What Are the First Signs of Perimenopause? Surprising Facts

One of the chief complaints I hear from my patients aged 35-55 years is worry that their hormones are all over the place. They notice changes in their bodies and menstrual cycles. Our conversations frequently include their frustrations of not feeling like their usual selves.

Many mention snapping over minor issues and experiencing tighter waistbands (despite sticking to a strict diet). Falling behind busy schedules (that used to be a breeze!), tossing and turning at night, forgotten sex drives, and a new onset of uneasiness are also common in our discussions.

My patients say they might expect some of these issues after menopause, which is why they are surprised to be dealing with them while still getting a period.

So what's going on? There's a space of about 10 years of a woman's life, typically between the ages of 40 to 50, before her cycle stops completely, which is aptly named perimenopause (fun fact: as a prefix, "peri" means "near" or "around"). Only after a woman's cycle has stopped completely for 12 months or longer has she reached menopause.

But the transition to getting there brings significant changes from the monthly periods and childbearing, often leaving even the most grounded woman in a tailspin. Let's talk about how to know if you're in perimenopause, the symptoms, and the best ways to navigate this often challenging phase of life.

At what age do perimenopause symptoms start?

Women start perimenopause at different ages; the average age for transitioning into menopause is 52, with a typical range of 40 to 58. Every woman is different, and there isn't a specific age of onset or a particular set of perimenopause-related symptoms she may experience.

For example, it's not uncommon for a woman to experience perimenopausal symptoms as early as age 35, such as a late or longer cycle or one that's heavier, diminished energy levels, or seeing the scale creep upwards. A number of factors can contribute to an early onset, including smoking, eating patterns, family history and overall health status, although there is no hard and fast rule.

There's also a hereditary component. Women can get a glimpse of what perimenopause will be like by asking their mothers; often, we follow similar patterns to those our mothers had while going through perimenopause. So, if hot flashes didn't haunt your mom during perimenopause (and menopause), chances are you may not have to deal with them either.

Top 3 first signs of perimenopause

The early signs of perimenopause can be mistaken for premenstrual syndrome and other conditions related to overall health status. Let's discuss the three most common ones.

1. Changes in menstrual cycle:

   A typical menstrual cycle occurs every 21 to 35 days and lasts about five to seven days. But a woman going through perimenopause may not see her next period for several months, or she may bleed heavier or for longer than her usual period. Another change women experience during perimenopause is a change in ovulation, which may also show up as skipped or more frequent cycles on their calendars.

2. Hot flashes and night sweats:

   The changes in sex hormones like estrogen and progesterone can bring on a wave of heat that spreads throughout the body, leaving women feeling warm and flushed. And it can happen at night, too. Women can wake up in the middle of the night, drenched in sweat and having trouble getting back to sleep.

3. Wider waist:

   Some women may struggle managing a healthy weight, even if they didn't have any issues during their teenage years, 20s or early 30s. A woman may gain extra inches around the midsection or abdomen, which can impact heart health in the future.

Perimenopause isn't the only reason why you could be experiencing these, of course—but, it's a pretty common and predictable one.

Other signs of perimenopause

In addition to these three, the following are some possible signs and symptoms of perimenopause and menopause:

• General fatigue
• Lower libido
• Mood changes
• Difficulty sleeping
• Vaginal dryness
• Head discomfort
• Changes in cognition, memory and attention
• Changes in bone density
• Itchy ears

Why such a wide array of symptoms? Changes in hormone levels are often to blame for all of these—and possibly others!

What hormones change during perimenopause?

During our fertile years, sex hormones like estrogen, progesterone and testosterone work together to keep us in harmony. These key hormones regulate menstrual cycles, fertility, sex drive, mood and head-to-toe wellness:

• Estrogen

  : Primarily produced in ovaries, but the adrenals and adipose tissue (body fat) produce some estrogen, too. It plays a critical role in ovulation, keeps our vagina well lubricated, contributes to bone density, circulation, and supports collagen in our skin and brain function.

• Progesterone

  : Also produced in ovaries, adrenal glands, and placenta when pregnancy knocks at your door. Healthy levels directly impact the menstrual cycle and bone health, influence mood and cognition, and complement estrogen's role in the body.

• Testosterone

  : Women produce testosterone in the ovaries, adrenal glands and peripheral tissues like fat and muscle cells. Testosterone drives our libido and sexual response and supports muscle mass, bone health and cognitive function.

What may be surprising is that we have receptors for these hormones in different body tissues, including the brain, reproductive and functional organs, skin, bones, muscles and fat cells. Which is why, when we transition through perimenopause and then menopause, the inconsistent production of these hormones lead to the wide variety of symptoms women experience.

7 ways to manage perimenopause symptoms

I'm happy to report that there's a vast spectrum of management tools to help women reclaim their well-being as they go through these changes and transition into healthier, happier versions of themselves.

