AT A GLANCE: Here are key things you will learn about perimenopause from ob-gyns Sarah Berg, MD, and Robyn Faye, MD, in this article:
- Most women begin experiencing perimenopause in their 40s, though symptoms can start in the late 30s or later in the 40s.
- Hot flashes, night sweats and irregular periods are common symptoms of perimenopause, but brain fog, mood changes, joint pain, heart palpitations, vaginal dryness and sleep problems can also occur.
- Keeping notes about periods, sleep, hot flashes, mood, and other changes can help your physician better understand what is happening because there is no single definitive test for perimenopause.
- Depending on your symptoms and medical history, treatment options for perimenopause may include hormone therapy, birth control, nonhormonal treatments and lifestyle changes such as exercise, improved sleep and stress management.
- Talk with a physician if symptoms interfere with daily life, sleep or well-being, or if you experience heavier or prolonged bleeding, persistent mood changes or bleeding after menopause.
For many women, changes such as irregular periods, hot flashes, sleep problems or shifts in mood may seem to come out of nowhere. But these symptoms can signal the beginning of perimenopause, which is a transition that can start years before the final menstrual period.
Perimenopause is a natural stage of aging, but the experience can vary widely from one person to another. Some women have few noticeable changes, while others experience symptoms that disrupt sleep, work, relationships and daily life. And because the transition often begins while periods are still occurring, it may not be immediately clear that changing hormone levels are behind those symptoms.
That uncertainty can leave women wondering what is normal, how long symptoms may last and when it is time to talk with a physician. Understanding what happens during perimenopause—and knowing the options available to manage bothersome symptoms—can help women navigate the transition and make informed decisions about their health.
The AMA’s What Doctors Want Patients to Know™ series gives physicians a platform to share what they want patients to understand about today’s healthcare headlines.
In this installment, two physicians took the time to share more about what patients should know about perimenopause. They are:
- Sarah Berg, MD, an ob-gyn and Menopause Society Certified Practitioner in Little Rock, Arkansas.
- Robyn Faye, MD, an ob-gyn in Blue Bell, Pennsylvania at Jefferson Abington Hospital and a Menopause Society Certified Practitioner. She is also a fellow of the International Study of Women’s Sexual Health.
Jefferson Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Perimenopause is the transitional stage before menopause
Dr. Faye describes perimenopause as “the transitional stage leading up to menopause when the ovaries gradually produce less estrogen and progesterone, and hormone levels fluctuate, which can cause a variety of symptoms.”
Then “menopause is reached when a person has gone 12 consecutive months without a menstrual period, so it’s only a year,” she said. “Perimenopause happens before that point and menopause is just a specific milestone.”
It is important to understand that perimenopause is “a normal life transition, but it doesn’t mean you have to suffer through it,” Dr. Faye said. “Symptoms shouldn’t be ignored. The symptoms are real and there are effective treatments and strategies available.”
It can be hard to define perimenopause
“Perimenopause is the pivotal start and it’s very misunderstood because people assume they’re supposed to know, so people are afraid to ask,” Dr. Berg said, emphasizing that “perimenopause is the long runway that leads up to menopause.”
“The reason perimenopause is a little bit harder to define is because there’s not a single point you can say, ‘Yes, this is perimenopause now,’” she said. “It’s understanding what it is and getting the information that lets you look a little bit retrospectively as well.”
“When you’re born, you have every follicle, or what we like to think of as an egg, that you will ever have for your entire life,” Dr. Berg explained. “And if you think of it like a bucket, when you first have your cycle, the bucket is overflowing, it’s really easy to pick up those follicles and move them.”
“As we age, that bucket is being depleted year after year, and there’s nothing we can do about that. That’s just how our bodies are made,” she noted. “Perimenopause is when we’re getting to the bottom of that bucket. There are still follicles or eggs left. They’re just not easy to get to and they may not be the most effective follicles or eggs because they’ve been there for longer.”
“It’s the process of your body still trying to go through the monthly reproductive stage, but having to work harder, which leads to symptoms,” Dr. Berg said.
Most women begin perimenopause in their 40s
“Some people start experiencing symptoms in their late 30s while others may not notice symptoms until their late 40s. And then it’ll last until the average age of 52 when menopause begins,” Dr. Faye explained.
“Most people don’t necessarily know it’s happening for a few years after it starts because they may chalk it up to other things going on,” Dr. Berg noted. “But it can start earlier with different people and it can start a lot later too.”
