Hot flashes, mood swings, irritability, depression… The symptoms may be all of the above or some. But the biggest indicator of perimenopause is when a 40-plus woman’s menstrual cycle becomes irregular.

“Some women may experience such changes even in their mid-30s. When hormonal changes start happening, there are a lot of clinical changes that one might notice — joint ache, fatigue, irregular menstrual cycle… The cycle could either lengthen or shorten, which means the periods could get either more frequent or less. One would also notice movement of body weight to the abdominal section. You are eating the same and exercising the same as before, yet the fat moves to the mid section. Along with all this, there are irritability, mood swings and hot flashes, which in turn leads to insomnia,” says Dr Roohi Khanna, a general physician and obesity medicine specialist who is associated with Apollo Cosmetic Clinic in DLF Galleria, New Town.

Adds her colleague at the clinic, dermatologist Dr Snuhi Bhuiya: “Perimenopause also leads to poor cardio-metabolic health. Estrogen, the key female hormone, maintains the level of HDL (high-density lipoprotein), or the good fat. As estrogen decreases, so does HDL while there is an increase in LDL (low-density lipoprotein) or the bad cholesterol. So there will be more deposition of fat along the walls of the blood vessels. Constriction of blood vessels can lead to heart problems.”

Another big issue, Dr Bhuiya says, is dryness of the vagina, which can cause itching. “The chronic itching may lead to eczema and lichenification (thickening of the skin due to scratching). Vaginal tissues may lose lubrication and elasticity, making intercourse painful. There is decreased libido too. Frequent urinary tract infection is another possible fallout of low estrogen level. There may be stress incontinence also due to which one may pass urine while coughing.”

A woman also needs to take care of her bone health in this phase, Dr Khanna points out. “With declining estrogen levels, one starts to lose bone density more quickly than it is replaced, a condition called osteopenia, increasing the risk of osteoporosis, a disease that makes the bones fragile.”

Perimenopause can last for years, even a decade, the doctors say. The symptoms spill into the menopausal and postmenopausal stages as well. While the effects cannot be negated, they advocate preparedness. “These changes will happen and one needs to be aware of that,” Dr Khanna says.

There is a stigma around hormone replacement therapy (HRT) as it brings with it a slight increase in the risk of breast and ovarian cancer. “With depleted estrogen, bone remodelling does not happen. If you are really suffering from osteoporosis, leading to frequent fractures, it impacts the quality of your life. So one should be open to a conversation with the doctor who can decide to offer HRT after weighing the pros and cons,” Dr Khanna says.

Other than HRT, according to Dr Bhuiya, there are symptomatic management options as well for dry skin, open pores, vaginal dryness, fine wrinkles and sagging of the face in the form of oral medicines like collagen supplements, Omega 3, fatty acid and antioxidants. “The daily water intake needs to be two to three litres. Omega 3 is a very important supplement that women should take, unless there are contra-indications like side effects of interactions with other medicines one might be taking, like abdominal bloating or flatulence. It increases HDL and helps with heart and skin health too. In case there are side effects, one should opt for natural sources of Omega 3 like fish, eggs, walnuts, pistachios, chia seeds or flax seeds,” she says.

Muscle up

Dr Khanna recommends starting strength training before hitting menopause. “At this stage, skeletal muscle mass decreases and visceral fat increases. The latter is the bad fat that gets deposited around your organs and gives rise to diabetes and insulin resistance. So make the muscles stronger. You could do yoga, hit the gym, swim or go for resistance training. Opt for a less sedentary lifestyle.”

To build skeletal muscle mass, she recommends “decent protein intake”. “Get the required amount of protein and fibre in your diet starting from your first meal of the day.

The protein requirement is 0.8g per kg of body weight which we barely hit but we can aim for it. We recommend 25g fibre minimum daily. Try to keep a balance on your plate every time you eat. There should be a decent amount of protein even in your breakfast and lunch. For vegetarians, it is a bit more work to get the protein intake right but it can be done,” she urges.

Dr Khanna recommends strength training to all her patients. “Even if you are walking, you can buy wraparound weights and attach them to your hands. It is called resisance training which helps to build muscles,” she says. “Also make sure that your body gets seven to eight hours of rest. Women do not sleep well because of these symptoms. So fix the sleep. Eat your dinner at least two hours before hitting the bed and stay away from the TV and mobile screen before sleeping,” the obesity medicine specialist says.

Addressing depression and stress also helps in improving sleep quality. “Meditate or keep a journal and pen your thoughts to reduce your stress. This is a helpful way if one does not want to take supplements for better sleep, like melatonin and magnesium. If you are not sleeping well five days a week, that is something to consult your doctor about,” Dr Khanna adds.

Blood tests that a doctor might recommend for women of this age group are cholesterol, calcium, vitamin D and D3, fasting sugar, HbA1c and liver function test. “Many develop fatty liver, to confirm which an ultrasonography also is needed. If you suffer a fracture in your early menopause stage, the doctor may also get a bone density test done.”

Skin talk

There will be a sudden change in skin condition when perimenopause hits. “It is common to experience dry skin which also becomes thinner and more sensitive. Even if one has oily skin, there might be a change. This is because collagen, which plays a role in maintaining ceramides, hyaluronic acid and lipid of the skin, degrades. There is almost 30 per cent collagen degradation in the first five years of menopause. Afterwards, there is 2.2 per cent degradation every year. Suddenly there are wrinkles and sagginess of jowls. The lines that were seen only when one smiled would now be visible even on a resting face. The fresh youthful look will be gone,” Dr Bhuiya warns.

The dermatologist explains: “As estrogen depletes and androgen (male hormone) remains the same, there is a chance of flare-up of acne and masculine pattern hair loss. Those who take medication for mood swings and hot flashes are susceptible to pigmentation, or melasma (dark patches or freckle-like spots on exposed skin parts).”

Tips for care

◘ Use a mild cleanser instead of hard face washes with exfoliant. Use hyaluronic acid serum on a wet face. Apply an emollient with ceramide to prevent loss of moisture. Use sunscreen with SPF50 and PA +++ (that protects from both ultraviolet A and B radiation) to prevent sun spots, pigmentation and further loss of elastin. Use an exfoliant to clear up the clogged pores at night.

◘ A retinol, peptide or vitamin C-based serum may be used at night to stimulate collagen production.

◘ Stay hydrated. Sleep early. Have a proper balanced diet.

◘ Use of collagen supplements, antioxidants, Omega 3 fatty acids can keep your skin soft, supple and hydrated. Take the supplement for two three months and give a break of six to nine months.

◘ Non-invasive procedures like laser treatments can be done for pigmentation, removal of excess hair on the face, sagging and wrinkles.