Perimenopause is the stage of life preceding menopause, during which the ovaries begin to produce less estrogen and progesterone in preparation for the end of the reproduction process. Menstruation still occurs during perimenopause, but often irregularly, and the lower levels of estrogen and progesterone can result in several symptoms that vary in intensity for each individual.
Read on to learn about the causes of perimenopause, its common symptoms, and what you can do to find relief.
What’s the Difference Between Perimenopause and Menopause?
Perimenopause is the stage before menopause where menstruation still occurs although it is often irregular, lighter, and sometimes heavier. Menopause is reached when menstruation has not happened for 12 consecutive months, typically around age 52.
Perimenopause is known to last for 7-12 years and once menopause is reached women are considered postmenopausal for the rest of their lives.
Although many symptoms of perimenopause ease once hormone levels stabilize and women enter menopause, some can linger into postmenopause.
What Causes Perimenopause?
The natural process of aging is the main cause of perimenopause. Typically beginning in the early to mid-40s, the female body intuitively comprehends that the reproductive phase of life is coming to an end and it starts transitioning into a stage of infertility.
For 7-12 years, estrogen and progesterone randomly drop and rise and the production of eggs (ovulation) from the ovaries decreases. This fluctuation of hormones causes menstruation to become irregular and perimenopause symptoms to come and go until periods ultimately stop and menopause is reached.
What is Early or Premature Perimenopause?
When women start perimenopause earlier than age 45 it is known as early menopause and when it begins before age 40, it is called premature menopause. Causes of early and premature menopause include certain health conditions, surgery to remove the ovaries (oophorectomy), cancer treatment, and genetics.
Symptoms of Perimenopause and Why They Occur
Although the hormone decline during perimenopause primarily occurs to shut down reproduction, the hormones estrogen and progesterone also play roles in other parts of the body.
Estrogen, for example, passes through almost every tissue, bone, and muscle. It also supports brain function, cardiovascular health, the skin, and metabolism. In addition to supporting reproductive health, progesterone boosts moods and improves sleep.
Therefore, lower levels of estrogen and progesterone can impact the body in several ways and result in a myriad of perimenopause symptoms. It’s helpful to note that not all women experience all perimenopause symptoms and when they occur, their intensity can also vary with each individual.
Another factor to note about perimenopause is that estrogen and progesterone production decline tends to happen erratically rather than in a regulated way. This erratic rise and fall of hormones is what causes perimenopause symptoms to come and go without warning.
Testosterone, which aids in metabolism, muscle tone, sex drive, and energy levels can also contribute to perimenopause symptoms but to a lesser extent than estrogen and progesterone because its production typically drops before perimenopause.
Common Perimenopause Symptoms include:
- Irregular periods
- Hot flashes & night sweats
- Interrupted sleep or insomnia
- Headaches
- Breast tenderness
- Joint pain & body aches
- Low libido
- Heart palpitations
- Dry skin
- Vaginal dryness
- Pain during intercourse
- Weight gain, particularly around the midsection
- Hair loss on the scalp
- Facial hair growth
- More frequent urge to urinate
- More frequent urinary tract infections (UTIs)
Emotional & Cognitive Symptoms of Perimenopause can include:
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Anxiety or mild depression
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Irritability
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Brain fog
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Unexplained mood changes
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Less focus & concentration
How Do You Know If Perimenopause Has Started?
In some cases, irregular menstruation or spotting between periods is the first sign of perimenopause as previously regular periods occur closer together or further apart, sometimes lighter, sometimes heavier. For others, however, the physical or emotional symptoms of perimenopause are the first hint that something has changed.
Many women in perimenopause may notice hot flashes, breast tenderness, or interrupted sleep before any change in menstruation becomes apparent.
Do The Changes During Perimenopause Have Any Long-term Effects?
Most perimenopause symptoms subside once the body adapts to permanently lowered estrogen and progesterone levels once menopause is reached. However, in some women, low estrogen levels during perimenopause have been shown to contribute to the onset of heart disease, osteoporosis, diabetes, and depression.
