Perimenopause occurs over several years leading up to
menopause, when a person with a uterus and ovaries stops menstruating. This phase begins when the time between periods becomes erratic, and it typically lasts four to eight years.
This stage of life typically begins in your forties as levels of
estrogen and other
hormones naturally start to decline. At first, the
menstrual cycle changes tend to be subtle, often with cycles getting a little shorter than usual. A woman might experience fewer or more days of bleeding or a heavier or lighter blood flow. As perimenopause progresses and a woman gets closer to full menopause, the time between periods can stretch out more, with cycles lasting closer to 60 days.
During this later stage of perimenopause, shifting hormone levels can also trigger a variety of symptoms like hot flashes and night sweats. Perimenopause ends and full menopause begins when you stop having your period for 12 consecutive months.
Signs and Symptoms of Perimenopause
One of the first and most obvious
signs of perimenopause is irregular periods.
As well as increasing variation in how long your periods last, bleeding can be heavier or lighter than normal. And people sometimes also experience different symptoms of
premenstrual syndrome (PMS) than they typically had before perimenopause.
There are two stages of perimenopause:
- Early Perimenopause Your menstrual cycle consistently fluctuates by seven or more days.
- Late Perimenopause You go 60 or more days between periods.
- Hot flashes, or a sudden feeling of warmth that spreads across your body
- Night sweats, or hot flashes that occur when you’re trying to sleep
- Vaginal dryness and discomfort during sex
- A frequent need to pee
- Sleep problems like insomnia
- Changes in mood, such as irritability, depression, or mood swings
Causes and Risk Factors of Perimenopause
Going through perimenopause is natural, and fluctuations in hormone levels trigger this transition period before menopause. Because it lasts several years and
ends in menopause, perimenopause is part of the “
menopausal transition.”
While this is a naturally occurring part of your reproductive cycle, certain factors are linked to an earlier perimenopause in some women, including:
- Smoking People who smoke may experience menopause one or two years before those who don’t.
- Family History If the women in your family went through early menopause, you have a higher risk of it.
- Cancer Treatment Receiving pelvic radiation therapy or chemotherapy to treat cancers may have links to early menopause.
- Hysterectomy Although your ovaries will still make estrogen and you won’t go through menopause immediately after a hysterectomy, having the procedure can sometimes cause menopause to occur earlier than usual.
- Oophorectomy The removal of both ovaries causes instant early menopause. Having one ovary removed might mean the remaining ovary stops working earlier than expected.
Fluctuating estrogen levels are usually the culprit, though there are other factors that can influence when perimenopause begins, such as certain surgeries, medical conditions like autoimmune or thyroid disease, and extreme weight changes. Estrogen and
progesterone levels rise and fall in a steady, predictable rhythm during a person’s reproductive years, resulting in monthly periods that follow a consistent pattern.
Two hormones regulate estrogen levels in the body. One is follicle-stimulating hormone (FSH), which prompts the fluid-filled sacs in the ovaries that contain eggs to produce estrogen. The other is luteinizing hormone (LH), which stimulates the ovaries to release eggs from their follicles, or sacs. These follicles then makes both progesterone and estrogen to prepare the body for pregnancy, and levels of FSH and LH decline. When there’s no pregnancy, progesterone levels decline again, and the menstrual cycle starts.
This cycle repeats each month fairly regularly — except during pregnancy — until a person reaches perimenopause. During this transition period, the ovaries stop working predictably and hormone levels become more erratic.
How Is Perimenopause Diagnosed?
Even though hormonal changes can trigger menopause,
testing hormone levels isn’t usually helpful or accurate for diagnosing this condition. That’s because hormones shift during the menstrual cycle, and irregular periods make it hard to know what the expected range of hormone levels should be at the time when lab tests are done.
In addition, FSH tests won’t show menopause-related FSH changes if you’re on
hormonal contraceptives because they suppress FSH levels.
