This is a book extract from ‘The M Word: How to Thrive in Menopause’ by Dr Ginni Mansberg*.
Chapter 2: Meet Your Hormones
We can’t start to talk about perimenopause and menopause without describing your hormones and their actions. I’m going to take a bit of a sprint through these and give you some definitions. Menopause marks the effective end-of-production of one of your hormone mega-factories, your ovaries. They have, hopefully, served you well up to this stage, giving you fertility and producing the hormones that help keep you youthful and healthy. Technically, the day of the start of your menopause is 12 months since the first day of your last period. We are hard at work to change this as it is tough on women who have had a hysterectomy or are taking a medication that suppresses periods. But that’s what we are stuck with for now. The average age of natural menopause in Western societies is 51 (one to two years earlier for smokers), although the range is huge. Hitting menopause anywhere between 45 and 58 is pretty normal. It’s worth noting that in Australia, 12 per cent of women go into menopause before age 45 and 4 per cent before age 40. But for most women, you can expect to live at least a third of your life as a postmenopausal woman. Or even a half!
Until the day you do hit menopause, you’re technically still in perimenopause. Perimenopause (‘menopause transition’) is defined by the World Health Organisation and the North American Menopause Society as the two to eight years preceding menopause and one year following your final period. What does perimenopause look like? Well, in 10 per cent of women it looks like nothing. Normal life . . . and then one day you realise it’s been a year since your last period; so, you’ve hit menopause with no symptoms at all. Ninety per cent of us get some symptoms, from hot flushes (up to 75 per cent of women) to heavy periods (25 per cent of us), unpredictable irregular periods, vaginal dryness, insomnia, mood problems, exhaustion, low libido and incontinence. Fun? Yeah, right.
What do my ovaries do?
In every typical premenopausal 28-day cycle, an amazing and mysterious miracle takes place: one of your millions of sleepy immature eggs is selected as ‘egg of the month’. Under the steady influence of follicle-stimulating hormone (FSH) released by the pituitary gland in the brain, the egg begins to grow inside its follicle or bubble. When the follicle reaches a certain size, it triggers the same pituitary to send in a surge of luteinising hormone (LH). LH tells your follicle to go ahead and release the egg, which heads off down the fallopian tube, hopefully to meet the sperm of her dreams and turn into a baby. What is left of the follicle is now called a corpus luteum. Along with the name change comes a function change. The corpus luteum produces stacks of progesterone and a more moderate amount of oestrogen; these hormones are essential for the health of the embryo. Assuming the egg didn’t meet her Casanova sperm and get fertilised, the corpus luteum eventually fades and, with it, your oestrogen and progesterone levels. Once they are low enough, your uterus can no longer hold on to its lining, which starts to break down and come out as a period. Once you are through menopause, your ovaries no longer release an egg of any sort. Your fertility is over.
What happens to all these hormones during perimenopause and menopause?
I want to start by saying that this area is poorly understood, including by doctors. It wasn’t until I was going through perimenopause myself that I got my teeth into the research and started hounding the experts. The easy part to understand is actual menopause. By now your ovaries have completely stopped working and practically no oestrogen is being made. A small amount of oestrogen will come from your fat (via aromatase, the enzyme that sits in fat cells and converts testosterone to oestrogen). And a small amount comes from the adrenal precursor hormones. But your oestrogen has pretty much flatlined. It’s perimenopause, the era I like to call hormone hell, that has everyone befuddled. While perimenopause and menopause are often thrown in together, hormonally they are as different as chalk and cheese. We know that progesterone does indeed start a steady decline from perimenopause. This decline starts way before your periods even start to become erratic.
It finally falls close to zero as you hit menopause. The perimenopause falls into two categories along a timeline we call the Stages of Reproductive Aging Workshop (STRAW). STRAW-2 (two steps from menopause, which we call zero) is the first half of perimenopause. During STRAW-2 you start ovulating less often and the ovulations you do have don’t give you a nice, well-functioning corpus luteum, so your ovaries simply can’t make progesterone like they used to. In STRAW-1 ovulation is even less common but your oestrogen levels start to decline too.
Old-school thinking was that oestrogen does the same thing: a slow decline. We now know that the picture is far more complex. Many studies have shown that, in fact, during perimenopause your oestrogen fluctuates up and down like a yoyo. This is because, as your ovaries are getting a little weaker and just cranking out less oestrogen generally, your pituitary gland in your brain leaps into gear and starts pushing out FSH. These slightly aging ovaries will move between sluggishly ignoring the FSH, to having a massive response and pushing out stacks of oestrogen. So, you can oscillate between low oestrogen and excessive oestrogen month to month, week to week, even day to day.
In the final stages of perimenopause (STRAW-1), particularly in the one to two years prior to your final period, your oestrogen levels finally do decline and you get less episodes of the excess oestrogen. Plus your androgens are doing a last bizarre surge before true menopause starts. All of which leaves you in hormone hell. On days when you get excess oestrogen and lack of progesterone, you’ll enjoy insomnia, anxiety, breast tenderness and swelling. The next day your oestrogen levels might fall, so you may get hot flushes from oestrogen withdrawal. Blood hormone level tests at this time are utterly useless, because the levels one day bear no relation to the levels the next day or the next week. It’s a difficult time for fertility too. The high levels of FSH can see women ovulate not once but twice.
So, in terms of fertility, you kind of lurch between very low fertility, and extreme excess fertility with a high risk of twins. And if you’ve had anxiety or depression before, watch out. You hit peak emotional roller-coaster around the time of your menopause transition.
*Mansberg, G. (2024). The M Word: How to Thrive in Menopause. Murdoch Books. (Originally published in 2020). Purchase a copy at www.eskcare.com.
Dr Ginni Mansberg is a GP specialising in menopause management, a TV host on Channel 7’s Sunrise and The Morning Show, and the author of The New Teen Age and Save Your Brain. Voted Australia’s most trusted healthcare professional in 2022, she is also a member of the Australasian and International Menopause Societies and co-founder of Don’t Sweat It – Menopause in the Workplace. She’s also the founder of ESK Evidence Skincare.
This article originally appeared in the Issue 01 2025 print issue of Professional Beauty magazine. Read it here.
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