# Perimenopause Lost—Reframing the end of menstruation Prior, J.C. (2006) ’Perimenopause lost—reframing the end of menstruation’. Journal of Reproductive and Infant Psychology, 24, 4, 323-335. Available at: [http://www.tandfonline.com/doi/pdf/10.1080/02646830600974071](http://www.tandfonline.com/doi/pdf/10.1080/02646830600974071) >[!Abstract] > Ordinary women and official statements confuse and conflate perimenopause—the long, complex, life phase of higher and chaotic estrogen levels—with the low and stable estrogen levels of menopause. This paints both perimenopause and menopause with an inaccurate ‘estrogen deficiency’ brush. Menopause is the hormonal, and (except for hot flushes) the experiential opposite of perimenopause. This feminist analysis is from my perspective as physician-scientist who experienced a perimenopause that was scientifically enlightening, but personally agonizing. Denial of perimenopausal and menopausal differences causes perimenopause to be ‘lost’ in several ways: (1) we may assume that perimenopause is chronic rather than ending in a largely asymptomatic menopause; (2) societal taboos isolate us, depriving us of solidarity with perimenopause ‘survivors’; (3) we are told we have dropping estrogen levels when our experiences, like pregnancy dreams, tell us the opposite; (4) gynaecology treats heavy flow with estrogen despite higher perimenopausal estrogen levels; (5) feminists ignore hormonal changes and attribute perimenopausal symptoms to (real) stresses of inferior social status and ageing; and (6) many of us thus become menopausal without the unique, self-actualization experience that perimenopause has the potential to provide. Thus perimenopause—a valuable transition into knowing and standing up for ourselves—becomes lost. %% ![[life cycle of ovarian hormones.png]] ### [[women have higher oestrogen levels during perimenopause]] > "I was able to find eight studies and perform a meta-analysis in four of estrogen levels in the follicular phase in 292 premenopausal versus 415 perimenopausal women and from the premenstrual portion of the cycle in 250 premenopausal versus 69 perimenopausal women. The data analysed within-centre by chi square testing showed significantly higher estrogen levels in perimenopausal women during both the follicular and premenstrual phases, respectively." ^it53l ![[oestrogen premenopausal & perimenopausal.png]] ## Notes > Why this concept of ‘estrogen deficiency’? It originated early in the 20th century following the first chemical isolation of estrogen. This new hormone immediately became a gynaecological therapy to treat women (’s inferiority) (Oudshoorn, 1994). > The construction of perimenopause as a time of dropping estrogen levels comes directly from the view that menopause is characterized by ‘stigmata of hormone deprivation’ (Byyny & Speroff, 1990). That is not to deny that estrogen levels are low in menopause. Something that is a normal part of the life cycle cannot at the same time cause major disease and debility. > The normal life cycles for estrogen and progesterone levels are shown in Figure 1. The low estrogen levels of childhood are mirrored by similar levels in menopause. Both the adolescent and perimenopausal transitions show higher and more variable estrogen levels. Progesterone is produced in high levels only during the luteal phase, the last third of the menstrual cycle following release of an egg (ovulation). The luteal phase has an optimum length of 10–14 days; however, luteal phases are short in puberty and perimenopause (Prior, 2002b; Vollman, 1977) (Figure 1). ## six ways in which the current gynaecological construction of ovarian ageing deprives us of the power of perimenopause ### Perimenopause as a chronic illness > Women lose the potential power of perimenopause, given that perimenopause and menopause are implied to be the same, because they feel their current, undesirable experiences (symptoms) will go on forever. This results in women seeking and finding (disease) diagnoses to explain and legitimize the suffering such as ‘fibromyalgia’, ‘chronic fatigue syndrome’ and ‘PMS’. All may be ways of explaining, in a medically sanctioned manner, the low energy and mood swings that some women experience (Kaufert et al., 1987). Consequently, a perimenopausal woman may start viewing herself as chronically ill. She also commonly ends up missing work with heavy periods (Cote et al., 2002), and may lose her occupation and/or have to go on long-term disability. Women currently, from popular literature and their physicians’ advice, cannot know that perimenopause ends in a kinder and calmer phase of life appropriately called menopause. Thus competent, valuable women become dependent on society or others, instead of contributing their creativity and energy. ### Perimenopausal isolation > Lack of