Who knew that your husband’s chewing could annoy you so much? This aversion to the sound of loud crunching, slurping or gulping is called misophonia. The annoyance you feel as a wordsmith when the simplest terms now evade you, however, is categorised under anomia. When your somewhat regular cycles are completely off kilter and swing back around faster than the merry-go-round at your kid’s local park, it is considered polymenorrhea. Your children’s incessant calling for ‘mum’, ‘mum’, ‘mum’ that triggers overstimulation and irritability, on the other hand… well, I don’t have a fancy word for that one. But, what if you haven’t experienced the infamous hot flashes or night sweats, otherwise known as vasomotor symptoms?
All of these little labels on things I’ve been experiencing lately have compounded into a big, all-encompassing question: am I perimenopausal, or is this just my new personality?
As a woman who is on the precipice of turning the ripe old age of 43, I’m noticing big shifts not happening just within myself, but with my girlfriends of the same vintage too. Our tolerance for noise and nonsense in equal measure is very low, which is quite the transformation from our people-pleasing selves of times bygone. Perhaps we are just older, so we generally have less f*cks to give, plus we have more experience under our belts and are more secure in our resolve than ever before. Or perhaps something less innocuous is changing within us on a cellular level and the cantankerous ‘vibes’ are just the symptom. Being a curious individual, I decided to take it upon myself to find out more. After all, this question, and I suspect my hormones, have been keeping me up at night anyway. Certifiably losing sleep over it.
Winter is coming
‘Second Spring’ or dì èr chūn, 第二春. This is how menopause is described in traditional Chinese medicine. The thought is that women are empowered by the change of Jing and blood flow used for menstruation, fertility and supporting pregnancy being redistributed to things like vitality and an internal restoration and regeneration. While I absolutely love this beautiful sentiment, if menopause is a flourishing vernal phase, does that mean perimenopause is the cold, bitter winter before hope springs eternal? When the wind bites your face, the trees shed their beautiful foliage and all you want to do is hibernate? If I’m facing this harsh season, figuratively speaking I’m going to need a warm shearling jacket, a hot caffeinated beverage and maybe even some mulled wine to get through it. To put it another way, if I consider myself in the chrysalis phase, I shall require some tools to help me complete the metamorphosis with grace. Perhaps a guide or two—cue the experts.
For Dr. Laura Biffin, Family Physician and Founder of River Valley Doctors, Singapore, perimenopause and menopause have become a particular area of interest. “I actually feel incredibly lucky to be turning 40 at a time when we are finally talking about this properly. I say to my girlfriends all the time: aren’t we fortunate that we know about perimenopause before it hits us? I genuinely think we are one of the first generations of women to have that privilege.” It’s true that our mothers’ generation sort of went into menopause blind, with symptoms shirked as ageing, stress, depression or just a general ‘comes with the womanhood territory’ label and to just grit and bare it. Their plight perceived as an inevitability.
Dr. Biffin believes we have an opportunity to do it differently now. “I love being able to see a woman at 40 or 42 who says, ‘I just don’t quite feel like myself’, and help her work out what is happening before she gets to the point of being completely exhausted or miserable.” She continues, “perimenopause can affect sleep, mood, periods, sex, bladder symptoms, bones, cardiovascular health, weight, relationships and work. You really need someone looking at the whole woman rather than each symptom in isolation.”
“I say to my girlfriends all the time: aren’t we fortunate that we know about perimenopause before it hits us? I genuinely think we are one of the first generations of women to have that privilege.”
What is perimenopause?
