With diminishing estrogen, or rather, the roller coaster of its erratic, fluctuating levels during perimenopause, anything can happen, and not just to the targeted female organs. Changing menstrual patterns and flows are expected, but the most common complaints are hot flashes, insomnia, vaginal dryness, and mood changes, the latter referring to depression (new, reappearance, or worsening of current) and anxiety as well as their cousins, prickliness, irritability, and rage.
Shrinking estrogen levels cause a narrowing of the thermoneutral zone in the hypothalamus (the thermostat region in the brain) which causes one’s range of comfortable temperatures to become smaller and predisposes the individual to hot flashes. So, if you were temperature sensitive to begin with, your intolerance to heat worsens and now, only a minuscule increase in ambient temperature precipitates flushing. WTF?!
Could be worse… At the same time, reduced estrogen increases sympathetic nervous system activity causing the neurotransmitter, norepinephrine, to be more readily released, preparing you for “fight or flight.” What does that mean for perimenopause? Not only might you have hot flashes, but you may also develop new or intensified anxiety, and maybe, palpitations, too!
To complicate matters, declining estrogen enhances the thermoneutral zone’s sensitivity to norepinephrine. So, any intense thought, interaction, or event that engages the sympathetic system may spark a hot flash.
Another lesser-known consequence of diminished estrogen is loss of its mild anti-inflammatory influence. This may account for random achiness in general and vague discomfort following exercise or mild exertion that previously was not a bother.
With higher sympathetic tone and fewer anti-inflammatory effects, it would not be surprising if diminishing estrogen doesn’t also heighten some sensory perceptions in women, especially those who are highly sensitive persons (HSPs) to begin with, an under-recognized personality trait. But first, what is a highly sensitive person? (https://hsperson.com/)
HSPs are individuals who are more sensitive to sensory stimuli (visual, auditory, olfactory, food texture and taste, temperature, touch, and pain) than most people. They may also be hyperaware of the moods, feelings, and opinions of others.
Growing up, they are often told that they are too sensitive to remarks or criticism, undermined about their sensations (how it’s not so bright, so loud, so hot or cold), and questioned about refusals to eat certain foods, wear uncomfortable (to them) clothes, or enter places with many people, noises, or scents. Additionally, they may require smaller doses of medications and are quite responsive to caffeine.
Even before perimenopausal hormonal shifts, many HSPs have high sympathetic tone and startle easily. Moreover, crowded settings, violence, and chaotic situations are physically and emotionally draining, and indeed, HSPs are thought to be more prone to developing hypervigilance and PTSD than neurotypical persons.
HSPs often mask their feelings to offhand remarks (hmm, was that disparaging?), criticism, or being told that something troubling them isn’t a big deal. HSPs can be introverted or extroverted, but like neurotypical introverts, they may need more “down time” after human interactions and returning from noisy, chaotic environments.
Social anxiety is common for many, as is depression. Feeling overwhelmed from sensory overload is often misinterpreted by others as anxiety. In these cases, the individual often has difficulty verbalizing their discomfort and instead, might have a “meltdown” or explode when what they really need is an escape from overstimulation.
Whether an HSP considers their hypersensitivity to be a weakness or an advantage depends on their upbringing, life circumstances, and work or social situations. They often feel like they are the proverbial “canary in a coal mine,” written off as a complainer or an outlier until something is measurable or noticed by others.
As patients, they often feel discomfort early or that something is off long before a physical exam or testing shows anything. Unfortunately, they are routinely told that nothing is wrong, and that they are just anxious. Sometimes, the issue is simply due to being very sensitive and reacting strongly to neural input, but on occasion, as symptoms ramp up (or don’t go away), they are finally taken seriously when further testing finally reveals a diagnosis.
Sensory, emotional, and social sensitivities may all occur in a single individual, but not always, and sensitivity to any of these elements varies individually. This neurologic difference in sensitivity is an example of neurodiversity, a concept first introduced about 25 years ago.
I first learned about HSPs while researching for my book, The Hot Flash Diet, and couldn’t help but question whether being highly sensitive impacts the presentation of perimenopausal complaints. Of women entering the menopause transition, it seems to me that HSPs might feel “the change” more keenly.
Is the brain’s thermoneutral zone in HSPs more narrowed and becomes smaller with lower estrogen? Or does it shrink more than that of other perimenopausal women and make subtle changes in room temperature even more noticeable? Would this scenario coupled with the high sympathetic tone (that already accompanies having numerous sensitivities) set the stage for intense and/or frequent hot flashes, and perhaps for a more prolonged period? How would these changes respond to menopausal hormone therapy or medications that affect norepinephrine? These are questions begging for research.
Becoming aware that one is highly sensitive is important for learning how to cope (https://health.clevelandclinic.org/highly-sensitive-person/). Realizing the neurodiversity of sensitivities for the first time is eye-opening when you recognize this trait in yourself or someone dear. Hopefully, it will allow you to be gentler with yourself or loved one and improve communication with family members and friends in times of overwhelm when “alone time” or quiet time is needed. It can lead to a better understanding of the self or other person and past interactions, perhaps leading to acceptance, forgiveness, and future planning.
Getting enough sleep, practicing meditation, and learning paced breathing can all reduce the “fight-or-flight” response which may also temper physical and emotional reactivity. Moreover, sensitivities to pain, other sensory stimuli, and medications might be discussed with receptive medical practitioners and taken into consideration with planning medical care. More information about HSPs is available in books and online.
Although internists and family practitioners are learning more about the menopause transition, a gynecologist or menopause specialist may still be the best doctor to ask regarding symptoms of perimenopause, especially if they seem overwhelming to you. You can find a menopause practitioner by going to The Menopause Society’s website, www.menopause.org.
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