What are Symptoms of Perimenopause?

Perimenopause is a period of transition between your menstrual and menopausal years. It marks the end of your menstrual cycle and reproductive years.

In North America, over one billion women will have experienced perimenopause by 2025. And yet, there still seems to be a lack of public awareness around the topic, though this is changing as more women speak about their experiences.

You may experience any number of menopause-like symptoms as your hormone levels change. In this article, we’ll provide an overview of symptoms of perimenopause, and how to treat those symptoms.

Overview of perimenopause

As your body prepares for menopause, it goes through a transitional time marked by decreased fertility and other symptoms. This period is called the menopausal transition or perimenopause.

What is perimenopause?

During the menopausal transition, profound hormonal changes take place, ovulation becomes erratic and estrogen levels decrease. Estrogen is a key female hormone produced by ovaries, adrenal glands, and fat tissues. It contributes to cognitive and bone health, the formation of breast tissue, vaginal lubrication and wall thickness, and other body functions. 

The three main types of estrogen are estriol, estradiol, and estrone. Estriol is primarily involved in pregnancy. Both females and males produce estradiol, the most common and potent form of estrogen. Estrone is a weaker form of estrogen present in the body after menopause. If necessary, it can convert to other forms of estrogen. 

Perimenopause vs. premenopause

Premenopause is the time between the first menstrual cycle and menopausal transition. It is the age of fecundity or your birthing years. Perimenopause is the process of changes preceding menopause with menstrual cycles slowing down or becoming more irregular and associated hormone changes. It follows premenopause but comes before menopause.

When does perimenopause start?

The average age range when perimenopause begins is 40 to 44 years, but it can start in the mid to late 30s for some women or the early 50s for others. Smoking, having low body fat, having received treatments like chemotherapy or radiation to the pelvis, or having both ovaries removed (oophorectomy) can cause an earlier onset of menopause. 

How long does perimenopause last?

Perimenopause can last anywhere from two to 12 years. There are two stages to the process — the early transition and the late transition. 

In the early transition stage, you’ll experience slight menstrual irregularities — you may not notice them at first, or you may disregard them, assuming the cause is medication, exercise, stress, or something else.

In the late transition, the menstrual cycle is delayed more often than not — the time between periods can get longer, lasting up to 60 days. 

During perimenopause, your ovarian reserve depletes and your reproductive system stops responding to the follicular stimulating hormone (FSH). Your healthcare provider can perform health screening tests and monitor your FSH and estrogen levels to help assess where you are in the cycle — in the first stage, your FSH levels are variable, but during the second stage, they’re usually high. 

After one complete year without menstruating, you are no longer in the transition — you’re in menopause.

Common symptoms of perimenopause

Perimenopause may cause mental, emotional, and physiological symptoms that are similar to those of premenstrual syndrome — with a few new additions.

Physical symptoms

Common physical symptoms of perimenopause include reproductive, vasomotor, muscular-skeletal, and genitourinary complications.

• Reproductive: Irregular periods, missed periods, and changes in flow are the most widespread reproductive symptoms of perimenopause. Women who have had a partial hysterectomy are less likely to notice these symptoms because even though they may have their ovaries, they no longer experience a menstrual period.
• Vasomotor: Hot flashes, night sweats, and heavy sweating are common perimenopause symptoms. Some women experience these symptoms more intensely than others. It can be described as feeling a sense of warmth or as intense as having a fire moving from the inside out. Though the mechanism isn’t fully understood, estrogen plays a role in these vasomotor symptoms, which diminish over time (usually by two years) but can last up to 10 years. Women who are overweight or smoke may experience more frequent vasomotor symptoms with a longer duration than their non-smoking, normal-weight counterparts. 
• Genitourinary: Vaginal dryness, frequent urination, and other genitourinary symptoms may occur as estrogen levels decrease and the genitourinary system undergoes physiological changes. The vaginal wall becomes thinner, and the resulting dryness can cause itching and irritation. This can sometimes cause pain with intercourse, lowering sexual desire. 
• Musculoskeletal: Joint and muscle pain and headaches can occur for some perimenopausal women, although they are often attributed to something else, like exercise, dehydration, vitamin deficiency, or lack of sleep. Breast tenderness is also common during perimenopause — but this is often attributed to the menstrual cycle.

