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Premenopause

This normal life phase extends from age 20 until the changes of perimenopause—our horizons now extend well beyond our families and original communities. It is when we find what work we want to do and complete the processes in learning to do it. It is also the time for making long-term relationships and creating our own home or family. During the premenopausal years we make choices about preventing or becoming pregnant—we learn the challenges as well as the joys of motherhood. 1. The jobs of the premenopausal years are to learn effective self-care, to grow into adult roles, obtain education/training, create a “family,” become financially and emotionally independent, perhaps to choose to become a mother (with all the additional roles and responsibilities that means) and to become normally ovulatory most cycles (meaning to ovulate with a normal time of 10+ days from release of an egg to the start of the next flow). 2. It is normal during the early premenopausal years to experience regular cycles but ovulatory disturbances, especially with stresses of moving, education, new jobs and new relationships, may persist. By the time of the first pregnancy, the likelihood of cramps and their severity are decreasing. It is also normal to develop mature breasts with at least a 2 inch areolar diameter. 3. Premenopausal women having sex with a man need effective and safe contraception so they can plan fertility, supportive friends, a trusted partner, an adult relationship with siblings and parents and secure health care, home and work. 4. In the premenopausal years, making a span of more than 25 years several things can go wrong including heavy flow, trouble getting pregnant and the development of Anovulatory Androgen Excess (AAE, also known as PCOS). Heavy flow can be reduced by half with ibuprofen (200 mg) each meal /resources/very-heavy-menstrual-flow ; trouble getting pregnant even if cycles are regular is commonly because of ovulatory disturbances (meaning anovulation or short luteal phases). Cyclic progesterone therapy will help /ask/when-should-i-have-sex-get-pregnant. Finally, AAE/PCOS can be effectively treated as explained here: /ask/pcos-aae-and-insulin-resistance. In summary, the premenopausal years are a long, important and usually productive time in our young adult lives. The skills we learn especially in healthy stress management and the more normal our cycles and ovulation the healthier we will be throughout the rest of our lives.

Relevant Topics

Anovulatory Androgen Excess AAE

AAE is a condition in women that usually develops in adolescence and is diagnosed in about five of every 100 women of any race and any country of origin. It is diagnosed by a combination of abnormal cycles (amenorrhea, oligomenorrhea or irregular cycles) and evidences that male-like hormones called androgens are either too high or too active causing hirsutism, acne and androgenetic alopecia (1). Traditionally this condition is called Polycystic Ovary Syndrome which focusses attention on ovarian cysts rather than on disturbed ovulation and too little progesterone production—the two fundamental problems.

CeMCOR's approach to AAE is innovative in three ways: 1) not relying on doing a pelvic or vaginal ultrasound and counting ovarian cysts to make a diagnosis (as in PCOS); 2) not giving women with AAE combined hormonal oral contraceptives (COC) which only produce regular but artificial "cycles" and minimal decreases in the androgen excess, but, 3) instead treating AAE with cyclic progesterone and also with a medication that blocks androgens (of course with a barrier plus vaginal spermicide for contraception). There are strong scientific reasons behind CeMCOR's approach to AAE; however, so far CeMCOR has either not been able to get funding for, not done the research or has not yet published the results. We persist because these approaches are acceptable by women, lead to basic improvements or even reversal of problems with abnormal cycles, facial hair and acne, infertility and can help prevent the problems of insulin resistance and obesity that are also frequently associated with AAE.

Reference List

(1) Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril 2009 Feb;91(2):456-88.

Fertility

Fertility—in its broadest sense—for women means being able to become pregnant and to deliver a baby.Too often in thinking of fertility we ignore men's important part in this process; problems with a man, although less well documented, likely account for half of all infertility.

