Let's Talk About Perimenopause
It’s the leadup to menopause, and it can cause some wacky changes in your body. Here, the doctor-vetted details on the symptoms and, if you need ‘em, the top treatments to help you feel calmer, cooler, and all-around less freaked.
You’re in your 40s or even 30s and—whaaaat? Period weirdness? Hot flashes? How could you be in menopause already? It’s possible that what you’re experiencing is perimenopause, the time frame before your periods fully stop and you enter menopause. While it used to be referred to as “the menopause transition,” it’s now got its own shiny name to help you ID what's going on in your body. We’re sure you’ve got questions…and we at HealthCentral are here with the answers—and relief—you need.
Our Pro Panel
We went to some of the nation’s top menopause experts to bring you the most up-to-date information possible.
Diana Bitner, M.D.
OB/GYN and author of "I Want to Age Like That! Healthy Aging Through Midlife and Menopause"
Monica Christmas, M.D.
Assistant Professor of Obstetrics and Gynecology and Director of the Menopause Program
Juliana Kling, M.D.
Associate Professor of Medicine and Associate Chair of Research in the Division of Women’s Health
Nope. Perimenopause is the natural transition and time before menopause; it’s a normal phase in a woman’s life. Early menopause is when a woman goes into full menopause before the age of 45. There’s also premature menopause, when you enter full menopause before 40. Usually, these two occur because a woman has had a hysterectomy (including removal of the ovaries) or has undergone chemotherapy, which can harm the ovaries and launch you into early menopause. If one of more of your female relatives went through early menopause, you have a higher risk of going through it yourself. But the chances are still low: Fewer than 5% of women enter early or premature menopause without having other health conditions.
Menopause means the cessation of periods for a full year, so if you've entered this phase and then bleeding starts up later on, see your doctor ASAP to make sure you’re not experiencing another health issue. In perimenopause, bleeding that lasts for more than two weeks or that is so heavy it requires a new pad or tampon every one or two hours is a reason to check in with your doc. That said, any bleeding that is uncomfortable or even inconvenient warrants a call to your doctor’s office. There are perimenopause treatments to help reduce heavy bleeding if it is getting in the way of living your life, whether it is considered heavy enough to be a medical issue or not.
Perimenopause is usually diagnosed by the main symptom—period changes. However, if you’re unsure or worried about how perimenopause could be affecting your fertility, your doctor can do a series of blood tests to confirm your hormone levels.
There is no official perimenopause quiz, and honestly, you probably wouldn’t need one. If you are having the symptoms in this article, suspect you are in perimenopause, and are around the average perimenopause age—from your late thirties to early fifties—well, you most likely are in perimenopause.
What Is Perimenopause, Exactly?
Perimenopause literally just means “around menopause” and is a normal state of life before a woman is fully in menopause. Many of the signs and symptoms most people associate with menopause—such as hot flashes, erratic periods, and mood swings—often begin during perimenopause, because menopause technically means that your periods have stopped altogether for a full year.
There is a wide range of time of when women begin having the symptoms of premenopause (as it’s known more colloquially)—it can start as early as your mid-thirties or as late as your late forties. Changes in your perioid—whether they are further apart or closer together, longer or shorter, heavier or lighter—are the first sign that you are perimenopausal.
But, as perimenopausal symptoms are caused by the same hormone fluctuations that eventually bring about full menopause, any and all menopause symptoms—such as hot flashes, sleep issues, vaginal dryness, and mood swings—can also begin to occur at this time.
During perimenopause, shifts in hormones may cause a broad spectrum of symptoms that range from the physical to the psychological, and can sometimes take women by surprise. You may initially think that issues such as trouble sleeping, weight gain, or a lack of interest in sex are a reaction to stress, career pressure, or living a full life—and, true, they very well could be. But it’s quite possible, if you’re around age 40 when these baddie symptoms hit, they could be age-related hormonal shifts and signs of being premenopausal.
What Causes Perimenopause?
Women are born with a set number of eggs. In a typical menstrual cycle, the brain sends a hormone called FSH (follicle stimulating hormone) to tell the follicles in the ovaries to mature and release one egg, which causes them to produce the hormone estrogen, eventually resulting in ovulation and the uterus building up a lining to house a potential fetus if the egg is fertilized. After the egg is released, the empty follicle discharges the hormone progesterone, which keeps the growth of the uterine lining in check, so it does not just keep building up indefinitely.
When the number of eggs a woman has dwindles with age, the ovaries have fewer eggs to dispense. Messaging between the brain and the ovaries is one way (the brain tells the ovaries what to do, but they can’t message the brain back), so if the brain releases FSH (follicle stimulating hormone) and the follicle does not have an egg to develop and put out, the brain may keep sending more FSH to try to trigger ovulation, which may cause the ovaries to overcompensate by releasing too much estrogen or progesterone, or they may just produce less over time as they run out of eggs. As a result, the ovaries react by sputtering hormones instead of dispensing them in an even and predictable stream, the way a leaky faucet may gush or drip or alternately do both.
