Are You in Perimenopause? How to Spot the Signs and Ease Your Transition

Your forties are a decade for celebration. Perhaps you’ve hit your peak earnings, or you’ve gotten married, started a family, or bought your first home. Things are looking good.

But there’s one aspect of your forties that many women approach with apprehension. Perimenopause.

Every woman goes through perimenopause, so it’s nothing to fear. In this article, we’ll delve deep into what perimenopause is, signs you may be in perimenopause, and how to support your body so you can thrive through your perimenopause and beyond.

What is Perimenopause?

The prefix “peri” means “around” or “near.” Therefore, “perimenopause” just refers to the gradual (and often unpredictable) process during which your body naturally transitions to menopause.

Perimenopause is not the same thing as premenopause, though. Although the two terms are sometimes used interchangeably, the North American Menopause Society (NAMS) differentiates them as follows:1

• Premenopause: The time between puberty (onset of menstrual periods) and the onset of perimenopause.
• Perimenopause: A span of time that begins with the onset of menstrual cycle changes and other menopause-related symptoms and extends through menopause (the last menstrual period) to 1 year after menopause.

The age of onset for perimenopause varies considerably among women but generally starts between ages 40 and 44. Some women may begin experiencing perimenopause in their 30s.

Although the average length of perimenopause is about 3 to 4 years, it can last up to 10 years for some women.2

The Difference Between Perimenopause and Menopause

Once you’ve gone 12 consecutive months since your last menstrual period, you’ve reached menopause. If you go a few months without a period but get one eventually before 12 consecutive months have passed, you’re still in perimenopause.

This also means that menopause is actually identified after you’ve reached it. Unlike perimenopause, menopause is not a transitional period; it’s more of a point in your life.

Menopause signals the end of a woman’s fertility. At this point, your hormone levels remain low, ovulation will stop, and you’ll no longer be able to get pregnant.

After menopause, most women continue feeling lingering symptoms of hormonal changes, such as hot flashes. In many cases, the symptoms resolve over time, though some can be long-lasting.

Signs You May Be In Perimenopause

Perimenopause is a complex, potent midlife rite of passage for women. To complicate matters further, no two women experience perimenopause the same way. Here are a few common signs and symptoms of perimenopause:

• Changes in menstruation (longer cycle, shorter cycle, heavier flow, etc.)
• Sleep disruption, insomnia
• Fatigue
• Brain fog, loss of concentration
• Mood swings, anxiety, depression
• Hot flashes and/or night sweats
• Weight gain
• Vaginal dryness
• Decreased sex drive
• Sudden or frequent urges to urinate
• Bone loss
• Changes in cholesterol levels
• Headaches
• Decreased fertility
• Uterine bleeding

You may be in perimenopause even if your symptoms don’t fit any of the above. If you consistently feel “off,” I recommend talking to a healthcare professional and getting your hormone levels tested using the recommendations below.

Despite the harrowing symptoms you may experience during perimenopause, keep in mind that perimenopause and menopause are not diseases. They’re both natural stages of life and aging.

However, the depletion of your sex hormones can lead to an increased risk of serious health concerns in addition to the symptoms above. Based on scientific literature, top common health issues associated with perimenopause include:3

• Cardiovascular diseases
• Musculoskeletal diseases
• Cancer (lung, breast, colorectal, pancreatic, ovarian, cervical)
• Dementia or cognitive decline
• Chronic respiratory disease
• Diabetes
• Metabolic syndrome
• Depression
• Vasomotor symptoms or hot flashes
• Sleep disturbances
• Migraine

What Causes Signs and Symptoms of Perimenopause?

Perimenopause is marked by wide fluctuations in hormone levels and changes in menstrual periods. But perimenopause is a lot more than just loss of estrogen. In fact, experts agree that estrogen levels either remain the same or even increase during most of perimenopause, up until a few months before menopause.4

In premenopausal women, small growing follicles in the ovaries produce antimullerian hormone and a protein complex called inhibin B. Inhibin B suppresses the release of follicle-stimulating hormone (FSH), which supports the recruitment and growth of ovarian follicles. As women age, there are fewer and fewer available ovarian follicles to produce inhibin B, which causes FSH levels to rise. This gradual rise in FSH is a cardinal feature of perimenopause.

Women in early perimenopause may find that their FSH levels are often normal or only occasionally elevated. According to the staging system set forth by experts at the Stages of Reproductive Aging Workshop (STRAW), you may continue to have regular menstrual cycles. However, the length of the cycles may change by seven or more days from your norm.5

As perimenopause progresses, your menstrual cycle length will become increasingly variable, with long cycles becoming more common.6 Because your ovarian follicle cohort may have shrunk considerably by this point, you may also have your first missed period. The declining follicle quality also leads to decreases in luteal progesterone levels.

