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Migraines, Hot Flashes, and Unpredictable Bleeding: Getting Through Perimenopause

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Migraines, Hot Flashes, and Unpredictable Bleeding: Getting Through Perimenopause

Dec 01, 2023

Perimenopause is the final stretch before you stop having periods altogether. For many women, it’s a frustrating time filled with hot flashes, heavy and unpredictable bleeding, and a lot of hormones. Even though perimenopause is different for every woman, Kirtly Parker Jones, MD, talks about what you can expect before those pesky periods leave your life forever.

Episode Transcript

There is a little story about the chicken farmer and his favorite hen. She'd been a very reliable egg producer for years and one morning he finds a nickel in the nest instead of an egg. The next day, a quarter. The next day a penny. Frustrated, he brings her to the chicken gynecologist. After a careful history and physical exam, the doctor says to the farmer, "No need to worry, Sir. She's just going through The Change."

I know, I know... it's hard to tell a joke on a podcast… but I think this little story shines a light on the frustration and the unpredictability of the menopausal transition, especially the time before the menopause.

What is Menopause?

The menopause is the last period.  Of course, you don’t know it is the last period when you're having it. You don't know until you look back a year with no periods and can say, "That period I had a year ago was my menopause." For many women, the most difficult time of the menopausal transition—the transition from periods to no periods—is the time before the last period when they are running out of eggs but they're not done yet, and hormones are made in fits and starts. The rock and roll of hormones. This is the perimenopause.

What is Perimenopause?

Perimenopause is that time between predictable periods that happen about monthly, and no periods. The average time of this unpredictability is about four to five years. But it varies. There are those very lucky 8% of women who are completely regular and predictable until one day they just stop having periods, and one year later, we can say that last period was the menopause. Lucky you.

That leaves 92% of the rest of us. We have to suffer the slings and arrows of outrageous hormones. Sometimes up, sometimes down. But the rule of the perimenopause is that the hormones are predictably unpredictable.

A significant number of women have had a hysterectomy but left their ovaries and they don't have unpredictable periods to tell them they're in the perimenopause, byt they do have some of the symptoms, so they kind of know that something is happening. So let's talk about the perimenopause.

Unpredictable Bleeding

Unpredictable bleeding. Sometimes very heavy, sometimes light, sometimes closer together, sometimes farther apart, and sometimes all of the above. Many of these periods are not under hormonal control of ovulation so they can be very heavy. And if you've had other gynecologic problems that come at this time of life, like polyps and fibroids, the bleeding can be very heavy.

This combination of hormonal irregularities and lumps in the uterus can bring women to their gynecologist to fix that. And fixing it can be done with hormones or hormonal IUD, and endometrial ablation, which gets rid of most of the uterus lining or hysterectomy.

But if you're bleeding is manageable, it starts and it stops, doesn't go on forever with persistent spotting or dangerous heavy bleeding, women all over the world ride this out. If the bleeding is persistent or heavy or you're just worried, you should see your clinician.

Hot Flashes

Let's talk about hot flashes. When the hormones are high, you don't have any. When they're low, you do. The Goldilocks phenomenon. Many women have hot flashes when their ovaries still make hormones, but the process is more off and on.

Usually, the hot flashes are not troublesome in the perimenopause and not as many as in the menopause, meaning, when you're really out of hormones. But if you're not managing, and you are rocking and rolling, you should see your clinician.


Headaches. About 17% of American women have migraine. More women have migraine than men and many women's migraines are hormonally triggered. Women with migraine may find the perimenopause particularly stormy as the ups and downs are higher and lower. Unfortunately, manipulation of the hormones isn't easy and it's often not that helpful. There are medications for migraine that can help both the migraine when it comes, and to prevent it in the first place.

The good news is we have better ways to treat migraines than we did even ten years ago. Many women with migraine get significant relief when they finally get over the rock and roll of the perimenopause and get through the menopause. For women with tension headaches, it doesn't really change with the menopause. Our stresses are still there, work, family, etcetera.

Hormones and Stress

So let's talk about stress. It is really unfair that the perimenopause often coincides with our children's puberty. Talk about hormonal rock and roll. Well, let's put everyone in the house, boys, girls, dads, moms, on birth control pills, and take the same hormones every day and see what happens. That's just a joke.

But for mood disturbances, women who struggle with the emotional responses to hormonal ups and downs when they were younger, like PMS or postpartum depression, many find perimenopause particularly difficult. Anxiety and depression noted in the previous years can be more troublesome.

