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Perimenopause is the transition period before women reach menopause. Menopause is refers to the end of primary ovarian function and characterized by cessation of monthly blood loss, production of ova by the ovaries and fall in the circulating female hormones (estrogen and progesterone). It is a natural biological phenomenon occurring in every woman usually after 50 years of age. Menopause does not occur abruptly rather it is a gradual change and the transition phase is known as perimenopause.
There is no exact age when perimenopause occurs however usually the symptoms of impending menopause namely irregularity in periods, heavy or too scanty blood loss occur during the 40’s but in some women the above mentioned symptoms become evident as soon as one enter mid 30’s.
The fluctuating levels of circulating female hormones, mainly the estrogen are the most important underlying factor. Other than menstrual symptoms other presenting symptoms include hot flashes, sleep disturbances, drying of vagina etc. When there is no menstrual bleeding for at least one year, one is said to have reached menopause after end of perimenopause period.
Different sets of symptoms appear during perimenopause; some of the symptoms are well evident while some are quite subtle. Common presenting symptoms include
1. Irregular menstrual blood loss: with unpredictable ovulation in every cycle the pattern and gap between two consecutive menstrual blood loss changes. There could be heavy or scanty amount of blood loss, longer or shorter duration of blood loss, the gap between two consecutive menstrual bleeding, is either very short or long. In women in late phase of perimenopause the gap between two consecutive periods usually becomes 60 days or more.
2. Hot flashes, excessive perspiration especially in the night usually lead to sleep disturbances
3. Mood swings: this symptom usually occur due to sleep deprivation and drastic fluctuations in the level of circulating hormones. Common presentation is increased irritability, frustration, tearfulness etc
3. Vaginal dryness: usually occurs due to low level of estrogen, loss of elastic tissue and decreased secretion of lubricating fluids. Dryness of the vagina may lead to painful intercourse and frequent episodes of urinary infections.
4. Decreased fertility; unpredictable ovulation is the main reason behind it. Again this unpredictability also increases the chance of accidental pregnancy thus requiring contraceptives for 12 months after the last period.
5. Weakening of bones and increased chance of fracture following minimal or no trauma. Low level of estrogen is the most common underlying cause. Hip, wrist, vertebral column and neck of the femur are the most commonly affected bones
6. Abnormal cholesterol metabolism: poor estrogen level in the blood facilitates rise of bad cholesterol (LDL) and fall of good cholesterol (HDL)
Common complications in perimenopausal period include excessive heavy bleeding requiring change of pad every 2 to 3 hours, prolonged bleeding lasting for more than 7 days, breakthrough bleeding in between two episodes of menstrual blood loss, shortening of the gap between two episodes of blood loss (about 21 days)
Extreme fluctuation in the level of the two circulating female hormones, estrogen and progesterone are the main cause.
Risk factors
Although perimenopause and subsequent menopause is inevitable in every woman; there are certain risk factors which may lead to early onset of perimenopause and subsequent menopause. These are
1. smoking: usually in chronic smokers the onset of menopause advances by 2-3 years
2. family history of early menopause
3. having exposed to chemotherapy and or radiotherapy for underlying cancer
4. surgical removal of uterus (hysterectomy): although only removal of uterus (partial hysterectomy) may not lead to menopause however bleeding stops but hormone production by ovaries continue till the appropriate age of natural menopause attained. But in case of total hysterectomy ovaries and tubes are also removed along with uterus leading to menopause (stoppage of bleeding and ovarian functions.
Perimenopause and subsequent menopause cannot be avoided however symptoms can be managed successfully by
1. systemic hormone therapy which can be administered as patches, creams, gels etc
2. vaginal application of estrogen
3. administration of antidepressants
4. gabapentin etc

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