Overview

Are you having irregular periods? Do you experience more mood swings these days? Are you in your mid-40s? Then, you may be in your perimenopause stage. Perimenopause is the transitional stage of your body when your body is producing less estrogen and is preparing itself for menopause. Menopause is the stage when you won’t have periods for 12 straight months. It’s the end of the reproductive cycle. Perimenopause is also called menopausal transition.

Age range and duration

People assigned female at birth (AFAB) usually enter the perimenopause stage when they hit 40. But it is not a hard and fast rule. Some may experience the changes earlier in their 30s, while others may observe the transition later in their 50s. 

According to one study, the duration of perimenopause ranges between seven and 14 years. The study also states that the duration depends upon lifestyle factors like smoking, age, race, and ethnicity.¹

Perimenopause affects each person AFAB differently. As they enter perimenopause, their bodies experience a shift in energy metabolism, causing them to utilise energy differently. Furthermore, this hormonal transition can lead to changes in fat cells, which may contribute to a greater susceptibility to weight gain. You may observe changes in your bone or heart health, body shape, and physical functioning.¹

Hormonal changes during perimenopause 

The hormonal changes during perimenopause are due to the hormone estrogen. The ovaries produce estrogen, which plays an essential part in maintaining the normal functioning of our reproductive system. When you enter the perimenopause stage, your body begins to experience a reduction in estrogen levels. Due to this decrease, the balance between estrogen and progesterone (another hormone secreted by the ovaries) is disturbed.² Both of these hormones together are responsible for ovulation and menstruation. The levels of both these hormones fluctuate during perimenopause.² After perimenopause, the ovaries release significantly less quantity of estrogen. This is why ovaries don’t release eggs; you stop having periods.

What are regular periods like?

Before discussing the signs and symptoms of perimenopause, it is vital to understand what regular periods are like for most people AFAB. 

• At least a 21-day gap between two consecutive periods
• Periods should last for less than ten days
• No spotting between periods
• A period should occur within 90 days of the previous one to ensure regularity

Signs and symptoms

Since you hit puberty, your body has consistently produced estrogen. So, it has to adjust itself to the decreased estrogen levels. Since every person assigned female at birth (AFAB) cycle is unique, the symptoms of perimenopause are different for everyone. But most people AFAB have at least one of the following symptoms.

Irregular menstrual cycles

You may observe a change in your regular cycle. Periods may be more frequent, or you may skip them for months. There is also a change in the menstrual bleeding pattern. It may range from just spotting to heavier bleeding than your usual pattern.

Hot flushes and night sweats

Hot flushes are a common perimenopausal symptom, and it is due to the hormonal changes happening in the body. You may feel very hot and sweaty. This episode of hot flushes can also happen at night, causing night sweats. The intensity of hot flushes may also differ among people AFAB. Some may feel only slightly warm, while others may sweat badly. One study suggests an association between those who experience hot flashes and an increased risk of cardiovascular disease.³

Perimenopausal depression

According to a study, the chances of depression increase as the perimenopause stage approaches. If those of perimenopause age show symptoms of depression, they should be treated accordingly. Perimenopausal depression and anxiety are due to hormonal changes.⁴

Mood swings and sleep disturbances

Sleep disturbances and insomnia are shared among perimenopausal people AFAB. Sleep disturbances have long-term health-related effects.⁵ Mood swings and sleep disturbances are usually due to the hot flushes and night sweats. Mood swings may also be associated with non-hormonal factors. The presence of symptoms related to insomnia disorder is linked to negative cardiometabolic outcomes.⁶

Changes in libido

During perimenopause, libido may change. But it is not always necessary. If you had satisfactory sexual desire before perimenopause, you may continue to have so. Certain factors like vaginal dryness or discomfort during sex can also lead to low sex drive.

Physical symptoms (headaches, joint pain, etc.)

According to a study, perimenopause may contribute to headaches and even lead to migraine. Hormonal fluctuations are responsible for migraine, and they can be controlled with hormone replacement therapy.⁷ When estrogen levels decline, the rate at which bone is lost exceeds the rate at which it is replaced, raising the risk of osteoporosis, a disease characterised by brittle bones.

