What Every Woman Should Know About Perimenopause

The period is having a media moment. We’re starting to talk about it, and everything surrounding it, as though it’s normal – because it is. It should not be a source of embarrassment or shame. Maybe, to badly paraphrase Gloria Steinem, we should take a page from men – because if they menstruated, you know they’d brag about it. They’d live-tweet that shit.

As the period is having her moment, let’s also turn the spotlight toward her older, wiser sisters: menopause and perimenopause.

When our periods began, most of us had mothers, grandmothers, or other experienced older women to show us the way. To tell us how to make it easier. But when we greet perimenopause and then menopause, we often do so without guidance; not because our foremothers didn’t want to show us the way, but because they didn’t know.

The year I turned 39, I started having weird, irregular periods. I’d have one every month, but would spot after it was supposed to be over for another ten or twelve days. I had a D&C – dilation and curettage; a scraping of the lining of the uterus, fortunately done under anesthetic. The bleeding returned. An exam showed nothing structurally wrong. (The nurse who examined my uterus memorably told me it was “cute and perfect, like a little golf ball in there.” Who knew a uterus could be cute? I felt weirdly accomplished – I have a cute-erus!) Ultrasound revealed a small cyst on my ovary.

I brought up other symptoms with my OB-GYN. I was having what felt like two weeks of the worst PMS of my life every month, complete with breast pain, bloating, food/carb cravings, and irritable moods. My libido was in the crapper. I was either spotting, on my period, or having PMS – there was no ‘normal’ anymore.  This was seriously affecting my quality of life. My doctor was a woman my own age; I expected her to be, if not sympathetic, at least understanding.


She offered me anti-anxiety drugs for what she referred to as my “mental symptoms,” recommended ibuprofen for the breast pain and suggested we take out the ovary with the cyst on it. Without any explanation (even when asked) of why that might be necessary, or how I would benefit from having the ovary removed.

I went home. Cried. Asked Google a lot of questions. And found another fucking doctor. I have done so much reading and research on perimenopause in the intervening years, and eventually had guidance from a great doctor. We shouldn’t have to work this hard to find out what’s going on at this stage of life. I’m sharing my experience here, in the hope of making the journey to knowledge and help a little shorter for someone else.

What is perimenopause?

My ‘new’ OB-GYN is an absolutely lovely woman. Going to see her is like going to see your mother, if your mother is comforting, encouraging and super supportive and knows everything there is to know about how your lady bits work. We’ll just call her Dr. Mom for short. She explained to me that menopause – the cessation of the menstrual cycle, which usually happens around age 50 – has a really long on-ramp, sometimes ten or fifteen years. This is what we now call perimenopause.

The things that were happening to me were natural and normal and part of the evolutionary plan. They were not “mental symptoms.” In most of our long human history, at 35 or so we became much more likely to die in childbirth, and/or bear a child with serious health problems. So Mother Nature doesn’t want me pregnant after that age – for my own good, and the good of the species. My collection of symptoms were designed to prevent that from happening. But ‘natural’ didn’t mean I had to live with it. There were options:

Hormone therapy: HRT and bioidentical hormones. Hormone Replacement Therapy, or HRT, is the name for something that used to be standard therapy for women entering menopause fifteen or twenty years ago. These are synthetic hormones, medications with names like Premarin or Provera. Subsequent research indicated women on HRT had poor health outcomes, and HRT was dropped as the standard of care. But there was nothing to replace it with.

Enter bioidentical hormones (thank God).

Bioidentical means the same-shaped molecules as the native hormones our bodies make. There is a lot of confusion and it can be really hard to tell which is which (the pharma companies want it that way). Dr. Christiane Northrup, MD and menopause expert, offers straight-up advice on how to tell the difference. If you’re going to try bioidentical hormones, she’s a great place to start.

Dr. Mom explained that for a long time, it was assumed that perimenopause symptoms like mine were due to reductions in estrogen levels. But it turns out that’s a myth – and the opposite is true. Levels of estrogen during perimenopause are high, out of proportion to its balancing hormone, progesterone. Estrogen dominance is the cause of many perimenopause symptoms (especially now, with environmental estrogens everywhere); and they can be addressed by progesterone supplementation.

Bioidentical progesterone cream is available over the counter, and for a bit I experimented with that. I saw mild relief of some symptoms, but it felt clunky and inexact. I wanted more relief, and more precision. Dr. Mom put me on a prescription called Prometrium. This is bioidentical progesterone in pill form, approved by the FDA and paid for by my insurance company. I took it for about ten days every month, during the PMS portion of my cycle.

