Perimenopause symptoms can vary. One sign: not feeling like yourself.

Boston-area gynecologist Marcie Richardson routinely sees women in their late 30s and 40s who use the same or similar four words: “not feeling like myself.”

Often they are experiencing irritability, trouble sleeping and anxiety, yet their symptoms have largely been dismissed by their doctors. These patients are often surprised to learn their symptoms could be the earliest signs of perimenopause, an understudied and under-the-radar phase in life, said Richardson.

“They are coming to me to try to find answers, wondering if there’s anything I can do to help them feel better,” said Richardson, an assistant clinical professor at Harvard Medical School.

A new view of perimenopause

Many women and even their doctors believe that menstrual irregularities are the first sign of perimenopause, the time in a woman’s reproductive life span that precedes menopause.

But changing hormone levels may cause a range of symptoms long before periods are affected.

These symptoms include fatigue, sleep issues, mood changes and feeling less able to cope. Many women experiencing these changes often are still getting regular monthly periods and don’t have some of the more talked about symptoms of menopause, such as hot flashes.

Richardson and her colleagues at the research consortium Women Living Better began to wonder if the phrase “not feeling like myself” may actually be a reliable clinical indicator that a patient is experiencing the earliest signs of perimenopause.

To find answers, they decided to crowdsource, asking more than 1,300 women age 35 to 55 to answer questions about their menstrual cycles, stress, overall health and well-being. And they asked women how often they reported “not feeling like myself.”

It was not a representative sample, but the answers were illuminating. Nearly two out of three women who responded reported “not feeling like themselves” at least half the time or more over the previous three months. The phrase was strongly associated with symptoms of fatigue, feeling overwhelmed or less able to cope, low mood and anxiety.

Notably, the phrase was not strongly correlated with two hallmark symptoms of menopause: hot flashes or vaginal dryness. The research was presented last fall at the annual meeting of the Menopause Society.

These findings and other published research suggest that in many women, the menopausal transition may start earlier than traditionally believed. A more nuanced understanding of what lurks behind the complaint of “not feeling like myself” could help women take better control of their health and allow clinicians to engage more effectively when patients share their concerns, researchers concluded.

“Just telling them, ‘This is ok,’ is helpful,” Richardson said of her patients. “Women will say, ‘Oh it’s so wonderful to be able to talk about this. I’m glad to know I’m not going nuts.’”

Perimenopause isn’t just hot flashes and period changes

Nina Coslov was 43 when she started waking up at 2 a.m., unable to return to sleep. These middle-of-the-night jolts seemed to come “from out of nowhere,” she said. But having left her job in biotech a few years earlier to raise three young children, Coslov wondered if her life situation was causing the sleep disruption. Still, she said, “It felt like a biological shift.”

When she consulted her primary care doctor and OB/GYN, the first question both doctors asked was: “Are you still getting regular periods?”

When she answered, “Yes,” they told her the symptoms were not related to perimenopause. Coslov’s internist prescribed anti-anxiety and sleep medications. Her OB/GYN told her that “a little anxiety isn’t always a bad thing.”

Coslov wasn’t satisfied. She began her own research and discovered a sizable knowledge gap. “Most of the studies about menopause really focus on the final menstrual period,” she said, noting that in her early investigations, she found only two studies that included women starting at 35.

She teamed up with a business school classmate, and built a website to educate women about the nuances of perimenopause. She began connecting with women’s health researchers and physicians, including Richardson, to help shine a light on this transitional stage in women’s lives. “We need to let women know that for some, it starts much earlier,” she said.

The group created an 82-question online questionnaire about menstrual patterns and symptoms. They distributed the questionnaire to thousands of women between the ages of 35 and 55 through newsletters, social media and various women’s groups. “Together we can create a clearer understanding of the 10 to 15 years leading up to our final menstrual period,” promised ads for the questionnaire.

Because the methods didn’t involve a random sample, the results can’t be applied to all women. But researchers say the data collected is useful to gain insights from midlife women. The data suggests that many of the less commonly known symptoms of menopause appear long before periods become irregular.

