A Perimenopause Survivor’s Guide

The truth about hormone fluctuations and treatment options.



Illustration by Sarah Ferone

When it comes to menopause, there is some good news: It only lasts for a day. After 365 days menstruation free, the 366th is menopause, and then women are considered postmenopausal. The experience of all the months leading up to it are actually the effects of being perimenopausal. 

“As women finish their childbearing years, the ovaries slowly stop producing estrogen, progesterone and testosterone,” says Dr. Elizabeth Louka, an OB-GYN with Crozer-Keystone Family Care and Women’s Health in Broomall and Crozer-Keystone OB-GYN in Drexel Hill. “They gradually taper off and, in that transitional period, some women experience erratic fluctuations of hormones that create symptoms, some of which are severe.”

Symptoms can include insomnia, acne, weight gain, irregular periods, hot flashes and night sweats. While the average age for menopause is 51, women can begin feeling perimenopausal symptoms in their late 30s. By age 45, most are getting at least a taste of them. 

Because “perimenopause” is a little-used term, women don’t immediately understand what’s happening. Some of Dr. Lynn Feinman’s patients think they may be pregnant or re-experiencing puberty. “The reality is that the climate has changed,” says Feinman, a naturopathic doctor in Paoli. “You’re at a new level of the mountain. You need new boots and a new map.”

Unfortunately, there’s no forecast for perimenopause. “The timing and severity of its symptoms are different for every woman,” says Dr. Beverly Vaughn, an OB-GYN and medical director of Main Line Health’s Women’s Health Source program. “While there is a slight genetic component, it may not matter what your mother or sister went through.”

The unpredictability of perimenopause only adds frustration. Blood and saliva tests can give a snapshot of hormone levels, but they’re constantly in flux. “Studies have looked at estrogen levels, and it’s not a steady decline,” says Louka. “They can be elevated one day and decreased the next day. Progesterone and testosterone are not in unison with each other, either. I think that’s what makes the symptoms so expressed.”

Dr. Lisa Freedman, who practices holistic medicine in Villanova, explains that estrogen, progesterone and testosterone are not the only hormones that create perimenopausal symptoms. Cortisol, follicle-stimulating hormone (FSH), dehydroepiandrosterone (DHEA) and lutropin (LH) affect ovulation and women’s overall health. “Of course, it’s a complicated, delicate system,” Freedman says. “We’re women.”

Feinman believes that women who have their weight, blood pressure, cholesterol and heart rate under control may have an easier time dealing with perimenopause. “On the other hand, there are superwomen out there—especially on the Main Line—raising their family and/or working and taking care of everyone but themselves,” says Feinman. “They hit a wall and crash, so to speak, and crawl through my door.”

Feinman’s perimenopause treatment focuses on micronutrients. That includes everything from A to zinc, with special emphasis on B vitamins, omega-3, calcium, magnesium and potassium. Diet also plays a big role. Women usually eat too little fiber and too much dairy, Feinman says. After a thorough evaluation, she puts her patients on a plant-based diet that begins with a 30-day cleanse, followed by a customized program. “I take a holistic look at my patients and get their systems back in order,” she says. “The healthier a woman is, the less she’ll be impacted by perimenopause.” 

Freedman believes that natural bioidentical hormone therapy is one of the most effective treatments for symptoms. Available in oral capsules, patches, lozenges, creams and gels, bioidentical hormones are made at pharmacies in Devon and Exton, among other places. Freedman tweaks dosages based on patients’ responses. “Bioidenticals are controversial,” Freedman concedes. “But I’ve used them for 21 years with great success.”

Neither Louka nor Vaughn prescribes bioidentical hormones because they’re not FDA-approved. Vaughn prescribes low-dose birth-control pills to regulate periods. Both have suggested antidepressants to perimenopausal women. For more severe symptoms like hot flashes and night sweats, Vaughn and Louka recommend pharmaceutical hormone therapy, including Prempro and Activella. 

Hormone therapy proved controversial when a Women’s Health Initiative study abruptly stopped it in 2002 because participants were determined to be at elevated risk for heart disease and breast cancer. Since then, additional research has been conducted, and the WHI released its full findings in 2013. Louka and Vaughn say that the report clarified when hormone therapy should be used and for which patients. They’ve had considerable success with it. “You have to understand the circle of symptoms,” Vaughn says. “Hormones don’t treat moodiness, but they can help with the heat fluctuations. That helps with sleep and can reduce moodiness from sleep deprivation.”

Louka’s patients often feel so good on hormones that they don’t want to stop taking them. Like bioidenticals, pharmaceutical hormone therapy has side effects—but that shouldn’t stop women from seeking medical help for their perimenopausal symptoms. “There’s no reason to suffer in silence,” says Freedman. “If this happened to men, there’d already be a cure for it.”

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