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Your reproductive life is marked by countless transitions. Among these, perimenopause is a pivotal point, signaling the onset of the transition to menopause. Many women have the same central question: How do you know you’re in perimenopause? In this Q&A article, we’ll answer that question.

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If you’re confused, you’re not alone! On a practical level, many of us use the all-encompassing term menopause, as do our doctors and the media. But there are actually several phases to this process that can, surprisingly, last as long as a decade!

Perimenopause means “around menopause,” and it actually refers to the time before menopause. Perimenopause is the transitionary time when we experience the classic symptoms associated with menopause, like hot flashes, night sweats, and sleep disruptions.

During perimenopause, the natural declines and changes in hormones eventually lead to the end of menstrual periods. One year after the last menstrual period is the point in time when menopause has been completed. In the United States, the average age of menopause is 51.

The time after that one-year point is referred to as post-menopause.

As you can see, because the concept of “menopause” is frequently associated with a woman’s 50s, many women in their 30s and 40s don’t realize that symptoms like fatigue, hot flashes, brain fog, and sleep disturbances are, in fact, the symptoms of perimenopause. “I’m too young for menopause!” they say.

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The average age of perimenopause onset is 47, and the average perimenopause lasts four years. This is not uniform, however, and when perimenopause starts – and how long it lasts – varies among different populations and ethnicities. It can also be affected by genetic, environmental, and lifestyle factors.

In fact, for some women, perimenopause can start as early as your late 30s and can last as long as a decade.

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Early perimenopause refers to the onset of perimenopause at a younger age than average, typically before the age of 45. While the exact causes of early perimenopause are not always clear, several risk factors have been identified:

Family history and genetics

Family history and genetics significantly determine the age at which a woman will enter menopause. Studies have shown that there is a strong familial link; if your mother or sister experienced early menopause, it is likelier that you will, too. Genetic variants associated with later menopause have also been linked to longer life spans, suggesting that the genes influencing menopause may also affect longevity.

Medical history

Certain medical conditions or treatments can increase the risk of early perimenopause. These include autoimmune diseases, such as lupus or rheumatoid arthritis, and cancer treatments like chemotherapy or radiation therapy.

Smoking

Cigarette smoking is one of the most consistent non-genetic factors associated with an earlier onset of menopause. Women who smoke may experience menopause one to two years earlier than non-smokers. The toxins in cigarettes are believed to affect ovarian function and accelerate the depletion of eggs.

Body Mass Index (BMI)

According to research, a higher body mass index (BMI) has been associated with a later onset of menopause, while underweight women may experience earlier menopause. This is possibly due to the fact that adipose tissue can produce estrogen, which may influence the timing of menopause.

Reproductive history

Women who have never been pregnant or have had fewer pregnancies may experience menopause at an earlier age. Conversely, those who have had more pregnancies may have a later onset.

Diet and nutrition

Dietary patterns may also play a role in determining the age at menopause. For example, a diet rich in antioxidants and healthy fats might delay menopause, while a diet high in saturated fats and sugar may lead to an earlier onset.

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Exposure to toxins and chemicals

Exposure to certain endocrine-disrupting chemicals and environmental toxins found in pesticides, plastics, and some household products may affect the timing of menopause. These toxins can interfere with the body’s hormonal systems and potentially lead to earlier menopause.

Ethnicity and race

Research has indicated that ethnicity and race can influence the timing of menopause. For example, African American and Hispanic women may reach menopause slightly earlier than Caucasian women.

Surgical history

Women who have had surgery to remove their ovaries (oophorectomy) or uterus (hysterectomy) may experience early menopause, depending on the extent of the surgery and whether one or both ovaries were removed.

Stress

Chronic stress may disrupt the hormonal balance in the body, potentially leading to early menopause.

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How do you know that you’re in perimenopause? Let’s look at the signs and symptoms.

Menstrual cycle changes

Changes in your menstrual cycle are often the first indicator of perimenopause. You may notice irregular periods that are unpredictable in terms of frequency and/or flow. You may also experience heavier or lighter periods than usual or have a shorter or longer menstrual cycle. You may also have more painful periods and more cramping.

Hot flashes/night sweats

Another common symptom of perimenopause is hot flashes, also called “hot flushes.” Hot flashes are caused by hormonal changes that affect the body’s temperature regulation system. These sudden feelings of warmth can spread throughout the body but are most intensely felt in the head and chest. They may also be accompanied by sweating and palpitations. Hot flashes occur at any time, but when they occur at night, they’re often referred to as “night sweats,” and can disrupt sleep.

Mood swings

Changes in estrogen levels can impact neurotransmitters in the brain, leading to mood swings, irritability, depression, and anxiety. You may find yourself feeling more emotional or easily agitated than usual. For some women, these mood changes are significant and debilitating.

Sleep disturbances

During perimenopause, you may have difficulty falling asleep, staying asleep, or experiencing quality sleep.

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Vaginal and bladder problems

Decreasing estrogen levels can lead to vaginal dryness, discomfort during sex, and increased susceptibility to urinary tract infections. Some women also report more frequent urges to urinate or urinary incontinence.

Changes in sexual function

Along with vaginal dryness, changes in sex drive are common, with some women experiencing a decreased interest in sex while others may notice an increase.

Brain fog

Some women report cognitive challenges during perimenopause, experiencing issues with brain fog, memory, focus, and concentration.

Weight changes and redistribution

During perimenopause, some women notice weight gain. According to research, approximately 20% of perimenopausal women gain 10 pounds or more during perimenopause, with an average weight gain of about 5 pounds during this stage. Other research has shown that women gain an average of 1 pound per year during perimenopause.

With or without weight gain, women also experience a redistribution of weight, primarily to the abdominal area, known as central weight distribution.