The transition (not condition) that is perimenopause is rather curious as it is predominantly a clinical diagnosis, in that bloodwork alone might not tell the full story. Oestrogen and FSH can fluctuate tremendously and as a result, a clinical evaluation, symptoms analysis and a process of elimination of other potential issues are used to draw conclusions. Dr. Biffin often looks at things like a full blood count, iron studies, thyroid function, B12 and folate, vitamin D, kidney and liver function, glucose or HbA1c and cholesterol as part of an overall health assessment, based on the individual. Cervical and breast screenings need to be up to date and depending on bleeding patterns, pelvic symptoms or history, sometimes a pelvic ultrasound might be requested as well. Then the entire clinical picture is taken into account: sleep, fatigue, irritability, mood, periods, headaches, libido, vaginal and urinary symptoms, contraception, family planning and medical history. For her, “unfortunately biology doesn’t work that neatly during perimenopause” and “it really is a little bit of an art, because every woman’s version of perimenopause is different.”
Perimenopause is defined by KK Women’s and Children’s Hospital (KKH) as menopausal transition. Essentially, it’s a time when women endure changes in their menstrual cycles, thanks to the ovaries fluctuating the production of hormones. These symptoms can go for many years before the final period takes place. Menopause signals the conclusion of the reproductive phase and oestrogen and progesterone drop dramatically—in Singapore that age is typically 49. Then, a woman is regarded as postmenopausal when she hasn’t had a period for twelve sequential months. As you could imagine, this physiological revolution can have deep impacts on the psychological, before, during and after the bodily coup d’état by our hormones is complete. But does this change in attitude and realignment to self just come down to that? Hormones? Or is it thanks to seasoned perspective and time-honoured discernment?
I saw a post on Instagram which said “Perimenopause is when your people-pleasing hormones fade away and your IDGAF hormones take over.” Some of the commentary on the post included things like “I can’t wait to turn off the ‘filter’” and “as a 40 year old woman who spent most of her life walking on eggshells and people-pleasing… I absolutely love it here.” Perhaps the situation is two fold in that the hormonal change is working in tandem with the overall shift towards being our authentic selves and boundary building in our midlife.
“I have witnessed this as a psychotherapist. Women in their forties often have a greater capacity to allow space for themselves and are intrinsically more connected to self. This, in turn, allows us to have stronger boundaries and live more consciously within our roles.” Aarti Mundae, Founder and Lead Psychotherapist at Incontact Counselling & Training puts down the phenomenon that mature women seem to ‘stop caring’ potentially down to things like “the accumulation of life experiences, which augments self-awareness and assuredness.” She goes on: “We have lived through enough to understand ourselves better, recognise what works for us and become more assured in our choices.” Although she suggests that there are ways to go about things and haywire hormones could also be playing a part.
Boundaries, boundaries, boundaries
I postulate that in this era, while women can often be dubbed as more ‘mean’, perhaps it is just people who benefitted from our lack of push back before this evolution that are behind that commentary. Could that be what’s happening here? Mundae thinks that we need not establish new parameters with abrasiveness and likewise those around us need to accept the new borders. And when it comes to this biological transition, as a 44 year old herself, Mundae says that “it’s only in the last five years that we have started talking about perimenopause more openly, and women are still blindsided by the changes. Sharing and connecting can be a powerful awakening to what’s happening to them and their bodies.”
She has observed the real connection between hormones and mental health based on research, but to assess the cause of the irascible disposition, exasperation or impatience et cetera of a woman in this age range, she needs to establish a timeframe. In summary, while one size doesn’t fit all, the more incidental the moods, she says the more likely the culprit is hormones. By contrast, more consistent the melancholy, that’s when it’s time to call a therapist. “Even clinical depression and anxiety can have strong links to the hormonal changes that your body is experiencing,” Mundae elucidates. “Serotonin, which is the more pertinent neurotransmitter in depression, is closely connected to oestrogen. Our body and mind do not work in a silo, and it has to be an integrated approach to explore your hormones, gut health, current life context and other physiological symptoms, including sleep.” Again, it seems a holistic picture needs to be taken into account before we start labelling.
“Women in their forties often have a greater capacity to allow space for themselves and are intrinsically more connected to self. This, in turn, allows us to have stronger boundaries and live more consciously within our roles.”
