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perimenopause: middle aged woman hugging dog

What To Expect During Perimenopause

Perimenopause is a natural part of every woman’s aging process, yet many people have little to no idea of what actually happens internally during perimenopause (or even menopause), and what symptoms it can cause. It’s time to shine a light on this under-discussed yet inevitable stage of life. 

Ahead, learn exactly what to expect during perimenopause, and what women can do to quell the most common symptoms. 

  • ABOUT OUR EXPERTS: Dr. Donna Adams-Pickett, M.D., Ph.D., F.A.C.O.G., is a gynecological surgeon and the founder of a coalition of over 800 Black OB/GYNs to share resources and guidance to women in need of healthcare. Catherine Hansen, M.D., F.A.C.O.G., F.R.C.S.C., N.C.M.P., M.P.H., is a physician who heads Pandia Health’s menopause hormonal care offerings. Veena Madhan Kumar, M.D., OB/GYN, is an obstetrician and gynecologist with the online virtual hospital iCliniq. Trista Best, M.P.H., R.D., L.D., is a registered dietitian.

Perimenopause, Explained

The prefix “peri” means “about” or “around,” so perimenopause literally translates to around (the time of) menopause, explains gynecological surgeon Dr. Donna Adams-Pickett, M.D., Ph.D., F.A.C.O.G., founder of a coalition of over 800 Black OB/GYNs to share resources and guidance to women in need of healthcare. As such, to understand what perimenopause is, you need to understand menopause more broadly. 

Menopause is marked by the ovaries ceasing function, explains Adams-Pickett. Prior to perimenopause and menopause, the ovaries make the majority of the estrogen, progesterone, and testosterone circulating throughout the body, she says. The ovaries are also the reproductive organ that produces eggs. Following menopause, ovaries stop production of these three key hormones, as well as stop releasing eggs. 

Read More: 9 Lifestyle Tweaks To Make For Healthier Hormones

The catch is that hormone production and egg maturation don’t just end suddenly; this happens little by little. “Perimenopause is the name of the transitional stage wherein ovaries gradually decrease their function and slow down the production of hormones,” explains Adams-Pickett.

When Does Perimenopause Start and How Long Does it Last? 

Broadly speaking, perimenopause takes place prior to menopause (which is considered to have officially begun once an individual has gone a full 12 months without a period), explains physician Catherine Hansen, M.D., F.A.C.O.G., F.R.C.S.C., N.C.M.P., M.P.H., who heads Pandia Health’s menopause hormonal care offerings. “The only distinct difference between perimenopause and menopause is that in menopause a person has experienced one full year with no menstrual cycle,” she says. “Until that anniversary, they are still considered perimenopausal.”

Exactly when perimenopause begins and how long it lasts varies from individual to individual. Genetics have been shown to be the main modulator of the age perimenopause begins and how long it lasts, but overall health, as well as environmental and lifestyle factors, play a role, too. Of note, obesity, substance use, and poor nutrition have all been linked with earlier menopause (and, thus, earlier perimenopause). 

While some individuals become menopausal much earlier or later (ranging from the early 30s to later 50s), the average age of menopause is 51. Most people enter perimenopause four to eight years prior to that, according to The North American Menopause Society. (So, on average, that’s anywhere from 43 to 47.) That said, for some people, perimenopause lasts just a few months, while it’s also been reported to last as long as fourteen years

Clearly, there’s a lot of variation here. All in all, though, “for most people, the road of perimenopause typically begins for women in their early to mid 40s and lasts a handful of years,” says Adams-Pickett.

4 Common Symptoms of Perimenopause

Typically, individuals are tipped to the fact they are going through perimenopause because their menstrual cycle changes, or they begin experiencing other symptoms commonly associated with this life phase. Here’s more on how it typically shows up.

1. Irregular periods

Menstrual irregularity is one of the most common clues that a woman is entering perimenopause, says Adams-Pickett. “Periods that are irregular in their timing and caliber are a hallmark of perimenopause, with menses skipping several months then occurring more frequently in subsequent months,” she explains. 

