Most women do not recognize the signs of perimenopause — what’s worse is that most physicians don’t either. As a consequence, often women’s symptoms get misunderstood, dismissed or what’s worse, sometimes even mistreated. You can end up spending a lot of time and money visiting the wrong specialists, being prescribed medication that has nothing to do with perimenopause, and being led on a completely wrong path.
Given these challenges, as a patient your best bet is to become informed about perimenopause early on, recognize its signs, and learn how you can advocate for yourself. Let’s start with the basics.
What is Perimenopause?
As women approach their mid to late 30s and 40s, their bodies undergo a major transitional phase known as perimenopause. This is the period leading up to menopause, where the ovaries gradually produce less estrogen and progesterone, two key hormones that not only regulate the menstrual cycle, but also impact other key areas of the body from metabolism, bone and muscle health, skin, hair, mood, memory, sleep and brain health.
When does Perimenopause start?
Perimenopause can begin as early as 35, and continue until you reach menopause, at the average age of 51. Menopause is officially diagnosed as a single day in a woman's life where menstrual periods have not happened for 12 consecutive months.
During this time, hormone levels fluctuate erratically, resulting in a range of potential symptoms as the body adjusts to decreasing ovarian hormone production. The primary sign of perimenopause is an irregular period, defined by a shifting date of more than 7 days earlier or later each month.
Perimenopause Hormone Changes Explained
During our reproductive years, the ovaries are the primary producers of estrogen and progesterone which regulate not only your menstrual cycle, but also key processes in your body from metabolism, weight, moods, hair, skin, mental, bone, muscle, cardiovascular health.
As women approach perimenopause, ovarian hormone production begins slowing down and becomes more erratic. Progesterone is typically the first hormone to decline, followed by a more dramatic drop in estrogen levels closer to menopause itself.
It's these fluctuating and diminishing levels of estrogen and progesterone that trigger many of the symptoms often associated with perimenopause like low energy, increased belly fat, poor sleep, mood changes, hot flashes, night sweats, and irregular periods.
Perimenopause is also often accompanied by elevated blood sugar and inflammation levels, which makes nutritional support that much more important.
Signs of Perimenopause
The symptoms of perimenopause can vary woman to woman, meaning it can be difficult to pinpoint if you're truly perimenopausal or if there are other root causes at play.
Perimenopause Symptoms
While every woman's experience is a bit different, there are some pretty universal perimenopause symptoms to be aware of, including:
- Irregular periods
- Hot flashes and night sweats
- Sleep issues
- Vaginal dryness and painful sex
- Urinary urgency
- Mood swings, anxiety, irritability
- Reduced sex drive
- Problems with memory and concentration
- Weight gain, particularly around the abdomen
- Breast tenderness
As Dr. Mary Claire Haver says ‘aging and perimenopause are not optional, but suffering from symptoms is’. There are key lifestyle and nutritional modifications, supplementation and pharmacology that one can consider during this transitional period that have been shown to effectively mitigate symptoms.
If you're 35+ and are experiencing any combination of these symptoms, there's a possibility you have entered the perimenopausal transition period.
How can I be sure my symptoms are caused by perimenopause?
Perimenopause is notorious for having no standard diagnostic criteria. This makes it difficult to be absolutely sure that your symptoms are caused by perimenopause. Good news however is that your age and your levels of estrogen and progesterone can tell a lot about your likelihood.
In addition to testing your reproductive hormones, it is also important to make sure you're assessing the health of other key areas of the body that can often hide behind common hormonal symptoms -- regardless of perimenopause.
- Nutritional deficiencies
- Thyroid function
- Adrenal health
- Metabolic health
- Reproductive hormones
Your doctor can order any of these tests on your behalf, or you can get the relevant at-home tests directly from Mohana.
Most Common Perimenopause Symptoms Explained
Perimenopause can be a confusing time. Let’s dig into some of the most prevalent symptoms and why they occur.
Irregular Periods
As ovulation becomes more erratic and infrequent, menstrual cycles will demonstrate increasing irregularity in flow, duration and frequency of periods. Your ovary production is slowly down as a whole, leading up to the period called Menopause when you cease to have your period altogether. Menopause is said to have started when you reach 12 consistent months without a period.
Hot Flashes & Night Sweats
The hallmark of perimenopause and menopause, hot flashes are perhaps the first thing most of us think of when we consider this time of our lives.
Hot flashes are sudden feelings of body heat, flushing and sweating caused by hormonal fluctuations. It can last anywhere from 30 seconds to 10 minutes, leaving you feeling almost hungover once it passes. Night sweats can also disrupt sleep, causing a broader ripple effect.
Hot flashes are caused by changes in your brain's thermostat, thanks to fluctuating hormones. They usually start occurring a few years before your periods end. Some women only experience mild hot flashes, while others are dealing with them multiple times a day and night.
What is a Cold Flash?
