Perimenopause and Early Menopause
Frederick R. Jelovsek MD
A menses after menopause -- can pregnancy occur?
How long does menopause last?
Does extreme fatigue mean low estrogen levels?
Terrible hot flashes after stopping HRT
Differential Diagnosis of
Mood, Feelings, Menopause Problems
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This happens fairly frequently which is why the definition of post menopause is one year without any menstruation. I couldn't find exact numbers on how frequently it occurs but have included some abstracts below that show it is well known to happen. My subjective impression is that ovulation can still take place sporadically for up to a year after menopausal FSH levels in about 20-30% of women. There are many other factors negatively affecting fertility at that age that we don't usually put women on contraception during that time but it is remotely possible to get pregnant.
Commonly now, during the perimenopause/?menopause period we will have women use very low dose contraceptives (1/20 level) as estrogen replacement if they are non smokers. This obviously has dual benefits although before we started doing this it was still quite rare (but not impossible) to have a late age pregnancy at 47.
Eur J Endocrinol 1994 Jan;130(1):38-42
Prince Henry's Institute of Medical Research, Clayton, Victoria, Australia.
This review examines the role of follicle-stimulating hormone (FSH) measurement in assessing the significance of symptoms and possible continuing fertility during the menopausal transition. Follicle-stimulating hormone measurement is advocated frequently as a useful diagnostic tool in perimenopausal patients. Several investigators have shown that the serum FSH level increases in the early--mid-follicular and early postovulatory phases in women over the age of 40 years who continue to experience regular menstrual cycles. The serum oestradiol level may fall (although this is controversial) and the immunoreactive inhibin level falls, being inversely correlated with the rising FSH level. When alterations in menstrual cyclicity or flow commence, signalling the onset of the menopausal transition, FSH levels may change abruptly, rising into the normal postmenopausal range and falling again into the range normally seen in young fertile women. Oestradiol and inhibin generally fluctuate in parallel with each other but inversely to FSH, although at times oestradiol in particular may be increased markedly. Postmenopausal FSH levels may be followed by endocrine evidence compatible with normal ovulation. After the menopause, FSH levels rise 10-15-fold, with low oestradiol and undetectable inhibin levels. It is concluded that FSH measurement is of little value, if any in the assessment of women during the menopausal transition because it cannot be interpreted reliably and because, apparently, ovulatory (and, presumably, potentially fertile) cycles may occur subsequent to the observation of postmenopausal FSH levels. Both oestradiol and inhibin are important negative feedback regulators of circulating FSH.
N Z Med J 1988 Mar 9;101(841):103-106
Department of Endocrinology, Princess Margaret Hospital, Christchurch.
Once weekly observations of the excretion of FSH, LH, oestrogens and pregnanediol have been used to monitor the changes which occur as New Zealand women approach and pass through the menopause. There were 3 patterns of hormone excretion. (1) Premenopausal women (aged 40-51 yr) had regular menstrual cyclicity with hormone patterns similar to those seen in the ovulatory cycles of fertile young women. (2) Women in the menopausal transition (40-55 yr) had irregular menstrual cyclicity with erratic hormone fluctuations. There were ovulatory cycles, postmenopausal episodes in which amenorrhoea was associated with high gonadotrophin levels and low urinary oestrogens, and times when the excretion of both gonadotrophins and oestrogens soared. Ovarian activity did not cease at the menopause, and postmenopausal women in the 6 months following final menstruation (44-55 yr) had hormone patterns which were indistinguishable from those observed in the long anovulatory cycles of the menopausal transition. (3) Older women (57-67 yr) had senescent ovaries with the unvarying high gonadotrophin and low oestrogen levels which are a consequence of ovarian failure.
Symptoms (without hormone replacement) can last 1-25 years. Most women though, don't have symptoms that last much past about 10 years.
By pre-menopause I assume you mean premature menopause, i.e., you are menopausal rather than perimenopausal. The doses you are on are at the level of menopausal replacement. Sometimes the estrogen levels need to be checked (estradiol) to see if you are on a correct level of replacement. To answer your question, yes, fatigue can be a result of too low estrogen levels but usually if that is true, you are also having sleep disturbances and hot flashes at the same time.
Most common causes of fatigue, assuming thyroid and estrogen levels are ok, is:
- sometimes allergy flares and certainly antihistamine therapy
- medications affecting mood
- other medical conditions
To see if hormonal levels or replacement therapy is it cause, ask yourself the following questions. Does the fatigue vary with the estrogen, Provera® therapy? Does it get better, worse, on weekends (if you have any)? If is doesn't vary with the hormonal therapy and it gets better on weekends, then look to causes other than hormones.
Terrible hot flashes after stopping HRT
You need estrogen replacement that is more consistent than with herbal preparations alone. It is very common to take estrogens, come off them and have hot flashes that are much worse worse than when you first started. Somehow the estrogen therapy sensitizes the receptors and when it is withdrawn, your "addiction" shows. That will get better over time. The main challenge now is to find hormonal therapy that will be absorbed by your body and cease of decrease you symptoms.