In the past couple of weeks, several women in their 30s have come into my office asking about perimenopause symptoms. None of the women were in perimenopause, defined as having periods that vary in length by more than seven days from the first day of one period to the first day of the next. Mostly they were feeling well, though one was more tired than usual and another was worried about increased hair loss.
Each of them mentioned that they saw stories in the media about a study that recently came out suggesting that more than 50% of women in their 30s are experiencing perimenopausal symptoms. They were concerned about the idea that these women’s symptoms are not being recognized or addressed. But they all wanted to know, do they need to watch for symptoms of perimenopause, and if they do have symptoms, what should be done about them?
What is this study, and what does this new data tell us?
The media reports my patients were asking about stem from a paper published in Nature Women’s Health. The authors collected data from more than 4,000 women between the ages of 30 and 60 about their menstrual periods, symptoms, and whether they had been diagnosed as perimenopausal or menopausal.
The women who participated in the study, recruited online or through the Flo app, were asked whether they had ever seen a doctor because of menopause symptoms and if the doctor had indicated that they were in perimenopause or menopause. The women were also asked about their menstrual cycles: were their cycles irregular; had they had cycles that were longer than 35 days, or 60 days; had they had a period in the past 12 months? Then participants completed the Menopause Rating Scale (MRS), a survey tool to quantify the presence and severity of women’s perimenopausal and menopausal symptoms.
Jep Gambardella
The authors found a number of associations in the data that were not surprising. Women who were over age 45 were more likely to have seen a doctor about menopause symptoms and were more likely to be diagnosed as being in menopause or perimenopause. Women who were diagnosed as being in menopause or perimenopause were more likely to have a higher score on the MRS, suggesting more severe menopause symptoms.
They note that relatively few women sought care for their menopause symptoms. Even among women between the ages of 45 and 55, when perimenopause and menopause symptoms peak in severity, less than half of participants sought care from a medical professional for their symptoms.
The women with the highest MRS scores were more likely to seek care. That means that the reason some of the women don’t seek care is because their symptoms are mild or they aren’t really symptomatic at all. But given that more than 60% of women have MRS scores indicating moderate or severe symptoms and just over 40% of women reported seeing a medical provider about their symptoms, there are clearly some women who are experiencing disruptive symptoms but aren’t seeking help from a medical professional to manage them.
To my mind, that is the most important takeaway from this study. We can do better supporting women in perimenopause. Grinning and bearing perimenopausal symptoms is unnecessary. We need to make sure women have access to medical providers educated in managing perimenopausal symptoms.
Should women in their 30s worry about perimenopausal symptoms?
One of the surprising findings from this study, and the one that the media focused on, was that some of the participants in their 30s had high scores on the MRS, indicating that they were experiencing significant symptoms. The authors suggest that this means women are having perimenopausal symptoms long before they are in perimenopause. And because women weren’t aware of this, they were not seeking care for perimenopausal symptoms.
My interpretation of the data is different. Let me explain why.
The tool the authors use to evaluate symptoms isn’t accurate for women under the age of 40
The way the authors determine whether a woman is experiencing perimenopausal symptoms is with the MRS. However, the MRS has been validated — meaning it has been shown to produce repeatable results — only among women over the age of 40. It has not been validated in women under age 40, and the authors in fact note this in the study. This means that they knowingly utilized a tool that has not been validated in a portion of their study population, calling into question the validity of those results.
A careful review of the data presented also shows that a large percentage of the participants in their 30s didn’t even complete the MRS. Often people who are more symptomatic are more likely to report their symptoms. The women who completed the survey are therefore likely to be different from the women who didn’t complete the survey. This further undermines the quality of the data reported.
The symptoms participants reported aren’t specific to menopause
Some of the questions on the MRS ask about symptoms that are relatively specific to perimenopause, such as hot flushes and vaginal dryness. But many of the symptoms the scale asks about are not specific to perimenopause, such as mood changes, depression, anxiety, sleep problems, and an unusual awareness of your heart beating. A participant could rack up a score of 17 or more points — the cutoff for severe symptoms — without having any symptoms specific to perimenopause. In fact, a participant experiencing severe anxiety from another cause may score quite high on the MRS.
The authors divided MRS scores into three groups by the type of symptom: urogenital (i.e. vaginal dryness, bladder problems), psychological (i.e. depression, anxiety, irritability), and somato-vegetative (i.e. hot flushes, heart problems). The participants in their 30s had much higher scores in the psychological category than the urogenital and somato-vegetative categories. The psychological symptoms are the least specific to perimenopause.
There isn’t a biological mechanism to explain perimenopausal symptoms in women who aren’t actually in perimenopause
The authors do acknowledge that high MRS scores among participants under 40 may be due to causes other than perimenopause but quickly dismiss this possibility without giving a reason why. I am not so quick to do so. Not only has the MRS not been validated in women under 40, there is also no clear biological explanation for why these premenopausal women’s symptoms would be related to perimenopause.
Perimenopausal symptoms are thought to be caused by rapidly dropping and low estrogen and progesterone, and to some degree by high follicle-stimulating hormone. Most women in their 30s, particularly those having regular menstrual cycles — which most of the participants in their 30s reported they were — would not likely have rapidly dropping or low estrogen and progesterone levels or high FSH levels.
It is possible that some participants, particularly those over the age 35, may be in the late-reproductive stage and thus may be having some symptoms related to increasing hormonal fluctuations, but only 37% of women in their 30s will be in the late-reproductive stage. Without a possible mechanism, it is hard to attribute the symptoms women in their 30s are experiencing to perimenopause.
Why does it matter whether the symptoms women are having are due to perimenopause or not?
It is important to accurately understand the cause of the symptoms women in their 30s reported in this study for a couple of reasons. First, when we wrongly normalize perimenopause as a process that women may experience in their 30s, women may minimize or dismiss the symptoms they are having. As we have seen, even in the years when perimenopausal symptoms are most common and most severe, women do not seek care for their symptoms. All women deserve care for the symptoms they experience that interfere with their daily functioning, regardless of the cause. But we cannot help women who do not seek care.
A small percentage of women do have signs and symptoms of perimenopause in their 30s. It is especially important for those women to receive appropriate care. Primary ovarian insufficiency (having your last menstrual period before age 40) and early menopause (having your last period between the age of 40 and 45) carry long-term effects, including an increased risk for cardiovascular disease and osteoporosis. As a result, women should be counseled regarding these risks and offered treatment for their symptoms.
Additionally, when women in their 30s are told their symptoms are a normal part of perimenopause, they may not have another cause for their symptoms identified and treated. A patient may have severe anxiety or a thyroid problem. But their doctor might attribute their symptoms to perimenopause rather than looking for another cause that would be treated very differently.
Ultimately, we are doing young women a huge disservice by suggesting that their moderate to severe symptoms are due to perimenopause, when the evidence that perimenopause is the cause of their symptoms is not convincing.
The bottom line
Survey data suggests that women in their 40s and 50s are experiencing moderate to severe symptoms of perimenopause and menopause but that many are not seeking care from medical professionals.
A high number of women in their 30s also reported moderate to severe symptoms.
The tool used to assess symptoms has not been validated for use in women under age 40. And there is no clear mechanism by which perimenopause would cause those symptoms in women who aren’t perimenopausal. As a result, it is likely these symptoms are due to other causes.
Wrongly attributing young women’s symptoms to perimenopause may decrease the likelihood that they will seek care and that they will be accurately diagnosed and treated for their symptoms.
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