women, it can be difficult to pinpoint which treatment to seek. However, when symptoms start affecting daily life, work, and causing irritability, Assoc Prof Rukshini advised: “It is essential to consult a healthcare professional for personalised advice and treatment options, if necessary.”

For hot flashes and night sweats, menopausal hormone therapy (MHT), previously known as hormone replacement therapy (HRT), may be used. Besides oestrogen and progesterone, MHT with testosterone may sometimes be prescribed to help with perimenopause symptoms.

Assoc Prof Rukshini said: “Many seek supplements like black cohosh, a North American traditional herb which helps with hot flashes, but it doesn’t work as well as MHT.”

She added that other methods like acupuncture have been reported to help with discomfort and even night sweats, but clinical trials have been inconclusive.

Here are some tips to manage perimenopause symptoms:

1. Staying cool: Wear light, breathable clothing to regulate body temperature. On humid days, use fans or turn on the air conditioning to reduce hot flashes.
2. Keep active: Engage in regular exercise to regulate your hormones, improve mood, enhance well-being, promote better sleep, and alleviate menopausal symptoms. Assoc Prof Rukshini encourages at least 30 minutes of moderate activity most days of the week to see benefits.
3. Eat a balanced diet and avoid trigger foods: Whole foods and a diet rich in vegetables, wholegrains, lean protein and calcium-rich foods will help with overall health and well-being. Reduce fried and spicy foods if they trigger hot flashes.
4. Practise sleep hygiene: Maintain a consistent sleep schedule by creating a healthy bedtime routine. Reduce caffeine intake and create a conducive sleep environment by putting away mobile devices for up to 90 minutes before bedtime.
5. Share with those who care: Be open about your experiences with family and friends. This way, they have an insight into how you feel and can provide emotional support in tough times.
6. Seek professional help: Consult a healthcare professional like your GP, or gynaecologist if symptoms significantly impact your quality of life. You will receive personalised treatment and guidance to navigate this time.
   
   Women can also seek help at the KK Menopause Centre, which combines family medicine, gynaecology, dermatology, and mental health with group support as well as early assessment and intervention of age-related health conditions. For more information, you can visit KKH Women’s Health and Wellness Centre WHWC or click here for the KK Menopause Centre.

Said Assoc Prof Rukshini: “Perimenopause and subsequently menopause are not diseases but are biological phases in a woman’s life.

“While it marks the end of a woman’s reproductive phase, it is also the beginning of another stage – one where they can take charge of their life emotionally, mentally and physically.”