We need to talk about what happens to women in the stage before 'true' menopause

By Nicola Whitfield
08 July 2016

Everyone knows about menopause – but there’s a period before it finally arrives that could be even worse.

IF YOU’RE a woman it’s as inevitable as death. Menopause – the phase past generations used to refer to as “the change”.

The time when your periods stop, your hormones go haywire and hot flushes sear through your body like a blowtorch on steroids.

This is all pretty well-known and most of us brace ourselves for the Big M. But there’s a stage before “true” menopause that many women aren’t aware of – and it can wreak havoc physically, emotionally and psychologically, and often be misdiagnosed

as depression.

It’s perimenopause, and in the words of Dr Marion Gluck, a UK-based specialist in women’s hormonal health, it’s “the single

most difficult time in a woman’s life. It’s arguably worse than menopause because your hormone levels can fluctuate wildly.”

For years research has revolved around menopause and postmenopause, but the peri part has largely been ignored. Yet

globally things are changing: experts are realising the difficulty many women are going through and are encouraging them to

seek help if they feel they can’t cope.

Lisle Jacobs, a 42-year-old account analyst of Athlone, Cape Town, says she doesn’t hesitate to get help “when I feel I need it”.

She’s already experiencing changes. Her periods, which she struggled with in her twenties and thirties, have become much lighter, but it’s the mood swings that are troubling her.

Her husband and two teenage children are learning to give her a wide berth when she has what she calls “my rages”. She says

she can’t control them. “It’s as if I can feel them boiling inside me.”

She also complains about forgetfulness, another symptom of perimenopause. “It’s terrible,” she says. “I work in a very competitive environment where you have to be on top of your game. It makes me mad when I can’t remember things.”

Lisle Jacobs, who is in her early 40s, is monitoring herself carefully after experiencing symptoms of perimenopause. PHOTO: Noncedo Mathibela Lisle Jacobs, who is in her early 40s, is monitoring herself carefully after experiencing symptoms of perimenopause. PHOTO: Noncedo Mathibela

Her weight is something else she’s becoming aware of. “I have to work to keep it stable now,” she says. “I go to gym four times a week and walk with my husband in the evenings. I also try to avoid carbs and make sure I take vitamins.”

Weight gain in peri- and menopausal women is what Dr Mike Davey, president of the South African Menopause Society

(Sams), refers to as “pears turning into apples”.

“The loss of oestrogen at this time results in insulin resistance that can cause a redistribution of fatty tissue to the central

part of the body,” he says. “There’s also an age-related slowing of the metabolism that results in weight gain in middle age.”

Lisle has no intention of soldiering on unaided if things get worse. “I’ll research hormone replacement therapy (HRT) and

see my gynae about it when the time comes.”

Tracey Short sought medical help when her symptoms made her “tricky”. PHOTO: Noncedo Mathibela Tracey Short sought medical help when her symptoms made her “tricky”. PHOTO: Noncedo Mathibela

Tracey Short (56) virtually sailed through her forties. In fact, she says, she was 53 before she started noticing any changes at all. Her periods became shorter and heavier as she approached 50 but she wasn’t aware of other changes.

“I had two periods after my 53rd birthday and haven’t had another one since. My menopause coincided with a traumatic lifechanging event – I had my first hot flush the very next day.”

Depression was another manifestation of her trauma and she decided to get help after her husband suggested it. “He rather diplomatically told me I was being ‘tricky’,” says Tracey, a Cape Town sales rep and the mother of two daughters. “I went to see a doctor and told her I was feeling moody and down.”

Tracey was given HRT and hasn’t looked back. She exercises six days a week, has embraced a high-fat, low-carb diet and takes vitamins and supplements. “My friend lent me a book that listed the so-called seven dwarves of menopause: Itchy, Bitchy, Sweaty, Sleepy, Bloated, Forgetful and Psycho. Who wants to be any of those?” menopause So exactly what is perimenopause?

It means “around menopause” and refers to the period during which a woman’s body makes its natural transition towards permanent infertility – or menopause.

Oestrogen and progesterone levels start to drop and the body produces fewer eggs. It usually starts around the age of 40 but

can begin as early as 35 and last from two to nine years, or be very short.

“With perimenopause, periods become irregular and may be shorter or heavier,” says Dr Trudy Smith, a Johannesburg-based

gynaecologist and a member of Sams.

“Hormone levels fluctuate and some symptoms – such as hot flushes, sleep disturbances, dry vagina, weight gain or headaches – could occur. “Menopause is when you no longer menstruate. Classically, we say someone is postmenopausal when they haven’t had a period for at least six months.” Why is perimenopause often misdiagnosed as depression? 

Dr Smith says it’s because depression is one of the symptoms. “Hormones are up and down and all over the place.”

You’re moody, tired, irritable, having trouble sleeping and generally feel rotten. Many women in their late thirties and early forties are confused about what’s going on and complain of worsening PMS.

“But in fact it’s probably the start of a whole new phase of life,” says Dr Marilyn Glenville, an expert in women’s nutritional health. And for many women, coming to terms with the fact that their reproductive years are drawing to a close can add to the depression. Is it okay to take hormone therapy if you’re still having periods? 

Yes. According to a report in the Daily Mail, the International Menopause Society now recommends earlier use of HRT in low doses to reduce hormone fluctuations and keep oestrogen levels boosted for longer. More and more doctors are advocating stepping in and prescribing medication before severe symptoms develop. During World Menopause Day, held in October, experts called for perimenopause to be regarded as “a time of great medical opportunity”, not the uncomfortable and slightly embarrassing stage it’s often been seen as in the past. There’s growing belief internationally that taking hormone therapy earlier not only controls distressing symptoms of  perimenopause but also provides protection against osteoporosis and heart disease. But doesn’t HRT increase the risk of breast cancer?

Dr Alice Shaw, a Knysna-based gynaecologist, tackles this issue on her website.

“A major study conducted by the US Women’s Health Initiative published in 2002 showed that patients taking oestrogen and progesterone had a slightly increased risk of breast cancer,” she says.

“Breast cancer is slow-growing and remains undetected for quite a few years. We actually think that oestrogen and  progesterone do not cause cancer but promote the growth of an existing cancer.”

In the study women who were taking hormones and developed breast cancer had a less aggressive form of the disease. “There might be a small increase in risk in patients taking combination therapy [oestrogen and progesterone], but to put it into perspective: a woman who drinks two alcoholic drinks every evening or is obese has the same increased risk,” Dr Shaw writes. What should you do if you’re in perimenopause?

Have regular gynaecological check-ups and make modifications to your lifestyle, Dr Smith advises. “Get enough exercise, maintain an ideal weight, stop smoking, cut down on alcohol and eat healthily.”

And if you feel you can’t cope, speak to your doctor about your treatment options. “We sometimes use the combined oral contraceptive in the perimenopausal period because women can still fall pregnant at this time, so it gives women contraception and contains progesterone,” she explains.

“We can also use a special loop called the Mirena, which contains progesterone. This is inserted into the uterus and decreases


For a dry vagina, local oestrogen that lubricates and moisturises the area is prescribed, she adds. “This treatment is available in the form of vaginal oestrogen tablets that are effective and simple to use,” advises Dr Smith.

Read more:

A meal plan for menopause

Tips to ease menopause symptoms

‘It isn’t all in my head’: Healthy food makes me ill

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