Patient Question: A patient in her later 40’s, who is having a tough time with perimenopausal symptoms, recently asked me which is worse, perimenopause or menopause?

Short Answer: After dealing with many patients over the years, it is clear that both Perimenopause and Menopause are difficult and the symptoms can have a significant impact on a women’s quality of life. However, there are better treatment options for menopause then for perimenopause.

PYHP 114 Full Transcript:

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Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the Progress Your Health Podcast. I’m Dr. Maki.

Dr. Davidson: And I’m Dr. Davidson.

Dr. Maki: So this morning, we’re just going to kind of sort of a question, but this was not actually one that someone answered on the website or wrote to us. This is actually from a patient that I recently saw. She’s 46, which is kind of a- I’m sure you would agree, it’s kind of like a very common age for our new patients. She’s kind of miserable at the moment, has a lot going on, and just does not feel very good. And she actually asked me the question because she hears horror stories about menopause, but she’s feeling pretty rotten right now. So she asked the question, “Which is worse, perimenopause or menopause?” So I thought that was a very nice way for us to do an episode around that.

Dr. Davidson: Exactly, because we see this all the time, you know, a lot of menopausal females, perimenopause. And sometimes, we kind of overlook a little bit of the differences between the two and how people feel because, you know, everyone’s different.

Dr. Maki: Yeah. Now, honestly, this is the reason why we’re doing the podcast in the first place, because when it comes to some of these female hormone issues in general whether it’s PMS, PCOS, perimenopause, menopause, the conventional treatments and approaches are just not very good. Women are kind of left to their own devices. They’re not really given a lot of options. We’ve kind of figured that out over the years, right? There’s this big gap in the problems that women are experiencing. Before, it used to be just, “Well, that’s just aging and you just have to deal with it.” I don’t think that’s really acceptable, really, in the 21st century.

Dr. Davidson: I think some people still hear that, you know, “It’s okay. That’s just getting older.”

Dr. Maki: Well, yeah. That’s easy for the practitioner to say when they’re not the ones dealing with it, right? But a busy woman that’s got kids and a job and a family and is running the household — all those things, I mean, she can’t afford to have her body not cooperate the way she wants it to. And, you know, perimenopause, there are a lot of similarities, but it’s a little different for every woman. And again, when it comes to them getting some kind of relief, the options are pretty limited.

Dr. Davidson: And, perimenopause can span from your late ’30s to your early ’50s, and then you got menopause from your early ’50s beyond. In some people, it lasts for a short amount of time and in other women, it lasts for years. So that’s a long time for somebody to have to not feel well or just feel like they just have to put up with it.

Dr. Maki: Yeah, right. I mean, you figure from the beginning of that. Let’s say 40, right? Let’s just say 40 is the beginning and then 50, 51, you start menopause, there’s a decade already right there. Plus, you know, menopause into postmenopause, you’re looking at probably another 5 plus years there. That is anywhere close to a 15 to 20-year-stretch of a woman’s life when life should be really good and things should be fantastic and the kids are grown and out of the house and women are just miserable. Again, the question, from your patient experience, if you had to answer that question which is worse, what would you say?

Dr. Davidson: I would say, it’s not really a simple answer. Like I said, everyone’s different, but I would say menopause, in some ways, is obvious, right? There are some real main symptoms with hot flashes, night sweats, and then you stop your period if you have a uterus. But, perimenopause, I think, is a little bit elusive and a little bit kind of like that… people don’t realize that “I don’t have to feel this way.” Or “Is this really my new normal?” So, a lot of people with perimenopause, it’s like they don’t feel gray[?] but they still just sort of trudge through it as, “Hey, this is life.” Or chalk it up to stress or aging or not sleeping enough. But at the same time, I feel like perimenopause, in some ways, can be worse because it’s like a lot of women are just like, they don’t want to complain. They don’t want to be the complainers. They don’t want to say they don’t feel well. They don’t want to say, “Well, I don’t understand why I can’t lose weight.” Or “Why I’m gaining weight?” Or “Why do I feel this way?” A lot of times, they just are quiet about it.

