Pre-menopause? Perimenopause? Post Menopause? How to Know What Pause You are In
Do You Need to Know?
In a perfect world, an alert would pop up on your phone announcing, “You are now in perimenopause,” followed at the appropriate time by “You are now leaving perimenopause and entering menopause.”
But it’s not a perfect world.
Search “How do I know when I’m in menopause?” You will learn that when you haven't had a period in 12 months, you are officially post menopause. Which is as helpful as a train conductor announcing “The next stop is mumble, mumble, mumble.”
For starters, that definition is only useful in retrospect.
If you haven’t had a period in 3 months, there is no way to know if you are going to get another one, and when it will be safe to get on an airplane wearing white pants without having a “just in case” tampon.
It seems that the best way to determine if you are in perimenopause or menopause would be to measure your hormone levels. But, in most cases, it's just going to mislead you, or is unnecessary.
I can’t tell you how many times a woman will come to me and tell me that she thinks she is in perimenopause, but her internist did an estrogen level and told her she was not. In most cases, the woman is right, and the internist was wrong.
During perimenopause, estradiol levels fluctuate like crazy. One month they can be low, the next month, sky high.
Therefore, a single random blood test can be highly misleading. Testing your blood estrogen level will give you an accurate measure of your hormones at 2:00 p.m. on Tuesday, when your blood was drawn; however, it may be significantly different two months later. A random level is not a reliable indication of the total picture. And by the way, if you are using contraception that contains estrogen, a blood estrogen test is worthless, because it is the pill talking, not your ovaries.
I know this sounds old school, but the best way for me to know if someone is in perimenopause or menopause is to listen to your story: The best indicator that you are no longer making estrogen is your age, your menstrual history, and how you feel. There are situations in which a blood test, or serial blood tests, are helpful, but only if interpreted by someone who puts results in the context of a bigger picture.
It’s pretty obvious that a 45-year-old with irregular periods, hot flashes that come and go, and crazy, unexplained mood swings and rages is in perimenopause.
It’s not rocket science to figure out when a women tells me her last period was two years ago, her vagina is like the Sahara Desert, and she has nonstop hot flashes that she is officially post-menopause.
I don’t need a blood test to prove that a 55-year-old woman who hasn’t had a period in three years has low estrogen. It’s kind of like getting a pregnancy test for someone who is in labor and being surprised that it is positive.
But things are a lot less straightforward for the millions of women who, despite ovaries that are pumping out estrogen just fine, don’t get periods.
So, who’s not getting a period even though she is not yet in menopause?
Women who have had a hysterectomy
Women who have a progestogen IUD
Women who have had an endometrial ablation
Women who are using hormonal contraception, such as birth control pills.
HYSTERCTOMY
Thirty percent of women in the United States have had their uterus removed. A total hysterectomy refers to the removal of the entire uterus, including the cervix. The uterus does not produce estrogen or any other hormone. A total hysterectomy, in the medical world, does not include removal of the tubes or ovaries.
Removal of the uterus, cervix, tubes and ovaries is referred to as a total hysterectomy with bilateral salpingo-oophorectomy.
Bilateral (both ) salpingo (fallopian tubes) oophorectomy (ovaries).
Unless ovaries are removed, a hysterectomy will not initiate menopause.
If you have had a hysterectomy, obviously you will no longer get periods, and you won’t be able to get pregnant, but, again, unless your ovaries were removed as well, nothing will change hormonally.
If ovaries that are still producing estrogen are removed at the time of hysterectomy and a woman is not already in menopause, she will skip perimenopause and enter menopause.
If someone has had a hysterectomy and years later starts having symptoms like hot flashes or vaginal dryness, there is no way to know if it is perimenopause or menopause without hormone blood tests. But, again, during perimenopause, blood tests or home menopause kits may be misleading since hormones are fluctuating. If you really want to know if someone is making estrogen, you generally need to do a series of blood tests.
Do You Need to Know if You Are in Perimenopause or Post Menopause?
No, you don’t need to know.
If you have no uterus and are having hot flashes, it’s fine to start estrogen therapy or one of the other non-hormonal options. If you are having vaginal dryness, I’m going to treat it even if your ovaries are still making some estrogen. It doesn't matter if you are in perimenopause or postmenopause.
So, just to be clear, if a woman has a hysterectomy at age 35, say for fibroids, but her ovaries are not removed, she’s going to continue to pump out estrogen, even though she is no longer getting periods. When she starts to have hot flashes at 46, I am not going to do a series of blood tests to determine if she is in peri menopause or post menopause. I’m just going to treat her hot flashes.
Progestogen IUD
The second scenario is the woman who isn't getting periods because she has a progestogen intrauterine device, such as a Mirena™ or Liletta™. Progestogen IUDs are commonly recommended in the 40-year-old crowd for contraception and/or to control heavy periods. Up to 50% of women with a progestogen IUD don’t get periods, even though they are still making plenty of estrogen.
