I was driving on the freeway when an intense rush of fear consumed me. I thought, “Do I pull over?” Luckily, a friend in the front seat started talking and it distracted me. Soon enough the fear dissipated (she never even knew). Following the car episode, I experienced times of increased heart rate, palpitations, and tightness when swallowing. These symptoms were familiar but it had been over 20 years since I experienced them! I got help, made some changes, and the symptoms eased.
I soon discovered that there was something else working behind the scenes: perimenopause. Even before the anxiety, I had experienced less-noticeable changes including more intense PMS, constant sore breasts, and irritability. I soon found myself researching this topic full steam. I’d love to say I found one easy answer but I didn’t. In fact, no other developmental stage has been less straightforward. But ladies, that’s why we need to discuss them!
So let’s get started.
How is Perimenopause Defined?
Perimenopause is the transition period before menopause when the menstrual cycle ends. It typically lasts 1-5 years but can last up to 10 years depending on how you define it. The start of this transition is not marked by age but by ovarian reserve. In short, how many eggs a woman has in her uterus. To understand this, let’s do a quick hormone-cycle review.
During the peak reproductive years, estrogen is produced by follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH stimulates the follicles to produce estrogen. When estrogen reaches a certain level, LH levels rise and the dominant follicle releases an egg. This is ovulation. The left-behind follicle produces progesterone along with estrogen to prepare for pregnancy. When pregnancy doesn’t occur, menstruation takes place and the cycle repeats itself. Because the quality and number of eggs diminish in the late reproductive years, anti-mullerian hormone (AMH) and inhibin B — indicators of ovarian reserve — decline. In an attempt to stimulate more estrogen, FSH levels rise and the varying levels of estrogen cause cycles to become irregular.
Sometimes it’s enough to produce ovulation and sometimes it’s not. The STRAW staging system (Stages of reproductive aging workshop) outlines the changes from the first period to the last and beyond. Early perimenopause is defined as a menstrual cycle that changes by 7 days in length and late perimenopause are when cycles are greater than 60 days apart. When estrogen levels get low enough — and don’t go back up — cycles stop completely. The median age for early perimenopause is 47 and late perimenopause is 49. Eighty-eight percent of women go through menopause at age 51 but the range is anywhere from 40-58 years. A woman is considered in menopause when she goes an entire year without a menstrual cycle. 
Very Early Perimenopause?
About a year ago I had some labs run –showing normal FSH and estrogen — and the conclusion that I was not perimenopausal (cycles regular). Like a lot of women, I went searching for answers. And that’s where I found The Centre for Menstrual Cycle and Ovulation Research (CEMCOR) and the work of Jerlynn Prior BA, MD, FRCPC Professor of Endocrinology and Metabolism at the University of British Columbia in Vancouver, BC.
Prior argues that instead of a time of declining estrogen, perimenopause is a time of climbing estrogen levels. This can begin as soon as the mid-thirties to early 40s, something CEMCOR calls “very early perimenopause.” At the same time estrogen levels increase, progesterone levels decrease putting the body out of balance. According to one study, 37% of perimenopausal cycles have a second surge in estrogen called the “luteal out of phase (LOOP)” event, causing estrogen levels to be higher.
“High estrogen and progesterone levels in pregnancy are normal and necessary, but in the perimenopause, estrogen is high but progesterone is not,” writes Prior. “It is this imbalance that can cause significant difficulties for many women.” According to CEMCOR, very early menopause occurs even when women have regular cycles and experience at least three of the following symptoms:
- New-onset heavy and/or longer flow
- Menstrual cycles that are shorter (25 days)
- New sore, swollen or lumpy breasts
- New mid-sleep wakening
- Increased cramps
- The onset of night sweats, typically premenstrually
- New migraine headaches or migraines that get worse
- New/increased premenstrual mood swings
- Unexplained weight gain
The Why Behind Perimenopause Symptoms
According to the current definition of perimenopause, symptoms typically occur late in the game because of declining estrogen levels and include hot flashes, poor sleep, vaginal dryness, adverse mood (depression and anxiety) and memory problems.
During this stage, 80% of women will have one or more of these symptoms. But other experts like Prior believe symptoms occur earlier due to higher (and erratic) levels of estrogen and lower levels of progesterone. Because the brain is accustomed to a predictable rise and fall of estrogen, during very early, early, and late perimenopause, these levels become irregular, which means they spike and crash. Even when levels drop back to normal in very early menopause, it’s the drop itself produces a discharge of stress and other hormones.
It’s kind of like puberty. Before levels get stable, they are less predictable which is why girls’ cycles take time to become regular. It’s like a rollercoaster instead of a smooth, predictable ride. And that rollercoaster ride sure is fun!
“What happens with a hot flush is like what a drug addict goes through during withdrawal — a major brain discharge of stress and other hormones,” writes Prior. “It is this hormonal discharge (along with the flush) that causes the anxious feelings, nausea and chest pain as well as the feeling of heat and the sweating that go with them.”