The reduced estrogen levels during menopause can lead to fat being stored around the waist instead of the hips and thighs, shifting from a pear-shaped body to an apple-shaped body.

Other symptoms

Some other perimenopause symptoms include:

• Heart palpitations, with sensations that the heart is racing, fluttering, or skipping beats
• Feeling dizzy, faint, or lightheaded
• Increased frequency or intensity of headaches
• Ringing or buzzing noises in the ears, known as tinnitus
• Decreased saliva and tear production, resulting in dry mouth and/or dry eyes
• Increased gum sensitivity or discomfort
• Muscle and joint aches, stiffness, or pain
• Shortness of breath
• Thinning hair
• Changes in skin texture, including increased dryness or itchiness
• Swelling, soreness, or increased sensitivity in the breasts
• Persistent tiredness not alleviated by rest
• Changes in body odor or sensitivity to smells

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During perimenopause, your body undergoes significant hormonal changes that lead to the eventual end of menstrual cycles. The primary hormones involved are estrogen and progesterone, both produced by the ovaries. Here’s an overview of what happens to hormones during perimenopause:

1. Fluctuating estrogen levels: As your ovaries age and their function declines, estrogen production becomes erratic. Estrogen levels may fluctuate widely, leading to various symptoms. Sometimes, estrogen levels can spike higher than during the reproductive years, while they can drop significantly at other times.
2. Irregular progesterone production: Alongside estrogen, the production of progesterone, which prepares the uterus for a potential pregnancy each menstrual cycle, also becomes irregular. This irregularity can lead to changes in menstrual patterns, such as longer or shorter cycles, heavier or lighter bleeding, and, eventually, missed periods altogether.
3. Decrease in ovarian function: As perimenopause progresses, the ovaries gradually reduce their production of both estrogen and progesterone. This decline is due to the diminishing supply of ovarian follicles capable of producing these hormones and releasing eggs.
4. Increased follicle-stimulating hormone (FSH): In response to lower estrogen levels, the pituitary gland increases its production of follicle-stimulating hormone (FSH) in an attempt to stimulate the ovaries to produce more estrogen. Elevated levels of FSH can be a biomarker of transitioning into menopause, although FSH levels can also fluctuate widely during perimenopause.
5. Luteinizing hormone (LH) changes: Luteinizing hormone (LH) levels may also fluctuate during perimenopause. LH, along with FSH, is involved in stimulating the ovulation. Changes in LH levels can affect the regularity of ovulation and contribute to the irregular menstrual cycles seen in perimenopause.
6. Androgen levels: Androgens are male hormones produced in small amounts by women’s bodies. As the production of estrogen and progesterone decreases, the relative levels of androgens can increase, sometimes leading to changes such as increased facial hair or thinning scalp hair.

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Diagnosis of perimenopause is primarily based on symptoms. There isn’t a specific blood test that can definitively diagnose perimenopause, and tests can be unreliable because levels fluctuate widely during perimenopause. However, certain hormone levels can be measured to help your healthcare provider – and you – determine if you are entering perimenopause. These include:

• Follicle-stimulating hormone (FSH): Since FSH levels tend to increase as a woman approaches menopause, elevated FSH can indicate decreased ovarian function, which is common in perimenopause.
• Estradiol: The estradiol form can fluctuate during perimenopause. Typically, estradiol levels decrease as menopause approaches.
• Anti-Müllerian hormone (AMH): This hormone is produced by developing follicles in the ovaries. AMH levels decrease as a woman ages and approaches menopause.
• Inhibin B: Inhibin B is produced by the ovaries and helps regulate FSH levels. Levels of inhibin B decrease as ovarian function declines during perimenopause.

Again, while blood tests can provide valuable information, they are not the sole determinant of a perimenopause diagnosis. Symptoms and clinical evaluation remain crucial in making a formal diagnosis of perimenopause.

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While the symptoms of perimenopause can be challenging, there are several strategies and treatments available to help manage them:

Lifestyle modifications

Regular exercise, a healthy diet, sufficient sleep, and stress-reduction techniques can alleviate many perimenopausal symptoms. Limiting caffeine and alcohol can also help, especially with sleep disturbances and mood swings.

Hormone replacement therapy

Using prescription hormones can be effective in treating debilitating hot flashes, night sweats, and vaginal dryness. It involves taking medications to replace the hormones that are low during perimenopause.

Non-hormonal medications

For those who cannot or prefer not to use hormone therapy, other medications and supplements can help manage symptoms. For instance, certain antidepressants can reduce hot flashes and improve mood.

Natural approaches

Many women find relief from perimenopausal symptoms with various botanicals, vitamins, herbs, and supplements, such as maca, black cohosh, red clover, soy isoflavones, dong quai, sage, and St. John’s wort, vitamin E, magnesium, and flaxseeds, among others.

Vaginal lubricants and moisturizers

Various lubricants and moisturizers can alleviate vaginal dryness and discomfort during intercourse and help reduce the risk of irritation in this sensitive area.

Education and support

Understanding perimenopause and talking about it can be therapeutic. Support groups and counseling can offer invaluable help through shared experiences and professional advice.

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Perimenopause is a significant life transition that affects every woman differently. You may experience a constellation of symptoms that signal the winding down of your reproductive years. By recognizing the signs and understanding the symptoms, you can approach this phase with knowledge and preparedness. As a Paloma Health member, you’ll be able to access offers comprehensive end-to-end care for hypothyroidism and perimenopause, including at-home blood test kits, virtual consultations with doctors, nutritionists, and health coaches, vitamin and supplement recommendations, and an active support community. By offering a blend of medical expertise, educational resources, and personalized care plans, Paloma Health can support your thyroid health at crucial phases of life, including perimenopause.

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