Menopause is the cessation of menses due to the depletion of oocytes/eggs in the ovaries. Perimenopause is the run up to menopause when ovarian function starts winding down with the fluctuations in oestrogen levels leading to various symptoms. It is an overarching term used to the describe pre-menopause, menopause and post-menopause.

Gynaecologist Dr Nozer Sheriar and macrobiotic nutritionist Shonali Sabherwal’s book, Finding Your Balance, looks at the various menopause-related challenges and possible solutions. Pic/Sayyed Sameer Abedi

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The transition usually begins an average of four years before the last menstrual period, usually sometime around mid-40s but in a few cases, it can begin in the 30s. It is characterised by several factors, including irregular menstrual cycles, hormonal fluctuations, hot flashes, vaginal dryness, mood swings, among others. 

For Lodaya, the symptoms ebbed for a while, but returned recently. “Now, I know how to deal with them better. If I notice I’m getting irritated, I realise my periods would be near and distract my brain.” She turns to hand-embroidery or watches something light on her phone. “I consciously change my activities—I don’t participate in serious or heavy conversations, or watch emotionally heavy TV shows/movies. I also avoid discussing topics that could become intense.” She tried going for walks, but couldn’t continue. “Before your periods, your body feels very heavy so you don’t feel like exercising,” she says.

There are days when she wants to withdraw from the world. “There are times I can’t [manage my emotions],” she admits. “I get upset and realise hours later that the incident was no big deal. Sometimes, just someone’s face angers me, without any rationale. Other days, I cry, but I try not to do it in front of others.”

When Ghatkopar-based Jasmine Lodaya recognises she’s being overtly emotional, she turns to embroidery to calm herself. Pic/Pradeep Dhivar

The problem, thinks Lodaya, is the lack of discussion around the subject. “It is taboo even today,” she says. “My friends don’t discuss it.” Lodaya found comfort in her mother-in-law and elder sister, who validated her experience.

For Neelam Sharma, it began two years ago, with severe pain in the lower abdomen and back during her periods. She had just turned 40; a year later, her menstrual cycle became irregular, ranging anywhere between 10 and 45 days. 

“There was significant fluctuation in mood around my periods,” says the Powai resident. Her skin started breaking out. “I have also started facing issues related to the thyroid gland, but I’m not sure whether that’s inter-connected.” A blogger by profession, Sharma lives with her parents and siblings. “I am a very let-go kind of person,” she says. “But now, hurtful words haunt me for days. I cry a lot at night. I caught myself replaying negative interactions repeatedly. It’s as if a tragic movie is playing in my mind.”

The emotional turbulence affects her work. “I procrastinate a lot,” says the professional blogger. “A five-minute job can take hours; sometimes, I can’t work for days.”  The day we spoke was one such day; she had a sharp pain in the lower abdomen. Sharma is glad she’s independently employed; taking mental health days off wouldn’t be easy in the corporate world. “A week before my periods, it becomes really tough,” she says. As an aid, Sharma has started stretching and doing pranayama, at least for 15 minutes every day.

Like Lodaya and Sharma, many women around the globe, mostly those in their 40s, are in perimenopause. “The stage lasts for several years on either side of the last menstrual period,” says Dr Nozer Sheriar, a consulting gynaecologist at Breach Candy, PD Hinduja and Holy Family hospitals. “The average age of menopause in India is 47 years. So, perimenopause can come any time in the 40s.”

Sheriar and macrobiotic nutritionist Shonali Sabherwal’s just-launched book—Finding your Balance-Your 360° Guide to Perimenopause and Beyond—is a comprehensive guide that includes clinical and nutritional perspectives. 

Sometimes, the solution is something we already know. For instance, for easier periods, “stop eating sugar, refined food, minimise dairy and have home-cooked meals,” says Sabherwal. “Substitute sugar with stevia or erythritol, and avoid breads as well. Have a traditional thali: Dosa, rice or roti with dal and subzi and a little bit of fermented food [such as buttermilk] to boost gut health. Ensure greens, fruits and seeds are included in your diet. Avoid or at least limit stimulants that push your cortisol levels, such as tea, coffee, alcohol and cigarettes. Start doing these two weeks before your period and chances of pain free periods will be high.” 

