If you're a person with a uterus, you probably got an awkward talk when you were around nine or 10 explaining some changes that were coming for your body. (Maybe you saw a movie that memorably involved pancake batter poured into the shape of the female reproductive system.)
Illustration by Angelica Alzona.
Whatever it was, you likely got something.
But it turns out there is no similar sex-segregated film screening for folks in their mid-30s. Plenty of women, then, find themselves caught off-guard by gradual changes to their menstrual cycles - and maybe, their overall sanity. This is not the big capital-C Change of menopause that we all have some vague expectations about, but her bitchy little sister, perimenopause.
What Happens in Perimenopause
For many women, there's a stretch of a few years between reaching for your DivaCup each month with clock-setting regularity and leaving the whole thing behind. The time leading up to menopause (which the American Congress of Obstetricians and Gynecologists defines as no menstrual period for 12 months because the ovaries have stopped producing hormones) is called perimenopause, and it may not be much fun.
Your cycle can lengthen - or shorten, who knows! You might bleed less - or more! You can experience hot flashes, sleep disturbances, bloating, headaches and truly horrible PMS. But your periods keep limping or racing along, and you keep experiencing hormonal cycles. The outcome is way more cute undies sent to an early period-only grave, and some serious physical and emotional discomfort.
"Many women and their providers don't recognise it," says Dr JoAnn Pinkerton. Pinkerton is executive director of the North American Menopause Society, and professor of obstetrics and gynaecology at the University of Virginia Health System.
"The symptoms can be very vague," she says.
It might not be missed periods, for instance. It could be weight gain and headaches or brain fog and painful sex. And, she says, some women cycle in and out of perimenopause, making it extra tough to pin down.
"Sometimes, women just come in and they think they're going crazy - nobody else around them is having symptoms," Pinkerton says.
And they may think they're too young, since changes can start in the late 30s or early 40s. The average age for menopause is 51, but plenty of women have it before 40 - sometimes because of cancer treatments, certain surgeries, autoimmune disorders, genetics, or the plain old luck of the draw, according to the Office on Women's Health, US Department of Health and Human Services.
Periods don't start out evenly, and they don't end up evenly, either. Their rough starts are mirrored as egg production and menstruation wrap up, eventually ending with menopause.
Pinkerton, for instance, says she recalls going out with her family to celebrate her first period (!) and then feeling really sheepish when it didn't return for several months. But that's typical. When young women are going through puberty and first get their periods, the hormonal pathway that drives the ovaries to produce eggs is immature, which leads to irregular menstruation for a while.
After those first few periods of possibly varying cycle lengths, puberty wraps up and they become more predictable. "Finally, women have regular cycles," Pinkerton says. "Many women have very predictable cycles until their mid to late 30s or 40s."
Your Doctor Can Help
Not every woman approaching middle age is in for a rough time. "Some women just march right through, other women are going to have lots and lots of fluctuations," Pinkerton says. "I think that taking care of women, getting them through perimenopause, is sometimes harder than getting them through menopause."
The most common symptoms of perimenopause are irregular periods, hot flashes, sleep problems, mood changes, lessening vaginal lubrication, increased urinary tract infections, incontinence, and changes in levels of sexual desire.
Pinkerton recommends perimenopausal women look at the issues they're having holistically. The comparison to puberty is only so apt - not a lot of 12-year-olds have mortgages, jobs, teenage kids and ageing parents to contend with, after all.
"When somebody walks in and says, 'I don't know what to do, I feel like I'm falling apart,' I draw a circle and I put the patient in the middle," Pinkerton says. She looks at stress, sleep, physical and mental health.
Help is available. A doc might provide hormonal birth control or an IUD to regulate and calm the ovaries. It might be useful to take a low dose of antidepressants, especially leading up to menstruation.
Pinkerton also adds that 16 per cent of new depression diagnoses happen in perimenopause, so it's one to watch out for. Flooding periods, where women soak through a pad in an hour or pass huge, grapefruit-sized clots, are an anaemia risk. Another fun surprise of perimenopause, she says, could be pregnancy - the second highest rate of unintended pregnancy, she says, is among women in their 40s.
"Even though your ovary isn't working as well, it's working," she says.
Despite all the potential doom and gloom, women can take steps to head at least some of this off. Healthy eating is important, and so is keeping up physical exercise. Good sleep habits may be hard to maintain in the face of sleep disturbances, but it's worth a try.
Above all, remember that help is out there. If your gynaecologist doesn't seem to be listening or dismisses your concerns, she says, seek another one.
"Women shouldn't suffer in silence," says Pinkerton. "If it's affecting your work or relationships, you need to come in."