Written by: Shuba Visweswaran
Medically Reviewed by: Dr. Shabnam Das Kar

Stages of Menopausal Transition
Figure 1: Stages of the Menopausal Transition

Perimenopause, meaning “around menopause” is the name given to the transition stage that happens before menopause. We don’t hear it discussed or raised by our doctors, so most of us—even if well informed—are not so sure about perimenopausal symptoms, how long it lasts, and what we should be doing to better manage our health during this phase.

We can’t overstate the importance of understanding what is happening now and what to expect as you transition to menopause. Because if we know what to expect, then we know when and where to reach out to get the support we need.

Sections:

1. What is Menopause?

2. How long does Perimenopause last?

3. Why does Perimenopause happen?

4. What are the signs and symptoms of perimenopause?

5. Treatments

– Lifestyle Treatment
– Natural Treatment
– Prescription Treatment
Ok, so menopause is…?

Well, technically it’s defined only after the fact. Meaning that once you have gone 12 consecutive months without a period you are said to have reached menopause and now entered the post-menopausal stage. And yes, that means if you have a period after a few months, the counter resets back to 0!

How long does perimenopause last?

We can experience perimenopause, the signs, and symptoms of hormonal changes up to 10 years before reaching menopause. It can be broken down into two phases: early perimenopause and late perimenopause. Early perimenopause can start while periods are still regular which can cause confusion. Late perimenopause is marked by long cycles or skipped periods.

And why does all this happen?

TL;DR Hormonal imbalance. As we enter perimenopause the symptoms are a result of estrogen peaking and dropping, while progesterone is dropping. As we go through late perimenopause, symptoms tend to be a result of the dropping estrogen and progesterone levels.

Estrogen hormones across stages of life

During Perimenopause, our level of hormones in our body fluctuate. Here is a graphic representation of the same.

Figure 2: Hormones Across Life Stages

Explain, please.

Hormones, specifically estrogen and progesterone have varied functions in the body—from the brain to the gut to our joints—affecting way more in our bodies than just our reproductive organs. When we are in our late 30s the number of eggs we have in our ovaries has declined significantly and the ovaries try desperately to hold on to what they have left. This results in fluctuations in hormone production, which cause changes in ovulation, our menstrual cycle, and as you will see below all the other varied signs of perimenopause.

During our reproductive years, we get used to a certain hormonal rhythm between estrogen and progesterone. When this rhythm is disrupted we experience the many effects it has on the body and mind.

Got it, now what are the signs and symptoms of perimenopause?

The important thing to know is that many of the symptoms that we associate with menopause— think hot flashes, night sweats—actually start in perimenopause and for many subside by the time they reach menopause.

Point to note: The menopausal journey is very individual. We list out the symptoms that are commonly experienced, but not everyone will have all of the symptoms. Symptoms also can come in waves, increasing and reducing for weeks or months at a time.

Early perimenopause signs and symptoms

We tend to notice any change in our menstrual cycle (e.g. shorter cycle length or heavier periods) so it is seen as the first symptom or sign of perimenopause. But in fact, early perimenopause, the first stage of the menopausal journey, can start with or without any change in your periods. This leads to many of us not understanding why we may be experiencing certain symptoms. The following symptoms mark early perimenopause:

  • Irregular periods: heavier flow or longer periods
  • Weight gain: without any change in exercise or eating
  • Sleep disturbances: with or without night sweats
  • Increased PMS: mood swings just before your period
  • Increased migraines
  • Breast pain: sore, swollen, and/or lumpy breasts
  • Menstrual cramps: more severe than usual
Medical tip: It’s a good idea to speak to a doctor if you have any of the following:
  • Periods are so heavy that you have to change pads or tampons every hour or two for two or more hours
  • Your periods last longer than seven days
  • Your periods are less than 21 days apart
  • Any change in previous cycles either in amount or duration should ideally be looked into

Perimenopause Symptoms
Figure 3: Perimenopause Symptoms from Early to Late

Point to note: The transition from early to late perimenopause is gradual and can take several years and not quite as clear cut as we would like, making it even more important to know what to look out for as you go.

As you move through perimenopause, you may experience the following symptoms:

Physical signs and symptoms

  • Irregular periods

Your periods could be heavier and longer one month and then entirely skip the next.

  • Hot flashes (also known as flushes)

As our body’s ability to regulate temperature changes with our fluctuating levels of estrogen and progesterone, we experience hot flashes. It’s a feeling of intense heat, a flushed face, tingling and even sometimes your heart beats faster. This very disorienting feeling lasts for an average of about four minutes. See more in our detailed guide on hot flashes here.

  • Night sweats

Hot flashes that you experience at night are called night sweats. Women often wake up in the middle of the night to find themselves and their sheets drenched. This obviously disrupts your overall sleep time and makes it so much harder to get the good night’s sleep that we all so desperately need. Not getting a full, restful night of sleep can cause other issues as well, so it’s good practice to track these changes as they happen.