Generally speaking, periods are considered irregular when the gap between them is less than 21 days or more than 35 days. As far as perimenopause is concerned, the irregularity is typically marked by a longer (not shorter) gap between periods. While menopause is marked by an individual not having a period for 12 consecutive months, individuals may go two, three, or even 11 months between periods during perimenopause, according to Adams-Pickett. 

What to Do: Healthcare providers may recommend interventions (typically hormonal birth control) for irregular periods if hormonal dysregulation like polycystic ovarian syndrome (PCOS) is at play. However, irregular periods during perimenopause are normal and nothing to worry about.

If irregular periods are also accompanied by more severe PMS symptoms, however, your provider may recommend any number of interventions, including over-the-counter pain relievers. In some instances, a birth control pill that contains a low dose of estrogen may be prescribed to ease menstrual symptoms. 

2. Night sweats and hot flashes

The culprit of most of the symptoms associated with perimenopause is declining estrogen, which is the root cause of both night sweats and hot flashes. 

Estrogen promotes vasodilation, or blood flow, which has been shown to augment the body’s heat dissipation response, keeping body temperature low(er), explains obstetrician and gynecologist Veena Madhan Kumar, M.D., OB/GYN, of online virtual hospital iCliniq. As such, higher estrogen levels are associated with lower body temperature, while lower levels are associated with a higher core body temperature, she explains. 

During perimenopause, estrogen levels gradually decrease. As a result, women are likely to experience symptoms associated with poor body temperature regulation—mainly, night sweats and hot flashes. (Biologically speaking, these two things are the same. Night sweats are simply hot flashes that happen at night.)

What to Do: If you’re shvitzing your way through the day or night, an omega-3 fatty acid supplement may offer support, suggests registered dietitian Trista Best, M.P.H., R.D., L.D. “Some studies have shown that an increase in omega-3 fatty acids intake can help reduce the occurrence of hot flashes, as well as night sweats,” she says. 

As such, many experts recommend that menopausal women consume at least one gram of omega-3 fatty acids per day, with a special focus on DHA and EPA, the two types commonly found in fish like mackerel, salmon, and cod liver. (A high-quality supplement rich in EPA and DHA is also a great option.) If you don’t consume animal products, you can get omega-3s from flax and chia seeds, as well as supplements made from algae oil, suggests Best. 

Another supplement that may offer support: Wile’s Hot Flash. Developed by a naturopath specifically for women in this season of life, the herbal formula combines sage leaf, chaste tree fruit extract (a.k.a. Vitex), hops, and kudzu root to help minimize and shorten flashes.

There are also a number of edits you can make to your wardrobe and environment to help reduce the severity of both hot flashes and night sweats. To start, if you have the ability to control your thermostat, the National Institute of Aging recommends turning it down. If not, consider using plug-in fans or opening windows to encourage a cross-breeze. 

Beyond that, dress in layers that can be removed if a hot flash starts up, says Hansen. She also recommends layering your bedding so that you can adjust your blanket and sheet set-up throughout the night as needed. Drinking cold water, quitting smoking, reducing substance use and alcohol intake, and eating a nutrient-dense, spice-free diet may also help. 

3. Trouble Sleeping 

A whopping 39 to 47 percent of people going through perimenopause report sleep problems. 

Typically, there are multiple factors causing these issues. On one hand, the hormone imbalances associated with perimenopause can increase the risk of poor sleep. “The decreased progesterone levels that accompany perimenopause are linked with increased occurrence of insomnia,” says Adams-Pickett. Progesterone acts on brain pathways in such a way that it has a hypnotic (or sleep inducing) effect on the body, she explains. So as levels decline, sleep disturbances become more common. 

Of course, other symptoms caused by perimenopause can lead to these sleep problems, too. As you might guess, night sweats have been shown to interfere with sleep. Perimenopause has also been shown to increase an individual’s risk of mood disturbances, which have been linked to an increased risk for sleep issues.

