Perimenopause, the transition between reproductive years and menopause, signifies the beginning of hormonal changes lasting from a few months to several years. While it won’t last forever, it can seem like an eternity if you’re experiencing symptoms like hot flashes, night sweats, irregular periods, and mood swings.
Even before you reach perimenopause, your body gives you hints that things are changing. Understanding why these symptoms happen and learning how to manage them can help reduce the impact these changes have on your life.
Your experience with perimenopause can be entirely opposite to your friend or colleagues, which can make it confusing when you're trying to figure out what might the cause. The most critical piece is paying attention to your body and understanding that the transition to menopause is unique for every woman. Here’s what to know about perimenopause, how long it lasts, and how to find the best support for your body.
What is Perimenopause?
Perimenopause signifies the gradual shift of hormones as you approach your final menstrual period (no period for a year signifies menopause). Changes in menstrual cycle are common—maybe shorter or heavier periods—until they eventually spread out and stop altogether.
The changes in hormones that control your period are the culprit for most uncomfortable symptoms associated with perimenopause. Up to 90 percent of women visit their healthcare providers for symptoms related to perimenopause.
During perimenopause, ovulation is more sporadic and eventually ceases. It is when ovulation stops that our periods also stop. Typically, the pituitary gland increases follicle-stimulating hormone (FSH) production. FSH levels rise and drop during perimenopause, which influences estrogen production in the ovaries. One month your FSH might be incredibly high (think brain screaming at the ovaries to make estrogen) and the next month it looks normal. This is why there isn't a reliable lab test to diagnose perimenopause and why may providers, myself included, use symptoms to guide treatment. If you've taken the quiz in Is This Normal, then you've got the exact list of what I use to evaluate my patient's hormones.
Estrogen levels can vary from from cycle to cycle which can leave you feeling both symptoms of excess and deficiency. Progesterone levels are unpredictable month to month due to infrequent ovulation and failure of the ovary to produce enough hormones should you manage to ovulate. A decline in estrogen paired with an imbalanced ratio of estrogen and progesterone leads to symptoms.
Oh, and PSA: you can still become pregnant during perimenopause. Even though ovulation may not be as regular, ovulation still happens—and it sometimes happens earlier or later in your cycle than it used to. So, you could become pregnant if you’re not using contraception.
When Does Perimenopause Start?
The early stages of perimenopause can vary, with ranges between the mid-thirties to your 50s. We understand that perimenopause can start as early as 10 years before menopause and menopause can occur as early as age 45. The average age of menopause can differ depending on race, ethnicity, or geographic location. Certain medications or chemotherapy can also push you closer to menopause ahead of schedule.
That said, studies suggest that generally, perimenopause usually begins around age 45 and can occur as early as age 35. Menopause before age 45 is should be investigated as it can be a sign of primary ovarian insufficiency, functional hypothalamic amenorrhea, hypothyroidism, or something else.
How Long Does Perimenopause Last?
Perimenopause can last a few months for the few who don’t experience many perimenopausal symptoms, but on average, it lasts at least four years or more if you start on the earlier side. For some, it can span a decade of their life.
There are generally four phases of perimenopause:
- Very early perimenopause: When periods are still regular, but symptoms are just starting to appear.
- Early perimenopause: Characterized by transitioning into irregular menstrual cycles.
- Late perimenopause transition: When the cycles are exceeding 60 days.
- Late perimenopause: Characterized by even more sporadic menstrual cycles, missed periods, and increased symptoms (as described below) and is the final 12 month stretch before you enter menopause.
How Do You Know If You're Going Through Perimenopause?
The first clue is that your periods are changing, especially your menstrual cycle length and number of days you have your period. For women and people with a uterus with regular cycles, this is an easy shift to notice (although you should always check in with your healthcare provider if you see significant changes). If you have had a hysterectomy, but retained your ovaries, you are no longer having periods. That makes the period piece a data point you don't have, however, as I'll explain later on, there's other symptoms you can use to identify if you're going through perimenopause.
It can also be a little trickier to track just the period changes if you're struggling with hormone imbalances or experience irregular cycles due to PCOS, but it’s still possible to recognize the change.
Once again, I want to reiterate that each person can experience perimenopause differently and at different ages. We try to make these general statements to help better understand the process. Still, if you differ from what’s considered “typical,” that’s okay too. This is why it’s so helpful to understand what’s normal for you so you’ll notice when things start to change. Now let's talk about some common signs of perimenopause to watch out for.
Signs of Perimenopause
Perimenopause signs and symptoms can vary from person-to-person. Depending on the severity of the hormones swings or which of the four stages of perimenopause you're in, you may be experiencing just a few of these symptoms or all of them.
Irregular and Heavy Bleeding.
As mentioned above, irregular periods are a sign you may be entering perimenopause. It can be confusing since periods often get closer together, so you’re bleeding more often than before. Many women find their periods are more frequent before they spread farther apart. This is because the ovaries are failing to make progesterone for the 10+ days in normally would. Less days of progesterone production means more frequent periods.
Also, something that I feel is rarely discussed is that as you approach menopause, periods can become heavy—like soaking through a tampon and pad heavy. This is also related to hormone changes. Again, because of low progesterone, your estrogen is left unchallenged and allowed to stimulate the tissues, which essentially makes you estrogen dominant. Estrogen dominance can cause heavy, clotty periods, but please make sure you rule out other causes with your doctor.
Hot Flashes and Night Sweats.
These vasomotor symptoms are probably what you most commonly associate with perimenopause. They can feel like a rush of heat to the face, neck, or chest, sometimes followed by a chilly cool-off.