  • Sleep disturbance

Sleep complaints are most common symptom after hot flashes. You could have trouble falling asleep, staying asleep or both. Sleep disturbances happen at this time due to night sweats or urinary problems. They also can happen as a result of harder to manage stress.

  • Urinary problems

In perimenopause urinary leaking can happen when you cough, laugh, jump, sneeze, or have sex, etc. What?!! Reduced estrogen can cause a thinning of the lining of our urethra—the short tube that passes urine out of the body. And the surrounding pelvic muscles also may weaken with time. As a result many of us have this involuntary leaking. And the surrounding pelvic muscles also may weaken with time. As we transition to menopause, increases in UTIs (urinary tract infections) is also common.

  • Weight gain

Unsurprisingly, most women complain of sudden weight gain at this time. It happens due to changes in hormones, yes, but also due to age, less sleep, hypothyroidism, and increased stress.

  • Joint aches and pains

Aching muscles and joints are common symptoms and in some surveys outrank hot flashes in how common they are. One of estrogen’s jobs is to reduce inflammation by binding to receptors in our joint tissue, and the other is to increase joint lubrication. So with increased inflammation AND less lubrication, there is more wear and tear on the joints.

  • Vaginal dryness

Low estrogen can cause a thinning of the tissues of the vagina, vulva, and urethra. It’s, unfortunately, one of the few long-term, rather than temporary symptoms of perimenopause and menopause. Symptoms also include itchiness, pain, and increased susceptibility to urinary tract infections (UTIs).

  • Bloating

Estrogen plays an important role in our digestive tract as well. At times of increased estrogen, we tend to retain water which can lead to bloating. And of course, we all know the role that stress and anxiety can play in our digestive system. Increased stress and anxiety [more below] are also commonly experienced during perimenopause further adding to digestive symptoms.

  • Changes to skin and hair

Dry and/or itchy skin is common at this time. Lower estrogen levels mean less elasticity and less collagen—which maintains our skin thickness. However, our skin is also a factor of many things in our lives, such as smoking, chronic stress, sun exposure, and aging.

Mental and Emotional Symptoms

The balance between estrogen and progesterone is no longer the way it was before perimenopause—and this causes many of the symptoms we experience, specifically the ones related to our mood and anxiety.

  • Mood swings

    Two factors contribute to mood swings at this stage. One, of course, is hormone fluctuations. Stronger PMS symptoms include more frequent mood swings. The other factor is the effect that the physical symptoms have on your mental health. Feeling bloated one day and having a headache the next would make anyone feel moody! Mood swings are a very common part of this stage, unfortunately.

  • Anxiety

The hormonal changes that happen during perimenopause can also drive feelings of anxiety. Women have an increased risk for depression as they transition to perimenopause so it’s important to track these emotional and mental symptoms and ask for support and help when you need it.

  • Fatigue

Your hormones are also responsible for giving your body’s cells energy. So the changes in the levels of hormones like estrogen, progesterone, and even thyroid hormones can cause fatigue and make you feel more tired than usual. You just don’t have as much energy as you’re used to so even daily tasks may make you feel worn out! It’s okay to take a break and give yourself time off when you can.

Medical tip: if you have significant fatigue, it could be a symptom of hypothyroidism and so you should speak with your doctor to get your blood levels checked.
  • Brain fog

The decrease of hormones also affects your memory. You may experience difficulty in concentration and short-term memory during this period.

Point to note: It’s also important that some of these symptoms can be terribly disruptive for days or weeks, only to disappear and then reappear after several months, in different ways. This unpredictability is what makes perimenopause symptoms often harder to manage than menopausal symptoms.

Late perimenopause signs and symptoms

This phase is marked by our periods moving further apart in preparation for menopause. We may get our period 1 month and then not for 2. As our cycles get longer, our bleeding patterns also tend to lighten. Eventually, if we go for 12 months without a cycle we are said to have had menopause, and we enter our post-menopausal phase.

How to get relief?

The unpredictability of perimenopause symptoms can make them hard to manage. But the good news is that there are many ways to get relief. The options range from natural supplements to making lifestyle changes that better manage stress, optimize nutrition and exercise, and improve sleep. These are good habits for all of us, but they have a big impact on how we journey through menopause!

While all of this can be quite intense and affect your quality of life, remember that this won’t last forever. And if nothing seems to help, it’s important to know that there are prescription treatments available if you are the right candidate.

Where do I begin?

Lifestyle Treatments

Stress

It’s more important than ever to manage our stress better now. Increased stress tends to lead to increased mood and anxiety symptoms which in turn, lead to increased stress because they are actually connected with our hormones.

  • Tried and tested techniques include exercise, meditation, mindfulness. But honestly, whatever serves as relaxation for you can help—whether it is going for a long walk outside, reading a book, playing with your dog, or dancing to music you love! Even a few minutes a day can do wonders to your spirit and mood.

Sleep

Make sleep a priority and try to get at least 7 hours a night.

Food and Nutrition

Building long-term healthy habits around eating are incredibly important in addressing many of the effects that perimenopause has on the body. We know it can seem like the universe is plotting against us now, but making even small simple healthy changes have shown to have a significant effect on overall energy and health.

