Conquering Perimenopause

By Marcy Holmes, NP, Menopause Clinician Women to WomenThe perimenopausal years bring on hormonal fluctuations that may cause emotional outbursts and feelings of rage. Learn what you can do to achieve balance and get back to being your old self again.

Conquering Perimenopause

During perimenopause you may notice that something is different – you may not know what, but you know it. Perimenopause refers to the years before menopause; hormone fluctuations can occur anywhere from the 2 to 10 years before a woman stops having her period. If you are aged 35-55, and you are still having periods but something is different about them, you are probably in perimenopause. The first sign of perimenopause is often a change to your periods in some way: the time between periods, or the number of days your period lasts, or how much you menstruate – any or all of these could be altered.

Women in the 35-55 age group are vulnerable to the type of anger discussed on the show as “perimenopausal rage.” Women usually say this is different than what they have experienced before – it’s totally new for them and very unsettling. This type of rage seems to pop up with no warning and feels totally out of place. Overall, it is often very different from the way they’ve reacted to stressors in previous years, before perimenopause. This is not just getting upset or angry in response to the little bumps in the road day to day – these are very obvious outbursts that involve overreacting above and beyond your normal anger level, way out of proportion to the situation at hand. It is extreme, emotional and hurts others. And it often triggers regret.  

It’s critically important to understand that these situations are very real for the thousands of modern women who experience them, especially the supermoms trying to “do it all” at work and at home! The rage we are talking about is one extreme example of what is essentially a heightened PMS experience that surfaces for the first time ever in many perimenopausal women. These types of emotional outbursts are usually more common in the PMS portion of a woman’s cycle – the two weeks before her period. 

If you think this sounds like you or someone you love, please read on! 

Warning Signs for Perimenopausal Rage


1. Mood Swings Within Minutes

Are you fine one minute, and sad, overwhelmed or crying the next – does this sound familiar? Your moods are changing like the flip of a light switch with no warning. This moment-to-moment flip-flop of emotions is often a sign of hormonal imbalance. 

2. Out-of-Proportion Anger           

Totally overreacting to even little things is part of this anger. These responses are over-the-top in regard to what is usually considered “small stuff.” Agitation and irritability surface in response to minor events.  

3. A Long History of PMS

If you already have had a tendency to experience premenstrual symptoms, the more extreme hormone fluctuations of perimenopause can exaggerate your symptoms tenfold, and can lead to perimenopausal rage. I almost always find that PMS is worse in women who don’t support their systems adequately using healthy nutrition and lifestyle measures.

4. Previous Postpartum Depression

I am always interested to hear what pregnancy was like for the women I meet in my practice. I have found that women with postpartum depression have brains that are wired to be very sensitive to hormone changes. From my experience, I consider women who report having postpartum depression in the past at greater risk for developing more difficult perimenopausal and menopausal symptoms, including this type of perimenopausal rage.


What’s Happening to My Hormones? 

Science has been trying to understand this, as women are complex and each of us is unique as well. There is a complicated and delicate balance of hormones in women, such as estrogen, progesterone, testosterone, DHEA and pregnenolone. What we know is that hormones start to change with the aging process and often fall far out of balance in perimenopause. This mismatch of hormone activity can impact the feel-good chemistry of the brain in many women and cause extreme emotions, including perimenopausal rage. It can also trigger hot flashes, night sweats, hair loss and restless sleep – just to name a few other symptoms.  

What I tend to see in perimenopausal women is that in the second-half of their cycles, progesterone declines while estrogen may fluctuate wildly. There can also be shifts in androgens like testosterone. But the overall mismatch between hormone levels or a change in proportions seems to be the real problem trigger in many women, and the source of this newfound rage. The key is promoting balance again.

Health-care providers can offer hormone testing to women so they can get a better picture of what’s going on inside them. We do this with blood or saliva, preferably at the PMS time of the month. Of course, this just gives us a snapshot of the rollercoaster ride; it’s important to interpret both the patient’s symptoms as well as the test results. (If you don’t have access to testing, you can take some time to learn more about how to read your body’s signals and promote balance naturally.)

What You Can Do to Feel Better: Solutions


At Women to Women, the practitioners strive to help women promote health and hormone balance nutritionally and naturally first, but we think it is always good for women to know all their options, including medications.  