Faced with this lack of eggs, sometimes the ovaries overcompensate by erratically producing and discharging more estrogen or progesterone in bursts before they taper off; other times they just gradually give off less. Indulge us another metaphor: If you think of your uterus as a garden, then estrogen and progesterone are fertilizer and weed killer, respectively. Estrogen signals for the uterine lining to build up (like a fertilizer), which can cause bloating, cramping, heavier periods, and more bleeding. Progesterone triggers the uterine lining to thin and stops it from getting too thick (like a weed killer), leading to lighter and less frequent periods.
Estrogen and progesterone have a tight relationship, and they affect each other—one can be more plentiful, stopping the other from doing its job to maintain the balance. This is why for some people, bleeding increases and periods get closer together during perimenopause, while others see their periods move further apart and bleeding lighten. Both are completely normal reactions to the ovaries releasing fluctuating amounts of estrogen and progesterone as they prepare to eventually stop ovulating altogether.
How Long Does Perimenopause Last?
Contrary to popular misconceptions, the amount of time that women usually have symptoms in menopause itself is only a few years. That’s because what most people commonly refer to as “menopause” is usually partly perimenopause. You’re likely to live in Perimenopause Land longer than Menopause Town, whose town slogan could be “where periods come to a full and final stop.”
More menopause math: Perimenopause can last up to ten years. Once you hit menopause, hormones usually stabilize at their new, lower levels within a few years, and the symptoms that began in perimenopause tend to subside. (A notable exception: vaginal dryness, which is permanent but can be managed.) So all said, the symptoms that show up from the estrogen/progesterone flux stick with you for a total of four to eight years, counting both perimenopause and menopause.
How Are Perimenopause Symptoms Different From Menopause Symptoms?
Perimenopause and menopause share the same symptoms, because they are both caused by female hormones changing as the ovaries prepare to and eventually stop releasing eggs. As perimenopause comes first, the symptoms and treatment tend to focus more on regulating periods and bleeding, because these hormones are still fluctuating and are not yet at the lower levels of menopause.
Other common menopausal symptoms—such as hot flashes, insomnia, sexual side effects, vaginal dryness, and mood swings can also all affect women in perimenopause—though they may not.
Remember, there is no symptom of menopause that is not also a possible perimenopausal symptom, so if you don’t find your symptom here and suspect you are in perimenopause, check out our article with more in-depth information. Any of these may also apply to you, as they are simply different names for two stages of the same overall transition. Though period shifts tend to come first and other symptoms later, that is not always the case, and there is much more overlap than most people suspect
So, What Are the Most Common Perimenopausal Symptoms?
First check out our quick list of the typical perimenopause symptoms. Then pop down below, where we’ve grouped them together based on the best treatments.
Period changes: Either it gets stronger or lighter, closer together or further apart. You may also experience spotting.
Breast fullness or soreness
Less (or no) interest in sex
Vaginal dryness or irritation
Having to pee more
Mood swings, which can also snowball into depression or anxiety
Hot flashes and/or their p.m. counterpart, night sweats
How Can I Treat Perimenopausal Symptoms?
Find your symptom below, then discover the cause, the OTC remedy, and the medical treatments available. It’s less fun than a choose-your-own adventure, but at least relief is on the way!
Worse cramping and bloating
Breast tenderness or swelling
Periods coming closer together or lasting longer than when you were younger
Cause: These symptoms are usually the result of an excess of estrogen being released while the ovaries are sputtering and then a steep drop before your period. Or it could be that the balance of estrogen and progesterone are thrown off by the ovaries releasing less progesterone, with estrogen dominating the uterine environment, causing a buildup of the uterine lining without enough progesterone to keep it in check.
OTC remedy: Period underwear! Yes, they’re a thing—and now come in lots of varied styles.
They’re typically made of super absorbent, high-tech fabrics that have layered combinations of cotton (closest to your skin because: comfortable, breathable) and some stretch (such as elastane); they often have added ingredients such as nonmigratory silver (nonmigratory means it stays in the fabric and does not transfer to your skin) to combat odor and bacteria as you wear them, and PUL (a waterproof fabric on the outer layers that prevents leaks) woven in with synthetic fibers (such as nylon and polyamide) so they feel soft and smooth.
Thinx is a brand that has styles for heavy days as well as light days, with some pairs being able to hold as much blood as two full tampons—allaying the fear that a gush of blood will flow when you’re ill-prepared.
Medical options: If you are not interested in becoming pregnant, you can talk to your doctor about the many oral, vaginal, and transdermal progesterone-based birth control options that also have the welcome side effect of reducing heavy periods, regulating them so they occur less frequently, or even stopping them entirely. These are combination estrogen-progesterone based options. There is also progesterone based IUD and endometrial ablation options.