Dr Sheriar admits hot flashes can be dramatic and drive a woman crazy. One solution he offers is hormone therapy, which shows results within weeks. “Menopause hormone therapy is the gold standard for relief from hot flashes and night sweats, and is safe for a short duration,” he says in the book. “It also helps vaginal dryness and mood disorders.” Another tip to balance oestrogen in your body is including tofu and soy. “Having tofu thrice a week can help balance oestrogen, where it is going up or down,” says Sabherwal. For mild hot flashes, she suggests cooling foods such as chia seeds and water-based vegetables such as dudhi and yams. “Avoid garlic,” she advises, “Wear lightweight, loose-fitting clothes made of natural fibres such as cotton, and get a gel mattress.”

“There are many myths surrounding perimenopause, and not everyone needs medication,” says Dr Sheriar, “but those who do, must seek help.” He points out that it is insensitive to ask women “who wake up due to intense hot flashes, are irritable due to lack of sleep, dealing with osteoporosis or with vaginal dryness, which makes intercourse painful and does not protect her against vaginal infections, to ‘handle it themselves’.”

A recent study found that 15 per cent of Indian women endure urogenital infections, itching and painful sex; 32 per cent suffer vaginal dryness, and urinary urgency afflicts 10 per cent. Most women suffer in silence, assuming these to be normal. “We are talking about half the world population here,” says the doctor, “They don’t need to deal with it alone. They should get whatever help they can—walking, exercise, diet, calcium and Vitamin D supplements, 
and counselling.” 

Fitness is an important tool to negotiate perimenopause, says fitness coach Pooja Pattar, who only works with women in their 40s and above. She herself is 44. “If someone is physically active,” she says, “they can deal with emotions better. Activity retains bone density, which raises quality of life.”

Pattar says strength training is especially important. Every woman should consider lifting weights, no matter how light or heavy. It helps retain muscle mass and delays osteoporosis by strengthening bones.”

“Women build up bones up till the age of 40,” adds Dr Sheriar. “After that, they lose bone mass. If a younger woman focuses on bone health, at 40, she will be at peak bone density. Her chances of getting osteoporosis are less than that of a sedentary person.”

He recommends a mix. “Cardio will help lose weight,” he says. “You need yoga for flexibility and strength. If you’ve had babies, you must include pelvic exercises, as the floor has been compromised and gravity isn’t kind.” 

Sabherwal, who is also a yoga and pilates instructor, suggests kegel exercises that strengthen the pelvic floor muscles and also help with vaginal dryness. 
A closely connected, but often overlooked disease is cancer. “Over eight lakh new cases occur every year,” says the book. “More than 80 per cent of cancers in women occur between the ages of 35 and 65 years, with the highest burden during perimenopause. The leading sites of cancer among women are mainly related to four organs: breast, cervix, body of the uterus and ovaries. These account for over 60 per cent of all cancers.”

Dr Sheriar recommends regular self-examination for breast cancer. “The HPV vaccine has a significant role in reducing the risk of cervical cancer,” he adds, “Get regular Pap smears and avoid smoking.” Since pregnancy is a rest-phase for the ovaries, women who haven’t given birth are at higher risk of ovarian cancer. “Women on long-term birth control methods such as pills and those who have breastfed are at lower risk,” he adds. 

A preventive tip from Sabherwal is ensuring limited exposure to endocrine disruptors. 

“Chemicals [such as Nonylphenol Ethoxylatein] found in makeup, detergents and plastic containers are endocrine disruptors, and play havoc with oestrogen.”

Are women getting menopause earlier?

Though women are reaching menarchy (point of starting menstruation) earlier, the age of menopause has not pulled back. Dr Sheriar says that while there is a variation, it isn’t widespread.

Oestrogen-balancing recipe by Shonali Sabarwal

The recipe makes a great sandwich filling, can be spread on crackers, or eaten by itself.

Mock Egg Tofu Salad
Ingredients
 250 gm tofu
 1 onion, grated
 2 celery stalks, cut fine
 2 carrots, grated
 1 tbsp of white wine vinegar
 Sea or rock salt to taste

Method
Steam the tofu (squeeze out all the water from the block) and keep aside. Mix all the ingredients, crumble tofu by hand and mix well. Chill for 10-15 minutes before serving.