Risk factors for perimenopause

Perimenopause is a natural process, and it is entirely normal to experience it, but there are some factors due to which you may enter the perimenopause stage earlier in life. These risk factors are

• Smoking
• Family history
• Cancer treatment
• Removal of the uterus

Chances of pregnancy

Perimenopause is the transition from regular ovulation to permanent loss of ovarian function, and the estrogen levels are reduced by half in the mid-forties. Even then, pregnancy can develop.⁸ Therefore, you are advised to continue your contraceptives.

Diagnosing perimenopause

Usually, the symptoms of perimenopause are so mild that they can be easily managed, but if you have

• Blood clots in menstrual discharge
• Spotting in between periods
• Bleeding after sex
• Periods occur in less than 21 days

Then, it would help if you saw your healthcare practitioner. As there are no specific tests for perimenopause, your doctor may make the decision based on your age, menstrual history, and changes you are facing.

FSH (follicle-stimulating hormone) levels are sometimes monitored for diagnosing perimenopause. FSH is a hormone secreted by the pituitary gland. An essential function of FSH is to signal the ovaries to release an egg, facilitating ovulation. Menopause may be suggested if there is a consistently high level of FSH. However, FSH levels don’t always indicate accurate results because hormone levels rise and fall unpredictably. Some medications and thyroid conditions may also affect the results.

Management and treatment 

There is no specific treatment for perimenopause because it is not a disease. It is a natural process; however, your healthcare provider may suggest over-the-counter medications to improve your symptoms.

Hormone replacement therapy (HRT)

Many symptoms of perimenopause can be treated with hormone replacement therapy, which is systemic estrogen. It is available in pills, creams, spray gels, and patches. Depending upon the severity of your symptoms and family history, your doctor may start treatment with low-dose estrogen. If your uterus has not been removed, you may also need to take progesterone along with estrogen. Systemic estrogen is effective in reducing the risk of bone loss.

Antidepressants

Antidepressants are used to reduce the symptoms of mood swings, depression, and anxiety.

Vaginal creams

Vaginal creams and gels are used to treat vaginal dryness and relieve discomfort during sex.

Gabapentin (Neurontin)

Gabapentin is used to help reduce hot flushes. This medicine is beneficial for those who can’t take hormone therapy due to health-related issues and those who have migraines.⁹

Fezolinetant (Veozah)

The mechanism of action of Fezolinetant (Veozah) involves inhibiting a brain pathway that plays a crucial role in regulating body temperature. It is a hormone-free medicine used to treat hot flushes.⁹

Lifestyle modifications

To improve perimenopausal symptoms without medicines, make simple lifestyle modifications:

• Eating a healthy diet, like fruits, vegetables, and nuts
• Exercise regularly to avoid weight gain
• Get enough sleep by avoiding screen time and relaxation exercises
• Limit alcohol and caffeine
• Quit smoking

Summary

Perimenopause, often occurring in the mid-40s, marks the transition when a person AFAB’s body produces less estrogen, preparing for menopause – the end of the reproductive cycle. This phase, lasting seven to 14 years, affects each person differently, with symptoms like irregular periods, hot flushes, and mood swings. Hormonal changes, especially in estrogen levels, disrupt the balance with progesterone, impacting ovulation and menstruation.

Beyond bothersome symptoms, perimenopause influences energy metabolism, fat cells, and bone health. Depressive tendencies may increase, and sleep disturbances are common. Libido changes may occur, and headaches or joint pain might arise. Risk factors include smoking, family history, cancer treatment, or uterus removal. Although pregnancy chances decrease, contraception is advised.

Diagnosing perimenopause involves monitoring symptoms and, sometimes, FSH levels. While no cure exists, managing symptoms is essential. Hormone Replacement Therapy (HRT), antidepressants, vaginal creams, and non-hormonal medications like gabapentin or fezolinetant offer relief. Lifestyle changes, like a healthy diet, regular exercise, sufficient sleep, and quitting smoking, can enhance well-being.

Navigating perimenopause involves understanding individual experiences and seeking medical guidance for personalised care. Embracing lifestyle adjustments and available treatments empowers women to manage this natural life transition confidently.