Written by Dr. Alyssa Dweck, MS, MD, FACOG, Chief Medical Officer
The thing with perimenopause is that it often takes women by surprise. Just when you least expect it, periods become wonky, moodiness is out of control, sleep is an often interrupted luxury and you find yourself gaining weight from just looking at a piece of bread. Since menopause, defined as 12 consecutive months of no menstrual flow with no other obvious cause, is a hindsight realization, it is no wonder why recognizing perimenopause is tough.
What is Perimenopause?
Perimenopause is defined as the years prior to your last period. The time frame can vary from four to eight years, give or take. During this transition, ovulation occurs irregularly and typically less frequently than once per month. Translation? The typical monthly synchronized release of hormones like estrogen, progesterone and even testosterone, becomes erratic.
Genetic, environmental, and lifestyle factors can influence the timing and nature of this transition. For example, smokers typically have an earlier and more notable experience, and not in a good way. Women on hormonal contraception for birth control and/or cycle control, may not recognize any changes at all. All else being equal, one’s perimenopausal experience typically mirrors her mom’s or sister’s in both timing and severity.
At What Age do Perimenopause Symptoms Start?
So at what age will perimenopause start? This is often tough to gauge, as there is unfortunately no definitive age; rather there is a range. In general, estrogen and progesterone levels may start to change near age 40. If you’re starting to experience symptoms, or have questions, it’s always a good idea, to check in with your doctor.
First Signs and Symptoms of Perimenopause
Irregular, skipped or unusual periods are the hallmark of perimenopause, and in truth, anything goes. One might skip an occasional menses or miss their period for many months at a time. Bleeding might be lighter or heavier, longer in duration or only a day, clotty and painful or barely there; this is all fair game in the perimenopause manual. When is there cause for concern? Bleeding more frequently than every three weeks, random bleeding in between flows or a super heavy flow with large clots (like more than two super tampons per hour heavy) should prompt a check-in with your gynecologist.
Some women experience a litany of other random symptoms including hot flashes and night sweats, difficulty falling or staying asleep, palpitations, anxiety, moodiness and irritability, joint pain, and difficulty maintaining or losing weight. Once other medical issues are ruled out, it’s fair to blame these symptoms on perimenopause.
Physical Perimenopause Symptoms
The symptoms associated with perimenopause can last from a few months to many years. In addition to the loss of a regular monthly period, the symptoms you may experience can impact your life in a variety of ways, some of which may come as a surprise. Irregular bleeding and other common symptoms can be incredibly disruptive—both emotionally and physically. Common physical perimenopause symptoms can run the gamut from hot flashes (which many women associate with menopause) to lesser-known physical symptoms, such as:
Perimenopause Bowel Symptoms
Many women complain of gastrointestinal distress both before menstruation as well as during the perimenopausal transition. These are both instances where you can blame your hormones for how you're feeling. Progesterone influences gut motility and can be responsible for symptoms like constipation, more frequent bowel movements, and bloating. Water retention can only worsen this distress, intensifying this symptom.
Perimenopause Breast Symptoms
A cyclical variation in hormones might cause breast tenderness, uncomfortable fullness and cystic changes. During the pre-menstrual time-period, this typically resolves with onset of your flow. Perimenopausal symptoms can be more varied. Similarly, hormone changes that occur during perimenopause — specifically, the rise and fall of progesterone and estrogen levels — can cause the breast tenderness, swelling and pain women typically associate with PMS.
Migraines and Perimenopause
As we’ve discussed before on the Bonafide® blog, many women may experience hormonal headaches. For those who menstruate regularly, headaches are often cyclical, typically starting just before their period when estrogen levels drop. Perimenopausal women may also complain of headaches since estrogen levels are so volatile during this time. Shifting levels of progesterone may also contribute to headaches during perimenopause, but the link is less clearly established.
Emotional and Mental Perimenopause Symptoms
While the physical changes women experience during perimenopause are often the most talked about, they are not the only symptoms that occur. Just as important are the emotional and mental symptoms that can accompany the perimenopausal phase. Like the physical, these symptoms can be diverse, and vary widely in terms of occurrence and severity among women. Here are a few common emotional or mental perimenopause symptoms to be aware of:
Perimenopause Mood Swings
While many women go through menopause without experiencing any major changes in mood, the North American Menopause Society,1 projects that roughly 23% of women experience mood swings during this transition. Mood swings, which are in part due to fluctuating hormones, can manifest as feelings of depression or anxiety. Estrogen and serotonin, a hormone associated with positive feelings, work side by side in the brain to promote an overall sense of well-being. Declining estrogen levels can certainly disrupt this balance.
Emotional changes and mood swings can even be indirectly caused by other perimenopause symptoms. Decreasing levels of estrogen associated with perimenopause can cause night sweats, hot flashes, and headaches. These symptoms may lead to a loss of quality sleep, which can trigger symptoms such as mood swings and depression.
Fatigue as a Symptom of Perimenopause
Speaking of sleeplessness: feelings of fatigue are another symptom some women report during perimenopause and menopause. Trouble falling asleep and staying asleep can cause daytime fatigue and mental fogginess. Sleep disruption is also directly related to the physical discomfort of night sweats and the need to get up to change sleep clothes, possibly multiple times in one night. The busy mind then takes over and getting back to sleep can become a torturous, viscous cycle. Additionally, progesterone and estrogen are two of the hormones that likely play a role regulating your body’s cellular energy and metabolism. The spikes and drops that happen during perimenopause can throw these two hormones out of whack, bringing on sudden bouts of tiredness.
Perimenopause and Sex
Questions about sex are often top of mind during perimenopause. While some women despair that they have lost their mojo, others experience the opposite effect, with a libido that is souped up, heightened and outright soaring during perimenopause. This is in part due to elevated testosterone levels. Just go with it ladies! One note: if you are still getting your period and still having sex, you still can get pregnant. Birth control of some sort is still needed.
How to Handle Perimenopause Symptoms
Commit to some important lifestyle changes. Follow a Mediterranean diet. This heart healthy, low glycemic diet is naturally low in carbs, processed foods and salt. Consider intermittent fasting and exercise regularly. Ideally, this should include 150 minutes a week of cardiovascular activity, in addition to strength training. Optimize flexibility and balance with yoga and stretching. Finally, and admittedly a difficult task, try your best to reduce stress. Try mindfulness, meditation or breathing exercises. Your mental health and your waistline will thank you.
Vitamins for Perimenopause Symptoms
Increasingly, women are turning to hormone-free solutions to manage their perimenopause symptoms. Vitamins and supplements are available to treat everything from hot flashes to vaginal dryness with non-hormonal ingredients like Swedish flower pollen and hyaluronic acid. If you’re considering a prescription-free option for your perimenopause symptoms, do your research: look for companies that use high quality ingredients, and offer products backed up by thorough research and development. Your doctor’s input can be valuable when it comes to vitamins and supplements as well, so be sure to ask if they have any specific recommendations.
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Other Treatments for Perimenopause
Hormone replacement therapy, antidepressants or other prescription medications might be in order for perimenopause symptom management, but this varies on a patient to patient basis. Talk to your doctor about your symptoms and possible treatments, and keep in mind that you may need to try out a few different options before finding the treatment that works best for you.