This can also help explain why I felt more anxious, a common complaint at midlife. In one study, out of 487 women aged 40-64, 53% of the premenopausal women reported anxiety and/or depressive symptoms, 66% of the perimenopausal did, and about half of the postmenopausal women. It’s no wonder that during this time women feel more stressed. 
What do we do about this?
Of course, not every symptom in midlife can be attributed to perimenopause alone, especially the mood changes. Life stressors that go along with midlife like raising kids, helping aging parents, lifestyle changes, and other struggles. But step one is understanding how female bodies change during this time, so you know what to expect.
In future posts, we’ll talk about how to ease these symptoms, what hormones changes mean for the health of our bodies, and how to use this time to recharge health and well-being. And I’m going to have Dr. Prior on my podcast to help explain this all so stay tuned! Have you experienced any symptoms of perimenopause? And if you went through it, any words of advice?
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Thank you for this post. I’m looking forward to the podcast conversation. I’m 41, have a 3-yr old and I’ve been aware of a shift in the last year or so (haven’t had my hormones checked). I’ve been frustrated to hear “you are too young” from my doctor, convincing me that nothing is changing yet. Well…If possible, could you address the issue the hormonal influence on intense nausea mid-cycle and on (one of the few new things for me!). From nutrition standpoint, how to manage your food intake if you can’t eat for a week or two each month…
I used to get nausea in my late thirties and early 40s but it went away. I also had a friend who experienced pretty intense nausea. Thanks for the suggestion and I will be sure to look more into it and ask Dr. Prior.
Martochka — You might want to read Estrogen’s Storm Season by Jerrilynn Prior. One of the stories in the book is of a gal with severe nausea and she gives many recommendations. You might want to check it out.
I NEVER comment on posts but felt compelled to do so…. My anxiety started driving my two young children around. I didn’t know what was happening to me. I would feel shortness in breath, my vision giving out, my heart rate increasing.. never had this before in my life! Simultaneously, I was bleeding heavy for a month or not having a period at all for a couple months. My hot flashes are insane! This all started at 38 years of age. My doctor had taken blood twice for my fsh and said that its normal for a woman my age and that I am too young to start perimenopause….BS! 6 months later, no period, not pregnant and hating on the hot flashes and mood swings.
Thanks for sharing. Did you go to a specialist in menopause or a primary doc? Because of your age, a specialist would be beneficial because there are special considerations when going through the change at a younger age. I would search for a NAMS certified practitioner you can find here https://www.menopause.org/for-women/find-a-menopause-practitioner
Other than that we will talk about ways to ease symptoms. Hang in there!
My symptoms began in my early forties…nausea, headaches and restless sleeping. I am now 51 and I still get my period….but it lasts 7-10 days before returning two weeks later. In the past year my breasts hurt constantly, and I’ve only skipped one period–that was last year. I am wondering when the heck my periods will finally stop?! One thing I began doing, though, back in my early 40s is rubbing progesterone cream behind my knees after my morning shower. It helped all my symptoms go away. I also walk five miles a day, which makes me feel amazing. Unfortunately, I know most women have the time to do that. The cream helps immensely, though, and though it doesn’t really increase my libido, it enables me to fully enjoy intimacy when I do actually get busy with my husband. Thank you for talking about perimenopause. Too many people don’t!
Thanks for sharing Susan! I just got progesterone cream and haven’t noticed a difference yet. How long did it take? I’m also an avid exerciser and it helps me too.
Hi Maryann, I’d say it was at around three month of daily use that I felt a difference. I was so happy to have a sexual response again. It made all the difference. The box says to use two packets a day, but I only use one packet and that’s been enough. I’ve been using it regularly for almost ten years now, and it is part of my daily routine.
(Typo alert: Oh, and in my original post I meant to say that unfortunately most women “don’t” have the time for that much walking…)
Fantastic article and so timely! I was just telling my sister yesterday that for the first time I left “anxious”. I was in the backseat of a car with two other people. We all are medium/small build. I never had issues with being in large crowds or with lots of people. In fact, in enjoy it most of the time. However, yesterday very suddenly, I felt like, ‘I’ve got to get out of here NOW”! I had to leave my friends go home and decompress. It was the weirdest feeling ever! Thanks to your article, I know it is part of perimenopause and I am not going crazy. I am 51 and started perimenopause 4 years ago. I have been taking Femmenessence MacaLife for the past 2 years and have experienced significant relief from hot flashes and other uncomfortable symptoms. As long as I avoid foods that trigger me, I am symptom-free!
Thanks, Dana. Lots of women experience anxiety and I will write more about what can help. I hadn’t heard about Maca Life before. I’ll check it out!