In addition, bone density loss increases as perimenopause transitions to menopause. Decreased bone density can be a serious condition, and early intervention can improve your overall quality of life in your later years.

Emotional symptoms

Emotional symptoms of perimenopause can create significant unease for women experiencing perimenopause. Mood changes like irritability and being quick to anger are common, as is major depressive disorder, especially in the late transition phase. 

Changes in sexual desire can also impact your emotional state. Some women experience a decreased libido as the result of physiological changes, like vaginal dryness causing discomfort during intercourse. 

Mental symptoms

Cognitive or mental symptoms often accompany perimenopause and include trouble concentrating and short-term memory loss. You may also experience sleep changes, including insomnia, difficulty getting to sleep or trouble staying asleep. For some women, these sleep disturbances are the result of discomfort from hot flashes and night sweating.

Less common symptoms

A variety of less common symptoms of perimenopause may occur during perimenopause, including:

• Changes in vision: Hormone fluctuations can impact the ocular tissue, leading to decreased tear production causing dry eyes and changes in pressure and cornea thickness.
• Hair growth: You may experience decreased scalp hair growth but increased facial hair.
• Body odour: Excessive sweating can influence the smell and frequency of your body odour.
• Taste: Decreased estrogen can lead to dry mouth and a changed sense of taste.
• Skin: Your skin may become drier, thinner and bruise more easily.

Diagnosis and Management

Perimenopause is typically diagnosed through a combination of symptom tracking and medical evaluation. Healthcare providers assess changes in menstrual cycles, hot flashes, mood swings, and other key indicators to identify this transitional phase before menopause.

How is Perimenopause Diagnosed?

Diagnosis usually begins with a review of symptoms and medical history. Doctors may also ask about the frequency of menstrual irregularities and the onset of typical perimenopausal symptoms, such as night sweats and changes in mood.

Tests for Perimenopause

While there’s no definitive test for perimenopause, certain blood tests can help assess hormonal changes. Tests that measure levels of estrogen, progesterone, and follicle-stimulating hormone (FSH) are commonly used to detect fluctuations that signal perimenopause. These tests, alongside symptom evaluation, help in confirming the diagnosis.

Treatment Options for Perimenopause

• Hormone Replacement Therapy (HRT): HRT is a widely used treatment to manage symptoms such as hot flashes, mood swings, and vaginal dryness. However, it’s important to discuss the risks and benefits with a healthcare provider, as hormone therapy may not be suitable for everyone.
• Non-Hormonal Treatments: Medications like antidepressants or other symptom-specific treatments can be effective alternatives for those unable or unwilling to undergo hormone therapy.
• Home Remedies for Managing Symptoms
• Many women find relief through natural methods. Some home remedies include:
• Dietary Adjustments: Incorporating foods rich in phytoestrogens (like soy), calcium, and vitamin D can support overall health.
• Exercise and Stress Management: Regular physical activity and relaxation techniques, such as yoga and meditation, can help alleviate mood swings and improve sleep.
• Herbal Supplements: Natural remedies like black cohosh, evening primrose oil, and flaxseed may provide relief for hot flashes and other symptoms, though it’s important to consult with a healthcare provider before starting any supplements.

By combining medical treatment with lifestyle adjustments, women can effectively manage the symptoms of perimenopause and improve their quality of life.

Prevention and Outlook for Perimenopause

While it’s not always possible to prevent the onset of perimenopause, certain lifestyle habits can delay its early onset and improve long-term health outcomes during this phase. Being proactive about managing symptoms and reducing health risks can enhance overall well-being.