“That is because “there’s a bell-shaped curve,” said Dr. Faye. “Just like at the reproductive point of menarche when there are girls as young as eight who start getting their period and as late as 17, it is the same thing with perimenopause and menopause.”
Some symptoms of perimenopause may surprise you
“The most common symptoms of perimenopause are the ones people think about the most, which are hot flashes and night sweats,” Dr. Berg said.
“Then there is genitourinary syndrome, so vaginal dryness, irritation, increased urinary tract infections and incontinence,” she explained. “Those are very connected to perimenopause, but some people don’t even realize that they are, so they think it’s something else going on.”
Other common symptoms of perimenopause include “irregular periods, sleep disturbances, mood changes, lower libido, fatigue and weight changes,” Dr. Faye said, noting that there are perimenopause symptoms that may surprise people. They are:
- Brain fog.
- Difficulty concentrating.
- Memory changes.
- Increased anxiety.
- Joint pain.
- Shoulder pain.
- Heart Palpitations.
- Changes in your skin and hair.
- New sensitivity to medications, alcohol and caffeine.
- Changes in contact lenses or glasses.
- Mouth dryness.
Dr. Berg agreed with the surprising symptoms, noting that “the two that are most surprising to people is the brain changes or the cognitive change, so the brain fog and mood shifts.”
“There are over 100 symptoms that all of a sudden are different when someone is going through perimenopause,” Dr. Faye added, emphasizing that there are “so many symptoms that people don’t realize are perimenopause and they think this is just aging or a different recipe for the moisturizer they’re using all of a sudden. But it is literally perimenopause.”
There’s no definitive test to diagnose perimenopause
“Perimenopause typically is diagnosed by age,” Dr. Faye said. “It can also be diagnosed by their menstrual changes and by their symptoms.”
“People should speak with a healthcare professional if the symptoms are affecting their daily life, work, sleep, relationships, overall well-being and if they just don’t feel like themselves anymore,” she noted. “There’s really no single definitive test for diagnosing perimenopause. We do some hormonal testing, but they’re not necessary because your hormones fluctuate significantly from day to day.
“When someone comes in and says, ‘I want hormone labs to see if this is what’s going on,’ that’s an understandable request, but it’s not going to answer the question they want to with a yes or no answer,” Dr. Berg said. “What I tell those people is that with perimenopause, your hormones aren’t doing something easy to follow.”
“We could check your hormone levels and they look perfectly normal because we happen to catch you in that one moment of time,” she said. “But then if we looked at them again six hours later or two days later, it could be a completely different thing. That’s why labs aren’t very effective for diagnosing perimenopause.”
Doctors will also rule out other conditions
“Perimenopause and menopause are diagnosed by clinical signs. That means you bringing in the information about what’s going on in your body which helps us make the diagnosis,” Dr. Berg said. “And when we do lab work around this time, it’s actually to rule out other things rather than ruling perimenopause in.”
When it comes to perimenopause symptoms, doctors will also rule out other conditions “to make sure there isn’t something else going on,” Dr. Faye said. That is because, “what is the leading cause of death in women? Cardiac issues.”
“If someone comes in with palpitations, anxiety, you’ve got to make sure it isn’t something else,” she said. For example, “thyroid disorders have to be ruled out and so do cardiac disorders, depression, anxiety and sleep disorders.”
Physicians also have to determine if there are “medication side effects causing these symptoms or if someone has anemia or iron deficiency that needs to be addressed,” Dr. Faye explained. “A person needs to go in and be evaluated because there’s other blood work that might need to be done and other things have to be evaluated.”
Be your own investigator and keep track of your symptoms
“I always tell people the best way to get diagnosed and understand what’s going on is what happens outside of the clinic rather than what’s happening in the clinic,” Dr. Berg said. That means “coming in with the information.”
“It’s really nice if you either use an app on your phone or an old school notebook—which is what I do—and are keeping track of what’s going on symptom-wise that’s been bothering you,” she said. Keeping track of “if you’re having hot flashes, if you stop sleeping and certain things are happening, and if you noticed mood changes, noting when it happened and what’s going on around it.”
It’s all about “being your own investigator,” Dr. Berg said. “That way when you come in and you have this story for your doctor, they have a better understanding of where to start.”
Perimenopause treatment depends on your symptoms
“Our toolbox is big and it’s getting bigger every year, which I love,” Dr. Berg said. “We have so much research to do, but we’re in a stage where people are realizing that, so we’re having more options and a lot of the treatments for perimenopause are the same as menopause.”