Do You Need to Know if You Are in Perimenopause or Post Menopause?
No, you don’t need to know.
If a woman in her 40's or 50's has a progestogen IUD and starts to have hot flashes or vaginal dryness, she can take estrogen to get rid of the symptoms without knowing her specific hormone status.
Usually, if someone is taking estrogen, they also need to take some a progesterone or progesterone alternative to prevent the uterine lining from building up. But, good news! The progestogen IUD provides that protection! Depending on which IUD you have, it may be good for up to 7 or even 8 years. So hang on to it.
More on the benefits of having an IUD during peri and post menopause in this article.
ENDOMETRIAL (UTERINE) ABLATION
An endometrial ablation is a minimally invasive procedure in which a device is used to destroy the lining of the uterus (the part that bleeds every month) to control heavy or irregular bleeding. While women who have had an endometrial ablation often no longer get periods, this procedure does not impact their ovaries, and therefore, there is no impact on hormone levels.
Do You Need to Know if You Are in Perimenopause or Post Menopause?
No, you don’t need to know.
Women post-ablation enter menopause at whatever time they are destined to do so; they just might not know it. Like the scenario in a woman with a hysterectomy, she can start hormone therapy anytime she starts to have symptoms.
However, unlike the hysterectomy scenario, women with an endometrial ablation need to take a progesterone or a progesterone alternative to protect the lining of the uterus unless they happen to have a progestogen IUD.
HORMONAL CONTRACEPTION
Many women in the 40- to 50-year-old range use hormonal contraception, such as a birth control pill, ring, or patch, not only to prevent pregnancy but also to manage perimenopausal symptoms and heavy or irregular periods.
The ovaries are essentially on hiatus if a woman is taking the pill, which means that a period—or lack of a period—is NOT an indication of ovarian function or estrogen output. Even if a woman is taking her pill cyclically and has a light monthly period, the disappearance of her period is not an indication of menopause. It is an indication that the lining of her uterus is thin and inactive because of taking the pill. In other words, it’s the pill talking, not the ovaries.
Is it possible for someone to enter menopause while on the pill? Absolutely. Many women taking birth control pills go through perimenopause and/or are post menopause without even knowing it.
But unlike the woman who has had a hysterectomy, or has an IUD or an endometrial ablation, women who are on the pill during perimenopause or menopause do not get hot flashes or other menopause symptoms because, as I explain in this article, the pill is HORMONE THERAPY!
The only indication a woman on the pill has that she is going through perimenopause or is in menopause is if she takes the pill cyclically (meaning she does not take an active pill every day) and notices hot flashes during the pill-free days.
Do You Need to Know if You Are in Perimenopause or Post Menopause?
No, you don’t need to know.
Since low-risk non-smoking women can continue to take the pill up to age 55, it is not unusual for a woman on the pill to sail into menopause without a single symptom. At age 55, it’s time to stop the pill.
Why 55? The average age of menopause is 51. By age 55, 95% of women will no longer be producing estrogen and no longer need contraception. 95% of women will be done with perimenopause fluctuations and irregular bleeding and don’t need the pill to regulate their hormones. 95% of women will be post menopause and can be transitioned to hormone therapy, which is dramatically lower than even the lowest dose pill. If you need or want to know what your ovaries are doing on their own, stop the pill, and after a few weeks, you can measure your hormone levels. It is never useful to get hormone levels while you are on the pill.
What About Home Menopause Tests?
In addition to all of the other reasons you shouldn’t waste your money, the test is not intended for women who don’t get periods because the main part of the algorithm is an analysis of the frequency of periods. So, it is worthless for about one-third of the women in America.
To be fair, the company states that these tests are not intended for women who don’t get periods. But you wouldn’t know that until you get home, rip apart the packaging, and eagerly pee on the stick to find out what menopause stage you are in. That’s right, while the front of the package helpfully tells you that a phone is not included in the box, you have to scan the QR code on the back of the box to find out that the “This product is not right for you if you: Use hormonal birth control or HT, have had a hysterectomy, or your cycle is affected by medication or a medical diagnosis. (Polycystic ovarian syndrome is one example of a medical condition that may cause someone to not get periods) .
So, to summarize,
If you have had a hysterectomy and don’t know if you are in menopause, it doesn’t matter. Just treat the symptoms.
If you don’t get periods because you have an IUD and don’t know if you are in menopause, it doesn’t matter. Just treat the symptoms.
If you had an endometrial ablation and don’t know if you are in menopause, it doesn’t matter. Just treat the symptoms. But you need to protect the lining of the uterus.
If you are taking hormonal contraception like a pill, patch or ring and are wondering if you are in menopause, stop wondering and just keep taking the pill until you are 55.