Here are my top seven recommendations:

1. Balanced, nutrient-rich meals

   : Women may notice their waistlines don't hold pizza and wine nights as they did in their 20s. That's why I recommend starting with nutritional changes and staying well hydrated, which can positively impact energy levels, muscle mass, mood and focus. Adjust your eating patterns to include more nutrient-rich, whole foods that give you fiber and protein as well as healthy fats, which can help manage perimenopause-related symptoms.

2. Regular exercise routine

   : Indubitably, staying physically active is a cornerstone of well-being. But as we enter perimenopause, having an exercise routine becomes imperative for maintaining muscle mass and bone density, hallmarks of healthy aging. Women in perimenopause should be strategic about how they work out. Excessive exercise can negatively impact sex hormone levels, like estrogen and progesterone, which can be counterproductive to our wellness goals. And no, it's not about skipping your workout but about adjusting your exercise routine. For example, swap intense cardio sessions for 20- to 30-minute weightlifting and resistance training three to five days a week.

3. Restful sleep: Sleep is our body's time to reset. You may need more rest as you find your way in perimenopause—this is normal. I recommend practicing good sleep hygiene and insisting that quality sleep is a non-negotiable for you, every night. Aim for seven to nine hours of uninterrupted sleep.

4. Observe cycle patterns (or lack thereof)

   : Tracking your cycle is a valuable practice. Take note of changes in menstrual irregularity, flow, cramps as well as any changes in your lifestyle to note connections. For example, does a wild night on the town seem to coincide with a heavier period? Being a careful notetaker can help you identify patterns and adjust your daily actions accordingly.

5. Supplements

   : Adding high-quality formulas to your routine can help smooth the roller coaster ride your hormones take during perimenopause. Supplements can help you keep perimenopausal symptoms at bay, particularly those with studied doses of ingredients like fenugreek seed, red clover and chaste tree. You can also look for PMS relief supplements containing ginger, magnesium and vitamin B6.

6. Stress management

   : Stress is another common culprit for the significant changes women experience in perimenopause. Breath work, spending more time in nature, tapping, and talking on the phone with loved ones are great ways to manage stress levels.

7. Hormone restoring regimens

   : This can be a wonderful option to help keep hormone levels healthy. Your doctor will recommend lab tests to keep track of your progress, suggest lifestyle changes and dietary supplementation to help you stay on track.

Can perimenopause affect mood and emotions?

Yes! As we've seen so far, we have hormone receptors in our brain, too. So, the see-saw of changing hormone levels has a direct link to how we think and feel.

However, there are other aspects that can impact our mental well-being other than hormones. Psychological changes in our perspective, beliefs and identity as we age also influence how we handle emotional or stressful situations, which in some ways may be more acutely felt by women going through perimenopause and menopause.

Does perimenopause affect libido?

No surprise here, it does! It also can affect lubrication in the vagina, which can make sex uncomfortable even when you are in the mood. Estrogen level shifts are the primary culprit for both libido and vaginal changes, but you don't have to take either of these lying down. (Pun intended.) Some supplements can help keep your sex drive alive and ensure you can enjoy the time between the sheets with your partner comfortably, but above all else, it's important to communicate your needs.

This is key because our sexual desire is about our minds as well as our bodies—sensuality and arousal go out the window when you're mentally not there. Sexual mindfulness can help you and your partner find different ways to explore each other, engage all your senses and spice up your connection. And of course, a natural lubricant can do wonders to keep the heat going.

How do I know if it’s perimenopause or something else?

Unfortunately, there isn't a one-size-fits-all approach to knowing whether what you're experiencing is the early stages of perimenopause or an indication of something else that's not just the normal process of aging. It's important to regularly see your OB/GYN and if you notice any dramatic changes in your energy levels, libido, mood, comfort levels or sleep, get on her calendar sooner rather than later.

A good rule of thumb for women of all ages is to connect with your body and pay attention to the changes and discomforts you're experiencing. So, if you notice your period arrives every other month (or is gone for several months), your flow is heavier or lasts longer, and you experience hot flashes and night sweats, you may have started your perimenopause journey (victory lap not required).

Bottom line: Perimenopause is not an ending—it's a new beginning. The right tools and knowledge help us embrace this transition and make our way happily and healthfully through the menopause maze.

References

• Bromberger JT, Epperson CN. "Depression During and After the Perimenopause: Impact of Hormones, Genetics, and Environmental Determinants of Disease." Obstet Gynecol Clin North Am. October 2018. https://pmc.ncbi.nlm.nih.gov/articles/PMC6226029/
• Harper JC, et al. "An online survey of perimenopausal women to determine their attitudes and knowledge of the menopause." Women's Health (Lond). January-December 2022. https://pmc.ncbi.nlm.nih.gov/articles/PMC9244939/
• Metcalf CA, et al. "Cognitive Problems in Perimenopause: A Review of Recent Evidence." Curr Psychiatry Rep. September 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10842974/
• "Perimenopause 101." The ‘Pause Life. https://thepauselife.com/blogs/the-pause-blog/perimenopause-101?_pos=3&_sid=f19245509&_ss=r