Confused about perimenopause? Don't worry - even docs don't agree!

What is climacteric?

Though it may appear simple, when we look a bit more deeply it becomes clear that the term "perimenopause" is controversial and confusing.

So what do doctors say? Have they got the picture nice and clear?

If only…

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Physicians in a fog...

In July 2001 a group of 27 experts met up in Park City, Utah, USA to try and make sense of all the confusion about women's reproductive aging process.

The experts' goal was to define each stage of woman’s journey through middle age: past the menopause ("final period" non-event), from reproductive to post-reproductive life.

This expert group has become known as STRAW, which is an acronym of STages of Reproductive Aging Workshop. The STRAW definitions are clearer than anything that had gone before and are still the ones most often quoted by doctors and scientists.

The STRAW group used the final (ever) menstrual period as the anchor of their staging system and then set about dividing up the phase before this last period and the phase after it, into 7 different stages.

The first 3 stages form the reproductive phase (early, peak and late). The 4th and 5th stages constitute the menopausal transition (early and late) and finally the 6th and 7th phases form the post menopause (early and late).

Still with me?

Although it may seem logical (if a bit complicated), the STRAW experts recognised that women’s bodies don’t work like machines and that in some cases we yo-yo back and forth between one phase and another.

Also not everyone goes through each stage in a logical order and some women may skip a stage altogether.

Which symptom when?

So what symptoms what symptoms can we expect at different stages of the transition?

Unfortunately this question, which is probably the one of most interest and concern to women, doesn’t have a clear answer.

This is what the STRAW group had to say about perimenopause symptoms, signs of peri menopause and the menopause transition:

"Not all women have symptoms as they transition to the menopause and women with symptoms experience them in different combinations and different levels of intensity. These symptoms are subjective by their nature, which makes quantification difficult. It has been observed that symptomatology varies markedly between ethnic groups, and even in different climates. Furthermore, these symptoms do not track closely with the menstrual cycle or endocrine change during the menopause transition."

Soules MR et al. Executive Summary: Stage of Reproductive Aging Workshop (STRAW). CLIMACTERIC 2001;4:267-72.

So in other words:

You might get any number of symptoms, in any old combination, at any time during your midlife passage. But on the other hand you might not.

Clear as mud, right?

What about the definitions of other terms related to menopause that STRAW came up with? We’ve talked about what the word menopause means, so let’s take a look at the definitions of those other old chestnuts:

Perimenopause, Menopausal transition and Climacteric

The STRAW group regarded the term "perimenopause" as a bit too general for use in "scientific papers". They didn't say so, but wishy washy – was probably what they were implying. Their comment was that perimenopause, just like that other term "climacteric" should only be used for talking with patients and in the lay press.

Unscientific it may be but women and their doctors use the word perimenopause all the time so the STRAW group had a go at defining when it starts. According to STRAW the perimenopause starts when periods first become irregular (Stage -2) and ends 1 year after that magic, non-occuring final menstrual period.

Hmmm...

Instead of perimenopause, say the STRAW experts, the term "menopausal transition" should be used (when talking scientifically one supposes). The menopausal transition begins, just like peri menopause, when periods become irregular. But unlike peri menopause, the menopause transition ends WITH the final menstrual period ... which of course nobody knows IS the final one till after 12 months have gone by without another.

Now if you’re finding this a little tricky to follow, fear not, because so have others:

Disagreement amongst experts

A few months after the STRAW definitions had been published, another group of experts, this time from Europe chimed into the debate, saying that instead of clarifying things the STRAW report made things even more confusing!

The European authors pointed out all sorts of contradictions in the definitions, and also made another very important point:

"As long as many aspects of the reproductive aging process in the female are not understood, it will remain difficult to design a classification system that is adequately and widely applicable".

Den Tonkelaar et al. "Executive summary of the Stages of Reproductive Aging Workshop (STRAW): not less, but more confusion." CLIMACTERIC 2002;5:399-402.

Women remain mysterious

So we come back to the point that many doctors and scientists prefer not to stress too much: Women’s bodies and our natural process of passing from fertility to infertility are still big mysteries.

So don't let anyone persuade you otherwise!

Published February 2010. Updated 26/2/2011

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