“In general, people think of hot flashes as the hallmark of menopause but there are many other symptoms, and those can include changes in mood, sleep and aspects of cognition, often called brain fog,” Coslov said.

Dismissed by their doctors

One concerning pattern emerged in the survey responses. Many respondents reported feeling dismissed by doctors when sharing their symptoms.

One patient wrote, “I was brushed off, told that I am getting older.”

Another said her experience was trivialized. “Welcome to your new normal.”

Another reported that her provider simply got it wrong. “Dr. said it wasn’t perimenopause if I wasn’t having hot flashes.”

Wen Shen, a physician and co-director of the Women’s Wellness & Healthy Aging Program at Johns Hopkins Medicine, said she hears the complaint — “not feeling like myself” — from her patients daily, and they often blame themselves for the changes.

“They used to be go-get-’em, multitasking whirlwinds. And then they hit perimenopause, and they can barely get out of bed,” said Shen, who was not involved in the study. “They wonder what’s wrong with them, and think they should just pull themselves together. But it’s really hard.”

Shen noted that perimenopause is a time in life when women are particularly susceptible to depression and anxiety.

Stephanie Faubion, a physician and director of the Center for Women’s Health at Mayo Clinic, said the new research “validates the fact that women don’t feel like themselves at this time, and they don’t always connect it with the menopause transition.”

Faubion, also medical director of the Menopause Society, said many patients come to her confused and fearful about their symptoms. They’ve experienced “weight gain, trouble sleeping, poor mood, panic attacks, heart palpitations, joint pain and they think that something is terribly wrong — but don’t link what’s happening to menopause,” she said.

“We have a situation where both women and clinicians don’t always know what’s going on during this stage,” she said.

Of course, each phase of a woman’s reproductive life — from the onset of menstruation to menopause — is unique to each individual, say experts. Timing and accompanying symptoms can vary dramatically from woman to woman.

These nuanced distinctions of perimenopause were long overlooked, said Judy Norsigian, a co-founder of the classic women’s health resource, Our Bodies Ourselves, and an adviser to Women Living Better.

“We’ve had a long history of the perimenopause experience being poorly understood,” she said. “Ob-gyns are not well trained in this area and don’t have the breadth of experience and knowledge necessary to help most women.”

Coslov said that as more of the data gets published in peer-reviewed journals, she hopes that health providers will “recognize, pay more attention and have some knowledge of associated symptoms when women use the phrase ‘not feeling like myself.’”

Women who have uttered the phrase “not feeling like myself” should talk to their physicians about their symptoms and whether they may be showing the earliest signs of menopause. Charting periods can help women gain a better handle on the relationship between various symptoms and their menstrual cycle.

Other self-care routines or therapies can help.

  • Medication: For some women with mood dips in perimenopause, Richardson said medication such as antidepressants can help. Other patients find relief taking continuous oral birth control or other hormone therapies to level out hormonal fluctuations.
  • Exercise: Exercise can alleviate low mood or anxiety and generally improves well-being no matter what the symptoms.
  • Sleep: Focusing on getting enough sleep is another basic intervention to ease hormonal distress. “So many women, they’ve got the kids in bed and finally have a quiet moment, so what do they do? They finish work, or just veg in front of the TV,” Richardson said. “They don’t consider sleep as the best option.”
  • Alcohol: Curbing alcohol consumption can also decrease symptoms.
  • Cognitive behavioral therapy: Some clinicians cite cognitive behavioral therapy as another effective non-drug intervention for some of the symptoms of perimenopause.

In the end, Richardson said, what is most crucial is getting information to women before changes begin, “just like we do with puberty, or with pregnancy.”

“For these life transitions, we inform people ahead of time, and I think that’s much, much needed here,” she added. “So anticipatory guidance and then validation, whether it’s a healthcare provider validating the experience of someone on the path to menopause, or women self-validating and normalizing their own experience.”

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