Solution #1: Medications

The Birth Control Pill

The Pill has been used for decades to help women in their 30s and 40s have easier periods. The Pill will suppress the hormones in your body that are affecting the brain. It may help even out the rollercoaster ride, and curb the highs and lows of your emotions. There are many types as well as new formulas to consider with your provider. If you didn’t like the pill 20 years ago, you should know that there are many different types today – and your experience could be much different this time around. 

The current data shows the birth control pill to be very safe in healthy women who don’t smoke, but there are risks and benefits you have to discuss with your provider.


Women in crisis may need to use this approach if they really feel they are “falling apart.” Antidepressants seem to support the brain chemistry and help stabilize mood despite the hormone changes that are happening. With this support, your brain might better handle any wild hormone fluctuations that are wreaking havoc on your emotions during perimenopause, and how you might be reacting to the triggers that result in rage.

There are various types and doses of antidepressants available by prescription from medical health-care providers and psychiatrists. In some women, these sorts of medications may be prescribed to use daily all month long, and in others, they are prescribed to use just two weeks of the month during the PMS timeframe. The benefit of only taking the antidepressants part of the month may be that it minimizes unwanted side effects on sexual response or weight. All antidepressants have risks and benefits that you should review with your health-care provider and pharmacist so you can make an informed choice.

Some types of antidepressants may work in a matter of weeks, while others may take a month or more for you to see results; you may need to adjust the dose to find the right level for you. This approach requires working closely with your doctor or nurse practitioner.

A healthy diet, high-quality multivitamin, essential trace minerals and omega-3 fish oil all have the ability to enhance results of using an antidepressant as well.

Solution #2: Progesterone Cream

Progesterone is one of the hormones that affects the brain chemistry and it is also one that changes in the perimenopause years. In my practice, I’ve seen remarkable results in many women using this easy approach of low-dose natural progesterone cream. It is not a one-size-fits-all sort of option, but it is one easy thing to try, and it works for many women. 

You can get the low-dose, over-the-counter formulas at most health food stores, or from many holistic practitioners’ offices. It’s important to look for “USP progesterone” on the ingredient list; that’s the active ingredient you want. Progesterone creams are also made to order at compounding pharmacies by prescription, which might be ideal (if this option is available to you) to ensure potency and quality.

For many women using progesterone cream, within days, it can feel like they’re taking in a breath of fresh air. If it is a good fit for you, you usually know right away. For others, it may take longer, or they might need something stronger or a different formula. I usually suggest giving it two cycles to see what it can offer you, along with nutritional support and dietary mindfulness.

I’ve seen very few side effects or serious concerns with natural progesterone, especially when taken in these low doses. Most of the risks in hormone use are linked to oral estrogens. If you have concerns about risks, you should certainly talk about them with your health-care provider, or choose another path altogether.

Solution #3:  Eliminate or Reduce Caffeine, Alcohol and Sugar

This natural and nutritional approach is my favorite! I have worked closely with women of all ages and the common theme we see is that sugar, caffeine, alcohol and stress will exaggerate any hormonal symptoms that are occurring. Unstable blood sugar and an over-activated stress response – on top of hormone fluctuations – create a perfect storm for emotional outbursts and perimenopausal rage.

If you can curb these dietary triggers, and pay more attention to what you put into your body, then your brain may be better able to cope with the hormone imbalances of perimenopause.

Alcohol may calm your nerves while you’re drinking it, but if you don’t drink in moderation, or if you use it nightly, then you may find it actually feeds your rage the next day!

There are so many benefits to the natural and nutritional support you get with a healthy balanced diet, and the basic foundation provided by certain key supplements that they can’t be ignored. The foundational support I suggest is:

  • High-quality multivitamin and mineral formula rich in B-complex vitamins and vitamin D
  • Omega-3 fish oil
  • Calcium and magnesium

Solution # 4: Therapy Options

Sometimes the hormone changes of perimenopause and menopause reveal the emotional issues you need to work on. There are options for anger management, couples counseling, or personal one-on-one therapy.  Some women find cognitive behavioral therapy very helpful. It can help you work on the problems you have in the “here and now,” but with new skills for managing them. Then, when you are ready, you may pursue deeper emotional work, which can help you grow as a person. The most important element here is to find a counselor you can feel comfortable working with.

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