Shoutout to the less common sister symptom to hot flashes — cold flashes! While hot flashes are more common, perimenopause cold flashes are just as bothersome. Hot and cold body temperature swings are caused by the same hormonal changes related to perimenopause. According to Healthline, “fluctuating hormones during menopause and perimenopause can cause a dysfunction in the hypothalamus … the part of the brain that regulates body temperature. A dysfunction of the hypothalamus can cause your body to temporarily become overheated (hot flash) or chilled (cold flash).” So if you’ve been feeling hot one minute and cold the next, you’ve got your trusty hypothalamus to thank.
DID YOU KNOW?
Hot and cold flashes are both “vasomotor” symptoms, which just refers to your blood vessels expanding and contracting. Three quarters of women in perimenopause and menopause are affected by vasomotor symptoms, which also includes palpitations and migraines. While 65% of White women experience vasomotor symptoms, a staggering 80% of Black women experience them, as well as experiencing more frequent rates of early menopause as a whole.
Perimenopause Weight Gain & Weight Loss
Many women report frustrating weight changes like weight gain around the abdomen or conversely, unintentionally losing weight during perimenopause.
The decline and fluctuations in estrogen can drive increased fat storage, particularly around the midsection. At the same time, muscle mass tends to decrease which slows metabolism. All of these factors can contribute to weight gain.
Thyroid issues and declining progesterone have also been linked to perimenopausal weight gain in some cases. However, research shows being physically active can help mitigate these changes.
For other women, hormonal chaos and high cortisol levels bring on symptoms of loss of appetite, gastrointestinal upset, anxiety, and unintentional weight loss during perimenopause. The good news is that whichever way your weight may be shifting, exploring functional foods and science-backed activities can help put you back in the driver’s seat.
Perimenopause Digestive Issues
Emerging research suggests the bodily hormonal changes of perimenopause may also influence gut health and function in some cases. Many women report increased gastrointestinal symptoms like bloating, constipation, diarrhea and generalized discomfort around their periods and during perimenopause's changing hormone levels.
Hormonal fluctuations also appear to alter the composition of the gut's microbiome - the trillions of bacteria and microorganisms residing in the digestive tract.
To help counteract these effects, experts recommend paying close attention to gut-friendly lifestyle habits like:
- Eating a nutrient-dense, high-fiber diet
- Staying hydrated and getting daily movement in to support gut motility
- Reducing your alcohol intake
- Managing stress
- Increasing your daily movement
- Considering prebiotic and probiotic foods or supplements
Perimenopause Sleep Challenges
The combination of hot and cold flashes, night sweats, and general hormonal fluctuations can wreak serious havoc on sleep quality during perimenopause. Insomnia and disrupted sleep are among the most common complaints.
These sleep disturbances can lead to chronic fatigue, depressive mood, irritability, lack of motivation and cognitive issues for many women. Poor sleep has also been linked to increased risk for heart disease, diabetes and other conditions.
To help improve sleep during perimenopause, doctors recommend:
- Reduce blue light exposure at night that interferes with quality sleep
- Regulate your sleep-wake cycles to support circadian alignment
- Creating a cool, comfortable sleep environment
- Limiting caffeine after noon, alcohol and heavy meals before bed
Perimenopause & Libido
It's very common for women's sex drive to take a dip during the perimenopausal years due to a combination of factors like hormonal changes, sleep deprivation, stress and vaginal dryness or discomfort.
Decreased estrogen can cause vaginal tissues to become thinner, drier and less elastic - leading to pain, irritation and low libido. In fact, up to half of perimenopausal women report issues like vaginal dryness according to research.
To help offset these effects, doctors may recommend:
- Vaginal moisturizers and lubricants during sex
- Low-dose vaginal estrogen creams, rings or tablets
- Hormone therapy to improve estrogen and progesterone balance
- Maintaining healthy intimacy, open communication, and prioritizing self-care can all help mitigate these sexual side effects as well.
Perimenopause & Vaginal Odor
Shifting hormones can cause a variety of changes in body odor, commonly including a shift in your vaginal odor. Throughout perimenopause and menopause, your vagina’s pH changes and becomes less acidic due to reduced estrogen, which can directly impact how it smells. While the physical changes in your vagina can be confusing and uncomfortable, rest assured that a change in vaginal smell is to be expected and most sour or metallic odors are not cause for any concern.
Vaginal odor that seems more like molasses, bleach, or fish, or smells that come along with pain or changes in discharge may all be signs that some else else is amiss, so don’t hesitate to discuss these changes with your doctor.
The most important thing to remember that vaginal changes during perimenopause and menopause are expected, nothing to be ashamed of, and the transition can often be eased or supported with a doctor’s help!
Perimenopause Mental Health Impacts
The hormonal rollercoaster of perimenopause has been shown to have significant impacts on mental health and emotional wellbeing for many women due to factors like:
- Extreme hormone fluctuations affecting mood, anxiety and depressive symptoms
- Sleep disturbances from night sweats and insomnia
- Stress compounded by physical symptoms and life changes
- Pre-existing mental health conditions made worse by hormonal changes
Many women experience depression, anxiety, irritability or sudden mood swings in the years leading up to menopause. The Study of Women’s Health Across the Nation (or SWAN) analysed data over ten years and confirmed that “risk for high depressive symptoms and disorder is greater during and possibly after the menopausal transition.”
