Let' talk about Perimenopause


[00:00:00] All right, tribe. So where's my GYN team at? I don't mean to exclude the pregnant women, but when I talk so much about pregnancy, I really do not at all ever want to alienate my GYN people because ladies, all, ladies pregnant or not listen up whether you are 12 or 70 or 80. , you are a woman, which means you have female anatomy. 

Whether or not you are utilizing that female anatomy for pregnancy or not is immaterial to me because we spend more of our life in our body, not pregnant, than pregnant, whether we choose not to be pregnant, whether we can't be pregnant, whether we're just in an age where we are not yet pregnant or done being. 

So today we'll go and talk about perimenopause again. Yeah. There's so much to talk about with perimenopause that I literally could do like a 10 part series and actually maybe I will. Um, today I wanted to talk about the bleeding associated with perimenopause. Okay. Not necessarily all the symptoms and all the different permutations of perimenopause, [00:01:00] but specifically the bleeding. 

This requires a quick definition. What is menopause? It is a. With no period and my parent parenthesis to that is a year with no period in someone who should otherwise be at the right age. Meaning if it's a year with no period, cuz you're on the birth control pill or you're using the progesterone i u d, or you're pregnant or you have polycystic ovary syndrome. 

Or other issues, then it's not considered menopause. So menopause is a year with no period. Assuming the patient is in that right age group, which is like late forties, early fifties, and assuming no other symptoms. If a 48 year old comes to me and says, I haven't had my period for a year, don't you think I'm in menopause? 

Oh, and by the way my boobs are leaking milk, then I would be remiss to not look for other causes. Too much prolactin hormone, just to be clear about that. Okay, so there are other things that can cause a year with no period outside of menopause, even in a 49, 50, 51 year old. But on average, the average woman will go through menopause at 51, [00:02:00] and it is one year with no period. 

Why is that important? Because if you are 50 and you've had 10 months without a period, and you say to me, oh, I'm in menopause, right? My response will always be, You might be in menopause. You're probably in menopause, but until you've gotten to a year, we cannot define you as menopause. So it's like you're temporarily perimenopausal until you've passed that year and then you're considered in menopause. 

So what's perimenopause? It's this ill-defined nebulous time that surrounds menopause. Peri means around or surrounding. Surrounding menopause in our world means up to 10 years before. You can be perimenopausal, which just implies that rather than having no hormone left, no estrogen hormone left, which is what happens in menopause. 

Your estrogen goes down and your follicle stimulating hormone, your FSH goes up in perimenopause, you have estrogen, you have fsh, but they are fluctuating not in that nice sine wave that goes up and down in our normal cycle. Right in our normal [00:03:00] cycle, our brain sends signals to our ovaries to thicken the lining of our uter. 

And it's like a nice predictable sine wave perimenopause. The hallmark of it is total irregularity, right? Unpredictability, no irregularity. Anything could happen with regard to symptoms quickly, which I would say common symptoms would be, ah, I'm a little sweatier. I'm a little flashier. I'm a little more pissed off and moody before my period. 

My boobs hurt a little bit more, I think. I feel my ovulation more. These are all potential signs of perimenopause. Maybe a little bit more weight gain. All subtle. Subtle enough that when patients say those things to me, My Spidey Sands goes, huh? 42 year old telling me some stuff. I'm already thinking she's perimenopausal, but I know I've done this for 28 years. 

It's not my first rodeo. I've gotta dip my toe gently when I say so. You know, I'm gonna say that P word that you guys hate, cuz somehow women think that means that I'm saying they're old and I'm not. Cuz by the way, I'm 51, so almost 51. So I'm not saying you're old. I am merely saying that once we get into our forties, our hormones will fluctuate. 

So [00:04:00] they will, instead of being the nice sine wave, Your hormones will fluctuate day to day, week to week, month to month. They could go back to being normal for a while and then go back to being irregular. Can we check for perimenopause? No, there is no blood test to check for it. I could check your hormones today and they will be different than tomorrow, than next week, than next month. 

And even if I could map out this entire month through doing saliva testing in all kinds of expensive things, it's not gonna tell me what's gonna happen next month because again, the hallmark is. up to 10 years before menopause. So that means by definition starting at like 39, 40, 41, and irregularity up, down all over the place with your estrogen. 

So this is where we're gonna circle back to the bleeding. What can happen with bleeding? You might have guessed it already. When I say anything can happen, that means literally anything. You could be bleeding heavier or lighter or longer or shorter. You could be bleeding 10 days in a row. You could be bleeding three weeks in a row. 