Lower progesterone levels are often the first sign we see changes with when it comes to perimenopause. Progesterone’s role in your body goes far beyond just your reproductive system though. It has protective effects against:

• Inflammation7
• Certain types of cancer8
• Neurodegenerative diseases9
• Musculoskeletal diseases10
• Cardiovascular diseases11

Symptoms of low progesterone, such as trouble sleeping or increased anxiety, may become more pronounced when you begin skipping periods.

Late perimenopause is marked by increasing frequency of skipped periods (anovulation). Eventually, estradiol and progesterone production stops, signaling the start of early postmenopause.

For many women, this is a long, drawn-out process during which we are exposed to highly erratic hormonal fluctuations. It’s no wonder women liken perimenopause to an emotional roller coaster.

How to Support Your Body Through Perimenopause

Test, Don’t Guess

I highly recommend doing baseline testing in your 40s and repeating them a few times a year to chart the changes that are happening. Here are the tests I recommend:

• Dried Urine Test for Comprehensive Hormones (DUTCH) test: This is one of the most advanced, validated tests that offers an extensive profile of sex and adrenal hormones and hormone metabolites.
• Day 3 FSH and estradiol (E2) test: A day 3 FSH and estradiol test (day 1 is the first day of your period) can help you determine if you’re ovulating and evaluate the status of your ovarian reserve. If your baseline FSH is elevated, it suggests that your ovarian reserve is reduced. FSH and E2 are often tested together because estradiol suppresses FSH. Therefore, it can help you determine the accuracy of your FSH test and provide context for interpreting your FSH test results. Learn more about day 3 fertility testing and the optimal levels for FSH and estradiol in my blog here.
• Luteinizing hormone (LH) test: The primary role of LH is regulating the length of your menstrual cycle and stimulating ovulation. Measuring your LH level on day 3 of your cycle can help detect any irregular ovulation patterns.

Learn About Your Options for Menopause

Hormone replacement therapy (HRT), as its name suggests, is the use of female hormones to replace the ones your body has stopped producing. It comes in two types:

• Estrogen only for women who don’t have a uterus- (although progesterone provides benefits beyond protecting the uterus)
• Estrogen plus progesterone (beware of synthetic progestins) for women who do have a uterus.

Women who don’t respond to non-hormonal therapies for severe hot flashes and other symptoms can benefit from HRT. Using progesterone HRT early on in your transition can help combat some perimenopausal symptoms.

But HRT isn’t without controversy. If it’s something you’re considering for yourself, I recommend doing thorough research. A good place to start is How Hormone Replacement Therapy Can Help You Through Menopause.

Support Your Adrenal Health

Your adrenal glands are two small, triangular-shaped endocrine glands that secrete cortisol, aldosterone, adrenaline, noradrenaline, and sex hormones (androgens, estrogens).

Your adrenal glands are the primary source of a hormone called dehydroepiandrosterone (DHEA). DHEA provides 100% of estrogens in your body after menopause, which means achieving optimal levels of DHEA is crucial for maintaining harmony in your body.12

Your adrenal hormones, including DHEA, become even more important as you transition to menopause. During perimenopause, you may find yourself getting flustered more easily or not being able to cope with stress as well. Scientists believe this occurs because changes in progesterone levels induce dysfunction in the hypothalamic-pituitary-adrenal (HPA) axis.13

HPA axis dysfunction, also commonly called adrenal fatigue, is why we see so many perimenopausal women struggle with symptoms like increased anxiety, depression, and insomnia.

Poor adrenal health may also intensify your perimenopausal symptoms. A study of 101 perimenopausal women showed that those who suffered more severe vasomotor symptoms also exhibited HPA axis dysfunction.14

More studies are needed to elucidate the relationship between perimenopausal symptoms and the HPA axis. However, it’s increasingly becoming evident that we need to support our adrenal health throughout perimenopause. You can learn about how to do so in 8 Top Ways to Nourish Your Adrenals and Restore Your Sparkle

Adopt a Healthy Lifestyle

From my experience working with thousands of women, most need to make diet and lifestyle changes to support and maintain their health through perimenopause. Keeping things the same can often lead to more symptoms and unexpected weight gain.

But changing your lifestyle isn’t about depriving yourself. Instead, try creating more presence and consciousness.

Support Your Body Through Perimenopause With a Women’s Hormone Expert in Boston

Perimenopause can be a difficult time for many women. Keep in mind there’s no “normal” to perimenopause – one woman’s experience does not necessarily mean yours will be similar.

If you’re struggling through perimenopause, there is support to help ease the symptoms. As a naturopathic physician and women’s hormone specialist, I’ve helped women in Boston and virtually throughout the U.S. ease their transition through perimenopause using integrative methods.

Schedule a 15-minute complimentary consultation with me to learn more about how I can help you.