Doctors can test FSH levels and sometimes use these tests to confirm if someone has entered menopause, particularly if periods stop before 40 years of age.
You’ve reached menopause once you haven’t had your period for 12 consecutive months and you have FSH blood levels of at least 30 milli-international units per milliliter.
Salivary hormone tests that producers market as a way to diagnose menopause also aren’t a reliable way to determine when someone is going through perimenopause.
Instead, the best way to diagnose perimenopause is by seeing a healthcare professional. By taking a detailed medical history and asking questions about your menstrual cycle and menopause symptoms, physicians can often figure out if you’re going through the transition.
Treatment and Medication Options for Perimenopause
Many of the same therapies used to manage menopause symptoms can also help with perimenopause symptoms. Women can get pregnant up until 12 months after their last menstrual cycle, so they need to be aware of contraception during this period.
Several medications, including hormone therapy, can help relieve symptoms. Some may also choose to use hormonal contraception to treat perimenopausal symptoms.
Medications
Medications that manage perimenopause symptoms include the following:
- Menopausal Hormone Therapy Systemic estrogen therapy, or hormone therapy, is available in pills, skin patches, sprays, creams, and gels for those who are in late perimenopause or are no longer getting regular periods. It’s considered the most effective way to relieve symptoms like hot flashes. People who still have a uterus will need to take progesterone along with estrogen. This type of therapy can help reduce your risk of bone loss, but it also has possible links to stroke, blood clots, and breast cancer. Discuss the benefits and risks with a healthcare professional.
- Vaginal Estrogen Applying hormones directly to the vagina by inserting a ring or applying a cream can release a smaller amount of hormones that only gets absorbed by the surrounding tissue. This helps mainly with changes during menopause, such as vaginal dryness, pain during intercourse, and urinary symptoms, as well as helping to reduce the risk of urinary tract infections.
- Antidepressants Some antidepressants in a family of medicines known as selective serotonin reuptake inhibitors (SSRIs) can help reduce hot flashes. These medicines can also help people who experience mood disorders during perimenopause. They are not as effective as hormone therapy for treating hot flashes and night sweats, but they’re helpful for those who cannot or choose not to use hormones.
- Gabapentin (Neurontin) This anti-seizure medication has been used to treat hot flashes. It can also benefit people who suffer from migraine or sleep disturbances during perimenopause.
- Fezolinetant (Veozah) This hormone-free medication helps regulate the body’s temperature by limiting neurokinin-3–receptor activities to treat hot flashes. It may also improve sleep.
- Elinzanetant (Lynkuet) This is a new medication that blocks both neurokinin-1 and neurokinin-3 receptors to reduce hot flashes without the use of hormones.
- Oxybutynin This medication is primarily a treatment for an overactive bladder, but it can also reduce hot flashes.
- Levonorgestrel-Releasing Intrauterine System (Mirena) Contraceptives combine birth control with added hormones, which can treat hot flashes for those in early perimenopause or who are having regular periods. This device is placed in the uterus and slowly delivers the hormone levonorgestrel, a synthetic progestogen, to stop eggs from fully developing. It’s also approved by the U.S. Food and Drug Administration (FDA) as a treatment for heavy periods. It may provide endometrial protection for those taking estrogen therapy.
Complementary and Integrative Therapy
To find further relief, many people with ovaries try
herbal remedies, supplements, or natural hormone therapy. More research is necessary to confirm whether they’re safe and effective, and studies are ongoing. However, options include:
- Black Cohosh Some people have used this herb to manage hot flashes and other perimenopause symptoms, but evidence for its safety and effectiveness is limited. Some research suggests that it may harm the liver, and it’s unclear whether this medication is safe for women with or at risk of breast cancer.