You could stop bleeding for six months and then all of a sudden pour out blood. So that's the annoying part is anything can happen when it comes to your period. When [00:05:00] it comes to perimenopause, because some of those cycles you actually will not ovulate. So you'll have a very thick lining that didn't get the signals to ovulate, and then that will be a heavier period. 

Sometimes your hormone levels will be low enough that you won't ovulate and you won't have any period and no thick lining. So again, it can be all over the map. So if you say to your doctor, my period has been weird, your doctor should address it. Now what I describe to patients is anything that I deem to. 

Less meaning, less heavy, fewer days, less frequent. No big deal as long as we assume you're otherwise feeling okay. No other symptoms of anything else. For example, considering thyroid dysfunction, which you usually get checked for, if you go to your primary care doctor once a year, they'll check your thyroid anyway. 

So again, if it's anything less bleeding, less frequent, less heavy, fewer. I am not worried. Let's assume that you've had your thyroid checked. If you haven't, it's an easy blood test that your gynecologist or your regular primary care can do and [00:06:00] then be on your way. No need to do anything else. If you are having anything more, it's heavier. 

It's longer than usual. I'm soaking through more pads. I'm bleeding in between my period, so anything more reverts to. Age old sentence that I say several times a day, which is, it's likely nothing, but let's check it out. And what I mean by that is it's likely just perimenopause. You're 42, you're bleeding more heavily, you missed your period for two months, and all of a sudden you got it for 12 days in a row. 

Am I alarmed? No, but I'm not alarmed because of this, because I can assume that it's probably perimenopause, but I'm not gonna just assume it. I'm going to disprove the things that I don't want to happen, right? Meaning I can't prove that your irregular bleeding is perimenopause. You could say to me as you do every day in my office, but don't you just think it's perimenopause? 

And my response is, oh, yeah, I do. I think it's probably perimenopause, but because I cannot prove that it's perimenopause, I am obliged for [00:07:00] your safety to disprove the things that I can disprove. Most importantly, anything concerning and malignant that could be in the lining of your. Or your cervix if you're having heavy bleeding. 

But let's also go on the assumption that you've had your pap smear. So again, you've come to me, you're there for your annual exam, which means you've had your pap smear, you've seen your internist, which means your thyroid has been checked, and you say, you know, my period's just been really super heavy. 

I've been bleeding more frequently, or I bled for two straight weeks. Any of those topics I'm gonna say to you, okay, likely. Probably just perimenopause. I can't prove perimenopause, but I can disprove something that could be growing in your uterine lining. How do we do that? We send you for an ultrasound. 

The ideal time for the ultrasound would be right after your period is finished, because that lining has now shed itself out. Your lining can be measured and should be pretty thin, and if it is, great, no big deal. Bleed away if you want. We'll talk about treatment in a second. Now, let's say your lining is. 

Am [00:08:00] I alarmed then? No, because it might be just the time of your cycle. It might be extra tissue that is totally benign. It might be extra tissue that is called hyperplasia, which is not completely benign cuz it can transform, but we can treat it. It might be a polyp, which is a little growth in the lining of your uterus. 

Or it might be a fibroid, which is a growth of the muscle of the. Polyps and fibroids, largely benign. Fibroids are always benign. Polyps are almost always benign, so the purpose of the ultrasound is to look at the uterus, look at the ovaries, but most importantly, in the, in the realm of heavier, regular bleeding, to see the lining of the uterus, to make sure that the lining is thin. 

If it's thin, goodbye, you're fine. If it's thick, Not alarming, but then your doctor will talk to you about one of two things, either doing an endometrial biopsy, which is a fancy way of saying, sampling the lining of the uterus. We have a skinny little straw that goes up into the cervix during your office visit. 

It's fairly quick. It's pretty crampy. I've had it myself, but it's a [00:09:00] great way for your doctor to say, oh, your lining is sick. But look, I checked. There's nothing in there that we're concerned about. The second way she could check would be intraoperatively. under anesthesia, she can look inside your uterine lining, and she might do that if she looks. 

And on the ultrasound, it really looks like there is a growth in there like a polyp. And the reason for that is the biopsy might not always sample the polyp, so that's something you'll discuss with her. And I should actually comment that a third way would be a fancier ultrasound where we push some saline into the lining. 

To distend the lining of the uterus to see if something's dangling in there. Again, that could be a polyp in my practice. Typically what I just do is the endometrial biopsy because it's very simple, it's very straightforward. It's very easy for patients to get in. They take ibuprofen ahead of time. As I joke, they'll hate me for 10 seconds, but then we'll be done and at least we've kind of put that to bed of proving there's nothing in there with fairly good, accurate. 

