What You Haven’t Heard about Perimenopause

Women deserve to be prepared for and educated on the unique physiological transitions throughout their lives, from menarche to fertility to perimenopause and beyond. Yet this isn’t the case.

I’ve been working in women’s health for over 20 years. It’s saddening how little women are prepared for these various important life transitions and how little support they receive from our medical system. Medical gaslighting, being told your symptoms are all in your head, is still very prevalent in women’s health, and women wait longer on average in the ER for medical care than men. Fortunately the tides are changing as more and more women are speaking out against these inequities.

But still, so many women with whom I work aren’t prepared for or know what happens during perimenopause. Sure, women know menopause is inevitable, but many don’t anticipate the phase that marks the beginning of the end of their periods. The conversations around women’s menopausal health are changing, and women are no longer going through the peri and menopausal transition shrouded in silence. We’re also seeing more medical care options for these periods of hormonal transition in women’s lives. The focus is no longer predominantly on fertility.

That said, here is what I’d like you to know–and what you probably haven’t heard–about perimenopause.

What is Perimenopause?

Perimenopause is a transition phase in a woman’s life leading up to the final menstrual period. This time is marked by changes in the menstrual cycle along with other physical and emotional symptoms. Perimenopause typically begins in your 40s and can last from two to 10 years with an average of seven years. Some women may not notice any major perimenopausal symptoms while others may experience more severe changes. Many women aren’t prepared for this phase, so the symptoms may seem alarming.

Experts generally agree that perimenopause begins with irregular menstrual cycles caused by declining ovarian function. It ends a year after the last menstrual period, and that is when you’re in menopause. The physical changes of perimenopause are caused primarily by fluctuating levels of estrogen, but other sex hormones fluctuate also. Ovulation may become erratic. The menstrual cycle can shorten (from, say, 28 days to 21 days) or lengthen, and flow may become irregular before your final period.

Here are a few things I’ve heard women say about the perimenopausal transition, many of whom did not know what was causing the symptoms:

“My periods would last a month.”

“I started bleeding and it just didn’t stop.”

“Distracting horniness alternating with zero desire”

“I am gaining and losing the same 5 pounds without changing anything.”

“I can’t focus. I have horrible brain fog and I hate everything.”

“I feel like my body has been hijacked”

“I recently had a doctor scoff that I was too young for any menopausal transition, but I recently had both 16 day cycles and 52 day cycles after being regular my whole life. I’m in my 40s.”

“I started the process of perimenopause when I was 35. And it was drastic and sudden. I got multiple periods per month. Cramps, clots, heavy flows, all the wonderful menstrual hell a period could be, about every two weeks. And then the chronic fatigue and pain set in. And despite seeing about a dozen various, “highly rated” specialists, from ob/gyns to endocrinologists, not one of them ever mentioned it could be premature menopause. Not one. Instead they put me through tons of testing, medical gaslighting, and hell. And when I asked if it could be menopause or something similar, I got told I was “too young” for such a thing.”

What You Haven’t Heard about Perimenopause

Most women experience menopause between ages 40 and 58. The average age is 51, but there are physical changes that begin years before the final menstrual period.

Overwhelmingly, I hear women say they attempt to discuss new symptoms they’re developing in their late 30s and 40s only to be told they’re too young for menopause, and also that hormone testing is useless since hormones are starting to fluctuate too much. Then–and here’s the kicker–they’re handed an RX for anti-depressants or sleep meds and sent packing.

There’s no “treatment” for perimenopause in conventional medicine, which may be a reason it’s not widely acknowledged. Add to that: Many doctors don’t have much experience addressing perimenopause or even menopause.

Here are the most common perimenopausal symptoms that may begin up to 10 years prior to menopause:

• Hot flashes, one of the most common and dreaded menopause-related discomfort. Can begin in the perimenopausal years
• Night sweats, hot flashes at night that interfere with sleep.
• Sleep disturbances
• Vaginal dryness & atrophy: When estrogen levels diminish, vaginal tissues may lose lubrication and elasticity
• UTIs: also caused by dropping estrogen
• wonky & irregular periods: they may come closer together or farther apart or both. Changes in flow are common also.
• Irritability & PMS symptoms
• depression & anxiety
• joint pain
• brain fog
• hair & skin changes
• belly bloat or increased abdominal fat
• weight gain, sometimes for no observable reason (eg you haven’t changed anything about your diet)
• decreasing fertility
• changes in sexual desire due to dropping hormones

These symptoms are caused by dropping estrogen and progesterone levels. Dropping progesterone can cause periods to come closer together, and dropping estrogen causes hot flashes, body composition changes, vaginal & skin changes as well as a potential worsening in PMS symptoms that are already caused by low estrogen. Testosterone, a hormone that is often overlooked in women, also drops, contributing to changes in sexual desire and loss of muscle mass.