To support mental health during this time, doctors recommend a multidisciplinary approach utilizing strategies like:
- Lifestyle adjustments (diet, exercise, relaxation techniques)
- Psychotherapy and counseling support
- Prescription medications like antidepressants if needed
- Hormone therapy in some cases
Making self-care a priority and building a strong support system can also go a long way in safeguarding emotional wellness during the perimenopausal transition.
How long does Perimenopause last?
There is no definitive timeline for when perimenopause ends, as it's different for every woman. However, most medical authorities agree that perimenopause is considered "completed" once you have gone 12 consecutive months without a menstrual period. At this point, you have officially entered menopause and estrogen and progesterone levels have reached a consistently low level.
Signs Perimenopause is ending:
- Your periods are more than 60 days apart
- Your symptoms including headaches and mood swings have lessened
- Your hot flashes and sleep challenges have worsened
If perimenopause symptoms seem to drag on longer than 8 years, it's advisable to consult your doctor to rule out any potential underlying conditions.
Perimenopause Tests
To help diagnose perimenopause and gauge where you might be in the transitional process, doctors may order certain blood tests to check hormone levels such as:
- Estradiol: Levels go down.
- Progesterone: Levels go down.
- FSH (Follicle-Stimulating Hormone): Levels rise as ovarian reserve depletes
- LH (Lutenizing Hormone): Levels rise with perimenopause.
- AMH (Anti-Mullerian Hormone): Reflects remaining egg supply
There are also a variety of tests that can assess additional deficiencies that may result from perimenopause or further aggravate symptoms. If you are struggling to get support from your doctor, the following tests are all available through Mohana and are always ordered and reviewed by a licensed physician.
Pharmacology for Perimenopause
Common medications for managing perimenopausal symptoms include:
Hormone Therapy
Estrogen therapy (ET) or estrogen/progestin therapy (EPT) can help relieve hot flashes, night sweats, vaginal dryness and bone loss by replacing diminished hormones. More on if this is the right choice for you below!
Off-label medications that can improve Perimenopause symptoms:
Research to support women’s hormonal health is evolving every day, and while all medications should be thoroughly researched and discussed with your doctor, there is evidence to support a wide variety of medications to improve Perimenopause symptoms.
Low-dose antidepressants
Certain antidepressants like paroxetine (Paxil) or venlafaxine (Effexor) have been shown to help reduce hot flashes and night sweats.
Gabapentin (Neurontin®)
Gabapentin is a seizure medication that also relieves hot flashes for some women.
Perimenopause Vitamins
Alternative Therapies, Vitamins & Supplements
Always check with your doctor before starting any supplements, as they can potentially interfere with other medications. While at Mohana, we advocate for a lifestyle and food-first approach to improving symptoms in the long run, some supplements can be helpful to offer short-term relief:
- Inositol or NAC to improve blood sugar imbalances, and insulin resistance
- L-Carnitine combined with resistance training to support bone and muscle health
- Omega 3s to fight inflammation and oxidative stress
- Vitamin D and K to support cardiovascular health, mood, vision and cognition.
- Magnesium Glycinate to support sleep and blood sugar.
- Black cohosh: An herbal remedy some women use to ease hot flashes, night sweats, and mood problems
- Vitamin E: May provide relief from hot flashes, vaginal dryness, and other hormonal issues
- Evening primrose oil: Contains anti-inflammatory compounds that can help with breast pain
- Soy: Contains isoflavones that may mimic estrogen and alleviate hot flashes
- St. John's wort: Some use this for mood and sleep issues related to hormone changes
Of course, always check with your doctor before starting any supplements, as they can potentially interfere with other medications. They're meant to support your body, not be a full treatment plan.
Should I Consider Hormone Replacement Therapy for Perimenopause?
For some women, perimenopause symptoms can remain severe even with supplements and lifestyle adjustments. In these cases, hormone replacement therapy (HRT) may be an option worth exploring.
HRT involves taking prescription medications containing estrogen, progesterone, or a combination to help replenish your depleted hormone levels. This can provide relief from severe hot flashes, vaginal dryness, sleep disturbances, and other moderate to severe perimenopause symptoms.
However, HRT does come with some risks like increased chances of blood clots, stroke, breast cancer and heart disease. So it's not a decision to take lightly. Have an open discussion with your doctor about whether the benefits outweigh the potential risks for your specific situation.
If HRT is recommended, they'll go over all the different forms like pills, patches, gels and more to determine which delivery method is best for you based on your health profile.
The key is to go with the lowest effective dose for the shortest period of time to get relief from your most bothersome symptoms. Your doctor can help find that ideal treatment window.
While perimenopause brings its unique set of challenges, being informed on the process and its potential effects can help women feel more empowered. With thoughtful management and the right treatment plan, it's absolutely possible to navigate this phase of life with minimized disruption.