Nothing, no biopsy is a hundred percent, but this is very close to it. And then we get to embark on the discussion of, okay, I have now proven that there's nothing wrong in there. [00:10:00] You tell me, do you want me to treat it? Because as I described to patients, if you come to me and say, I'm having heavy irregular bleeding, my first and foremost goal is to prove that there's nothing in there. 

Because if there is. The simple answer is, God forbid, it's something not good in there. Like, God forbid it is endometrial cancer, we can fix it. So it falls under those categories of what you guys know. I love finding and fixing. My secondary goal is, okay, I've already proven there's nothing in there. Now what do we do about it? 

Do you want me to help fix your bleeding? Because some patients, believe it or not, say, just prove it's nothing. I'm gonna bleed away. I don't get that. But they do, and that happens a lot. So those patients who want to be treated and figure out how to fix the. We run the gamut. We could be as kind of holistic and Eastern as sending you to an acupuncturist who really can hormonally shift things in a way that will help. 

It tends to work less if there's a structural reason for bleeding, like fibroids or a polyp. But if it's a hormonal reason, meaning your perimenopausal bleeding, then the acupuncture really can help sometimes. Doing different herbs that [00:11:00] I don't understand, but certainly the integrative doctors and the traditional Chinese medical doctors and the naturopaths can comment on, sometimes it's a matter of nutrition because your body is responding in a way and having you bleed heavier or more irregularly based on nutrition. 

So those are impactful, but very, Indirect, longer, slower processes that you really have to be, um, willing to be a part of and willing to make changes for it, which many of us can't and are not. The opposite spectrum is, okay, well, if there's something structural, like a polyp, we will go in and remove it. Or if it's a fibroid, we'll go and remove the fibroid or even remove the uterus. 

And then the in between is managing it with some form of hormonal medication. Birth control pills, rings and patches are really safe. They suppress ovulation to make things more even, and they keep the. Thin. So even if you are 40 or 45 or 49, as long as you are not smoking, have not had a blood clot, have not had a stroke, and don't have a risk of uterine or breast cancer, then, and when I say risk, I don't mean having a long-term risk because if you've had risks of uterine cancer, [00:12:00] the birth control pill can fix it. 

I mean, having uterine cancer, we have to prove you don't have it. So the birth control pill patch ring is one impactful way to stop your bleeding. A second way is giving you just straight out progesterone hormone, not in birth control. But that can thin out the lining and keep it nice and narrow so that you don't actually have heavy bleeding. 

And a third way is the progesterone i u d that gets placed inside your uterine lining. It works for birth control if you need it, but it also keeps the lining thin so that you again, have very little bleeding or period. There are some other medications that I don't tend to use as much, but they actually work on the level of the actual bleeding profile. 

So those can be used as well. And many doctors will implement those if the patient can't or doesn't wanna be on the birth control. Patch ring or the I u D. So those are the biggest ways we deal with it. Now, if we're talking surgically, there's also something called an ablation where the doctor under anesthesia, occasionally in the office, if they have the capacity to do that under local anesthesia. 

But for the most part, many of us will do it at a surgical center or the hospital. You go under very safe anesthesia [00:13:00] and the doctor puts a device into the uterus. There are various forms that will go into the. And believe it or not, they will burn the lining of the uterus. It sounds barbaric, but uterine ablations, where we literally ablate the lining of the uterus so that your hormones are the same. 

They're trying to thicken the lining, but the lining has now been burned so that it can't thicken up. It's a very impactful way to stop your bleeding in that perimenopausal period of time when in the past, as of 15, 20 years ago, all these women would have to have hysterectomies. So many of you, if you're watching in your, in your sixties, seventies, eighties, you might have had a hysterectomy. 

Many of us who are in our forties or fifties, our mothers had hysterectomies in their forties for heavy irregular bleeding, and many of us will live with our uterus forever. I don't have mine, but that's for different reasons. But you guys can live with it forever because we now have alternatives. We know that the birth control pill patch ring are safe. 

We know the I U D is safe and we have the ability to do an ablation. So these are all. Great ways that we can decrease your bleeding if you are having perimenopause. And again, if you wanna continue to bleed away, as long as you're not getting [00:14:00] anemic or passing out, by all means you can do that. Okay. I hope that was helpful. 

I love you guys and I'm realizing more and more and more how fun it is to be in this community and get feedback from you guys. So thank you for your dms. If you are not, uh, watching us on at Tribe called V, please go over there. Please go to tribe called and sign up for the email list so you can hear more about what's going on. 

Cuz we've launched our pregnancy kit, but we are gonna be doing GYN focused material coming up in the new year and we're so, I'm like beyond excited about that stuff. Okay, bye.