Keep in mind that not every woman will experience perimenopause symptoms. They vary widely and vary by the person. Factors that cause perimenopausal symptoms include your current health status, genetics, stress level, even ethnicity.

Interestingly, most American women have hot flashes around the time of menopause, but studies of other cultures suggest this experience is not universal. Far fewer Japanese, Korean, and Southeast Asian women report having hot flashes. These differences may reflect cultural variations in perceptions and lifestyle factors, such as diet, potentially because Asian cultures consume a less processed food and seafood rich diet with modest amounts of soy, which has estrogenic effects that counter dropping estrogen levels.

How to Ease Perimenopause Symptoms

First off, I do recommend hormone testing during your 40s. It’s true that hormones are fluctuating quite a bit, but luteinizing (LH) & follicle stimulating (FSH) hormone levels can tell you if you’re in perimenopause or menopause. These levels start to rise in perimenopause years and are even higher in menopause. LH & FSH are involved in ovulation.

You can order an at-home test kit to measure these levels. Click here and navigate to the women’s health section for the perimenopause test kit.

You’ll also likely see dropping estrogen, progesterone, and testosterone, though these may be on the low end of ‘normal.’ Still, there are herbs, supplements, and lifestyle changes you can add to counter the symptoms these dropping hormones cause. Read this post for my top perimenopause supplements. The one I find the most effective is this particular type of maca specially formulated for perimenopause. I take it myself and have found it especially helps with perimenopause sleep changes, and users say it diminishes hot flashes also.

Here are my tips for navigating perimenopause

Keep in mind that knowing what causes which symptoms will help you address said symptoms. Most are caused by dropping hormone levels, but perimenopausal weight gain, for example, can be caused by both dropping estrogen and rising blood sugar.

• foremost, educate yourself about the changes in your body. I’m loving this new book about menopause.
• get labs done. I like the DIY women’s health panel from EverlyWell (kit comes to your house; easy to use). Find it here in the women’s health section. The women’s health kit is good if you’re still cycling somewhat regularly. If your periods are all over the place, try the perimenopause kit.
• maintain balanced blood sugar by eating in regular intervals. Blood sugar levels naturally rise in menopause and perimenopause, and that contributes to weight gain. More on blood sugar here.
• increase protein to boost energy and counter weight gain
• stick to a daily routine
• very important: sleep hygiene. Get my tips here.
• start using vaginal creams to keep your vag in shape. May also help prevent UTIs by toning skin down there. Julva counters atrophy, and Silky Peach is great for dryness.
• consult a menopause practitioner if needed (your dr probably won’t be much help). There are also numerous online resources where you can get hormone replacement therapy if needed or other meds to ease symptoms. I list some here.
• topical progesterone can help if cycles are coming close together (best to test to see where your hormones are)
• if you’re having hot flashes, take the maca I recommend, and determine your triggers. Main ones are spicy food, alcohol, caffeine, hot weather, smoking

Conclusion

This post really has two important themes: the fact that women don’t get the education or helpful medical interventions they need during perimenopausal changes, and secondly, what you need to do during perimenopause to prevent or counter uncomfortable symptoms.

Doctors often overlook perimenopausal symptoms, and women’s symptoms are dismissed. They’re told testing is useless (it’s not), that they’re “too young” to be experiencing symptoms (anytime after roughly age 37 is not too young, but perimenopause may hit even earlier in some women), and that hormone replacement therapy is dangerous or not needed (it can in fact be very useful for preventing menopausal issues like bone loss or cardiovascular disease).

But women are becoming more vocal about medical gaslighting and are insisting on better care in the post-reproductive years, which are not nearly as prioritized in women’s health as the fertility years. I’ve heard so many women tell me they feel invisible post menopause, which is heartbreaking.

Understanding what happens during perimenopause can help you properly address symptoms, and it is also validating to know you’re not crazy, that there is a physiological reason these symptoms are occurring. There are also more resources available to help navigate the transition (read more on that here).