“I was 40 when I first started getting symptoms, and at first, I didn’t realize what was happening,” says Sarah. “Menopause wasn’t on my radar. So when I started noticing more facial hair, mood swings and weight gain — after maintaining the same weight for two decades — I just figured that aging and a busy lifestyle were the culprits.”
Like Sarah, around your early 40s to early 50s, you might start experiencing signs that your hormones are shifting. Perhaps you’re moodier, having bigger reactions to what should be small conflicts. Maybe you’re starting to get massive headaches. You may wonder if there’s something wrong with you, even though nothing in your life is technically wrong. The cycles of your period are starting to get shorter, and your period could be lighter — or it could be heavier.
Welcome to perimenopause.
In this stage, your body is getting ready to shift from the hormonal cycles that support fertility to new levels in menopause. This transition often lasts 4 to 8 years before your final period, and wild swings in your hormone levels can kick off a range of symptoms.
As with menopause symptoms, everyone experiences perimenopause differently. This is in part because a person’s psychosocial experience influences the reaction to symptoms. So a woman’s perimenopause is influenced by everything from her quality of life, levels of stress, social stigmas and mental health, including a history of depression, anxiety, post-traumatic stress disorder, or mood disorders.
Racial and ethnic differences also affect perimenopause experiences. The Study of Women’s Health Across the Nation (SWAN), for example, found that African American women in the transition to menopause may experience more frequent vasomotor symptoms such as hot flashes and night sweats, compared with other racial groups. They also reported more discomfort with symptoms. Experts don’t yet fully understand these racial differences.
Bottom line: While certain changes are common in perimenopause, your experience will be your own. But with a solid understanding of what’s going on, you’ll be well equipped to advocate for your needs, adjust what you can in your lifestyle, and manage the transition smoothly.
“I told my health care provider about my symptoms. I worried that something might be wrong with me. But after an evaluation, she said that I’d started perimenopause,” Sarah says. “I was surprised — but also relieved that my symptoms weren’t a sign of something more serious.”
What’s going on with my hormones?
If you’re feeling thrown off-kilter by perimenopause, there’s good reason. Most likely, you’ve been going through the hormonal patterns of the reproductive cycle since you were a teenager. Each month, your ovaries have been getting a signal of follicle-stimulating hormone (FSH) from your pituitary gland, which tells the immature eggs in your ovarian follicles to start to grow. As the follicles and eggs mature, they produce more estrogen and progesterone. Then the hormone inhibin B sends a “turnoff” signal to stop the pituitary from making more FSH. At that point, one of your ovaries releases a mature egg, and if there is sperm to meet it, there’s a chance of conceiving a baby. If not, then your progesterone levels drop, leading to your period.
In perimenopause, those patterns change. The pituitary gland still dishes out FSH to stimulate your ovaries to make more estrogen. Your ovaries are still releasing eggs — but not every month, and their quality and supply is lower. Because of this, your body is making less inhibin B. So FSH levels continue to rise, signaling to the ovaries to produce more estrogen. But with a lower egg supply, your estrogen levels respond less to the FSH signal and become more erratic.
Inevitably, your body is reacting in new ways to these changing signals. Your brain circuits and your body’s systems are used to functioning with a certain pattern of estrogen levels, and then those levels starts to fluctuate wildly. It’s no wonder if you’re experiencing symptoms from this transition. Think of when Han Solo hits the controls to take his spaceship to hyperspace in Star Wars. At first, the ride is a little bumpy.
What kind of symptoms can I expect during perimenopause?
The wild cycles of high and low estrogen during perimenopause can be very unsettling physically and emotionally. These fluctuations of estrogen can be more erratic, meaning higher highs and lower lows, than during a typical menstrual cycle. This is what’s behind hot flashes and night sweats, middle-of-the-night awakenings, and the moodiness, anxiety, and foggy thinking that are common in perimenopause.
These hormonal shifts are also why your periods are becoming more irregular and unpredictable. As you approach menopause, this abnormality is entirely, well, normal. If you have a persistent change of seven days or more in the length of your menstrual cycle, you may be in early perimenopause. If you have a space of 60 days or more be- tween periods, you’re likely in late perimenopause.
Other common symptoms of perimenopause include migraine headaches that last up to 1 to 2 days right before your period, joint pain, and increased irritability or anxiety, especially right before your period.
Some studies have found that women who tend to be more sensitive to premenstrual syndrome (PMS) also have stronger reactions to the hormonal changes of perimenopause. Let your health care practitioner know about any symptoms or changes, as some health changes that seem unconnected may indeed be related to your hormones. Also, it’s important to note that early-onset hot flashes in perimenopause — which start before you’re noticing big fluctuations in your period — may be a predictor of future heart disease risk. So it’s worth paying attention to anything that seems out of the ordinary and talking with your practitioner.
Are there any symptoms that are worrisome?
Your period will become more irregular as you enter perimenopause — that’s almost a given. This can mean bleeding that’s lighter or heavier than in the past, more days of bleeding or fewer, and longer or shorter cycle lengths. When estrogen levels are higher in comparison to progesterone, it often results in heavier bleeding during your period as the lining of the uterus is shed. A skipped period can also cause the lining to build up, leading to heavier bleeding over the next few months.
But some symptoms may point to underlying problems with your reproductive system. Call your doctor right away if you’re experiencing any of the following:
- Bleeding that’s heavy enough that you need to change your tampons or pads every hour or two. This can be a sign of fibroids, infection, a sexually transmitted disease, a thyroid problem, endometrial polyps or, in very rare cases, cancer.
- Bleeding that lasts longer than seven days.
- Bleeding that occurs between periods.
- Periods that regularly occur less than 21 days apart.
- Bleeding with intercourse.
If I think I’m perimenopausal, what do I do about it?
To help you manage this stage, it’s important to see a doctor or other clinician who understands the menopause transition — even if you’re not currently experiencing symptoms. Choose someone with whom you feel comfortable so that you can keep an open line of communication about any symptoms that do crop up, including emotional changes such as anxiety and depression. As your hormones shift over time, your health care team can help you find treatments and self-care tips to manage a variety of symptoms.
Some hallmarks of perimenopause, such as hot flashes, night sweats and mood changes, may continue long after your final period. Even so, health care practitioners approach the two stages in different ways and with separate treatments because of the difference in hormonal patterns at each stage. After the wild fluctuations in estrogen levels during perimenopause, in the years after your final period, estrogen falls to a more consistent, low level.
In addition, preventing pregnancy is still a concern until you’re certain you’ve had your last period. This is why a low-dose birth control is a common hormone treatment for perimenopause. The hormone therapy offered in menopause, in contrast, doesn’t contain high enough doses of hormones to override the perimenopausal swings of hormones and prevent ovulation.
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