Perimenopause: An "invented" disease

The latest media event is perimenopause, yet another time in a woman's life when the characteristics of her menstrual cycle give her a chance to be considered abnormal. Menopause itself is an arbitrarily defined non-event useful primarily for targeting a group of women for pharmaceutical marketing. Perimenopause increases both the number of women eligible for unnecessary tests and treatment, and the duration of their eligibility for special attention from pharmaceutical companies.

What is Perimenopause?

The story of perimenopause is closely connected to the hoopla around menopause itself. Menopause is when menstrual periods stop permanently. Unlike the menarche (first menstruation), however, a woman's last period is not dramatically announced, nor can it be predicted or diagnosed by lab tests. Determined retrospectively and by an absence, menopause is defined as the time after which no menses occur for 12 months. But rather than ceasing abruptly, menstrual periods commonly space out prior to stopping altogether. As women age, it is normal to progress from having periods about once a month to having them every two, three or more months, following which cycles start up again. Menstrual periods are unlikely to start again after being absent a full year.

If menopause is an arbitrarily defined point on the continuum of normal changes in ovarian function, perimenopause is both vaguely and variously defined (under some definitions, this "phase" could last 20 years). As women get older, their ovaries become less sensitive to follicle-stimulating hormone (FSH), which stimulates the maturation of an egg and the release of estrogen. With continued aging, the response to FSH may diminish to the point that an egg does not mature, ovulation does not occur, and hormone levels are not high enough to cause uterine bleeding. Lack of bleeding does not signify a complete lack of eggs or even a complete lack of hormones, but only an amount of estrogen or progesterone too low to cause the uterine lining to bleed.

During the years prior to her last menstrual period, a woman's response to FSH is not uniform. Varying levels of hormones may change menstrual-related symptoms and bleeding intervals. Some variability is normal throughout the reproductive years. The 28-day cycle is a myth - normal cycles can vary from 25 to 34 days or more, with few women experiencing the same interval cycle after cycle. In the years prior to menopause, however, variability can become more extreme. Associated symptoms such as mood changes, breast tenderness and bloating can also be highly variable. It is this period that has become known as perimenopause.

The term perimenopause became popular among health care providers and the media only a few years ago. Creating a medical term has invited medical researchers to take ownership of the condition and thereby to study it. Unfortunately, such studies require that criteria be invented for defining a condition, and particular creativity is involved when the condition itself is invented.

Some researchers have defined perimenopause as the 10 years prior to the last menstrual period; but of course this definition can only be made in retrospect. Other definitions start perimenopause at age 40, under the assumption that the average age of menopause is around 50. But this ignores the fact that the normal age range of menopause is from 40 to 60. One of us heard a lecture defining perimenopause as the first break in menstrual cyclicity, with "early perimenopause" defined as less than three months without a period and "late perimenopause" as more than three months without a period. We wondered if "pre-perimenopause" would soon join the lexicon.

There may be no agreement on when this elusive condition begins, but the symptoms it encompasses include an ever-growing list. Perimenopause has become a new disease. Symptoms attributed to it include irregular periods, heavy periods, light periods, cramps, hot flashes, night sweats, memory loss, sleeping problems, mood swings, anxiety, irritability, lack of libido, vaginal dryness, frequent urination, migraines, bloating and breast tenderness. Not one of these symptoms is specific to the "perimenopausal" age group (irregular periods, for example, are common among adolescents, athletes and lactating women). Instead, the list is a compilation of symptoms attributed variously to menopause, menstrual cycle changes, pregnancy and just being a woman.

Irritability or mood swings, for example, have been attributed to women's jumpy hormones for eons; such labels have long been used either to overmedicate women or to dismiss their complaints. Hormones may be one factor in influencing moods, but personalities, relationships and stress are probably far more important.

The growing number of symptoms or conditions attributed to perimenopause allows its purveyors to cast their diagnostic net over as many women as possible. Their justifications for lumping discordant symptoms can border on the absurd. An article in the Female Patient (a pseudojournal funded by drug companies and distributed free to doctors) titled "Perimenopause: surviving the transition to menopause" notes that problems with perimenopause include fertility or infertility. Well, that about covers the bases: who escapes one of those two categories? In the same article, a researcher is quoted as saying, "The one consistent thing about perimenopause is its inconsistency," a statement one may as well make about life.

Hormone levels may vary more sharply before menopause. Women may have symptoms (breast tenderness, mood changes) that they never had before, or never had to the same degree. They can have both high estrogen (breast tenderness) and low estrogen (hot flash) symptoms in rapid succession. In fact, hot flashes are not directly related to estrogen levels - after all, girls have low estrogen levels and no hot flashes - but may be related to rapidly falling estrogen levels. Women who suddenly stop estrogen therapy rather than tapering off, for example, often have severe hot flashes.

But what if a woman finds the increased variability of these years to be disturbing? If symptoms such as heavy bleeding, bloating, breast tenderness, mood changes or hot flashes are troublesome, they can be managed. It is acceptable to consider treatment, even for a non-disease. Treatments may include pharmaceuticals, herbs, dietary supplements, dietary changes or exercise.

Then again, many women have no "perimenopausal" symptoms at all, and many others have mild symptoms that are not troublesome. Most women feel absolutely fine simply knowing that these symptoms are a normal part of life and not evidence of poor health. Perimenopause is no more a disease than is peripuberty, and we might be a lot better off if the term would just go away.

by Tony Scialli, MD and Adriane Fugh-Berman, MD

Tony Scialli, MD, is professor, Department of Obstetrics and Gynecology, Georgetown University Hospital, and editor of Reproductive Toxicology. Adriane Fugh-Berman, MD, is assistant clinical professor, Department of Health Care Sciences, George Washington University School of Medicine, and a former board member of the National Women's Health Network, U.S.

Copyright Initiatives for Women's Health, Inc. May/Jun 2003
Provided by ProQuest Information and Learning Company. All rights Reserved