Anita McCallum, 48, was sitting in her car one day when she began to menstruate so heavily, it soaked through her clothes and into the upholstery of the car. It happened with no warning and no time to prepare. "I was hemorrhaging uncontrollably," she recalls. The incident left her severely shaken for several days afterward.

Anita is in the throes of perimenopause, a hormonal upheaval that signals impending menopause. Those unpredictable periods, as well as other physiological symptoms such as mood swings, night sweats and vaginal discomfort, could occur for years before the "change" finally arrives.

The age-related transition from fertility to infertility can begin as early as the mid-30s, but for most, signs of perimenopause become apparent in the early to mid-40s. Generally the symptoms continue for five to seven years before menstruation ceases altogether and menopause begins, usually around age 51.

Some women simply sail through this time of transition. Many don't. Like Anita, they grapple every month with a myriad of annoying and sometimes painful symptoms.

Perimenopause has become a recognized health entity just in time for the baby boomer bulge to move through the so-called prime of life - the fabulous 40s - and into life's second act. Ten years ago, a woman complaining of menopausal symptoms before reaching her 50s was more often than not dismissed as being too young for intervention.

Today, doctors listen carefully to women's perimenopausal complaints and prescribe appropriate relief. Meanwhile, perimenopause is attracting increasing attention from researchers, physicians, psychiatrists, counsellors and others.

Causes
While there is some debate about what exactly is happening to a woman's body during perimenopause, what is clear is that the ovaries are beginning to gear down their egg production. As they do, the delicate balance of the female hormones estrogen and progesterone is thrown off kilter.

Both hormones are produced by the ovaries and work together with intricate timing to orchestrate ovulation and to complete the menstrual cycle. "We used to think that estrogen levels gradually dwindled as the reproductive capability of the ovary waned," explains Dr. Suzanne Montemuro, a family doctor and the director of the North Shore Menopause Information Centre in Vancouver. "But we're beginning to think that perhaps there is a surging as well as a falling of hormones."

She compares perimenopause to adolescence, when the reproductive system is gearing up and teens experience erratic periods and raging hormones as the body adjusts to the reproductive cycle. "In perimenopause, the system is gearing down and the same thing seems to be happening," she says. "Overall, the hormone levels are going to fall but they seem to be doing so in a sporadic fashion."

Signs
The result of all this hormonal activity is wacky menstrual periods that can become more or less frequent and may be heavier or lighter than usual.

At the same time, premenstrual syndrome (PMS) with its mood swings, bloating and breast soreness, may take on a new intensity and may coexist with other signs of menopause, such as hot flashes, night sweats, sleep disturbances, memory changes, fatigue and headaches.

Many women also complain that perimenopause exacerbates other medical conditions they may have, such as arthritis or fibromyalgia. The reasons are unclear, but the stress of perimenopause and lack of sleep may impair coping skills and make all problems appear worse, say specialists.

An annoying twist to this scenario is the unpredictability of any or all of the perimenopausal symptoms. Constant change is the hallmark of perimenopause. Every month may be different from the last one.

Page 1 of 2 - on page 2: Lean about the treatments for perimenopause

Treatments
The good news is that there is a smorgasbord of treatment options for women experiencing difficulty during perimenopause. The bad news is that the option that works for one woman may not work for another, and a treatment that works one month might not work the next. "It's often a matter of trial and error to find what works," explains Montemuro.

That unpredictability makes perimenopause much more complicated than menopause itself, says Dr. Jeffrey Nisker, a reproductive endocrinologist and professor of obstetrics and gynecology at the University of Western Ontario in London. "Some months, the ovaries may function like a 25-year-old's," he says. "Other months, they don't function at all, as in menopause. And there are all kinds of shades of grey in between. It's a very complex medical issue to talk about."

When you do find something that works, it may not work all the way through perimenopause." Take, for example, hormone replacement therapy (HRT). A woman suffering from hot flashes, insomnia and other symptoms of menopause may choose HRT in order to boost her estrogen levels. "But every now and then, her ovaries will work, and she'll have too much hormone, which will cause irregular bleeding," explains Nisker.