“We’ve got the hormone therapies and treatments, which we now call menopause hormone therapy,” she said, noting that “we’re just trying to get you clinically feeling better and that’s the whole purpose.”
“But then there are so many nonhormonal options and nonmedical options that are also great and have great evidence behind them,” Dr. Berg noted. “So, we don’t always have to turn to a pill, but it is an option either way.”
Hormone therapy can help perimenopause symptoms
“Hormone therapy may be considered for patients with moderate to severe symptoms, such as hot flashes, night sweats or sleep disruption,” Dr. Faye said. “But when I say hormone therapy, I also need to include birth control because if a woman is having more periods than not, she still requires contraception, and birth control pills may be what’s needed to control her symptoms.”
“Not all women in perimenopause are started on menopausal hormone therapy,” she said, noting “that’s also something that’s misrepresented when people come into an office and think that they’re perimenopausal and everyone gets started on hormone therapy.”
“In perimenopause, if she’s having more periods than not, the level of hormone therapy might not be sufficient to control her symptoms or her ovulating ovary and we need to talk about birth control, even if she’s had a tubal ligation or he’s had a vasectomy because it’s not enough to control that ovary,” said Dr. Faye. “That is why it is important to discuss all her symptoms and history with a certified menopause practitioner who knows all the nuances and options available for each patient.”
Lifestyle changes can help with symptoms of perimenopause
When it comes to perimenopause, lifestyle changes are also important such as “regular exercise, improving sleep habits, stress reduction and maintaining a good weight,” Dr. Faye said. “We also talk about limiting alcohol and tobacco, and cognitive behavioral therapy for sleep.”
“With exercise, it supports your cardiovascular health, mood and weight management,” Dr. Berg said, noting that “strength training helps preserve muscle mass and bone strength because we lose both as we get older, which increases our risk of sarcopenia and osteoporosis.”
For nutrition, as women get closer to menopause, they should be eating between 1.0 to 1.6 grams of protein per kilogram of body weight daily. This is about 0.45 to 0.7 grams per pound. For women who are active or those in strength training, 2.0 grams per kg or more is needed. It is important to speak with your doctor about the appropriate amount of protein for your individual needs.
“We should also be getting adequate calcium and vitamin D,” Dr. Faye explained. Meanwhile, “sleep is essential for cognitive function, mood and just overall health.”
“Then stress management helps everything. It reduces symptom burden and it improves resilience, so they’re all important,” she emphasized.
Before starting a supplement for perimenopause, talk to your doctor
“My suggestion is, before anybody starts anything—because most of them have limited scientific evidence—discuss those supplements with a healthcare professional,” Dr. Faye said. “And don’t buy everything people are selling because they say they’re natural. Just because they’re natural doesn’t mean anything.”
Additionally, “you don’t know whether the supplement is going to mix with the medication you’ve been taking for a long time,” she said.
If you don’t feel heard, seek someone else
“There’s no single correct experience when it comes to perimenopause. Be informed, seek guidance early on in your transition and it’ll make it so much easier for you,” Dr. Faye said. “Learn that you can feel better, you can live your best life, ask questions and if you’re not getting them from someone, even if you’ve been with them forever, you need to go somewhere else.”
“The Menopause Society has a website where you can find a practitioner who’s going to listen to you and help you. We exist,” she said. “They’re certified menopause practitioners who’ve been trained to take care of people during perimenopause and menopause. That’s what we do.”
“We really care to help people get through this because we recognize this is an important stage of life, not just a reproductive transition,” Dr. Faye emphasized.
Ask your doctor these questions about perimenopause
One question Dr. Berg wishes patients would ask at their doctor appointments is, “What can I do at home to have the best quality of life?”
“I never want the whole conversation to be about all the things that are negative and wrong. I want to think about how we can feel our best,” she said. “So, thinking about the preventive tools, thinking about the education side, what can they do to best inform themselves?
“Because they should be the most invested person in their own health,” Dr. Berg said. “I want women to think about ways they can prioritize themselves in their home life and outside of this one office visit because I want them to think about themselves as one of the most important people in their own lives.”
Reach out to your doctor about perimenopause
“Women should seek medical attention, even if they say they don’t want to take any medication and want to do it naturally, meaning by themselves with just exercise, good sleep habits and working out,” Dr. Faye said. “They should see their doctor if they have heavier, prolonged bleeding, are bleeding after menopause, their moods are not getting better or they’re not sleeping well.”
“If their symptoms are interfering with daily activity, they don’t feel like themselves and they just don’t feel good, they need to contact someone,” she said.
