9 Signs You're Entering Perimenopause—and How to Cope
Here’s a fun fact: Perimenopause usually begins four to eight years before a woman’s last menstrual period. Once a woman is period-free for an entire year, the peri is dropped for full-on menopause. The average age for that? 51. “But every woman’s timespan is different and so is the way she experiences perimenopause,” says Lauren F. Streicher, M.D., medical director of the Northwestern Medicine Center for Sexual Medicine and Menopause in Chicago. “Some women have years of symptoms related to hormonal fluctuations, while others can be perimenopausal and never even realize it.” No matter where you fall, it helps to know the signs.
Your Period Becomes Wonky
Perimenopause begins when the ovaries stop functioning consistently, causing erratic estrogen production. The pair of these occurrences result in irregular periods. “Most often, this is the first sign of perimenopause,” says Sherry Ross, M.D., an ob-gyn and author of She-ology: The Definitive Guide to Women’s Intimate Health. Period. “Periods can become heavy, clotty, or light and brown; they can last for days or weeks on end. The only constant is the irregularity.” Of note: If you are already on the Pill, or use other hormonal birth control like Mirena, you may not even notice this irregularity because your periods are already minimized or have disappeared entirely.
You May Get "Starter" Hot Flashes
Hot flashes usually occur within the first few years of menopause, says Dr. Streicher. But you may get “starter” flashes during perimenopause, where you’re hit with a quick 30-second to 5-minute burst of heat that radiates on the face, chest, and head. Women who are obese; have symptoms of depression or anxiety; and/or are in poor overall health are more likely to have hot flashes during perimenopause, according to research in Menopause. For healthy, non-smoking, still menstruating women who are also looking to prevent pregnancy, Dr. Streicher notes that birth control pills can help. (These six drug-free options can help, too.)
Your PMS May Get Worse
“While it’s not well-studied yet, I see many women who have an exaggeration of PMS symptoms during perimenopause,” says Dr. Streicher. “Women will say things like, ‘Suddenly before my period my breasts are tender, and I’m a lot moodier.’” Blame those fluctuating hormones. It can be difficult to distinguish honest-to-goodness PMS symptoms from signs of perimenopause itself. If you’re bothered by them, talk to your health care provider who may recommend hormonal intervention. They may also test your thyroid: Both hypothyroidism and hyperthyroidism can mimic symptoms of perimenopause, and they’re more likely to arise during the peri years.
You May Feel Fried
Fatigue during the day or experiencing “brain fog” during perimenopause is often due to a lack of sleep — from hot flashes. “Women may wake up in the middle of the night, but they often don’t realize that it’s due to night sweats,” says Dr. Streicher. One clue: The covers are off. If this sounds familiar, dial back caffeine and alcohol. “I’d shoot for one large cup of coffee in the morning and not more than three to four alcoholic beverages a week,” recommends Dr. Ross. Not only is caffeine and alcohol thought to spur night sweats, they also disrupt sleep patterns.
Your Pants May Get a Bit Tighter
“Many women tend to gain weight around perimenopause due to hormonal changes that cause our metabolism to slow down,” says Dr. Ross. While you can’t do much to rewind your metabolism, you can alter your calorie intake to offset the shift. “You’d need to eat about 200 to 300 calories less to maintain your same body weight,” says Dr. Ross. (The easiest way to do this? Stop after-dinner eating.) Bonus: A new study in The Lancet Diabetes & Endocrinology reports that shaving 300 calories off your daily diet can also lower blood pressure, total cholesterol, and improve insulin sensitivity.
Your Period May Get Heavier
Researchers at the University of Michigan found that most women experience an increase in blood flow (and bleeding duration) during perimenopause. Women produce less progesterone, which allows the uterine lining to thicken more than before. The result? A heavier flow. “The best treatment for this problem tends to be low-dose oral contraception,” says Dr. Ross. If you are bleeding daily or the flow is extremely heavy, however, consult your gynecologist right away.
