Menopause, the cessation of menstrual periods is defined as a natural transition, much like puberty. It is thus not considered a medical condition and not covered by insurance companies. And yet, it seems to have become more of a struggle for so many women.

With every woman I see, I usually encourage learning about our biology, the hormonal fluctuations of the menstrual cycle and also the sex steroid pathway- how we make hormones and how they can become imbalanced and ways to re-address this.
Evidence shows that understanding how our bodies work can also improve our health outcomes.

Befriending our hormones and our bodies can sometimes be more helpful than trying to control them in my opinion.

Our hormones are neuro-steroids also, they interact with our neuro-transmitters and influence everything- our mood, ability to learn and maintain a sharp brain.

Oestrogen peaks around ovulation, then declines slowly until the period starts, whereas progesterone is only made when/if we ovulate (mid cycle- usually day 14), peaks around 21 then drops before menstruation.

Oestrogen is responsible for our curves, stimulates the lining of the womb, creates our periods, lifts our mood and perhaps is responsible for our feminine softness; Estrogen also may have a ” hormetic “ effect- this means the effects can be different depending on the amount of it circulating in the blood stream- a bit of a “goldilocks effect”- both too low and also too high may create symptoms of a hormone imbalance.

Progesterone has a calming and anxiety relieving effect; it interacts with GABA (gamma amino-butyric acid- a calming neurotransmitter). If we don’t ovulate regularly, our levels may be lower and mood swing, anger and PMS may ensue.

Testosterone is made 50% in our ovaries and 50% in the adrenal glands (the two small glands sitting on top of our kidneys). Although our levels are 8-10 time less than men’s, we need it just as much. Not only for sexual function/libido but also for maintaining muscle mass and bone health, a good sense of self-esteem and assertiveness.

Cortisol- known as the stress hormone, which helps with our fight and flight response, is actually part of our sex hormones pathways and can influence everything from periods regularity to libido, mood and memory. Whilst stress can be a great adaptation response and essential for survival, we can at times, feel locked in a sense of hypervigilance if we don’t take time to rest and replenish between our cortisol and adrenaline surges. The research on the interaction between cortisol and estrogen and progesterone is expanding rapidly; estrogen can smooth over our stress response, allowing for a more measured response. Conversely, prolonged periods of too much cortisol flooding the system can interfere with the effectiveness of our sex hormones, and even good levels of estrogen may feel inadequate as the hormones cannot bind into the estrogen receptor (cortisol downregulates our sex hormone receptors).

What hormone changes happen in our 30’s and 40’s

POST PILL symptoms- In our thirties we may consider coming off the contraceptive pill, which can sometimes result in hormone imbalances (which are still under-researched and often misunderstood). As the combined contraceptive pill stops natural ovulation, when it is discontinued, it may take between a few weeks to a few months for hormone balance to restore. For some women, the period after stopping the pill can cause not just menstrual irregularities, but also acne, migraines, mood swings and even a worsening of digestive symptoms (bloating, IBS). Nutritional interventions aimed at balancing blood sugars, avoiding processed foods and minimising stress can often be helpful.
PCOS (polycystic ovarian syndrome) can sometimes worsen as we age. Insulin as the hormone that helps putting glucose inside the cells often increases, causing further weight gain, which can create a vicious circle impacting all hormones. Periods can be irregular and skin issues can sometimes worsen.

Heavy bleeding, prolonged periods

Heavy periods are common but they are not normal part of ageing and although there are many helpful lifestyle changes, they should be discussed with your GP or a hormone specialist.
Progesterone is the hormone to decline first as we age as ovulation can be less regular, even when periods are still regular (this was studied over time in a cohort of women having regular hormone tests over a ten year period https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5505186/
Conversely, estrogen levels can sometimes increase in some women in their 40’s as they transition into peri-menopause. The Study of Women’s Health Across the Nations (SWAN) found that almost 50% of women transition into peri-menopause with very high estrogen levels (highest than ever before) https://pubmed.ncbi.nlm.nih.gov/22659249/. This may cause heavy bleeding and even flooding.