accurate, available information isolates women from each other and often causes women to seek medical help, or pay large sums of money for preparations that may/may not be helpful. ### Perimenopause as dropping/deficient estrogen levels > I experienced high estrogen levels in perimenopause—I knew that because of many more days than usual of stretchy mucus, breasts that were swollen and tender, not just before flow but for most of the month, and because of fluid retention and a tendency to feel blue. These experiences occurred occasionally at my midcycle estrogen peak or premenstrually during my 34 premenopausal years—I had enthusiastically monitored my menstrual cycle experi> ences and basal temperature for at least 10 years by the time I began perimenopause. > So, when experts said perimenopause was about dropping or deficient estrogen levels, I secretly scoffed. And then I became angry. I further felt a keen need to scientifically confirm what I was experiencing. ### Perimenopausal heavy flow—erroneous concepts and inappropriate therapies > Perimenopausal women with heavy menstrual bleeding, because they may have co-existent fibroids, ‘hear’ (understand) that these cause the excess flow. Fibroids, however, arise from the uterine muscle wall and rarely impinge on the lining that is bleeding. Also, a case-control study of perimenopausal women with heavy bleeding clearly showed higher estrogen levels compared with premenopausal controls (Moen et al., 2004). Furthermore, endometrial biopsies documented hyperplasia, an abnormal result that develops with low progesterone and higher estrogen levels, as commonly occurs in perimenopause (Moen et al., 2004). The heavy bleeding in perimenopause often requires therapy. However, effective non-surgical therapies are available (Baldaszti et al., 2003; Fraser, 1990; Irvine et al., 1998) including non-steroidal anti- inflammatory drugs, such as ibuprofen,2 that decrease flow by 25–45% (Fraser et al., 1981). ### Perimenopause as social and cultural loss > Premenstrual symptoms, although poorly understood, are worse when estrogen levels are higher and progesterone levels are lower, in a within-woman analysis (Wang et al., 1996). Evidence suggests that premenopausal premenstrual symptoms are decreased by exercise of increasing intensity (Prior et al., 1987) but become resistant to the physiological feedback of exercise in perimenopause (Prior, 2002a). Several prospective studies have shown that midlife women with increased premenstrual symptoms were more likely to have hot flushes later in perimenopause (Freeman et al., 2004; Guthrie et al., 1996; Morse et al., 1989). > To understand these relationships, one must realize that hot flushes occur because the hypothalamus has been exposed to higher levels of estrogen (hence premenstrual symptoms). The brain then reacts when estrogen levels decrease at all, even from extremely high to high (Gangar et al., 1993). Such swings are common during perimenopausal hormonal chaos. Therefore, women with premenstrual symptoms and the highest estrogen levels early in perimenopause were more likely to experience troublesome night sweats/hot flushes later. It is also clear that stress increases hot flushes (Gold et al., 2000; Swartzman et al., 1990). Thus, stress responses, premenstrual symptoms, and hot flushes in perimenopause cannot be understood without integration of biological and cultural variables. ### Perimenopause without self-actualization > "It would be a tragedy to live through perimenopause thinking that you had a chronic disease from which you would never recover, and to never learn that many others had survived similar symptoms in perimenopause. It would also be ultimately sad to feel further devalued in perimenopause because your experiences didn’t fit with the dropping estrogen levels you were told you had, or to have undergone hysterectomy when the bleeding could have been treated medically. There would also be major loss if a woman were to blame herself for her inability to cope with the estrogen-related amplification of life’s midlife stresses. The biggest loss of all would be to avoid the self- learning intrinsic to perimenopause—that is the final of the six losses related to perimenopause." > "In summary, this paper has reframed perimenopause and described six reasons why perimenopause may be ‘lost’. It is an important loss to have become menopausal without experiencing the perimenopause ‘graduation’ that implies new and essential self-knowledge. Each of these six reasons can have tragic consequences for a woman’s well-being. These reasons include not knowing that perimenopause is self-limited and we all survive, that it can be a time of solidarity with the millions of women present and past, and that our symptoms are related to higher rather than dropping estrogen levels"