Your Migraines May Get Worse
For women who already suffer from migraines, the hormonal ups and downs during perimenopause can increase their frequency, notes a study in the journal Headache. (“This is especially true for perimenopausal women experiencing irregular periods,” notes Dr. Ross.) And even women who were previously migraine-free may suddenly get these types of headaches, according to Italian researchers. The good news? Migraines often decline after menopause. Talk to your doctor about which treatment might be best, including non-drug options like biofeedback, acupuncture, and getting more rest.
Your Risk of Feeling Blue Goes Up
Even with no history of depression, women in perimenopause are at an elevated risk for depressive symptoms, according to a report in the Journal of Women's Health. It’s unclear if this relation is hormonal, however. Researchers note that life-stage stressors (like aging parents, kids going to college, divorce, etc.) and the emotional toll of other perimenopausal symptoms, including sleep-sapping night sweats, may be involved. Working with your doctor to find some relief for those may also help lighten your mental load, but if you’re really struggling, don’t hesitate to reach out to therapist.
Your Sex Life Might Change—a Little
Vaginal dryness is a big worry for perimenopausal women, but it’s not that common of an issue. “While vaginal dryness due to hormonal changes can and does occur during perimenopause, for most women, it happens after menopause,” says Dr. Streicher. Instead, changes in your desire for sex may be tied to other midlife or perimenopausal changes, like lack of sleep, moodiness, and/or fatigue. If you’re dealing with dryness, however, Dr. Streicher recommends using a lubricant that’s pH balanced, preservative-free, and has what’s called “low osmolality” to decrease the chance of irritation. Good Clean Love and Sylk Natural are good water-based choices, while Replens Silky Smooth and JO Premium Personal Lubricant are smart silicone picks.
You Feel Nothing Different at All!
“There are definitely some women who don’t even know they’re in perimenopause,” notes Dr. Streicher. And still others don’t experience perimenopausal symptoms because they’ve been on birth control pills. “For healthy, non-smokers, it’s the best way to go through perimenopause,” says Dr. Streicher. “You often don't have any of the symptoms. Basically, you stay on low-dose birth control till 55 years old and then your doctor can transition you to an even lower dose hormone therapy and you many never experience one day of symptoms.”
- Starter hot flashes: Menopause. (2016). “Measuring hot flash phenomenonology using ambulatory prospective digital diaries.” ncbi.nlm.nih.gov/pmc/articles/PMC5079773/
- Benefits of calorie reduction: The Lancet. (2019). “2 years of calorie restriction and cardiometabolic risk (CALERIE): exploratory outcomes of a multicentre, phase 2, randomised controlled trial.” thelancet.com/journals/landia/article/PIIS2213-8587(19)30151-2/fulltext
- Heavier periods during perimenopause: An International Journal of Obstetrics and Gynaecology. (2014). “Bleeding patterns during the menopausal transition in the multi‐ethnic Study of Women's Health Across the Nation (SWAN): a prospective cohort study.” obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.12768
- Increased migraines: Headache. (2016). “Perimenopause and Menopause Are Associated With High Frequency Headache in Women With Migraine: Results of the American Migraine Prevalence and Prevention Study.” headachejournal.onlinelibrary.wiley.com/doi/abs/10.1111/head.12763
- New migraines in perimenopause: International Journal of Women’s Health. (2015). “Migraine in menopausal women: a systematic review.” dovepress.com/migraine-in-menopausal-women-a-systematic-review-peer-reviewed-fulltext-article-IJWH
- Depression: Journal of Women’s Health. (2019). “Guidelines for the Evaluation and Treatment of Perimenopausal Depression: Summary and Recommendations.” liebertpub.com/doi/10.1089/jwh.2018.27099.mensocrec
- Oral contraceptive safety in perimenopause (1): Chonnam Medical Journal. (2018). “Use of Combined Oral Contraceptives in Perimenopausal Women.” ncbi.nlm.nih.gov/pmc/articles/PMC6165915/#B10
- Oral contraceptive safety in perimenopause (2): UpToDate. (2019). “Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use.” uptodate.com/contents/combined-estrogen-progestin-oral-contraceptives-patient-selection-counseling-and-use