Osteoporosis
Due to the lifelong support the bones receive from estrogen, declining levels during perimenopause can cause a loss of bone density. If left untreated, the loss of bone density can weaken bones, increase the likelihood of bone fractures, and increase the risk of osteoporosis in later life.
Cardiovascular Disease
Throughout life, estrogen plays a role in managing cholesterol levels and keeping the blood vessels healthy. When estrogen production reduces during perimenopause, the lack of support to manage cholesterol and keep the blood vessels healthy has been shown to increase the risk of heart disease and stroke in some women.
Diabetes
Estrogen is also vital in maintaining healthy blood sugar levels and the metabolism of food into energy. Therefore, in some women, low estrogen can raise the possibility of developing type 2 diabetes.
Depression
Estrogen and testosterone are vital for healthy brain function, however, lowered levels of these hormones during perimenopause can affect serotonin production (the happiness hormone) and mood management long-term. Physical changes like extra weight gain, or life changes like getting divorced or becoming an empty nester, are also known to increase the onset of depression at this stage of life.
How to Relieve Perimenopause Symptoms?
Perimenopause symptoms can be relieved through menopause hormone therapy (MHT) or a combination of lifestyle changes that counter the impacts of declining hormone levels on the body and improve overall quality of life. Both approaches are explained in more detail below.
Menopause Hormone Therapy
Following the confusion in the aftermath of the 2002 Women’s Health Initiative study, menopause hormone therapy (MHT) has become one of the most researched medications in modern times. Although the 2002 study initially linked MHT use to an increased risk of breast cancer, blood clots, and stroke, follow-up studies have found that MHT risks are minimal and do not apply to all women.
In fact, extensive research in the years since has shown that MHT is a safe and effective method of relieving perimenopause symptoms, improving quality of life during the menopause transition, and lowering the risk of more serious conditions postmenopause.
The key to safe MHT use is taking the appropriate hormone combination & dose and administering it in the right way. It is also highly recommended that MHT is taken during the perimenopause years, rather than beginning hormone therapy once menopause is reached.
There is a common misconception that MHT should not be taken until periods have ceased for 12 months, however, this is simply not true. In addition to easing perimenopause symptoms, taking MHT during this time can help prevent the onset of osteoporosis due to the accelerated loss of bone density.
What Are the Different Types of Menopause Hormone Therapy?
MHT administration methods include pills, creams, patches, gels, sprays, and rings. Menopause hormone therapy can also be divided into systemic MHT and local MHT.
Systemic MHT is absorbed throughout the body to treat several symptoms. Whereas, local MHT is used to treat symptoms relating to one part of the body, as in the case of genitourinary symptoms like vaginal dryness, bladder issues, and discomfort during sex.
Why one type of MHT would be recommended over another depends on a patient’s symptoms, age, family history, where they are on their menopause journey, and whether they’ve undergone a hysterectomy.
Women whose uterus remains intact, for instance, are typically advised to take an estrogen-progesterone combination to protect the uterine lining from higher estrogen levels and prevent uterine cancer. Estrogen-only MHT is usually only prescribed for women who have had a hysterectomy, although progesterone therapy can also be helpful in some cases.
Transdermal estrogen, which is administered via the skin, is typically prescribed for women prone to blood clots to prevent the slightly increased risk of clotting and stroke when taking estrogen pills.
Vaginal estrogen, to treat genitourinary symptoms like vaginal dryness and pain during sex, is also safe for most, even when systemic hormone therapy is not suitable.
Some perimenopausal women may also require testosterone supplementation.
Those considering MHT to ease perimenopause symptoms are advised to consult with a menopause expert or gynecologist to ensure they receive the right type of MHT for their situation.
That said, when an underlying condition means MHT is not suitable, or women prefer to relieve perimenopause symptoms without hormones, certain lifestyle changes are also effective for relief.
Lifestyle Changes to Relieve Perimenopause Symptoms
Eating healthier, consuming certain vitamins & nutrients, exercising regularly, managing weight gain, practicing relaxation techniques, caring for dry skin, adjusting the type of clothes you wear, and managing pelvic floor health can do a lot to relieve perimenopause symptoms.
