Perimenopause: Common Symptoms, Early Signs & What to Expect

What Is Perimenopause?

Perimenopause is the stage at which your body transitions into menopause. In this stage, the ovaries decrease production of estrogen and other hormones; as a result, the menstrual cycle becomes irregular and unpredictable. Menopause represents the end of your reproductive years, and the many physical and emotional changes that accompany this transition vary greatly from one woman to another.

Menopause occurs after you experience no menstrual flow for 12 consecutive months, ending perimenopause. During this stage, there is a possibility of becoming pregnant, even though your menstrual cycle has become irregular. If you don't want to become pregnant while you're in perimenopause, use birth control.

When Does Perimenopause Start? 

Perimenopause begins approximately in the mid-40s, which is about 8 to 10 years before reaching menopause. Some women, however, begin to go through perimenopause in their mid-30s. On average, perimenopause lasts four years. However, it could take as little as a couple of months or as long as 8 years for every woman.

Certain factors can cause perimenopause to start sooner than anticipated. Smoking or using tobacco products, a family history of early menopause, receiving chemotherapy for cancer treatment, and or having had your uterus or ovaries surgically removed are just a few examples.

Common Perimenopause Symptoms Every Woman Should Know

Perimenopausal symptoms arise due to variations and decreases in estrogen levels. Each woman's symptoms will differ in severity and type. Most common symptoms include the following:

Hot flashes (heat waves):

Sudden sensations of heat spread over different areas of your body. The sensation is often accompanied by excessive sweating and flushing of your face. 

Irregular menstrual cycles: 

Irregular cycles resulting in heavier, lighter, or longer/shorter than typical menstrual flows. Irregular cycles can also cause complete cessation of flow.

Night sweats (nocturnal hot flashes):

When hot flashes occur during your sleep cycle and interrupt your ability to get restful sleep. 

Vaginal dryness: 

Due to decreased estrogen production and subsequently diminished moisture in the vagina, sexual intercourse is uncomfortable. 

Sleep problems (insomnia): 

Difficulty falling asleep or difficulty remaining asleep. Night sweats are a frequent contributor to insomnia in perimenopausal women. 

Mood changes (emotional sensitivity): 

Mood swings, irritability, feelings of sadness/depression, and being emotionally sensitive.


Decreased libido: 

Lowered sex drive. Decreased libido can be due to both hormonal fluctuations and vaginal discomfort. 

Increased urination frequency: 

Increased need to urinate more often than usual.

Less Common Signs of Perimenopause Women Often Overlook 

In addition to the well-known symptoms of perimenopause, many subtle changes are easily overlooked or misinterpreted as something else entirely. Examples include:

• Irritability (anxiety): an ongoing feeling of concern/worry related to a situation that seems inappropriate to the degree of concern felt by the woman. 
• Difficulty with memory and concentration (brain fog): feeling like "you cannot think clearly" with respect to memory issues (i.e., you are unable to remember things) or difficulty concentrating. 
• Weight gain: weight gain, especially in the abdominal area, due to a lowered metabolic rate as a result of decreasing estrogen levels. 
• Muscle & joint discomfort: muscle & joint pain similar to the early stages of arthritis. 
• Skin & hair issues: skin & hair changes (e.g., dryness/thinning hair, etc.) due to the lowering of estrogen levels throughout the body. 
• Worsening PMS (premenstrual syndrome): PMS worsens during perimenopause.

As many of the above-mentioned symptoms mirror other diseases, it would be beneficial to discuss them with your healthcare professional for confirmation regarding whether the symptoms are indeed related to perimenopause.

Why Do Perimenopause Symptoms Happen? 

Symptoms of perimenopause primarily occur because of changing hormone levels (particularly decreasing estrogen). Estrogen performs many functions throughout the female body, including maintaining the reproductive system, maintaining bone mass, supporting cardiovascular function, regulating emotions, supporting skin health, and more. When estrogen levels drop too far, the ratio of estrogen drops out of balance. Since hormone levels fluctuate wildly and randomly during perimenopause, symptoms can vary greatly in terms of intensity from one day, week, or month to another.

Eventually, when hormone levels drop to the point where ovulation stops altogether and menstruation ceases, menopause occurs. Additionally, prolonged loss of estrogen increases the risk of developing osteoporosis and cardiovascular disease later in life, post-menopause.

How Is Perimenopause Diagnosed?

A doctor diagnoses perimenopause based on your age, symptoms, and menstrual history rather than testing. Your doctor will perform a physical exam and discuss your symptoms with you. Blood tests during perimenopause are unreliable because hormone levels fluctuate dramatically. An FSH (follicle-stimulating hormone) level test may be ordered since persistently elevated FSH levels signal that the body is entering menopause. To rule out other conditions that present with similar symptoms (such as thyroid disorders), your provider may order diagnostic tests for you.

Treatment Options for Perimenopause

While there is no medication available that can stop perimenopause, as it is a natural process, there are a variety of treatments available to help manage your symptoms effectively.

Examples of medications prescribed by your physician include:

1. HT (hormone therapy): estrogen or estrogen and progesterone. Hormone replacement therapy can stabilize your hormone levels and alleviate symptoms of perimenopause. 

2. Combined contraceptive pill:  regulates your menstrual cycle and minimizes symptoms of perimenopause. 


3. Antidepressants help treat hot flushes, mood swings, anxiety, depression, and emotional sensitivity. 


4. Gabapentin/oxybutynin treats hot flushes instead of antidepressant therapy. 


5. Vaginal cream/lubricant: relieves vaginal dryness during sex. 


6. IUDs (intrauterine devices) such as Mirena manage heavy or unpredictable bleeding.

Lifestyle Changes:
Making lifestyle adjustments can greatly impact your ability to cope with the milder aspects of your perimenopausal symptoms. These include:

• Eating a diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats
• 
Engaging in regular weight-bearing exercises (walking, hiking, strength training, etc.)
• 
Wearing layered clothing to help control varying temperatures

• Limiting caffeine/alcohol consumption

• Practicing good sleeping habits (reducing screen time before bedtime, practicing relaxation techniques, etc.)
• 
Quitting smoking

References:

• Avis, N. E., Crawford, S. L., Greendale, G., Bromberger, J. T., Everson-Rose, S. A., Gold, E. B., Hess, R., Joffe, H., Kravitz, H. M., Tepper, P. G., & Thurston, R. C. (2015). Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Internal Medicine, 175(4), 531–539. 
• Harlow, S. D., Gass, M., Hall, J. E., Lobo, R., Maki, P., Rebar, R. W., Sherman, S., Sluss, P. M., & de Villiers, T. J. (2012). Executive summary of the Stages of Reproductive Aging Workshop + 10: Addressing the unfinished agenda of staging reproductive aging. Journal of Clinical Endocrinology & Metabolism, 97(4), 1159–1168. 
• Monteleone, P., Mascagni, G., Giannini, A., Genazzani, A. R., & Simoncini, T. (2018). Symptoms of menopause — global prevalence, physiology and implications. Nature Reviews Endocrinology, 14(4), 199–215. 
• Santoro, N., Roeca, C., Peters, B. A., & Neal-Perry, G. (2021). The menopause transition: Signs, symptoms, and management options. Journal of Clinical Endocrinology & Metabolism, 106(1), 1–15. 
• Stuenkel, C. A., Davis, S. R., Gompel, A., Lumsden, M. A., Murad, M. H., Pinkerton, J. V., & Santen, R. J. (2015). Treatment of symptoms of the menopause: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 100(11), 3975–4011.