THRIVE IN YOUR 40S: Health Checks & Lifestyle Strategies During Perimenopause

While menopause can seem like a daunting and abrupt end to a significant chapter in a woman’s life, it’s preceded by the gradual transition known as perimenopause. This phase, which is literally “around menopause,” signifies the body’s slow and steady shift away from its reproductive years.

Perimenopause is not a crisis or a disease, but rather a period of transformation and self-discovery. It’s a time for women to tune into their bodies, understand the changes that are happening, and learn how to navigate them with grace and confidence.

This blog aims to demystify the perimenopause transition by providing evidence-based information, practical wellness strategies, and helpful tips for managing the various symptoms that may arise during this phase. 

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THE PERIMENOPAUSAL SHIFT: Hormonal Changes & Common Symptoms

Understanding perimenopause requires a clear distinction from menopause itself. Perimenopause is the transitional phase leading up to menopause, marked by fluctuating hormone levels, especially oestrogen (estrogen). 

For those who appreciate a more clinical perspective, the Stages of Reproductive Ageing Workshop (STRAW +10) system provides a standardised way to define these stages. According to this system, perimenopause officially begins when you notice consistent changes in your menstrual cycle length, specifically a difference of seven or more days between consecutive cycles (Stage -2). This phase continues until you have gone 12 months without a period, signalling the arrival of menopause (Stage +1a). Essentially, STRAW +10 gives us a roadmap, helping healthcare professionals and individuals understand the timeline of ovarian ageing.

Stages of Reproductive Ageing Workshop (STRAW +10)

Image Source: AUSTRALIAN MENOPAUSE SOCIETY

Menopause is a specific moment: it’s officially declared when a woman has gone a full 12 months without a menstrual period. This milestone signals the permanent end of menstruation and, consequently, fertility. Simply, perimenopause is the journey, and menopause is the destination. 

Perimenopause, on the other hand, unfolds at varying ages for women. While many begin noticing changes, like menstrual irregularities, in their 40s, some may experience these shifts as early as their mid-30s. During this transition, estrogen levels fluctuate unpredictably. Your menstrual cycles may become longer or shorter, and you might have cycles without ovulation. Despite these irregularities, periods still occur, and pregnancy remains possible.

You may also encounter menopause-like symptoms, such as hot flashes, brain fog, sleep disturbances, headaches, palpitations, joint/ muscle pains and vaginal dryness. As estrogen levels decline, vaginal tissues can lose lubrication and elasticity, potentially making intercourse uncomfortable. This decrease in estrogen can also increase susceptibility to urinary or vaginal infections, and contribute to urinary incontinence due to reduced tissue tone.

Furthermore, the decrease in estrogen accelerates bone loss, elevating the risk of osteoporosis, a condition characterised by fragile bones. This hormonal shift can also impact cardiovascular health. Lower estrogen levels may lead to an increase in LDL cholesterol (“bad” cholesterol) and a decrease in HDL cholesterol (“good” cholesterol), both of which increase the risk of heart disease.

Finally, mood fluctuations, irritability, anxiety or an increased risk of depression are common during perimenopause. These emotional changes can often be linked to sleep disruptions caused by hot flashes.

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Perimenopause Health Checks & Proactive Wellness Strategies

Irregular periods are a common signpost of perimenopause, and in most cases, they’re perfectly normal. However, certain changes warrant a conversation with your doctor. Schedule an appointment if you experience extremely heavy bleeding, periods lasting longer than seven days, bleeding between periods, or regular cycles occurring less than 21 days apart.

Beyond menstrual changes, if perimenopause symptoms like hot flashes, mood swings, or shifts in sexual function are impacting your quality of life, don’t hesitate to seek professional guidance.

Your doctor can offer a range of assessments to support your well-being during this phase. These might include:

• Hormone Testing: To evaluate levels of FSH, estradiol, LH, AMH and TSH, providing insight into your hormonal status.

• Physical Exam: A thorough examination to assess your overall health.

• Bone Density Scan: To evaluate bone health and assess osteoporosis risk.

• Lipid Profile: To monitor cholesterol levels and cardiovascular health.

• Mental Health Assessment: To address any mood-related concerns.

• Pelvic Exam, Ultrasound, and Pap Smear/HPV test: To evaluate the health of your reproductive organs.

• Mammogram and breast ultrasound: breast screen starts from 40 years and especially important for women approaching and over 50.

Furthermore, it’s crucial to discuss age-appropriate cancer screening programs, including those for bowel, breast, and cervical cancer, with your healthcare provider. Prioritising these preventative measures is a vital part of your overall wellness strategy during perimenopause and beyond. These services are available at the Dr. Pamela Tan clinic for your convenience.

Treatment Options for Perimenopause Symptoms

While perimenopause is a natural part of a woman’s life and cannot be stopped, there are ways to manage symptoms that you may experience during this transitional period.