Dr. Maki: Well, yeah. I also think too, like you said, menopause, in some ways, they’re both- You know, some women have a really tough go with things in both instances — perimenopause and menopause. I would say though that there are a few more treatment options for menopausal women than there are for the perimenopausal, which is why we’re kind of focusing on the perimenopausal because as you just said, that’s kind of more of the trickier ones. And the options that they have available are much more limited. So I would say, just from that standpoint, giving women some relief, I would say perim- And I’m a man so I really don’t know anything, right? Take what I say with a grain of salt, but I would say from that standpoint that perimenopause would be a little bit more of a transition. A woman’s body is working just fine. They’re doing all the things they have to do. And believe me, the patients that we see, they’re doing a million things on a daily basis which in some ways, is kind of adding to their symptom picture. And then all of a sudden, it’s almost like overnight, their bodies just stopped cooperating. Maybe it’s the surprise of that. They’re expecting all of that stuff to happen in menopause but it happens maybe 5 or 6 years early and they don’t know what it is. And even their practitioner — they go see their doctor, their gynecologist, their GP, whatever. They don’t even know what it is necessarily. So, if I had to pick one, and just some of the feedback we get, I would say that perimenopause is probably a little bit more challenging to deal with. It can be a bit more, at least in the beginning of it, a little bit more debilitating.

Dr. Davidson: You’re right. There’s not really a lot of treatment options and it’s not a disease. Menopause isn’t a disease. These are just the changes as we go through our lifetimes. But I do think that those hormonal changes can really impact how someone’s feeling. Like you were saying, 40 years old, when you look at the treatment options, someone comes into their physician, their gynecologist, their primary care, and they say, “I’m not sleeping. I’m really irritable. I’m freaking out. My hair is doing funny things. My hair has changed.” Because you will see a lot of hair changes in hormonal changes. I put on 15 pounds over.” Do you hear that? That’s our little buddy. Chewing on his elk. What is that his little elk thing?

Dr. Maki: Yeah, his elk antler. Yeah. Our little co-host down there.

Dr. Davidson: Sorry for the interruption, but he sure is adorable.

Dr. Maki: It happens every time.

Dr. Davidson: Like I was saying, they see their practitioner and they’re saying, “I don’t feel well. I’m having night sweats. My periods are all over the board. My libido ran out the door. I gained 15 pounds which feels like it happened overnight even though I’m exercising and eating well.” And then, what does a practitioner do? I understand it’s not a disease, it’s either- And the last thing you want to do is put a female in their ’40s on birth control pills, and then there are antidepressants and anti-anxiety medications and sleeping pills. And the last thing you want to do is get medicated like that.

Dr. Maki: Yeah, right. And honestly, I know that antidepressants, anti-anxiety medications, or birth control pills are really the only options that are available. And I think all of them, in some ways, have some potential downside to them.

Dr. Davidson: Yeah. I mean, in certain situations or circumstances, oh, my gosh, they can turn someone’s life around — antidepressants and whatnot. But, I don’t think that’s something, you know, when someone’s coming to you saying, “My periods are- I have two periods in a month and they’re really heavy. And all of a sudden, I have fibroids. Where did those come from? I’m not sleeping at night and I’m kind of grumpy with my husband –” Don’t even wink at me. Yes, I am in my ’40s.

Dr. Maki: Yeah. I’m living the perimenopausal nightmare myself.

Dr. Davidson: The perimenopausal dream.

Dr. Maki: Yeah. I know. It’s all good. From some of the things I hear, and we just got a comment the other day from someone on the website. It wasn’t really a question per se, but someone said, “Perimenopause is hell.” It was really dramatic, but at the same time, it’s like-

Dr. Davidson: But it can be.

