Perimenopause 101: What You Need to Know
Ask a room of 20- or 30-something women about menopause and
they’ll likely be able to tell you a thing or two about what symptoms
to expect and what’s going on in the body. But ask the same group
of women about perimenopause and you might hear crickets
instead. If this is the first time you’re hearing about perimenopause,
you’re definitely not alone.
The word “perimenopause” literally means “around menopause”
and describes the transition period between a woman's first
symptoms of perimenopause and full-blown menopause, which is
marked by 12 consecutive months without a period. After that, a
woman will remain in menopause for the rest of her life, an era that
is also commonly described as “post-menopause.” Perimenopause
typically begins 8 to 10 years before menopause when women are in
their early- to mid-forties.
Perimenopause Symptoms: What to Expect
It’s common to mistake popular symptoms of perimenopause—like hot flashes, night sweats, and mood swings—for those of menopause. But for many women, those symptoms start to subside once they reach full menopause. In other words, the worst is sometimes over by the time your period goes away completely.
Most symptoms of perimenopause are due to changing hormone levels. According to the Cleveland Clinic, the beginning of perimenopause is typically marked by the following symptoms:
Breast tenderness and pain
Worsening of PMS, both emotional and physical
Irregular periods (anything from shorter cycles initially, to skipped cycles later)
Periods that are heavier or lighter than usual
You may well be in in perimenopause when you notice a number of the following:
Hot flashes and night sweats, especially right before and during your period
More irregular periods
Emotional changes like irritability, mood swings, and mild depression, especially before a period
“Brain fog” - more difficulty with concentration and short term memory
Vaginal dryness and/or discomfort during sex
Dry skin, dry eyes, or a dry mouth
Some of these symptoms come and go and some happen all the time, as the experience of perimenopause is very individual and varies woman to woman. They typically peak about one to two years before menopause when the drop in estrogen accelerates.
How long will these symptoms last? Typically about 5 years, but it varies greatly among women. While some women may only experience a change in their period as they near the time of menopause, some experience symptoms for as long as 10 years before then. Of course, the symptoms listed can have other reasons, including common conditions such as thyroid abnormalities, so make sure you are properly evaluated first.
Perimenopause Facts: What’s Really Happening to Your Hormones
We know hormones are to blame for the symptoms above, but what’s really happening to our hormones during perimenopause? Just understanding the science behind our symptoms can help us better cope with them.
The worst is usually over by the time your period goes away completely.
Perimenopause, in contrast to the predictable ebbs and flows of our hormones during regular premenopausal cycles, and the low but steady level in post-menopause, is one long hormonal fluctuation spanning sometimes several years. In perimenopause, the levels of estrogen and progesterone, the two main female hormones, can be quite variable. FSH and LH, hormones produced by the pituitary gland in the brain, normally direct the ovaries to make estrogen and go through the process of ovulation, which is necessary for progesterone production and a period - when pregnancy does not happen.
During perimenopause, however, FSH levels fluctuate significantly, leading to more estrogen production one cycle and less the next. Ovulation may or may not happen, also resulting in menstrual irregularity and changes in bleeding patterns. Menopause occurs when ovaries stop producing adequate levels of estrogen in response to the FSH signal and the low estrogen production is insufficient to result in ovulation, and therefore a period. Although traditionally FSH was considered as the “test” for menopause, it is not very useful in perimenopause as a predictor of the last period - the level of FSH varies so much that it is just not helpful in anticipating the length of this transition. This role may be played by the hormone AMH, now often used to assess “ovarian reserve,” or the level of remaining egg cells. AMH reliably decreases with age until it is essentially undetectable which happens around the time of menopause. There are currently AMH tests in development that could be used to assess whether a woman’s last period will occur in the next 18 months or so.
Common medications and treatments for perimenopause include low-dose oral contraceptives for a short period of time and hormone replacement therapy. That said, most doctors will suggest lifestyle changes before medication, as these medications do have some risks and their use should be highly individualized.
If you’re experiencing perimenopause symptoms—or simply want to do your best to live with them—lifestyle is key. Studies have also shown that women with healthy lifestyles experience fewer perimenopause symptoms and are better able to cope with the symptoms they do experience.
Dietary Changes for Perimenopause
On top of the typical healthy lifestyle recommendations like eating plenty of fresh vegetables and fruits, getting eight hours of sleep per night, limiting alcohol and avoiding tobacco, exercising regularly (including weight-bearing exercise in addition to aerobics to protect the bones), and reducing stress, there are some perimenopause-specific lifestyle changes you can make as well. According to Andrew Weil, M.D., leading integrative medicine physician and founder of the Arizona Center for Integrative Medicine, some herbs and supplements to consider are magnesium, D and B vitamins, black cohosh, Dong Quai, and Evening Primrose oil. Chasteberry, also known as vitex, is also sometimes used for menstrual and PMS related complaints in perimenopause.
So what about perimenopause-specific dietary changes? It’s often recommended that women increase their intake of whole soy products.
and flaxseed to take advantage of their mild estrogenic effects. Dr. Barbieri also recommends a diet that is low in processed foods and added sugars, and incorporates a wide range of whole foods, especially vegetables and healthy fats such as those in olive oil, avocados and fatty fish. That said, she does not suggest the same exact nutrition plan for every patient. "There is not one perfect diet for everyone. But the common themes are plant heavy and whole food, with low refined carbohydrates and sugar.” She says it’s all about balance. “I love to see the tremendously beneficial effect a dietary change can have on my patients while being aware that we also do not cross over into obsession and rigid patterns. The ability to maintain a healthy, sustainable change over a long time is more important than eating perfectly for just a couple of days.”
For too long, too many women have entered perimenopause without the tools and resources they need to thrive. Arming yourself with knowledge during perimenopause can make all the difference. Understanding exactly what’s happening to your hormones and knowing that perimenopause looks and feels differently for every woman can eliminate the fear of the unknown and empower you to tackle perimenopause with the same strength and perseverance you’ve used to overcome life’s other tests and challenges.
Perimenopause & Premature Menopause FAQS — North American Menopause Society
Perimenopause — Dr. Weil Center For Integrative Medicine
Perimenopause — Mayo Clinic
Menopause, Perimenopause, & Postmenopause — Cleveland Clinic
Menopausal Transition: What Is It? — American Society for Reproductive Medicine