Asiri Blog

Preparing for the season of transition - Perimenopause

In an interview with the Sunday Island, Consultant Obstetrician and Gynaecologist, Dr. Romanie Fernando asserts that, a woman who is prepared for menopause-transition, known as ‘perimenopause’ is on a better footing to handle the emotional roller coaster and other physical challenges which come along with it.

Mood swings, irregular menstruation, troubled sleep, fatigue - these could be symptoms of perimenopause or menopause-transition. The onset of this phase in a woman’s life is several years before menopause (the end of a woman’s menstrual cycle). Perimenopause is the time when the ovaries gradually cease their function. Ovaries produce estrogen- the most significant hormone for women. Perimenopausal symptoms start when estrogen production gradually reduces.


As the Consultant Obstetrician and Gynaecologist, Dr. Romanie Fernando points out, preparing one’s self early for this transition could help a woman navigate this emotionally and physically challenging period more smoothly. "The symptoms- both mental and physical, entail a spectrum which could aggravate once she reaches menopause. Hence empowering one’s self holistically is critical to face the transition with ease."


Perimenopause largely starts in a woman’s 40s although a small percentage could experience it even in their 30s. The peak period of menopause is usually between 45 to 55, says Dr. Fernando. "While the average length of perimenopause could be around five years, for some women, it could even continue for ten years and perimenopause ends when she has not had her menstruation for about 12 months."


The underlying cause for perimenopause is the reduction of estrogen which is an essential hormone for sexual and reproductive development in women. During perimenopause, the ovarian functions start to fail and thereby reduce the production of estrogen. The emotional roller coaster of perimenopuase could be disturbing to many women unless they are aware of their emotions and tune their minds to manage them. "This phase could be emotionally challenging to women and they are often unable to handle stress and get provoked easily. Their mood swings, irritability and aggressiveness could impact others around them as well including the family and colleagues at the work place," observes the Consultant.


The mismanaged stress could manifest in way of frequent headaches which could very often be misdiagnosed, warns Dr. Fernando. "These tension-induced headaches could sometimes be misread and pain killers could be prescribed. Hence, a careful diagnosis of a woman prone to frequent headaches during this stage is required." Apart from headaches, a woman during perimenopause could also experience body aches and pains. As Dr. Fernando further notes, some of these physical symptoms could mimic other conditions including thyroid problems, hence ruling them out with proper investigations is important.


Insomnia or inability to sleep is another common condition associated with perimenopause-induced stress. If unaddressed, this could trigger depression. "Addressing symptoms before a woman reaches a stage of depression is crucial. Today there are many behavioural therapies to manage them including mindfulness techniques, breathing practices and stress-management sessions conducted by qualified psychologists which women can access. Besides these, incorporating simple activities into the daily routine to relax the mind such as gardening, listening to good music, reading, meditation etc. are recommended by the Consultant.


Despite perimenopause being part of the natural course of every woman’s life, the reaction to it is determined by the personality of each woman, says Dr. Fernando. "Women who are more spiritually-inclined whatever the religion is, those whose minds are relaxed and more aware of their minds can brave this phase better than women who are constantly on the run with little heed to mental relaxation." Mindfulness practices are strongly recommended for women to be in control of their action and speech and thereby avoiding unpleasant situations created by their careless words and sometimes unintentional anger bouts, adds Dr. Fernando.


Addressing regular headaches and insomnia before they develop into depression is vital, warns the physician who encourages women to talk to a trusted family member or friend who would lend an empathetic ear. "Very often speaking to a person a woman trusts could help ease her mind. Professional counseling is also available in the absence of a family member or a friend who could offer appropriate counseling."


Altering one’s lifestyle with sufficient physical exercise and a proper diet cannot be underpinned during perimenopause. Activities such as yoga, walking and any other regular physical activities which could impact the mental equilibrium are recommended. In addition, regular exercises which could strengthen pelvic floor muscles could prevent urinary incontinence or the unintentional passing of urine when sneezing or coughing which is also a common symptom of perimenopause.


Irregular menstruation is also during this stage. Dispelling the myth that heavy bleeding is quite natural when a woman is nearing menopause, Dr. Fernando urges proper clinical investigation in such event. "It is certainly not normal for a woman to have prolonged periods (often beyond a week) or heavy menstrual flow. In both these events, she needs to consult an Obstetrician to be investigated for underlying problems," reiterates Dr. Fernando who goes on to note that investigations will help exclude either endometrial cancer (cancer in the uterus) or cervical cancer (cancer in the neck of the womb) which 5-10% of women could be experiencing at this stage.



A pregnancy, during perimenopause, although rare it is possible, has lesser chances than when a woman is younger, says Dr. Fernando. "Continuing with contraception is therefore important. However, if a woman has a history of heart disease, high blood pressure or blood clots and is over 35, birth control pills may not be the best option for her. Also, women over 35 who smoke are at particularly high risk for cardiovascular diseases. Taking birth control pills may increase such women’s risk of cardiovascular complications, such as blood clots, heart attack and stroke. The birth control pills, although may contain estrogen, could increase the risk of non-communicable diseases (NCDs)."


Preventing obesity too should be a priority at the perimenopausal age as obesity is the leading cause of NCDs, says Dr. Fernando adding that, if mood swings, hot flushes and sexual dysfunctions associated with this stage are severe, consulting a gynaecologist and getting the opinion of the best treatment of the type of hormone to be taken is vital.


Altering one’s diet, ideally before the onset of perimenopause (around 35 years) can help mitigate many issues, observes the physician. A plant-based diet rich in anti-oxidants and phytoestrogen (plant-based estrogen sources) could supplement the estrogen deficiency during this stage. "Japanese women are reported to be having minimal perimenopause and menopause symptoms largely because of their plant-based diet rich in which soya beans occupy a prime place," notes Dr. Fernando who cites natural soya beans (NOT the genetically-modified type) as one of the best sources of phytoestrogen. Natural soya milk and soya milk products are recommended for perimenopausal women.



Revisiting the traditional Sri Lankan diet which is largely a plant-based one is also crucial, reflects Dr. Fernando. "Sri Lankan women who would opt for traditional food sources could also experience minimal symptoms unlike in the west where many women seek hormone-replacement therapy." Anti-oxidant rich sources such as cinnamon, lime, ginger could also regenerate cells while traditional local foods such as jak and bread fruit can also provide ample nutrition. Green leaves, grains, nuts, legumes (especially dambala) mushrooms, broccoli are among the other highly recommended foods. "Mindful eating without binging on unhealthy food should be avoided at all costs and ideally a woman should increase her calcium intake after 35. Small fish, sprats and wood apple are among high-calcium sources," points out Dr. Fernando.


The non-communicable diseases (NCDs) which are on the rise could be worsened with the onset of perimenopause, hence managing the life style with appropriate physical activity, correct diet and combatting stress are of utmost importance as the Consultant explains. In a country such as ours with the rapidly ageing population and the majority of the population being women, interventions to support women going through perimenopause and menopause are much wanted, she adds. "Support groups within a community, workshops on mindfulness and other behavioural therapies at workplace, providing trained counselors at company level and a system of public health nurses who could interact with older women are wants of the hour."


By Randima Attygalle (Sunday Island)