Dr. Maki: Yeah, right. I mean, she was even saying how bad she feels for her family — her husband and her kids. One minute, she’s happy and the next minute, she’s pissed. In the next minute, she’s crying and it’s all over the place and no one knows what’s really going on. I was actually doing a bit of research before we started recording this episode, looking up just some keywords and different things. And I found one, it said “Perimenopausal Guide for Husbands” Or “Perimenopausal Resources for Husbands” Or something like that. And I’m like, “Yeah, they have no idea.” It can be a little bit of a hurricane sometimes. You don’t understand what’s going on. But this is also- We had an episode a long time ago, it’s like how hormones affect behavior. If men went through perimenopause and menopause, granted, men’s testosterone declined so they have their own andropause, whatever else. But if men went through the same kind of transitions, there’d be a hundred treatment options to be able to address these kinds of things. But because it’s a woman and it’s not really a disease, it’s not even a- I know you and I have talked about this, there’s not even an insurance billing code for perimenopause. Either you have PMS or menopause, and then there’s really nothing in between.

Dr. Davidson: There’s like endocrine hormonal imbalance, I think, that you can use.

Dr. Maki: Yeah. The whole system is kind of skewed away from dealing with a- And now, granted, perimenopause, like you said, is not a disease. Menopause is not a disease, but they’re both a kind of a collection of symptoms that are very common from woman to woman. I don’t know. I see things online. I hear some comments from patients, and it seems to me, anyway, that perimenopause is a little bit tougher to deal with.

Dr. Davidson: I agree. And even with menopause, like I said, it’s pretty obvious. They’re having the night sweats, having the hot flashes, they’ve no more periods. And then when you tell somebody, “Well, you know, I’m going through menopause.” Or “She’s going through menopause.” Or “My mom went through menopause.” People seem to understand that and they’re like, “Oh, yeah.” You know, they understand what that is, but when someone says, “Well, I’m having a tough time because I’m going through perimenopause.” A lot of people don’t really know what that means, and then they’re like, “Well, don’t give me any excuses. You’re fine.”

Dr. Maki: Yeah. Right. ” You just suck it up. You’ll be okay. This is what every woman goes through.” Now, I will say, stress level- Women are doing a lot these days, right? Women have always done a lot but they’re still doing a lot. They’re taking care of the kids. They’re working full-time. The to-do list that I hear women have to do on a daily basis, it makes me tired just listening to what they have to do, right? Then they can’t sleep and then they’re just kind of running themselves ragged. They’re taking care of everybody else in the family, but there’s no one there to take care of them. They have no time to decompress. They have no time to relax. It’s just this constant “go, go, go” all the time. And that level of stress, I think, over time, is what exacerbates this perimenopausal transition. If that’s, let’s say, normal- and I don’t think anybody necessarily[?], especially with all the pandemic stuff. I don’t think anybody has “normal stress.” I will say though, and maybe if you notice this too, that during the pandemic when people are kind of locked down, some people’s stress actually went down because of the lockdown and some of their symptoms actually got better.

Dr. Davidson: I agree. Working from home, I noticed a lot of my female patients seem to do really well with that. Then my, you know, some male patients are like they can’t stand all, the different- I think as females, we can definitely micromanage a lot more than men can. I hate to be stereotypical right there, but I did notice a lot of females were like, “Yeah, working from home, I felt more efficient. I could get things done. I can work when I want to work.” And then, of course, the kids are at home because where we were at, none of the kids were in school, so they got to help them with their homeschooling or their computer school. So, it’s been really interesting, actually. But like you said- I have to say you’re right. During your ’40s, there’s a lot of stress. Your kids might be teenagers, they probably have a little more autonomy than when they were little. You’re working, you’re balancing. But, it’s like that chicken and the egg because when those hormones change in perimenopause — because they do certainly change. They don’t go… they don’t get extinguished like they are in menopause. But the hormonal balance does change that it can create, probably, one of the biggest things. Of course, it’s the irritability but also sleeplessness. So, you think about it, a human being sleeping for a couple of hours, and then waking up all night, or either being up for 2 hours plus and then waking up all night. So maybe in the morning, they’ve had maybe 4-ish hours. I mean, that’s going to make people feel more stressed, more tired, more forgetful. So it’s like this sort of domino effect, I think, that can happen just from those hormones changing.