In addition to boosting your physical wellness, this combination of lifestyle modifications can also improve mental well-being during the menopause transition.
Eating Healthier
During perimenopause, it’s vital to ensure that adequate levels of calcium are consumed to counteract the loss of bone density due to fluctuating estrogen levels. Vitamin D is also important to ensure optimal absorption of calcium. Sufficient protein and fiber are advised to enhance bone strength as well as muscle mass.
Oemga-3 fatty acids lower blood pressure, support cardiovascular health to prevent heart disease, help moisturize dry skin, and boost the immune system. Magnesium helps lift moods and promote sleep, and vitamin B6 aids in hormone regulation.
It can help to speak with a menopause expert or nutritionist to find the right balance of nutrients and vitamins required to ease your unique perimenopause symptoms through diet.
Regular Exercise
Getting into the habit of regular exercise can be a game changer for alleviating several perimenopause symptoms. For instance, aerobic exercise for 20 minutes, 3 times per week, can reduce weight gain, enhance heart health, and improve sleep.
Adding strength training 2-3 times per week is recommended to boost bone strength and maintain muscle mass, which helps to prevent joint pain and the onset of osteoporosis in later life. Yoga or Pilates can be practiced to reinstate diminishing flexibility & balance and improve posture.
Interestingly, weight gain during perimenopause has been proven to worsen hot flashes, whereas maintaining a healthy weight can reduce their severity. Regular exercise is also known to boost serotonin release, which improves energy levels and moods, eases brain fog, and relieves anxiety or mild depression.
Clothing & Bedroom Adjustments
When the body’s thermostat is affected by declining estrogen levels hot flashes and night sweats can occur as the body cools down. While one of the best ways to relieve hot flashes is through MHT, wearing clothes made from natural materials helps too.
It’s helpful to wear layers that can be easily removed to cool the body during a hot flash and put back on once the flash has passed. Carrying a hand fan in your bag is also useful when hot flashes emerge while you are out and about.
Bed sheets made from natural materials rather than synthetic ones can help minimize the effects of night sweats, as can a fan or air conditioner in the bedroom. If you suffer from hot flashes or night sweats, it can also be a good idea to abstain from triggers like alcohol, smoking, and spicy food.
Non-hormonal Medication for Hot Flashes
When severe hot flashes and night sweats occur during perimenopause and hormonal therapy is not suitable or preferred by the patient, non-hormonal medications can also be helpful.
Certain selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are known to relieve hot flashes by up to 60% by rebalancing chemicals in the brain that trigger hot flashes and night sweats.
Fezolinetant is a new medication designed to treat menopausal hot flashes & night sweats. It works by blocking neurokinin-3 receptors in the brain to prevent the thermoregulatory center from becoming overstimulated. Studies thus far have revealed it can reduce vasomotor symptoms by as much as 63% and it has recently been approved in the US, UK, and Europe.
Because SSRIs, SNRIs, and fezolinetant can react with other medications and may cause side effects in some people, it’s important to consult with a healthcare provider before taking them for hot flashes.
Dry Skin Care
Throughout life, estrogen promotes the production of collagen and oils to protect the skin and enable the body to retain moisture. So when estrogen levels drop during perimenopause, the skin can become dry, itchy, and irritating.
The same can happen to the vaginal skin, resulting in vaginal dryness, a condition known as vaginal atrophy.
To relieve dry skin, moisturize the body daily and consider purchasing an organically-made vaginal moisturizer to nourish the more sensitive genital skin. If sex is uncomfortable due to friction from vaginal dryness, a personal lubricant can help immensely during foreplay and intercourse.
Pelvic Health Tools
As previously mentioned, fluctuating estrogen during perimenopause can cause a loss of muscle mass all over the body. When this occurs in the vaginal muscles and/or pelvic floor muscles, the vagina receives less physical support due to weaker muscles, and pain can ensue during intercourse, a condition known as dyspareunia.