If you are in perimenopause and also trying to conceive, you won’t want to take progesterone or contraceptives, but there are other options that can help balance hormones and may even increase your chances of conception. There is usually supplementation of both estrogen and progesterone with IVF through the first trimester of pregnancy.
Vaginal dryness or irritation during sex
Increased urinary frequency or urgency
Cause: Low estrogen can have the benefit of making periods lighter and more spaced out premenopause, but it can also result in sexual issues, and a suite of symptoms affecting the vaginal and vulvar tissue known as genitourinary syndrome, as the lack of estrogen causes the whole area to become dryer, thinner, and more prone to irritation and infections.
OTC remedies: In a word: lube.
If you had a bad experience with an icky lubricant when you were younger, times they have a’changed. There are ziliions of options today. Look for a lube or vaginal moisturizer that is free of fragrance or alcohol, which can further irritate already delicate vaginal tissue and which has an osmolality that is close to the vagina’s own, at around 380 (the number you don’t want to go above: 1,200).
In science-speak, osmolality is the number of other substances immersed in a solution; in human-speak, it means you want a lube that is watery, slippery, and not too sticky or thick—so, as close to natural vaginal secretions as possible. The pH should also be a near match to the vagina’s, between 3-5. Both of these numbers should be on the product label. Two brands that make a wide variety of vaginal moisturizers and lubes free of irritants and within this sweet spot range are Yes and Good Clean Love.
Medical options: Topically applied estrogen is the go-to prescription for this group of symptoms, and there are low-dose creams, gels, and pills and what’s called a “vaginal ring,” all of which you can insert; thse have lower risks and more localized effects than oral hormones. Coconut oil, untoasted sesame oil, hyaluronic acid (Revere is one type) can also be used.
Talk to your internist, gynecologist, or fertility specialist about the right hormone therapy (HT) option that will not have adverse health effects (people can be afraid of HT because of outdated studies). Many localized options that are applied transdermally (such as a patch or cream rubbed into the thigh) low risk even for women who do have contraindications or don’t want to take oral or systemic hormones.
Mental health issues such as depression or anxiety
Cause: Estrogen and progesterone are both mood-boosting hormones. Progesterone also aids in sleep. As they decline, well, so can your mood. Some women may experience drastic emotional and mental health symptoms, as well as disrupted sleep, hot flashes, and night sweats.
The link between estrogen, progesterone, and serotonin is still not fully understood, but they are related, which is why drops in hormones that affect sleep and cause hot flashes can also bring about mental health shifts, and the same meds are FDA-approved to treat this whole suite of symptoms.
OTC remedies: Let’s focus on sleep, because it influences mood, too. First, make sure your bedroom has good “hygiene” (that means charging your phone in another room, or at least not within arm-grab distance, and avoiding screens a few hours before sleep). Cutting caffeine and sugar and exercising regularly. Melatonin is one of the few safe supplements that has been demonstrated to assist with sleep issues and insomnia.
Medical options: Women who have previously suffered from severe PMS emotional disturbances, postpartum depression, or other mental health issues are more likely to experience a resurgence during perimenopause. Don’t brush these feelings aside! Seek out the professionals, medications, and therapies that worked for you in the past. If this is the first time you’re experiencing mental health symptoms, know that they're real and valid and it's best to talk to a therapist about your options.
Fortunately, many psychiatric medications, such as SSRIs (selective serotonin reuptake inhibitors), have also been shown to help with hot flashes and insomnia. Women who have systemic emotional and physical issues—a.k.a. those not localized around the uterus and vagina—benefit most from systemic hormone therapy, so it’s worth talking to your doctor about HT to see if it's right and low risk for you. See our Menopause Treatments page for a full breakdown of all of the different hormone and non-hormonal medications and treatments that are FDA-approved to treat these symptoms.
Perimenopause Symptoms: The Mayo Clinic. mayoclinic.org/diseases-conditions/perimenopause/symptoms-causes/syc-20354666
Bleeding During Perimenopause: American College of Obstetricians and Gynecologists. acog.org/Patients/FAQs/Perimenopausal-Bleeding-and-Bleeding-After-Menopause
Sex During Perimenopause: Menopause. ncbi.nlm.nih.gov/pubmed/31738734
Stages of Perimenopause: Journal of Women’s Health. ncbi.nlm.nih.gov/pmc/articles/PMC4834516/
Weight Gain in Perimenopause: Journal of Clinical Investigation. dx.doi.org/10.1172/jci.insight.124865
Perimenopause and Mood: Obstetrics and Gynecology Clinics of North America. ncbi.nlm.nih.gov/pmc/articles/PMC3197240/?report=reader#!po=1.97368