Dr. Maki: Yeah, right, yeah. And that’s one thing that we always try to pay a lot of attention to, which is not always easy, right? That insomnia, whether it’s falling asleep or staying asleep, that’s kind of a challenging thing and quite often, actually. But it’s also, as you just said, it’s like the most important thing. Because if you got all these things to do on a daily basis and you have all this psychological stress and pressure, you need to be able to rest and recuperate to be able to get back up and do that again. Your circadian rhythm needs to be in kind of good working order. But then, like you said, that insomnia could literally last at some women a decade or more.

Dr. Davidson: Yeah. So, like I was saying, that chicken and the egg, you would say, stress is going to make perimenopause worse. Yeah, of course, it is. But even when stress isn’t there, it can still be bad because they’re not sleeping. They’re feeling forgetful, they’re tired, they’re hungry, mentally tired. Then they’re trying to exercise to offset the weight that came on. You were saying, stress can make perimenopause. I think, in some ways, perimenopause makes stress.

Dr. Maki: Well, I think you’re right. I think there’s a chicken before the egg or the cart before the horse, right? I think you could say that in both directions. One exacerbates the other.

Dr. Davidson: Or vice versa.

Dr. Maki: Or vice versa, for sure. But just in the 21st century, we live complicated lives. And usually, when there’s lots of stress going on, it seems like those symptoms are kind of magnified. But like you said, when you are not sleeping and you’re irritable and you’re having all these emotional changes and physical changes, that just adds to this because there are so many things you have to get done on a daily basis. It’s a pretty challenging thing. Now, menopause — kind of switching gears a little bit, from our patients, you’re not quite there yet in menopause. But we’ve heard just as many horror stories in menopause as well. But some of the symptoms that women experience are just slightly different, right? They’re not exactly the same. Still, sleepless issues, but in perimenopause, like you said, it’s more of not being able to stay asleep, where menopause, you just can’t fall asleep, right? So it completely changes almost like overnight. The minute their period stops and their sleep quality or their sleep schedule, completely, is different.

Dr. Davidson: Yeah, you can definitely see differences between the two in terms of symptoms. I’ve had a lot of women tell me though that they thought they were in, they’re like, “I’m in menopause. My doctor says I’m in menopause. I’m in menopause.” I’m like, “You are not in menopause. You’re in perimenopause.” So, there’s definitely a little bit of a gray area between the two that I think sometimes gets confused. So, women don’t know where they are, “Am I in menopause? Am I in perimenopause?” But I think it’s only because a lot of people don’t really think about perimenopause or really look into the hormonal imbalance between that. In menopause, it’s just they just throw it under the big umbrella, “Hey, it’s all[?] menopause.”

Dr. Maki: Yeah, right. And even menopause, I know that you talked about FSH a lot or we’ve talked about it before-

Dr. Davidson: Follicle-stimulating hormone.

Dr. Maki: Yeah, yeah. In your new book, there’s a whole section in there about FSH. And that’s really the tool or the objective value that you use to kind of determine where a woman is.

Dr. Davidson: Sort of.

Dr. Maki: Sort of. Yeah, sort of.

Dr. Davidson: Because the reference ranges for a typical FSH, according to your lab, is humungous that a lot of perimenopausal females get lumped into menopause because of the FSH. So yeah, I go into that explanation a little bit. But, if you do have a uterus and you’re having a period, you’re not in menopause.

Dr. Maki: Right. We’re going to do another episode specifically about FSH and kind of breaking that down a little bit. So when you go to your gynecologist or your GP and you get your labs done for yourself, you can kind of tell where you are based on your FSH level. It is a fairly good determinating factor. Now, again, if a woman’s got an FSH of 100, then that’s fair to say that she’s probably either in menopause or approaching menopause. Her period has probably stopped six months to a year before. But in perimenopause, that’s where it can be a little more of a gray area. And there’s not really a firm criterion to diagnose perimenopause. And like you said, that’s why women get lumped into the menopause category all the time because- I don’t think there’s any agreement or you can’t look it up in a textbook or anything like that to say, “Okay, what are the diagnostic criteria for perimenopause?” There isn’t really one. One of our future episodes coming up here shortly is we’re going to kind of dive into that and actually talk about how you would actually diagnose perimenopause.