PMS- premenstrual symptoms can include anything from painful periods and cramps, to bloating, fatigue, sugar cravings to mood swings, especially anger and irritability in the lead up to the period.

Why does PMS sometimes seems to get worse at this time of life?
PMS tends to get worse in our 40’s because during this time the hormone fluctuations are wider than ever before. Estrogen levels can fluctuate from the highest to the lowest levels in the space of months. Moreover, progesterone- with it’s calming and anxiety relieving effect consistently diminishes, so it can feel it is harder to relax and there is less resilience to stress. In addition, the stress we take on may peak as we juggle careers and families as well as looking after elderly parents. Having had worse PMS or postnatal depression can predict a worsening PMS as one transitions to peri-menopause.
For many women, aside from the physical symptoms above it can come with a frightening feeling of “not feeling myself”, almost “like becoming another person” in the lead up to periods. Addressing specific hormone imbalances with both lifestyle changes and hormone balance therapies can restore well-being.

What is PMDD? How can it be managed?

Premenstrual dysphoric disorder is a severe form of PMS that can severely affect quality of life.

It includes psychological symptoms (mood swings, anger, irritability, overwhelm that are cyclical and severe in the second half of the cycle and improve within 1-3 days of menstruation), behavioural symptoms – increased sensitivity to conflict and rejection as well as physical symptoms (bloating, breast tenderness, increased fatigue to name a few). Given it’s cyclical nature, it can only be diagnosed by tracking symptoms for at least two consecutive months. There are many ways to track but a great resource is https://iapmd.org/symptom-tracker. PMDD is not necessarily characterised by severe hormone fluctuations but rather by the impact that hormone fluctuations can have on the individual brain and the complex interplay between hormones and neurotransmitters (estrogen and serotonin and progesterone and allopregnanolone and GABA receptors). It is currently hypothesised that in patients with PMDD the interplay and binding between hormones and neurotransmitter receptors is affected.
Although suppressing ovarian function is the most common approach- through the use of combined contraceptive pills, most of the patients that come to our clinic have already tried this and could not tolerate them. Other modalities of suppressing ovarian function include GnRh analogues- hormones that suppress ovarian production or surgical removal of ovaries/womb.
Another approach is the use of SSRI’s found to be beneficial in some people and it is interesting that some patients with PMDD may benefit from low dose of SSRIs very quickly when used in the lutheal phase only rather than continuously.

We strive to offer each patient with PMDD a very individualised treatment, include a thorough history and the opportunity to be deeply listened to.

A functional medicine approach may include a very detailed look at the hormone pattern during a monthly cycle (how do estrogen and progesterone fluctuate during different timepoints in the menstrual cycle in the individual) and how this correlates with a mood diary done during the same cycle. Significant drops in estradiol during the lutheal phase may sometimes benefit from a very low dose of estrogen. Conversely, although progesterone is generally feared in PMDD because of it’s adverse effects being confused with progestins (their synthetic counterparts) it has sometimes been shown to have a bimodal effect (meaning that there may be a dose-dependent effect on the way progesterone interacts, through it’s metabolite allopregnanolone, with the GABA receptor). More research is needed. It is interesting that allopregnanolone (natural metabolite of progesterone) has now finally been licensed to be used for severe postnatal depression with incredibly successful effects.

As PMDD is a response of the brain to hormone fluctuations and cortisol can have an impact on hormone binding to receptors, this is also discussed.
Other supplements that have some evidence base for PMS include magnesium (glycinate), higher dose of vitamin B6 (50mg) and interestingly vitex agnus castus has some randomised control trial data as beneficial for PMS (but not PMDD as such). The association with childhood adverse events and PMDD is significant and our trauma treatment modalities are rapidly evolving. Working in a team to include a trauma specialised psychologist and a nutritionist as well as deepening resources for understanding the condition and self care and sup[port is often beneficial.