In early perimenopause, when you’re still ovulating, your cycles may shorten, perhaps going from twenty-eight or thirty days down to twenty-one or twenty-four days. This is your body’s way of giving you more opportunities to become pregnant one last time before the shop closes down. The first half of your cycle, the follicular phase, shrinks from fourteen days down to ten. This is when you feel halfway decent and may even be attracted to your partner, thanks to estrogen and testosterone levels being relatively high. Then you ovulate, the egg dies, and it’s all downhill from there in terms of mood and libido.
Around the early forties, the quality of the released egg starts to fall precipitously, as does the leftover part that makes progesterone, the corpus luteum. Lower progesterone levels become the norm. Progesterone is what stabilizes the uterine lining, so expect heavier, longer periods with more cramping. Weight gain, water retention, headaches, breast tenderness, cysts, moodiness, and disrupted sleep cycles all characterize this high estrogen / low progesterone state. The closer you get toward menopause, when your periods stop, the more likely you are to have longer cycles where no egg is released at all, called anovulatory cycles. Then you’re stuck in the follicular phase, where there’s a buildup of unopposed estrogen. Your boobs hurt, you feel bloated, and, man, are you moody. This is PMS for the big girls.
Both estrogen and progesterone levels decline with age, but progesterone goes first, and the slope is steeper. A menopausal woman has 5 percent of the progesterone she had in her twenties, but perhaps still 40 percent of her estrogen thanks to her fat cells, which continue to pump out that hormone throughout her life. This means estrogen dominance is a bigger problem if you’re overweight. As usual, there’s a vicious cycle. Estrogen promotes fat storage and weight gain, and the fat cells make more estrogen. Add to this the xenoestrogens, external sources of estrogen coming from meats, plastics, pesticides, and soaps, which are stored in fat cells, and you have a recipe for disaster. Unopposed estrogen is not just uncomfortable, it’s dangerous, putting you at risk for uterine, ovarian, breast, and colon cancer.
In the second stage of the perimenopause transition, your ovaries finally poop out and estrogen levels take a nosedive. Estrogen dominance is gone, and you have a new set of symptoms due to low estrogen, not low progesterone, but still topping the list are moodiness and irritability, even “rages.” Lower estrogen levels mean memory loss and decreased concentration, bone loss (osteoporosis), and a lot more hot flashes and night sweats. Your appetite for food goes up. For sex, it goes down. The urge to mother or nurture, reliant on estrogen all those years, starts to give way to thoughts of Why do I have to do everything around here? When is it my turn? More on this later. First, let’s talk about my belly.
The Menopot: Abdominal Obesity in Perimenopause
I can’t get rid of my menopot and it’s driving me crazy. I always had wide hips and thighs, but my belly used to be relatively flat. No more. After two kids and waning hormones, I am now the not-so-proud owner of a “muffin top.” I can grab a handful of flab and cop a Scarface accent. “Say hello to my little friend.” In the fertile years, estrogen dictates that fat gets deposited at the breasts and hips, forming the hippy gynoid shape. The waist stays small, creating that low waist-to-hip ratio every (heterosexual) man goes gaga for. In the nonfertile forties, it’s all about belly and back fat.
Women between thirty-five and forty-four gain weight faster than at any other time in their lives. By their late forties, a majority of women are overweight or obese. The biggest reason is that by menopause, our caloric requirements are about 65 percent of what they were when we were in our twenties. And it’s not a gradual decline but a fairly abrupt shift. You’ll need to learn how to eat all over again. Your risk for diabetes rises as your hot flashes worsen, and carbs, more than ever before, can make you fat. So can stress. As estrogen levels fall, the pelvic paunch becomes more sensitive to cortisol-stimulated fat accumulation. Menopausal women have an increase in abdominal fat, increasing their risk for cardiac disease.
Where’s progesterone when you need it? Progesterone can help with weight loss and enhances the action of thyroid hormones, which help to keep your metabolism revving along. In pregnancy, women commonly feel overheated because progesterone signals the hypothalamus to run hot. Perimenopause, with its low progesterone levels, does the opposite. The metabolism downshifts and slows way down, so you’re cold when you’re not burning up.
If you don’t ovulate, you’re going to feel even fatter, because unopposed estrogen means more water retention and bloating. Worse still, high estrogen levels signal the liver to make a protein called thyroid-binding globulin, drastically lowering the available free thyroid hormone. You need this to keep your metabolism humming. So if you’re feeling sluggish, your thoughts are slowed down, you feel cold all the time, your skin is dry, and your weight is up, make sure your doctor measures your free thyroid hormone levels and not just your TSH, which is the typical test to order when looking for thyroid troubles. An underactive thyroid is seen fifteen times more often in women than in men. It is quite common for my female patients to have undiagnosed thyroid problems at any age, but especially at perimenopause. Fifty-year-old women produce half the thyroid hormones that twenty-year-olds produce. Many of the complaints of depression are also seen in hypothyroidism: low mood, low energy, low libido, and problems concentrating. This is another reason not to jump on the SSRI bandwagon right off the bat. Have your thyroid checked first.
To compound the effects of a sluggish metabolism, welcome your new companion, a ravenous appetite. Rats that have their ovaries removed, mimicking menopause, have an increased desire to eat and drink, which is normalized when they are given estrogen supplements. You know how you get hungry during PMS? It’s a bit like that, only it’s not just for a day or two every month.
Reproductive Depression Revisited
Somewhere along the way in my psychiatric training I heard a term for perimenopause that I just loved, “climacteric psychosis.” Climacteric is an older term for the menopausal period, and psychosis, well . . . in effect, perimenopause can make you crazy. This is a prime time for psychiatric complaints. I will often get a patient in her late forties or early fifties coming into my office. She’s never seen a psychiatrist before, but she’s at her wits’ end due to insomnia, panicky sweats, crying at the drop of a hat, or just not giving a shit anymore. Often, one of the first symptoms of perimenopause, before the hot flashes, before the disrupted sleep, is depression. Your risk of depression nearly triples in the perimenopausal transition. The prevalence of depression is highest in women aged forty to forty-nine and lowest in women older than sixty; hence, the storm before the calm.
When you remove a female rat’s ovaries, depleting her of estrogen, she shows increased anxious and depressive behaviors, which can be reversed by administering estrogen.