Dr. Davidson: Yeah, and we have that a little bit in the book too. Because really, we want to give you tools so that we can educate. That’s our big thing — we want to educate so you understand. And then, once you understand, then you can decide, “Okay. Well, what direction do I want to go with this? Do I want to take some of these medications? Or maybe I don’t, I want to do something different.” So, that way, you have the tools and the understanding.

Dr. Maki: Yeah, right. So, what else do we want to say about the difference? Granted, we’re kind of leaning a little more towards perimenopause just because that’s kind of what’s… And honestly, like you said in the beginning, I don’t think there really is a distinction which one’s worse because I think that the woman experiencing either one at the time would say, “That one’s worse.” Right? Because that is the most kind of present thing she’s dealing with. But, my preference or my opinion is that perimenopause seems like it could be at least a little bit more challenging, both for the patient and for the practitioner, as far as dealing with some of the symptoms.

Dr. Davidson: Yeah, no. Exactly, I do think both can have their pros and their cons because once you’re in menopause, you don’t have to worry about getting pregnant. And hey, you know what? Nobody really wants to have a period for the rest of their life, although there are a handful of women that do. And we have that hormonal balance for them too. But, I would say, menopause is not- There are lots of tools to make it a very easy transition, a beautiful time, and then just kind of moving forward. But at the same time, I think with perimenopause, it’s a little bit of a mind game because people are telling you you’re fine. “Oh, you’re fine. You’re fine. You’re fine. You’re fine. You’re healthy. You’re healthy.” But I don’t feel like it. So it’s a little bit of this weird dichotomy that I think a female goes through of “I’m fine. They say I’m fine, but I don’t feel fine.” Or in menopause, they’ll say, “Well, you’re in menopause. Go deal with it.” I think it’s just kind of a different mindset.

Dr. Maki: Yeah, sure. From a conventional perspective- and that was kind of my point at the beginning is that the perimenopause part- Now granted, there’s a little bit more awareness and women are certainly more familiar with the term, doctors are becoming more familiar with the term. But still, there’s a little bit of a lack of awareness and as I said, a lack of treatment options too to help women deal with some of the things so they can just get back to their lives and do the things that they have to do. It doesn’t have to be so complicated or they don’t have to be operating on such a deficit from what their bodies are used to, what they’re experiencing usually with their bodies.

Dr. Davidson: I agree. So even though that was one patient- because we got to talking about this that you had yesterday, and saying, “Which is worse?” We start talking about it and we thought “You know what? I think, sometimes, we deal with so many hormonal issues with our patients” — because that’s pretty much our niche and what we do, that we forget to kind of step back and say, you know, instead of saying, “Oh, what’s your FSH? What are your periods like? What are the symptoms? What are the treatments we’re going to do?” Step back and kind of think about some of those questions that do come up, because it’s true. People are wondering, “If this is bad, is it going to get worse?”

Dr. Maki: Yeah, right. That’s kind of what her question was like, “I feel horrible right now.” Like that comment we had got on the website, “This is hell. Why is this so awful? Is menopause even worse than that?” And I wouldn’t say that it’s actually worse. I’d just say that it’s maybe different. And I keep going back to it, but treatment options, there are quite a bit more treatment options on the menopausal side. When a woman was having hot flashes, that’s a pretty easy problem to solve, you know, sleeping- On both sides, perimenopause, whatever, that might be a little more challenging. But in perimenopause, when a woman is still menstruating regularly, from a hormone replacement perspective, it minimizes the potential possibilities of which you can actually do. And, just giving women testosterone, which I know is another common thing to do, that’s, sometimes, the worst thing that a woman can do. That’s not really going to help her. It’s just giving her a bunch of testosterone.