  • Incorporating more vegetables and reducing processed foods, refined carbohydrates, and sugar (in any form) in our diet has been shown to have the most benefits.
  • Increasing protein from meat, fish, legumes, and other vegetarian sources prevents the muscle mass decline that escalates at this time.

Exercise

Don’t underestimate the power of getting out and moving—a long walk, a jog, or playing badminton, for example.

  • Include strength training to build lean muscle. Your muscle can significantly help protect against the bone loss that happens in perimenopause

Natural Treatments

Our bodies require different amounts of nutrients, vitamins, and minerals in our 40s than we did in our 30s or our 20s.

While it is always best to get our nutritional needs from foods, there are some that are quite difficult to get from diet alone. During perimenopause it can help to increase your intake of the following vitamins and minerals:

Vitamins and Minerals

  • Calcium is needed to help prevent bone loss. It’s best that this comes from food sources such as dairy products (cheese, yogurt, and whey protein in particular), seafood, nuts and seeds, and leafy greens.
  • Vitamin D3 is essential for bone health, our moods, immunity, and sleep. An adequate level of vitamin D is associated with a lower risk of weak bones and hip fractures in postmenopausal women. Our bodies do make Vitamin D when exposed to sunlight, but still, Vitamin D deficiency is one of the most common nutritional deficiencies that we have. Try foods like oily fish (salmon, herring, and sardines), egg yolks, fortified foods, or cod liver oil.
  • Vitamin B6/B12 help us in producing energy as they support our red blood cells and nervous system. Try leafy greens, organ meats, fortified cereal, milk and dairy products, fish such as salmon, trout, and tuna, shellfish like oysters, clams, and mussels, and legumes.
  • Omega 3 fatty acids are very important for cardiovascular health and to help with your cholesterol levels.
  • Magnesium is essential for joint aches and recovery as well as sleep.

Natural herbs

Natural herbs have helped many women around the world reduce symptoms such as sleep disturbances, hot flashes, fatigue, anxiety and mood swings. Some of the herbs that have been used successfully to reduce perimenopausal symptoms include the following: Black Cohosh root, Passionflower, and St John’s Wort.

Supplement safety

Supplements are NOT regulated by most governments throughout the world. This means that there isn’t any regulatory authority that verifies that the supplements actually contain what they claim to on their label. There is also no lab testing required on the product to ensure that it is not contaminated with heavy metals and microbial organisms.

Points to note:
(1) Beware of any natural supplement claiming to be a cure-all or quick-fix.
(2) Natural ingredients in supplements are not regulated by most governments. This leads to frequent contamination with heavy metals and microbes. Only put things in your body that you know are safe.
(3) It is also often found that the active ingredient amount is not what the label says. So it is extremely important to go to a trusted source.
(4) Treat supplements like medication: take it for a purpose and aside from preventive ones (vitamin D, B etc), re-evaluate after 3 months to see if they are helping.

Prescription Treatments

Prescription medications can be effective in treating perimenopausal symptoms. But they do come with their own risks, so it’s best to discuss with a doctor to see if you are a good candidate.

1. HRT (Hormone Replacement Therapy) or MHT (Menopause Hormone Therapy)
Hormone therapy, which is usually the combination of estrogen and progesterone is the most widely used and studied treatment for menopausal symptoms, including hot flashes, night sweats, anxiety, vaginal dryness, loss of sexual desire, bladder problems, and depression.

However, recently more doctors are treating perimenopausal symptoms with progesterone alone. Progesterone is effective in reducing symptoms such as sleep disturbances, mood swings, and anxiety.

But it’s important to note two things: they must be started at an appropriate time in your menopausal journey, and the specific hormone combination used is based on your personal medical history and personal risk factors.

If you want to consider HRT then it is important to have a detailed discussion with a doctor that is up-to-date with the clinical guidelines around menopausal usage by the various Menopause Society organizations globally. Point to note: The form and dosage is usually much lower than hormonal birth control. Estrogens available today are also much safer than the ones used many years ago.

2. SSRIs (selective serotonin reuptake inhibitors)
SSRIs are a class of medications used mainly as antidepressants. However, they have been shown to also help with hot flashes and other menopausal symptoms. Again, the specific medication and dosage required may be different for hot flashes, so you need to consult a doctor that is up-to-date on this usage.

Armed with the right information you can tackle this stage with the same strength that you have everything else that has come your way! And we’re here to support you every step of the journey.

So this means that it’s not the complete chaos that it often feels like.

Disclaimer: This information is for general educational purposes, and should not be used as a substitute for medical advice, diagnosis, or treatment of any medical problem or health condition.

Like with anything you put into your body, taking dietary supplements can involve health risks. It’s best to discuss any supplements you wish to take with your doctor, as there may be interactions with other medication you may be taking.


* Hormone Repair Manual, Lara Briden, 2020
** How to Survive the Great Progesterone Crash of Perimenopause, Lara Briden

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