Changing Hormones Equals Changing Emotions

It was Monday morning and Sari awoke to the sound of her alarm clock. Her husband, Sam, walked over to the bed, gave her a hug and asked her to join him for breakfast, which was almost ready in the kitchen. He was happy and smiling and ready to start the week. Sari shook her head, fighting the tears that were about to spill over. She did not have the heart to bring Sam down again. When Sam left to have his breakfast, Sari dragged herself into the shower. As the hot water poured over her, she allowed the tears to flow, as she had done so many times before. For the hundredth, if not the thousandth time, Sari searched her heart and her mind for what could possibly be so wrong to make her feel this way. With a loving husband, happy healthy children, financial security and a job she loved, why now, was she so miserable?

When a woman's body enters perimenopause the regular cycling of hormones that she has been accustomed to since puberty begins to undergo a change. An irregular pattern of hormonal fluctuations is activated, beginning with a significant rise in levels of estrogen and ending with a gradual decrease in estrogen and progesterone. Although all of the hormones, estrogen, progesterone, follicle stimulating hormone (FSH) and luteinizing hormone (LH) are still cycling, the patterns of the cycle begin to become unbalanced. This is often when the emotional struggles begin.

Before a woman enters perimenopause, approximately a week after menstruation has begun, low estrogen levels signal FSH to stimulate the ovarian follicles to maturity. One prevailing follicle matures and begins secreting large quantities of estrogen. This in turn, shuts down further production of FSH and stimulates the release of LH, a signal of imminent ovulation. Ovulation is the process by which the follicle ruptures and the egg is released. The ruptured follicle, the corpus luteum, now begins to secrete large quantities of progesterone in preparation for a potential pregnancy. When no pregnancy occurs, the corpus luteum depletes its store of hormones, which results in a lowering of estrogen and progesterone. The lining of the uterus prepares for shedding and menstruation begins along with a new cycle.

When women are in their late thirties, their ovaries begin to accelerate the ripening and loss of follicles every month. Eventually, the number of follicles available for ovulation diminishes until there are none left. This is the body's way of discarding old, potentially defective eggs. FSH increases as it did before, but in the forty-something perimenopausal woman the follicles are no longer as sensitive to the effects of FSH. FSH is knocking on the follicle door, but no one is answering. With the lowered sensitivity to FSH and the highly variable amount of estrogen that is secreted, FSH production is not suppressed. In early perimenopause when estrogen levels may be even higher than in the premenopausal woman, FSH levels are still on the rise (when, in fact, they should be falling). The problem this creates is that with elevated FSH levels, LH is not signaled for secretion. Without LH no follicle matures, no follicle is ruptured, no egg is released, there is no corpus luteum and progesterone production is not signaled. This is the process by which women begin having anovulatory cycles in perimenopause and the start of the emotional ups and downs that we saw in Sari.

These changes in the menstrual cycle do not follow a linear pattern, and that makes this period a very trying one. A woman may have months of normal cycles followed by a stretch of irregular cycles. Some women have a pattern of one month normal, and the next irregular but any type of pattern is possible. In one study on perimenopausal women, 100 different patterns of menstrual flow and cycles were documented in 300 women! This irregular releasing of the hormones creates the variability in the menstrual cycles causing the physiological and psychological effects of perimenopause. As we will learn in the coming chapters, estrogen and progesterone have powerful effects on mood. When estrogen levels plummet, women will experience anxiety, especially if progesterone levels are low or declining with the estrogen. With estrogen levels bouncing around, as they do in perimenopause, a woman's mood, or ability to tolerate stressful events changes in accordance with those estrogen level changes.

When no progesterone is produced in the anovulatory cycles, there is an insufficient amount of progesterone in comparison to the amount of estrogen. This creates a situation called "estrogen dominance." As we will learn, balance among hormones is key to feelings of wellbeing. Estrogen dominance in combination with excess FSH and the elevation of estrogen in the follicular phase of the menstrual cycle are all major culprits in the emotional distress of perimenopause.

Progesterone is the "feel good" hormone. In pregnancy, it is the abundance of progesterone that leaves women with a peaceful, calm and radiant emotional experience. In perimenopause when progesterone is in short supply and estrogen levels are erratic, women are inclined to feel that the...