Better the devil you know…
If we look at the early findings of a joint study by Singapore Council of Women’s Organisations (SCWO) and James Cook University (JCU) of 300 women aged 40-59 years old released last year, we must recognise that this is something that needs to be spotlit and taken seriously. 48-50 percent of women surveyed reported experiencing mental health tribulations. Despite this, only 59 percent of those women had sought professional help. At the Summit for Action on Gender Equality, panellists shared that the aggregation of perimenopausal and or menopausal pressures plus caregiving for parents and children while trying to hold down a job was taking its mental toll. It can be a uniquely challenging juncture in a woman’s life. I guess one huge side of understanding all this is acknowledgement and education.
Earlier this year, Singapore’s first set of Guidelines on Management of the Menopause Transition were launched by KKH Maternal and Child Health Research Institute (MCHRI). They’ve recognised this often overlooked stage requires a consistent, evidence-backed framework to standardise care for women, but with tailored recommendations. This is a huge step in the right direction. Then, coupled with a nuanced understanding of Hormone Replacement Therapy (HRT) these days—it’s now widely seen in Singapore as a safe and effective way of managing symptoms in healthy women below 60—suddenly, we have more research and options at our fingertips. For a while there, the 2002 Women’s Health Initiative study created enormous fear around HRT, linking combined oestrogen-plus-progestin therapy to an increase in breast cancer, heart attacks, strokes and blood clots. Millions of women discontinued its use because of it.
“Nobody necessarily puts the jigsaw puzzle together.”
So, how do we deal with all this?
While we can now reconsider if HRT is right for us to help in a hormonal deficit, up until this point I feel information around women’s health, but very much perimenopause and menopause has seemed opaque. There is no one ‘holding our hand’ through these transitions. Dr. Biffin would agree. “I think women have historically been prepared remarkably badly for this stage of life. We learn about puberty. We learn how not to get pregnant. We learn about pregnancy and childbirth. You could argue these were also badly explained. But if that was deficient, well the peri is the ultimate black hole. Nobody sits you down at 38 and says: ‘Over the next ten years your hormones may start behaving differently. Here are the things you might notice. Here is what is normal. Here is what isn’t. And here are the things we can do about it.’ That is crazy to me when you consider that almost all women will experience this transition.”
If we revert back to the start of the article, there’s also so much guesswork involved too. Dr. Biffin continues, “medicine has historically dealt with women’s symptoms in silos. You see somebody about insomnia. Somebody else about anxiety. Somebody about heavy periods. Somebody about recurrent UTIs. Maybe somebody else about migraines. Nobody necessarily puts the jigsaw puzzle together.” It seems being proactive and an advocate for your own physical health is certainly instrumental. On the mental front, we can also harness therapy and nervous system regulation resources to help with management of mental perimenopause symptoms like rage, sensitivity or irritability.
But we can also embrace the change with the help of our community. “The biggest gift I would want from my loved ones is for them to educate themselves. I would want them to label, acknowledge and help me reframe the noise”, says Mundae. “We need to not just educate women, but involve partners and teenage children. And, not to miss workplaces, we need more aware and inclusive workplaces for women in their 40s. This needs championing and companioning—to retain and grow perimenopausal women through accommodation and recognition.”
“It can also be a phase of life where we are ready to explore outside of the social conditioning we have been living with.”
In Mundae’s view, it’s not all grim by any stretch. If we learn and recognise what is happening to our bodies, to not just contain and regulate, we can actually celebrate and thrive. This segue to a new season can be an empowering exercise in recalibration. “Career pivots and reinvention can happen at this stage of life as we are more desensitised to fear and our risk appetite has expanded. We are more experienced with life and more connected to self. All of this allows for more creativity in the way we see the world and ourselves. It can also be a phase of life where we are ready to explore outside of the social conditioning we have been living with.”
Maybe it is perimenopause and my new personality. Maybe winter isn’t so bad after all.