Fertility in women requires a lot of things to be optimal—we require normal anatomy (ovaries, open and working fallopian tubes, uterus, cervix and vagina), regular menstrual cycles (having enough estrogen) and ovulation (egg release) providing an egg that can be fertilized. In addition, the corpus luteum from which the egg is released needs to provide enough progesterone and keep providing it for at least 12 days (so that the endometrium will be prepared for the fertilized egg to implant). Obviously we have to be interested in and have sex at the right time in the cycle. We are usually most fertile from the start to the end of stretchy midcycle mucus. It is essential also to have normal immune function that is compatible with the sperm so that the egg doesn't block sperm fertilization and so that the fertilized egg is not blocked from implanting into the uterus. After all that, the corpus luteum needs to continue to make enough progesterone to support the implanted egg until about 12 weeks into the pregnancy at which time the placenta takes over making progesterone.

Thus fertility is a multi-organ, multi-system complex process that usually works quite normally.

Fibroids

Fibroids are non-cancerous little balls of muscle that start in the uterus's muscle wall and grow in response higher levels of estrogen. Most women after about age 30 are growing fibroids; however, most of us will never have any problems related to them. Very rarely fibroids can interfere with pregnancy, or grow so big that they cause urine or bowel blockage, bladder symptoms or pain. Fibroids shrink when women become menopausal.

Most women first learn that they have fibroids when they develop heavy flow (often in perimenopause). Because there is the wrong understanding that fibroids cause heavy flow, many family doctors will then order a uterine ultrasound. Very commonly this ultrasound shows fibroids. However that doesn't mean that the fibroids are causing the heavy flow. Higher estrogen levels cause both heavy flow and fibroid growth.

Fibroids tend to grow in three directions—within the muscle (the most common situation), pushing outside of the uterus (called subserosal or, if on a stalk, pedunculated) and into the endometrium (called submucosal). Submucosal fibroids are the only one of these three kinds of fibroids that could potentially cause abnormal vaginal bleeding—they make up less than 1 of every 10 fibroids. Instead, heavy bleeding is caused by the higher estrogen and lower progesterone levels of perimenopause and these hormonal changes make fibroids grow. Remember that fibroids are common and usually cause no problems.

Cramps and painful periods

"Cramps" is the common name for painful periods or what doctors call dysmenorrhea. Cramps typically start just before and are most severe during the first days of menstrual flow. Younger women and those who have never been pregnant or delivered a baby are more likely to have and to have worse cramps. Interestingly, cramps also seem to increase in perimenopause (the transition to menopause). The pain of cramps is due to increased release by the lining and muscle walls of the uterus of a fatty hormone called a prostaglandin. More prostaglandins are made when the opening of the uterus is very tight (and therefore pressure inside it builds to high levels) and also when estrogen levels are higher. It is likely (but not yet adequately studied) that higher progesterone levels counterbalance estrogen's effects and decrease cramps. Painful periods can be effectively treated with ibuprofen, an over-the-counter pain pill that is from the "anti-prostaglandin family". Ibuprofen (400 mg or two 200-mg tablets) must be taken at the first hint of cramps and a further 200 mg tablet taken as soon as the pain begins to return (even if that is only an hour later). If you wait, ibuprofen won't help because ibuprofen works to prevent the formation of the prostaglandins that the cause the pain.

Contraception

Contraception means preventing pregnancy. There are many ways women can prevent pregnancy—they range from refusing to have sex (being celibate), to using a physical barrier (such as a condom for a man or woman, diaphragm or cervical cap) plus a spermicide, to an operation that "ties" the fallopian tubes preventing fertilization of the egg and causing permanent sterility. (Note—researchers have now learned that risks for ovarian cancer arise in the tubes therefore any woman choosing tubal sterilization should request tubal removal.) Most contraception is reversible but tubal removal or ligation and vasectomy are not.