Preventing Early Onset Perimenopause

Factors such as smoking, poor nutrition, and high-stress levels can contribute to earlier onset of perimenopause. Maintaining a healthy lifestyle by eating a balanced diet, avoiding smoking, and managing stress through relaxation techniques or exercise can help delay the onset of perimenopause. Regular check-ups with a healthcare provider are also essential in monitoring reproductive health.

Reducing Risks of Complications

Complications like osteoporosis, heart disease, and severe hormonal imbalances are risks associated with perimenopause. Women can reduce these risks by staying active, consuming adequate calcium and vitamin D for bone health, and closely monitoring blood pressure and cholesterol levels. Hormone therapy, when recommended by a doctor, may also mitigate certain risks.

Prognosis and Health Risks

The prognosis for women entering perimenopause is generally positive, with most women eventually transitioning into menopause. However, the hormonal changes during perimenopause can elevate the risk of certain conditions, such as cardiovascular disease and osteoporosis. Awareness and preventive measures, such as weight management and regular health screenings, can help mitigate long-term risks.

Pregnancy during Perimenopause

While fertility declines during perimenopause, it is still possible to become pregnant until menopause is fully reached. Women should use contraception if they wish to avoid pregnancy during this time. However, pregnancy during perimenopause can carry higher risks, including miscarriage and complications, so it’s important to consult a healthcare provider if pregnancy occurs or is planned.

How are perimenopause symptoms treated?

Even though this is a natural and unavoidable phase of life for women around the world, you don’t have to suffer through uncomfortable symptoms. Effective treatment options include dietary and lifestyle changes, topical creams, vitamin and mineral supplements, and prescription medication.

Dietary and lifestyle changes

An overall healthy lifestyle can help reduce the frequency or intensity of menopause symptoms.

• Eat a well-balanced diet rich in fibre, fruits and vegetables and probiotics to help you maintain a healthy weight and support your system as you transition to menopause. 
• Increase your water intake for adequate hydration — and decrease your caffeine, soda, and alcohol intake. 
• Get regular exercise — move more. Ten minutes of movement in pockets of your day can add up. Aim for 150 minutes of physical activity (flexibility and balance, strength and cardiovascular endurance training) each week. 
• Try to get seven to eight hours of sleep each night. If you have trouble sleeping, talk to your doctor or speak to a sleep consultant. 

Vaginal Estrogen

Vaginal estrogen creams offer relief from many of the common genitourinary symptoms caused by reduced estrogen production during perimenopause and beyond. These low-dose hormones are available by prescription to replace some of the estrogen lost, improving symptoms like vaginal dryness and pain during intercourse. They can also help reduce the risk of urinary tract infections (UTIs), which become more common during and after perimenopause.

Magnesium

Magnesium can help reduce the severity of several common symptoms of perimenopause, including hot flashes and sleep disturbances. Taken with Vitamin D, it can help convert Vitamin D into its active form, improving calcium absorption for bone health. Taken with vitamin B, it can help regulate your moods. Speak with a dietitian to get help adding more magnesium-rich foods into your diet. It may be a good idea to speak with your healthcare provider before taking supplements, especially if you are on medications.

Antidepressants and/or counseling

If you experience a major depressive disorder during perimenopause, you can seek out a psychiatrist, who may recommend antidepressants.

Sometimes, depression during menopause is related to the complex emotions around aging and the end of fertility. Online therapy can help women come to terms with their changing bodies — if you’re having trouble finding a therapist — demand for mental health services and specialists has surged in the last several years — specialists and mental health therapists can be booked directly on Maple. 

When to See a Doctor

You can speak to a doctor anytime the above symptoms interfere with your comfort and well-being. If you’re one of 6.5 million Canadians without a primary care provider, you can see a doctor or a nurse practitioner 24/7 on Maple. If prescriptions are needed, Maple can send them to your door or your closest pharmacy. 

Information presented here is for educational purposes, and not to replace the advice from your medical professional. Virtual care is not meant for medical emergencies. If you are experiencing an emergency like chest pain or difficulties breathing, for example, please call 911 or go to your nearest emergency room.