Oh, sweet relief.

Progesterone is the ‘mother hormone,’ from which all others are made. When we’re young, we’re all swimming in it. It is incredibly calming, and when taken at bedtime, eliminates the insomnia that often comes with perimenopause – and good sleep alone will change your life.

The breast pain, irregular bleeding, painful breasts and murderous moods were all gone.

Hormones for low libido. Remember that part about how Mother Nature doesn’t want me pregnant after 35? Low libido is a big weapon in her arsenal. Hard to get pregnant if you can’t stand the thought of the male of the species within five feet of you. The good news, doc said, was that my libido fluctuates during my cycle – high right after my period, progressively lower as my period approaches. That means my low libido is related to my hormone fluctuations and not something else, and can be addressed – and also that it will return to normal (and perhaps even be increased) after my menopause is complete.

Dr. Mom prescribed bioidentical testosterone cream. Yep, ladies make testosterone too, and we need it. It’s not only responsible for our libido, but it has a hand in mood, metabolism and energy, and helps us maintain muscle mass and definition as we age. I applied the cream every day about two hours before bedtime, enough to keep my testosterone levels at the high end of normal for a female. I had to get it through a compounding pharmacy, and my insurance did not cover it. It helped; on a scale of one to ten, it took my libido from a zero to a five. Great progress, but not yet where I want it to be.

I recently stopped the testosterone cream to try a less messy and less expensive option called DHEA. It’s the precursor to testosterone, and I take one every morning, in combination with an herb called maca. It’s only been a couple weeks, but I feel it’s delivering a steadier boost, and I’m hopeful about continued progress.

Ovarian cysts. Our ovaries, I learned, are not useless to us once we’re done having children. These things are our lady-balls, and even after their reproductive function is over, they produce hormones that are central to our well-being. Removal should be a last resort – not, as in the case of my original OB-GYN, the very first suggestion. Women who have had their ovaries removed are at risk of a cascade of cardiovascular, cognitive, sexual and quality of life effects.

And making cysts is sort of what they do. If your cysts aren’t cancerous (and a biopsy can tell you this), the major risk is torsion – where the cyst makes the ovary become so heavy it falls over and twists on itself. I elected to live with this risk. It’s painful enough that I’ll know if it happens, and deal with it then.

Surgical options. Endometrial ablation is the destruction, with heat, of the lining of the uterus. It’s an office procedure or outpatient surgery. While it was originally meant for women with uncontrolled bleeding as an alternative to hysterectomy, many women who’ve had one say it helped with their PMS-like perimenopause symptoms as well.

Hysterectomy is still an option, especially for women with very heavy bleeding. Now most surgeons preserve the ovaries (and thus our health) and remove only the uterus unless there’s a definitive reason to take the ovaries too.

It’s all up to you. How we handle this time is very personal and personalized; it impacts us all differently, and there is no wrong way. It also changes over time, the closer we come to menopause. My cyclic progesterone recently stopped controlling my symptoms and I felt like I was back to square one. Dr. Mom changed my progesterone so I am taking it every day. It’s too early to tell if it works.

If it’s possible to be ‘tempted’ by surgery, then I am tempted by endometrial ablation. I know six women who have had it, many of them for symptoms just like mine; they were all turned off by the tinkering involved in working with bioidentical hormones. And they each say the ablation is the best thing to happen to them in years. But I’m freaked out by the thought that I’d be ‘destroying’ a part of myself, a part heavily symbolic of my femininity and wisdom. Which sounds totally woo-woo but there it is.

As always, these are my experiences only, and not medical advice. Let’s surface these issues, talk freely about them and share our knowledge, so when our daughters arrive at this point in their lives they will greet it with confidence, knowing how to care for themselves.

Maybe they’ll even brag about it.

Maybe they’ll live-tweet that shit.



2 thoughts on “What Every Woman Should Know About Perimenopause

  1. Hugely informative. I’m really enjoying and getting a lot out of your blog. Especially appreciate the information on hormones and nutrition you have shared. Thank you! You are right, it’s crazy we feel ashamed to talk about this stuff. I was really lucky to see Gloria Steinem speak the other week in Auckland, she is a fabulous lady. She was very keen to urge us to get together and talk about issues we face. In many ways the Internet is a new space to meet. I’m certainly enjoying finding and reading different women’s voices who I would never have had the opportunity to benefit from hearing before. Thanks again for your work on the blog xx


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