What to Do: Many of the tips recommended to perimenopausal and menopausal individuals struggling to log Zzzs are the same as those given to any other demographic—and they all come down to boosting your sleep hygiene. 

The best ways to improve sleep when you are perimenopausal is to go to bed at the same time each night, rise at the same time in the morning, avoid naps, and develop a nighttime routine that signals to your body that it’s time to shift into sleep mode, says Kumar. It can also be helpful to cut down on caffeine and alcohol consumption, and to cease smoking, as all of these substances mess with the body’s circadian rhythms. 

Additionally, implementing any stress-reduction practice into your life can help. “Practicing a relaxation protocol like yoga, breathing exercises, or meditation will help keep stress from adding to your sleep woes,” Kumar shares. 

Lastly, consider trying a supplement made specifically to help women manage the various lifestyle-impeding shifts that come with perimenopause. Wile’s Perimenopause Support Herbal Supplement, for example, contains alfalfa, fennel seed, chaste tree fruit extract (a.k.a. Vitex), and ashwagandha to support sleep, stress response, and mood.

4. Vaginal and sexual changes 

The three main hormones that dip during perimenopause —estrogen, progesterone, and testosterone—all support natural vaginal lubrication and sexual desire. So, when these hormone levels drop and become erratic, it is common for individuals to notice a dip in their interest in sex, as well as reduced lubrication levels, says Hansen. It’s also common for individuals to notice generalized vaginal dryness, or dryness outside of the bedroom.

Read More: An OB/GYN Debunks 5 Libido Myths

Commonly, vaginal dryness causes symptoms such as the sensation of itchiness in and around the vagina, increased need to urinate, and greater occurrence of infections like UTIs or yeast infections. Vaginal lubrication, particularly vaginal discharge, helps cleanse the vaginal canal of infection-causing bacteria, per the American College of Obstetricians and Gynecologists. So, when lubrication levels drop, foreign pathogens have more time to make a home and wreak havoc internally. Plus, estrogen loss can decrease the elasticity and strength of the muscles in the urethra, making it easier for bacteria to enter. 

What to Do: Not only can vaginal dryness be uncomfortable, but the reduced interest in sex can make people feel disconnected from their bodies and their partners, according to Hansen. The good news is that there are several treatment options for vaginal dryness. 

First, a number of vaginal moisturizers are on the market, says Hansen. These non-hormonal options usually come in the form of vaginal suppositories or topical creams that moisturize your internal tissues, much like a facial moisturizer does your face, she explains. You can also purchase lubricants specifically for use during intimacy. “In general, silicone- and oil-based lubricants tend to be more optimal for perimenopausal folks than water-based options, since the body absorbs water-based products,” says Hansen. (Just keep in mind that silicone lube can’t be used with silicone toys, while oil-based can’t be used with latex barriers.)

If non-prescription options don’t cut it, talk to your doctor about prescription hormone replacement therapy (HRT), suggests Kumar. These estrogen-containing medications increase estrogen levels either systemically (when taken orally) or locally (when inserted vaginally) and can help bring about relief. 

When To Talk To A Healthcare Provider 

As a general rule, it’s best to consult with a healthcare provider whenever you experience any of the symptoms associated with perimenopause. Reason being, in addition to signaling perimenopause, the aforementioned symptoms are also common signs of serious health conditions like ovarian, cervical, breast, endometrial, or uterine cancer. A healthcare provider will be able to determine whether or not you are, in fact, perimenopausal, or if there is another underlying cause for the new crop of symptoms. 

Hansen specifically recommends working with a provider who specializes in menopausal patients. You can find one near you by searching the Menopause Society Certified Practitioner database. “These providers will have the knowledge necessary to give you personalized advice for navigating your particular symptoms,” she says. 

As you navigate this life transition, you may also find it helpful to work with a therapist who can help you learn to love this particular version of you, says Adams-Pickett. “Perimenopause is not a time for grief but instead a time for celebration,” she says. After all, soon you will be free from the monthly constraints that are often placed by our periods. Plus, “your body has now gained the experience of time and you now have the agency to explore its capabilities,” she says. 

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