Unlike 10 years ago, when it was rarely offered during perimenopause, HRT is now the treatment of choice of many doctors if the woman's symptoms are due to estrogen deficiency, says Dr. Janice Owen, a family doctor at Womens Health of London in Ontario.

Owen realizes that women worry about the use of HRT and breast cancer, but she says they shouldn't be concerned if they use HRT for a short period of time. According to the 1998 Canadian Consensus Conference on Menopause and Osteoporosis, there is no increased risk of breast cancer if hormone replacements are used for less than five years. "What works best by far with a lot of the ravages that come with menopause is replacing the estrogen levels," says Owen. "I would like women not to be fearful if they can truly benefit."

What's more, she adds, just because you took hormone replacements during perimenopause doesn't mean you can't use them again during menopause and beyond - as long as you're monitored carefully. While HRT may slightly increase the risk of breast cancer, it's a valuable tool after menopause in the prevention of heart disease, which is the leading cause of death among postmenopausal women, and osteoporosis.

Each woman must weigh the risks and benefits and decide what's best for herself. "It's a balancing act," says Owen. "You have to be knowledgeable."

Opting to use HRT may reduce hot flashes but may not do a thing for insomnia. Treatment in perimenopause is decided symptom by symptom. If enhanced PMS is the biggest problem, there are other choices, including lifestyle and diet changes, herbal remedies, and the birth control pill, which regulates hormone levels and the menstrual cycle.

If irregular periods or heavy bleeding are the problems, the birth control pill, which is a combination of estrogen and progesterone, may be an option. However, it doesn't work for everyone. If it doesn't work for you, another option might be to try progesterone alone. Production of progesterone drops when ovulation decreases during perimenopause, and without progesterone the uterine lining becomes thickened, which leads to heavy periods.

Natural alternatives can boost estrogen levels, too. These include soy, tofu and other foods, and some herbal products, such as black cohosh. Owen warns, however, that quality control with herbal products is still a problem. While there are no government regulations in place, consumers can look for labels that say the products are standardized, which means their contents meet at least some minimum criteria. She also warns women not to fall for slick marketing of such things as progesterone cream, which she says doesn't work because progesterone isn't absorbed through the skin.

At Children's & Women's Health Centre of British Columbia in Vancouver, Dr. Shaila Misri, a psychiatrist with training in obstetrics and gynecology, says three to eight per cent of women experience mood disorders in perimenopause severe enough to require treatment. They tend to be the same women who suffered from PMS before perimenopause, struggled with postpartum depression and have a history of depression in their families.

There is mounting evidence that antidepressants used only at the critical time of the month - the two weeks following ovulation - are effective. Misri is an investigator in a new multicentre trial that is testing the use of the antidepressant Paxil at particular times of the month. Already the study is showing promise; the mood swings actually disappear, says Misri. She advises women experiencing the psychological and emotional fallout of hormone imbalance to be proactive in seeking appropriate treatments for their ailments.

Whether you choose a prescription or herbal remedy, or opt for no intervention at all, the most effective approach to perimenopause is education, say specialists. Understanding what's causing the signs and symptoms is, in most cases, treatment itself, says Nisker.

Despite the physical and emotional havoc perimenopause can cause, many women see the transition as a period of awakening, a time to reflect on life and to make positive changes. "It's often the first time in her life that a woman answers to herself," says Stephanie Smith, a counsellor in London, Ont., who runs menopause information and support groups. "You come to a new stage of life and you have to get there to know what you want."

For More Information About Managing Your Menopause…
If you are noticing the first signs of perimenopause, such as the odd hot flash or night sweat, it might be a good time to bone up on your nutritional needs. To help you, Leslie Beck, a registered dietitian, has written Nutrition Guide to Menopause (Viking Canada, 2003). Beck offers advice on easing symptoms of perimenopause and her expert opinion on remedies ranging from soy foods to supplements.

In addition the book gives advice on how to manage weight problems you may experience as you age and offers suggestions on how you can lower your risk of developing breast cancer, heart disease and osteoporosis - all potential threats to women as they age.

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