Lifestyle measures

1. Identifying and avoiding triggers for hot flashes, such as caffeine, alcohol, spicy foods, and stopping smoking can be helpful.
2. Exercise : 150 min of weekly exercise including strength training exercise to counter muscle atrophy with increasing age. High body weight is associated with higher incidence of hot flushes and weight loss with improvement of symptoms. Exercise is important for mood, bone density, sleep, cognitive functioning, weight maintenance and cardiovascular disease. 
3. Cooling interventions: air cons, fans, adjusting clothing eg thin cotton breathable fabric clothes, hydration with iced water
4. Cognitive behaviour therapy, hypnosis, yoga, meditation and paced breathing. 

Hormonal treatments 

Menopausal hormone therapy (MHT): the mainstay of treatment which is most effective (eg more than 90% reduction in hot flushes) and continues to be effective as long as used. This involves oestrogen and often progesterone ( for those still with a uterus) and is used to alleviate common symptoms like hot flashes, night sweats, and vaginal dryness. MHT comes in different forms, including pills, skin patches, gels, creams, and vaginal  creams and pessaries, allowing for tailored administration. 

For the majority of symptomatic women, the benefits of menopausal hormone therapy outweigh the risks. We always aim to commence MHT within the first few years of menopause and not initiating it several years later after it has started. Transdermal preparations of estrogen like cream and patches are superior to tablets as there is a reduced risk of thromboembolism ( blood clots in veins). Progesterone can be given as natural micronised progesterone or as a mirena intrauterine device for those still with a uterus. For patients with a previous hysterectomy ( surgical removal of uterus), it is not necessary to use progesterone. 

The main concerns with MHT stemmed from the Women’s Health Initiative study. The current formulations of estrogen and progesterone used are different from that study and the average age of women started on MHT is typically not 63 yr old like in that WHI study (different study population). 

Breast cancer risk: for women prescribed MHT close to menopause and short term use (<5yr), there were 3 extra cases per 10,000 women years for oestrogen alone and 9 extra cases per 10,000 women years for oestrogen plus progesterone use. The risk is increased with longer duration of use esp in women > 60 years old. The risks decreased after MHT was ceased. 

Cardiovascular risk: no evidence of harm from cardiovascular disease for women commenced on MHT close to menopause and there was a trend toward reduced risk for these women. 

Thromboembolic risk: transdermal MHT eg patches or gels has not been associated with an increase in venous thromboembolic disease at doses < 50 mcg/24 hours. The effect of higher transdermal doses is less clear but is less compared to oral oestrogen (2-3 per 1000 women years on oral oestrogen versus 1 per 1000 women years in non users). 

The good news is that besides relief of menopausal symptoms, MHT is also protective against osteoporosis, colorectal cancer and diabetes. 

In some cases, healthcare providers may suggest low-dose birth control pills for a short period to help stabilise hormone levels and manage symptoms especially if patients are in the early transition phase.

For vaginal dryness, vaginal oestrogen creams, vaginal lubricants, and moisturisers especially with hyaluronic acid can provide comfort. Recent studies demonstrated no increase risk of breast cancer with vaginal estrogen usage. 

Non-hormonal options 

1. Veoza (fezolinetant) is a new FDA approved drug for the treatment of hot flashes. It works by binding and blocking the NK3 receptor in the brain that plays a role in the brain’s regulation of body temperature. Hot flashes occur in around 80% of menopausal women. Women with a history of stroke, heart attack, blood clots or liver disease cannot take hormonal therapies but can try Veozah. 
2. Certain antidepressants, particularly SSRIs eg escitalopram and SNRIs venlafaxine, have been shown to reduce hot flashes. These may also be helpful if you are experiencing mood swings and other mental health issues like anxiety and depression at this time.
3. Complementary herbal therapy: There is mixed data and not much robust evidence for many complementary adjuncts sold over the counter. Some studies suggest some limited benefit of phytoestrogens eg soy extracts or black cohosh. An early placebo effect may be seen in up to 50% of users for the first 3 months hence sustained efficacy beyond 3 months is the true measure of whether the therapy is effective. 

To maintain bone health, weight bearing exercise is key. Vit D deficiency is extremely common in Singapore despite all the sunshine. Vitamin D and calcium supplements are additional adjuncts often given.

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Tips for Working Professionals Experiencing Perimenopause Symptoms

Navigating perimenopause symptoms while maintaining a demanding professional life requires a proactive and adaptable approach. Put self-care on top of your priority list. Incorporate regular exercise, such as brisk walks or yoga, to manage stress and improve sleep quality. Pay close attention to your diet, focusing on whole foods, and limiting caffeine and alcohol, which can exacerbate hot flashes and mood swings. 

Finally, don’t hesitate to seek professional medical advice to explore hormone therapy or other treatment options that can significantly improve your quality of life and work performance. Dr. Pamela Tan Medical Clinic offers Menopause Care services, your one-stop care point from perimenopause to menopause. To schedule an appointment, please call +65 9039 1000 or send us a message.