Brain Fog

Another brain symptom that has caught hold in the world of women is "brain fog."  I am pretty sure that brain fog is not a medical term and it is not well defined if I look it up in the medical dictionary.

When asked, women have a hard time describing it but they know that their brain isn't working at the speed and capacity that it used to. It may come and go. There are many reasons that someone doesn't feel that their brain is at its best. Lack of sleep—that could be hot flushes, teenagers, crabby partners, worries about money, worries about the planet, post-viral symptoms like long COVID, or other hormone problems.

Even very experienced and widely read clinicians can have a hard time pinning down the reason for what women are describing as brain fog. When other reasons are ruled out and a woman is in her 40s and her periods are irregular, it may be perimenopause. Approaches to therapy can focus from that point.

Mood Disturbances

If there's a mood state that's the hallmark of the perimenopause it's irritability, crabbiness, and for a dozen good reasons, hormones, bleeding, weird kids, older parents that need help. Most women who experience irritability in their 40s have a perfectly good reason to be irritable. But for some women an irritable brain—noises too loud, lights too bright, everything just a little too much—perimenopausal hormone changes can be the reason and there are medical and alternative medicine approaches to this problem. A knowledgeable clinician has a bunch of tools in their menopausal tool kit.

Most women don't need to be treated medically for their irregular hormones or moods or their perimenopause. Often girlfriends, exercise, private time, care about healthy eating, and regular eating, all these can be helpful. But remember, what worked for your sister, your mother, or your girlfriend may not work for you. Because you are the only you that is. You and your clinician can decide if you could use professional counseling, but medications should be used sparingly except in the case of serious depression and anxiety.

Weight Gain

Lastly, but not leastly, weight gain. Sorry ladies, it probably isn't your hormones. Many studies all over the world have documented the discouraging weight gain that begins  in the late 30s and early 40s, but isn't associated with the hormonal fluctuations unless you're a stress eater when you get crabby. It's related to slightly lower caloric needs with aging and decreasing physical activities. Sorry, I am more sympathetic than you can possibly know, but you know what you need to do.

Choosing the Right Resources and Clinician for You

So the perimenopause is a natural, if aggravating transition in the lives of all women who live that long with their ovaries. Eighty-five percent of women get through it without medical intervention.

I think one of the hardest things to navigate in the menopausal domain of the perimenopause is which clinician to see. There are pop-up online menopause doctors and nurse practitioners and others who claim that they are experts in menopause and perimenopause and can help you over the internet. Well, they might be experts and they might not be and you will have a hard time figuring it out. Sometimes the therapies offered have medical and scientific foundations, and some don't.

There are also people in the community who are not licensed physicians or nurse practitioners or PAs, or maybe they are, who may practice outside the rather vague lines of standard care of the menopausal transition. That doesn't mean that they might not be helpful, but some are prescribing drugs that are not FDA-approved or supplements that have not been proven to work.

The problem with perimenopause is that the hormonal bar is moving all the time. It is hard to pin down where a woman actually is from month to month. You might feel better on a nontraditional therapy because you were going to get better anyway. Or it could be the placebo effect. This makes it very difficult to navigate the health care landscape. There are many licensed and knowledgeable clinicians who don't really know much about the perimenopause.

If I could offer a suggestion, consider a clinician who is part of a midlife women's clinic or program. Here at University of Utah, we have a Midlife Women's Health and Menopause Program specifically to see women with questions and problems in midlife and the menopausal transition. Consider a clinician who has taken special training in hormonal problems such as reproductive endocrinologists. Consider a clinician who has done some extra training in midlife women's health and is certified by the North American Menopause Society. If your regular clinician isn't any of these, but you have a long relationship with them and you have developed mutual trust that together you will work through this transition, that would be good too.

Whoever your clinician is, if you are having heavy bleeding, they should do a careful physical exam and pelvic exam. They should know what problems other than perimenopause can lead to heavy periods, irregular periods, mood swings, hot flashes, sleep disturbances, and brain fog. If you aren't feeling better by listening to your own inner physician and working with your regular clinician, you may have to look around. Be careful—the internet is filled with good and bad information and it is very difficult to know what is what. The good news is that this won't go on forever, even though it feels like it might.

You will share The Change with the sisterhood all over the world. It makes for some great stories, and ladies, I know you can do it. When you get to the real menopause it gets easier, even if the hot flashes might get worse. If you don't think you can make it, we can help.


updated: December 1, 2023
originally published: May 21, 2015