While a personal lubricant can relieve the uncomfortable friction from vaginal dryness, it won’t do much to support the vaginal or pelvic floor muscles. Kegel weights are recommended to strengthen the pelvic floor muscles, but should not be used if pain is present. This type of exercise can also help alleviate urine leaks or the frequent urge to pee during perimenopause.
In some cases, the vaginal and pelvic floor muscles can tighten in protection mode after experiencing painful intercourse due to vaginal dryness or weak pelvic floor muscles. The condition is known as vaginismus and attempting penetration when it occurs can cause the muscles to tighten even further, causing more discomfort and pain.
If you are suffering from vaginismus during perimenopause, learning how to use a set of vaginal dilators from a pelvic floor physical therapist can help relax the muscles and restore comfort during sex. Once you’ve learned how to use them, dilators can be used privately in the comfort of your home.
Meditation & Socializing
The aging process, physical body changes, grown children moving out, low estrogen levels, and its impact on cognitive function can all contribute to a sense of mild depression during perimenopause.
Whilst this reaction is understandable and perfectly normal, ignoring its impact on one’s happiness can lower quality of life and allow it to linger into postmenopause.
To relieve sadness, negativity, anxiety, or mild depression; perimenopausal women are encouraged to practice daily relaxation techniques and socialize with friends at least once per week.
Sitting in meditation, following guided relaxation, or practicing conscious breathing techniques are proven ways to release negative thoughts and consider the mind and body in a more positive light. Perhaps even coming to the point of celebrating the aging process rather than grieving the loss of youth.
Socializing with friends or other perimenopausal women is also helpful. Bonding over shared symptoms and experiences, recognizing similarities, and supporting one another through them can be an eye-opening and empowering reminder that perimenopause will pass, the severity of symptoms will fade, and life will resume.
Conclusion
Known as the transition to menopause, perimenopause lasts approximately 7-12 years before menstruation stops. During this time, declining estrogen and progesterone production can result in a wide range of symptoms such as hot flashes, weight gain, poor sleep, dry skin, and low libido.
Lowering levels of estrogen during perimenopause can also raise the possibility of heart disease, osteoporosis, and diabetes developing after menopause.
To relieve perimenopause symptoms, improve your quality of life during the transition, and prevent the onset of more serious conditions later in life, menopause experts recommend using the right type of MHT for your situation or a combination of natural lifestyle changes to counteract the effects of low estrogen.
References
Office on Women’s Health – Menopause Basics - https://womenshealth.gov/menopause/menopause-basics
Cleveland Clinic – Premature and Early Menopause - https://my.clevelandclinic.org/health/diseases/21138-premature-and-early-menopause
British Nutrition Foundation – Managing Menopause with Diet - https://www.nutrition.org.uk/nutrition-for/women/menopause/managing-menopause-symptoms-with-nutrition-and-diet/
National Library of Medicine - Physical Activity and Health During the Menopausal Transition - https://pmc.ncbi.nlm.nih.gov/articles/PMC3270074/
Mayo Clinic – Hot Flashes - https://www.mayoclinic.org/diseases-conditions/hot-flashes/symptoms-causes/syc-20352790
National Library of Medicine - Contemporary Non-hormonal Therapies for the Management of Vasomotor Symptoms Associated with Menopause - https://pmc.ncbi.nlm.nih.gov/articles/PMC8676100/
Balance Menopause - Fezolinetant Explained - https://www.balance-menopause.com/menopause-library/fezolinetant-explained/
Taylor and Francis Online Medical Journals – Understanding Weight Gain During Menopause - https://www.tandfonline.com/doi/full/10.3109/13697137.2012.707385
Balance Menopause - Pelvic floor health during the menopause Factsheet - https://www.balance-menopause.com/menopause-library/pelvic-floor-health-during-the-menopause/
National Library of Medicine - Reducing Menopausal Symptoms With Mindfulness-Based Meditation - https://pubmed.ncbi.nlm.nih.gov/38363970/
Web MD - Menopause and Dry Skin: The Hormone Connection - https://www.webmd.com/beauty/features/menopause-dry-skin-hormone-connection