There are two basic kinds of contraception: those that rely on high hormone levels to disrupt reproductive hormonal cycles and those that don't. Hormonal contraception is traditionally in the form of "The Pill" but today combined hormonal contraception (CHC, combined estrogen and a progestin) usually for 21 of 28 days, can be a pill, a patch or a vaginal ring. The CHC hormone levels, although called "low dose" must be high enough to interfere with normal menstrual cycle hormones, ovulation and preparation of the lining of the uterus for implantation. The common CHC dose of 20 microgram ethinyl estradiol is approximately four times higher than natural menstrual cycle estradiol levels. CHC must be taken reliably to be effective, disturbs cyclic hormones, carries a risk of blood clotting and may cause adolescent bone loss. The progestin-only pill is also a possibility—it is taken daily, is an androgenic (male-hormone-like) progestin and often gives irregular bleeding. Hormones are sometimes part of intrauterine devices (IUD) as in the levonorgestrel (an androgenic progestin) IUD used to decrease heavy bleeding in perimenopause. Depo-MPA (sometimes called Depo-Provera) is 3-monthly high dose injection of a non-androgenic progestin—its advantages are its effectiveness, 3-months duration and its disadvantages are weight gain and depression.

Non-hormonal reversible contraception uses a diaphragm or a condom as a physical barrier and always requires simultaneous insertion of vaginal spermicide. These methods cause no hormonal disruption, can be quite effective contraception, prevent sexually transmitted diseases but are of little value if not consistently and conscientiously used. Copper IUDs are also a long-acting, effective, non-hormonal contraception that can now be chosen by nulliparous or young women. They are highly effective and have few serious adverse effects.

Ovulation and menstrual cycles

It was commonly believed that we always ovulated whenever we were having regular menstrual flow with normal-length menstrual cycles of 21-35 days apart. CeMCOR and other groups of scientists have now shown that variability in ovulation and huge variation in the amount of progesterone that each menstrual cycle makes are very common. This frequent but not obvious cycle variation is called an "ovulatory disturbance" that includes not releasing an egg (anovulation) as well as releasing an egg with too short a time from egg-release to the next flow (short luteal phase). Ovulatory disturbances are silent within regular and normal menstrual cycles. It is still true, however, that irregular or far apart cycles are even more likely to have ovulatory disturbances.

Who's at increased risk for silent, ovulatory disturbances? We don't know for sure because few studies have tracked women's cycles for ovulation over extended periods. Adolescent and young women (in the first 10 years after first period or menarche) are more likely to have ovulatory disturbances; irregular flow is also common in the first year. Also, women in perimenopause have increasing ovulatory disturbances; luteal lengths can be normal but progesterone production too low during this life phase. Obesity is associated with ovulatory disturbances, as is cigarette smoking. But probably the most common reason for having a regular cycle with too little or no progesterone production is being under stress: the "threat" can be physical (illness, over-exercise), emotional (break-up with a partner, grief, depression), nutritional (not being able to afford or get to, enough nutritious food or not eating enough for body needs), social (bullying, sexual abuse, social isolation) or spiritual (not feeling life has fundamental meaning). Thus CeMCOR investigators have come to see a normally ovulatory, regular menstrual cycle as a sign of health and well-being.

Do ovulatory disturbances matter? Yes. We all know that normal ovulation is needed for fertility. But CeMCOR scientists recently showed that half of about 430 women had over a third of cycles with ovulatory disturbances per year in a review of all published scientific articles about changes in ovulation and in spinal bone in young women. Thus women with less than a third of cycles having ovulatory disturbances each year kept their peak bone mass but the rest, with more frequent ovulatory disturbances, were losing almost one percent of spinal bone density a year. So for premenopausal women's bone health, normal ovulation as well as menstruation matters. Normal premenopausal ovulatory menstrual cycles likely also matters for the later risk of heart disease and breast cancer.

Join a Study:

Hot and Bothered? Perimenopausal Women Needed for Hot Flush Study

CeMCOR is now recruiting Canadian women for this CIHR-funded randomized controlled trial to test whether oral micronized progesterone is more effective than placebo as therapy for hot flushes and night sweats in perimenopausal women.

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