Please do keep writing! I would love to read! By the way, if I make it to July without a period, I will officially be in menopause 😉
Yes, Femmenessence MacaLife does not introduce any hormones into the body. Since you are a doctor, you will find it so interesting how it works.
https://www.femmenessence.com/femmenessence-macalife.html
Video is informative and hilarious! http://www.Femmenessence.com – Clinically Proven Menopausal Support
https://youtu.be/ol38XVdN7q4
Well written. And very informative
Thank you!
This is awesome information. I am 50 years of age and have been experiencing anxiety for the past 5 years, though, I seem to be going through peak of anxiety at this phase in life than before. My anxiety comes when I am driving and when I am in a crowd. Loud noise just makes me want to run away.
Due to my lack of enthusiasm in driving these days, my husband has to drive kids to and from all the activities and it is bothering me big time to not be of any help. How do I get over my anxiety? I do Isha foundations Inner Engineering Meditation. It helped some but not with my anxiety.
My coworkers (ladies) were quick to judge that I am going through depression. However, the anxiety comes and goes very unpredictably which I do not account as depression. It’s just the fear of when will anxiety strike again, makes me not function at a 100%. I am looking forward to reading more from you. Thank you Maryann.
I just remembered another thing I do that helps immensely with anxiety. I started taking a powder supplement called “Calm”. Perhaps there are other brands out there….it is magnesium citrate. I have trouble breathing when I’m clausterphobic, and this stuff helps. I mix it with warm water to activate it and I take it at bedtime.
Hi Monica. I highly recommend the DARE book and program. Just look on Amazon for the book. IT comes with a free very helpful app. You also can get on the private Facebook page and ask questions. It has helped me with my driving…I was avoiding freeways but now I can go anywhere. The premise is to allow all anxiety feelings. In fact, ask for more when you feel the sensations. By letting the feelings in (knowing they won’t hurt you) they lesson and you get control back. There are many different treatments for anxiety but for panic attacks and difficult sensations this program is the best I’ve found. I will be writing a post on this subject so stay tuned!
Hi Maryann,
When I looked up DARE program on the web, it showed me Drug Abuse Resistance Education. Is that the same program you are referring to or should I be looking for something different? Thank you for your feedback.
Sorry…. meant to say search Amazon books. Here’s the link https://www.amazon.com/Dare-Anxiety-Stop-Panic-Attacks-ebook/dp/B0158S7E1G/ref=sr_1_1?keywords=Dare&qid=1555025313&s=books&sr=1-1
Thank you, I will look it up.
I also forgot to mention that I still get my periods but lesser intense flow. My doctor does not think that anxiety or panic attack happen during perimenopause and hence I would like to share your articles with her.
Hi, thank you for this post! It is great to hear that all these symptoms have a reason. I must add that apart from anxiety, night sweats, insomnia, migraines… I also suffer from GI tract symptoms. I have bloating, gastritis and abdominal pain. I still have regular periods; in fact all my life I’ve had long cycles, ~40 days. Now for the first time my cycles are 28 days. But I have intense PMS and headaches associated with it. Im 40!
Hi Filis,
Can you, please, share what have you tried for alleviating GI problems? I have suffered with the same thing tremendously for the past 1.5 years. I lost about 25 lbs in the very beginning of my problems (when my anxiety was at its peak) but I gained only about 5-7 lbs back if so. I can’t eat normal. I get bloated in my upper stomach and under rib cage. Done tons of tests, took PPIs and prokinetics, spent several thousand dollars on copay, procedures, medicines, supplements, alternative Dr’s appts. Nothing helps. I decided to try taking Maca Root which I haven’t taken yet, not sure if it will help or not. If you know of some supplement that helps, please share with me. I also have heavy periods, anemia during periods, and moderate anxiety (no panic attacks anymore, Glory be to God for that). And migraines stopped about a year ago too. But indigestion and bloating is horrific
Sorry to hear that you are both having problems. Have you tried working with a dietitian on a low fodmap diet? These are carbohydrates that can be tough to digest. As I tackle nutrition I will look more into the connection between periomenopause and GI symptoms. Trying different probiotics may help.
Hi Maryann, Thank you for informing us about this topic. It is a very interesting one actually to do a research on. Will you please recommend any good books for nutrition during perimenopaus or hormonal displacement! Or maybe something on how to correct this with herbs or nuts! Many thanks in advance and looking forward to your next research topics.
I’m working on that book myself because I can’t find something that covers what I need. I’ll be posting about natural remedies this week and nutrition will be next. Be sure you are subscribed so you get posts. I also have a Patreon group if you are interested.
Hi Victoria, I have in fact discovered that my bloating came from drinking to much of mineral water with CO2. I’ve been drinking it at every meal almost 1/2 liter in a day. Suddenly I stopped for one week and no more bloating. 😀. However, the pain in the upper abdominal area persisted for months after that. Finally, I decided to take Omeprazol for 2 weeks, every morning 20 mg 30 min before breakfast. Now the pain stopped. And one step at a time I will also try to reduce sugar and carbohydrates from my diet to see if migraines and PMS go away.