Some women notice them every day multiple times a day, while others may have hot flashes infrequently. But it’s estimated that up to 80 percent of women will deal with these vasomotor symptoms during perimenopause, especially as they get closer to the final period (and even after). Factors like genetics, alcohol and smoking, body weight, and ethnicity may play a role in how long or severe these vasomotor symptoms are.
Insomnia and Fatigue.
These two perimenopausal symptoms go hand-in-hand because if you aren’t sleeping, you’ll, of course, feel exhausted the next day. But perimenopause fatigue is something special because you can feel completely wiped out during the day and then feel wide awake all night long.
Insomnia can be related to night sweats—studies have found that women with more severe vasomotor symptoms are more likely to experience insomnia. But trouble falling or staying asleep or waking up early is common, so nourishing the adrenals is critical here.
Additionally, low progesterone means less stimulation of the GABA receptor and can also result in an inability to stay asleep. This is why we include vitamin B6 and chaste tree berry in our Balance Women's Hormone Support formula to encourage the ovaries to keep up with the progesterone production.
Vaginal Dryness and Decreased Libido.
Drops in estrogen also affect your libido and sexual function. Estrogen keeps vaginal tissue plump and lubricated, so sex becomes painful and uncomfortable.
Feel like crying one minute and raging at your partner the next? It could be perimenopause. Lack of sleep is one factor that affects mood, and your overall quality of life.
But studies suggest that women are especially vulnerable to depressive symptoms during perimenopause, especially if they’ve been diagnosed in the past (although the risk of a new diagnosis of depression or anxiety also increases). A potential link also exists between increased vasomotor symptoms and more depressive symptoms during perimenopause.
Estrogen is neuroprotective, meaning it helps keep your brain cells healthy and supports cognitive function. As estrogen levels drop, you may experience brain fog or memory issues. Plus, you’re more likely to feel foggy if you aren’t sleeping well.
Is There a Test for Perimenopause?
Perimenopause is usually diagnosed based on symptoms like cycle irregularities or hot flashes. Since hormones vary throughout perimenopause, testing doesn’t always help and may not correlate with symptoms.
Tests are available to look at hormone levels, especially if you’re experiencing symptoms earlier than expected. I often use the DUTCH testing (dried urine testing) to assess hormone levels if this is the case, but generally, I pay attention to my patients’ symptoms, age, and medical history when signs point to perimenopause symptoms.
Follicle-stimulating hormone (FSH) tests may also be used to see if you’re ovulating, but levels can be variable and aren’t always indicative of perimenopause. Sometimes anti-mullerian hormone (AMH) is used to assess ovarian reserve (the number of eggs a woman has left). However, using menstrual cycle patterns is just as effective, so it’s not commonly used as a marker for perimenopause.
Did you know that part of my new book, Is This Normal, is an extensive lab guide that covers a variety of hormonal imbalances with guidance on what and when to test? Grab your copy here and get the inside scoop on lab testing!
Natural Options to Reduce Perimenopause Symptoms
Hormone replacement is sometimes used to reduce perimenopause symptoms, but that’s a topic for another article. Natural support for perimenopause symptoms can be incredibly effective in helping you regain your life and feel good in your body.
Your diet should be a priority (plus a high-quality multivitamin to fill any nutrient gaps). Still, supplements are especially powerful tools to nourish adrenals and address symptoms. Here are some of my favorites (and I have an entire article about all these and others if you want to read more):
Adaptogenic herbs or adaptogens are botanicals that help your body better deal with stress, burnout, and feelings of overwhelm. They can be calming or even promote better sleep by supporting adrenal health. There are several types of adaptogens, but ashwagandha (often called the mother of all adaptogenic herbs) is gaining popularity. Some research suggests that ashwagandha helps with perimenopause symptoms and hormone balance.
Passionflower is another adaptogen that is best known for its calming effects. It is often used to help with relaxation and restful sleep, but can also be used for quieting an anxious mind. As a result, it may be beneficial for women struggling with perimenopausal insomnia, but it can also be taken during the day for anxiety.
Rhodiola has been linked to boosting mental and physical endurance, which can be highly beneficial for the symptoms of fatigue, brain fog, and decline in exercise tolerance that can be seen in perimenopause.
A healthy stress response needs the correct dose of B vitamins. B vitamins are required for energy production and stress resilience, so they are essential for perimenopause support.
You can find B vitamins in my product B-Active Plus, which helps to further aid your adrenals so they can help your body continue to produce vital hormones, like estrogen and testosterone.
I’ve paired B-Active with Adrenal Calm and Adrenal Support in my Optimal Adrenal Kit, which work together to help nourish your adrenals and give them the comprehensive support they need during perimenopause.
L-Theanine is a calming amino acid that can help reduce stress and increase relaxation. It influences the calming neurotransmitter GABA to promote a relaxed but alert state.
L-theanine can be helpful for anxiety and insomnia, as well as hot flashes and night sweats. You can find L-theanine in green tea, but also in supplement form. I use it as part of my product, Adrenal Calm, mentioned above, to promote better sleep and relaxation.
Another botanical, black cohosh, has a long history of supporting women in perimenopause and menopause. It’s been shown to help with night sweats and hot flashes, possibly because it contains a compound that acts like estrogen, helping to balance levels in the body.
Our bodies don’t produce Omega 3s on their own, so it’s necessary to get them through food or supplementation. Estrogen helps convert plant-based omega precursors into omega-3 fatty acids, making fatty fish and supplementation all the more important as we age.
You Don’t Have to Suffer Through Perimenopause
Perimenopause can last several years, so taking steps to support your body and
hormones are essential to making this transition as smooth as possible. Listening to the clues your body gives you can help you take action to reduce stress and optimize adrenal health. Focusing on lifestyle, diet, and natural supplements can help reduce symptoms and help you feel good again.
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