Perimenopause

If you’ve noticed unexpected changes in your body and mood, and the once predictable rhythm of your menstrual cycle is now off beat, you could be in perimenopause. This transitional period before menopause brings both physical and emotional changes. Women’s health expert Abby Sexton, DO, UnityPoint Health, helps demystify these changes by discussing what to expect when you enter perimenopause and how to get some relief.

What is Perimenopause?

Perimenopause refers to the physical changes happening in a woman’s body leading up to menopause. During this transitional phase, hormonal fluctuations occur as the ovaries gradually reduce estrogen production.

“In menopause, the brain is trying to stimulate the ovaries, but the ovaries aren’t producing hormones anymore,” Dr. Sexton says.

What is the Normal Age for Perimenopause to Start?

Perimenopause happens about 4-8 years before a woman enters menopause, but its onset varies. It typically occurs for women in their 40s, but it can range from the mid-30s to early 50s. 

“The average age of menopause in the United States is 51,” Dr. Sexton says. “Early onset menopause, occurring in the early 30s, is abnormal and requires a further work-up to look for ovarian failure or other medical conditions.”

Outside of smoking, there aren’t many lifestyle factors and underlying conditions that cause early or late menopause.

“Cigarette smoke may cause women to go through menopause 1-2 years earlier,” Dr. Sexton says.

There can be, however, trends in families that predict when perimenopause or menopause starts. For instance, if a woman’s mother went into perimenopause in her mid-40s, there’s a chance she will, too.

How Long Does Perimenopause Last?

Perimenopause can last anywhere from a few years to a decade or more. A sign perimenopause is ending is the absence of periods for an entire year. This new phase of a woman’s life is then considered menopause.

Can You Get Pregnant During Perimenopause?

If you’re still having periods, you can still get pregnant.

“Your periods might not be regular, so you may not be ovulating every month. When you do have a period, there’s a chance ovulation can occur, and so pregnancy is a possibility,” Dr. Sexton says.

What are the First Signs of Perimenopause?

“Most of the time, the first sign women notice is their changing menstrual cycle. Periods can become longer, shorter, heavier or lighter. Women may start to skip months. It’s different for each person,” Dr. Sexton says.

Symptoms women experience during perimenopause include:

• Irregular periods: Periods can become longer, shorter, heavier or lighter.
• Fatigue: Some women feel more tired during perimenopause.
• Hot flashes: These include sudden and intense feelings of heat.
• Joint or muscle pain: Some women experience aches in their joints.
• Low sex drive: Changes in sexual desire may occur.
• Mood changes: Irritability and feeling more vulnerable to stress are common.
• Night sweats: These are similar to hot flashes but occur at night.
• Trouble sleeping: Difficulty falling or staying asleep is common.
• Vaginal dryness: Decreased estrogen can cause vaginal itching, dryness or discomfort during sex.
• Weight gain: Lower estrogen levels can contribute to changes in body composition and metabolism.

“A woman may be in perimenopause for many years of her life, and the severity of symptoms are different for each person,” Dr. Sexton says. “Someone may experience hot flashes, but they don’t interfere with daily life. For others, they can be debilitating.”

When to Worry About Perimenopausal Bleeding

Changes in period frequency and volume are common and typically one of the first signs of perimenopause. Although changes in your menstrual cycle are expected during perimenopause, you should always talk to your doctor about bleeding changes to rule out any other underlying health conditions. The American College of Obstetrics and Gynecologists recommends talking with your doctor if you notice bleeding or spotting between periods, bleeding or spotting after sex, heavier than usual bleeding during your period or longer than usual periods. 

How to Reduce Perimenopause Symptoms

“Often, I think women just try to grin and bear it, but there are options for women looking to feel better,” Dr. Sexton says.

There are several ways to help reduce uncomfortable symptoms of perimenopause. For example, some antidepressants help with treating hot flashes.

Hormone replacement therapy is another option. Dr. Sexton says it’s a misconception that hormone replacement therapy is only for after menopause. It’s a good idea to talk to your doctor about whether it can be an option for you.

“During hormone replacement therapy, you’re adding back estrogen and progesterone to help relieve the perimenopausal or menopausal symptoms,” she says. “Typically, dose increases and adjustments are performed based on your symptoms, not necessarily lab values. The goal is treatment of the whole person, including the bothersome symptoms you’re experiencing.”

Hormone replacement therapy comes in several forms, including a pill, patch, cream or gel. While it can greatly alleviate perimenopause and menopause symptoms, it does come with some side effects, such as irregular bleeding, breast tenderness and headaches. 

You should have a conversation with your doctor about the risks and benefits of hormone therapy, as it may not be right for people who have a history of blood clots, clotting disorders, stroke or certain types of breast cancer, as well as ovarian or uterine cancer.

How Can I Balance My Hormones During Perimenopause?

Dr. Sexton says tried and true healthy habits help with balancing hormones naturally during perimenopause. People who maintain a healthy weight, are physically active and eat a well-balanced diet may experience less severe perimenopause symptoms. She recommends the following:

• Focus on nutrition
• Supplement with calcium and vitamin D
• Do weightbearing exercises
• Keep up with routine yearly check-ups, such as gynecological, general wellness, dental and mental health therapy, if needed

“There are many plants and herbs that have historically helped with improvement of symptoms, most of which aren’t FDA-approved. Talk to your doctor before you start taking any supplements,” she says.

How Do You Test for Perimenopause?

In menopause, the follicle stimulating hormone (FSH) is elevated, because the brain is trying to stimulate an ovary that no longer can respond.

“An elevated FSH gives us a clue that a woman’s in menopause, and it correlates with the decreased estradiol (estrogen) level,” Dr. Sexton says.

During perimenopause, there’s a slow, gradual increase of FSH accompanied by a similarly paced decrease in estradiol and progesterone. However, Dr. Sexton advises against checking hormones routinely because hormones fluctuate throughout the menstrual cycle.

“Treating perimenopausal symptoms is more beneficial than chasing specific hormone levels. Symptom relief is really what we’re looking to achieve,” Dr. Sexton says.

Consider talking to your doctor about menopause if you’re no longer having periods but experiencing potential menopausal symptoms that impact your daily life.

Talking to Your Doctor about Perimenopause

Your doctor is an excellent resource for questions about perimenopause or menopause.

“Women seek help from providers who specialize in women’s health for a variety of different things all throughout life. This is another one of the steps in the journey through womanhood. Bothersome symptoms during perimenopause and menopause happen to a lot of people, so don’t be afraid to talk about what you’re going through. We’re here to help you live your perimenopausal years to the fullest,” Dr. Sexton says.