Dr. Davidson: Yeah. Everyone’s different. It all needs to be a little bit of, what are their particular symptoms? What are their goals or their family history? What’s their personal history? What’s their health history even right now in terms of moving forward? What’s their hormonal balance moving forward? But like you said, conventionally, I would say, there are more options for menopause. Conventionally.

Dr. Maki: Yes. That’s what I mean. Conventionally.

Dr. Davidson: But what we do- my goodness, I would say, when I first started out in practice in 2004, which I was very green and very, very young, I probably dealt more with menopause, that was kind of like- because that was more known about, that was kind of what would walk through my door. And then, now, I would say I probably deal more with perimenopause.

Dr. Maki: Mm-hmm. Yeah, even myself, yeah. I would say, I went through the same transition. Menopause is more front and center, that was what got all the attention. And now, it has definitely shifted- but a decade and a half almost earlier, 10 to 15 years earlier from the typical menopausal patient for sure.

Dr. Davidson: But those patients, we will soon- as I said, in a few years, we’re going to go through menopause. So, let’s create a nice foundation now moving forward. So I, maybe- you know, everybody’s practice is different.

Dr. Maki: Yeah, right. Well, and then also, probably, for the ones that we’re already dealing with that are already in perimenopause, it smooths their transition a little bit. They’re not having to start from scratch. There are already some things in place that make it a lot easier for them. I don’t think we need to necessarily beat a dead horse about this, but it was just a question that came up just a couple of days ago. And I’m like, “You know what? That is actually a really good podcast episode. Which one’s worse?” The conclusion is I wouldn’t say that there isn’t necessarily one worse than the other, they’re both really challenging for women to deal with.

Dr. Davidson: Yeah, and they’re not bad. I mean, everybody’s bodies, you know, we’re not statues. We have different stages in life from birth until we’re no longer on this planet. We’re always changing so I wouldn’t say they’re bad. It’s just, “Okay. Well, what can we do to make the circumstances smooth and easy and make this a good time?”

Dr. Maki: Yeah, sure. Right. So, if you have any questions, you can always reach out to us at [email protected]. That’s an easy way for you if you want to stay anonymous. You can just ask us questions. When we do actually read listener questions on the podcast, we, of course, always change everybody’s name just to keep a little bit of anonymity there so you can ask your question with some discretion. Now granted, this is obviously a podcast kind of designed for women, so we get all these different types of questions and we welcome them. So again, [email protected]. Dr. Davidson, do you have anything else to add or can we call this one a wrap?

Dr. Davidson: Like you said, this podcast is for women but to be honest, like you were talking about the “Husband’s Guide to Perimenopause”, I think it could be for everybody. So we need to do something for the fellows or the partners.

Dr. Maki: Well, I don’t know… but maybe they would. Maybe just with the right title, maybe a husband or a boyfriend or something would actually listen to it. So it’s like, “Please help, what’s going on?”

Dr. Davidson: Or “I just want to be supportive and helpful.”

Dr. Maki: Yeah. Well, I don’t necessarily feel sorry for the men necessarily. But at the same time, I hear from the patients that their husbands will kind of blame it on their hormones all the time. And I don’t think that’s necessarily fair either. They get to use that as an excuse. And believe me, I’m just a dumb man so I know that we can drive our better counterparts crazy sometimes. And I’m certainly guilty of that myself. I think men are just a little bit ignorant and they just don’t understand sometimes the complexities of these hormonal issues. They don’t understand why things are happening. So, hey, if men listen, great. And that’s not really who we’re targeting. I don’t think we’re going to shift that much because I think it would be lots of crickets on the other end. But still, nonetheless, it’s good to get the information out there and hopefully, this was helpful for everyone. We’re going to do a few more, you know, kind of perimenopausal-specific ones over the next few episodes. So, if you do have your questions, please send them in. Until next time. I’m Dr. Maki.

Dr. Davidson: I’m Dr. Davidson.

Dr. Maki: Take care. Bye-bye.