- Phytoestrogens These are estrogens that naturally occur in some plant foods, including isoflavones and lignans. Soybeans, some other legumes, and red clover provide isoflavones, while flaxseed, whole grains, and certain fruits and vegetables contain lignans. Some plant compounds also act like estrogen in the body. However, the impact of phytoestrogens on perimenopause symptoms — and also breast cancer risk — is unclear.
- Dehydroepiandrosterone (DHEA) This is a precursor to sex hormones in the body, meaning it later becomes estrogen. Your body naturally makes DHEA, but it’s available as a supplement. DHEA products claim to help with painful sex due to menopause-related vaginal dryness. However, research on its effectiveness is mixed, and its link with cancer needs more research.
- Bioidentical Hormones These products are still made in a lab, but the word “bioidentical” means the hormones they provide are the same as those your body makes. The FDA has approved some bioidentical hormone products (transdermal estradiol and oral micronized progesterone) for use in perimenopause management. However, you’ll also see products known as compounded bioidentical hormones available, often marketed as “natural” — but that doesn’t mean they are safer. These differ from those with FDA approval in their regulation, product consistency, and the level of evidence supporting them.
Speak to a healthcare professional before trying herbal or
natural remedies for perimenopause. Other, lower-risk options for complementary symptom relief that may help include:
- Acupuncture This therapy may reduce hot flashes, although more evidence is needed.
- Relaxation Techniques These can reduce stress, which might help with symptoms. Options might include yoga, tai chi, or mindfulness meditation.
- Cognitive Behavioral Therapy (CBT) This is a type of talk therapy that can empower people with coping skills to support improved mood and well-being during perimenopause. CBT might also support better sleep and comfort during sex.
- Hypnotherapy Some studies have shown that an induced state of deep relaxation and altered consciousness can help reduce hot flashes and improve sleep during perimenopause.
- Weight Loss People with obesity might find that losing body weight improves hot flashes and night sweats early in the menopause transition period.
Lifestyle Changes for Perimenopause
You can’t prevent perimenopause, but taking certain steps can help make it a more comfortable transition into menopause and beyond.
Use Water-Based Lubricants or Moisturizers to Improve Vaginal Comfort
Over-the-counter lubricants (like JO, Sliquid Organics, Pink, and others) or moisturizers (Hyalofemme, Replens, Sliquid Satin, and others) can help reduce vaginal dryness. Sticking to water-based products and avoiding those containing glycerin or parabens can help protect your health in the long term. Glycerin can cause irritation or burning, and parabens have links to possible cancer development.
Stay Sexually Active
If possible, staying sexually active can help you retain vaginal moisture. Sexual activity might improve blood flow to the vagina, which may also reduce the effects of vaginal dryness.
Eat a Nutritious, Balanced Diet
Perimenopause can increase your risk of bone issues and heart disease, so
eating a wide range of high-fiber, low-fat fruits, vegetables, and whole grains can help you protect yourself against these complications. Adding high-calcium foods like milk, cheese,
yogurt, and
kale supports long-term bone strength.
Get Regular Exercise
Consistent exercise can help prevent weight gain, improve mood, and support better sleep during perimenopause. Try to exercise for at least 30 minutes daily on most days, avoiding it just before bedtime. Resistance training with weights can also help protect your bones against fractures during aging.
Complications of Perimenopause
Hormonal changes that begin during perimenopause can increase the risk of serious health conditions, according to the Office on Women’s Health.
Other shifts, such as weight gain, can also contribute. Some risks include:
- Heart Disease Estrogen helps maintain healthy blood vessels and normal cholesterol levels. When estrogen levels decline, cholesterol and other fatty deposits can build up on blood vessel walls, making these channels stiffer and harder and increasing the risk of heart disease. Cholesterol buildup in blood vessels leading to the brain also increases the risk of stroke.
- Osteoporosis Declining estrogen levels starting during perimenopause can cause bones to become brittle, weak, and more prone to fractures.
- Urinary Incontinence Lower estrogen levels can also weaken the urethra, resulting in leaking urine and difficulty holding in urine.
