Perimenopause – Misconceptions, Symptoms and Management

Every woman has heard of menopause: that period of transition, change and the dreaded hot flashes which women often experience in their 50’s. Yet, despite this being a process that affects almost every woman, it is often misunderstood.

One common misconception is that the onset of menopause (a year after the final menstrual period) marks the beginning of hormonal changes and subsequent symptoms.

In reality, the “menopausal transition” occurs for years before a woman is officially in menopause. The common name for this period is perimenopause.

When does perimenopause start?

Beginning in a woman’s 30’s or 40’s the amount of estrogen produced by the ovaries can begin to fluctuate. The start of early perimenopause is often marked with the onset of irregular cycles (varying by 6-7 days from the start of one flow to the next).1 The duration of early perimenopause varies greatly between women and depends on the age of onset.

The transition into the “late stage of perimenopause” is typically characterized by a lengthening in the time between periods (from 25 days – 32 days, to 40 days – 50 days) and eventually progresses into more dramatic changes in a women’s period: skipped cycles and absent periods.1 This stage typically lasts for one to three years before the final menstrual period.

On average, the menopausal transition occurs at age 47 yrs.2

Of course, not all women follow the “typical” perimenopausal pattern. In fact, few do! One of the frustrating aspects of the “menopausal transition” is the variability between women. In a study involving women over the age of 45, the researchers found that there were over 100 different menstrual cycle patterns among the 324 participants.3

What happens to a woman’s hormones during perimenopause?

The menopausal transition occurs in response to a women’s declining follicle reserve. The follicle reserve refers to her egg count. As egg count levels decline, a hormone called follicle-stimulating hormone (FSH) increases. It would be ideal if the hormones changed in a nice linear fashion, however, it is more complicated that that. The hormones fluctuate dramatically: increasing and decreasing over short periods of time. One blood sample may show a high FSH and low estradiol (estrogen) level consistent with menopause, but soon thereafter, they may return to a normal premenopause range. Figure 1 (below) outlines the ecpected timeline of the the menopausal transition.1

What are the symptoms of Very Early Perimenopause?

There are multiple symptoms that can be attributed to perimenopause. The Centre for Menstrual Cycle and Ovulation Research created a list of common changes experienced in very early perimenopause, which include:4

• New heavy and/or longer menstrual flow
• Shorter menstrual cycle lengths (<25 days)
• New sore, swollen and/or lumpy breasts
• New or increased menstrual cramps
• New mid-sleep wakening
• New or markedly increased migraine headaches
• New or increased premenstrual mood swings
• Notable weight gain without changes in exercise or food intake

What is a common symptom of perimenopause that is largely unknown?

Anxiety. Often women express that they feel an increase in anxiety during the menopausal transition. Research strongly suggests a link between hot flashes and increased anxiety.5 In addition, perimenopause can be a time of increased stress, hormonal fluctuations and changing physical symptoms, all contributing to anxiety levels.

How do I manage my symptoms in perimenopause?

While perimenopause can be marked with bothersome symptoms, there are ways to manage this transition. It’s also a period in life where you can focus on preventative health and can build a proactive health care plan.

Here are some tips for managing your symptoms:

1. Track your symptoms 

I often encourage my patients to track their periods and symptoms. This means that we have objective data to refer to, when trying to determine what their hormones are doing. My favourite period tracking app is the Clue App. This allows you to track the length and variability of your menstrual cycles. I also have my patients fill out a hormone questionnaire. This provides us the ability to track symptoms, the severity and change over time.

2. Prioritize Sleep

Women in perimenopause and menopause often experience sleep disturbances, secondary to changing hormones and menopausal symptoms. Sleep is integral for our immune system, and our ability to cope with stress. Prioritizing sleep increases the chances of getting good quality sleep.

3. Find a healthcare practitioner to discuss your hormones and symptoms with

As a naturopathic physician, who takes a functional medicine approach, there are many ways we can address symptoms of perimenopause. This starts with an in-depth history and understanding of the women’s overall health. Some of the tools I use include:

• Hormone testing (blood and urine)
• Bioidentical hormones replacement therapy
• Herbal and supplemental support
• Diet and exercise

Further reading

• Proactive Menopause Plan (free download)