Perimenopause—More than Just Hot Flashes
Gen X and elder millennial women are not going quietly into menopause. Older generations may have discussed menopause only in hush-hush tones with friends and doctors—if they talked about it at all. But women in their 40s and 50s experiencing perimenopause symptoms for the first time are speaking up, asking questions and demanding answers.
Social media is filled with discussions and tips on how to manage hot flashes, mood swings and brain fog. But with the surge in menopause conversations also comes bad advice, confusion and misunderstanding.
It’s important that people going through the menopause transition understand what is happening to their bodies—and how they may be able to safely and effectively treat bothersome or disruptive symptoms.
“Perimenopause and menopause is really a time of desperation because women really don’t know what’s going on,” said ob-gyn L. Dawn Mandeville, MD, the managing partner at Atlanta Gynecology & Obstetrics P.C. “They don’t feel well. They are not sleeping. Their lives can be in flux, whether it’s not being able to concentrate, having brain fog, thinking they have dementia. … There are so many issues that come up in this time, and a woman doesn’t really know what’s going on, but just that she needs help.”
Menopause vs. Perimenopause
Menopause is when the ovaries stop producing eggs and your menstrual periods stop forever. The average age of menopause in the U.S. is 51–52. Menopause is confirmed only after a woman goes 12 months without a menstrual period.
“Menopause is actually a retrospective diagnosis; it is a moment in time. It is the final menstrual period that a woman will have. But you don’t know that until 12 consecutive months have gone by to say, ‘hey, that was it,’” Dr. Mandeville explained.
Once you hit menopause, you will be in menopause the rest of your life, though symptoms may gradually decrease.
Perimenopause can begin in your early 40s or even earlier and last four to 10 years. The average time is four years.
However, before that happens, a woman goes through “perimenopause.” This is when women may experience a variety of new, bothersome symptoms, as the ovaries begin to slow down production. Perimenopause can begin in your early 40s or even earlier and last four to 10 years. The average time is four years.
“‘Peri’ means ‘around’ the final menstrual period, by definition,” said menopause expert Pauline Maki, PhD. “So, perimenopause includes the first year after the final menstrual period—that time of uncertainty, during which hormones are recalibrating.”
Dr. Maki is a professor of psychiatry, psychology, and obstetrics and gynecology at the University of Illinois College of Medicine, where she is also director of the Women’s Mental Health Research Program and senior director of research in the Center for Research on Women and Gender.
There is not a specific clinical test to determine when a person has reached perimenopause. The determination is based on their symptoms. While blood tests can check your hormone levels, they aren’t usually necessary or that accurate. Because hormones such as estrogen can fluctuate greatly during perimenopause, a blood test is only measuring hormone levels on that particular day. Blood tests might be done to rule out other health conditions or to identify suspected menopause for women who did not have regular periods before menopause.
Perimenopause Symptoms
Hot flashes and night sweats are probably the most known of perimenopause symptoms—and the most common. More than 80% of women experience hot flashes, which can start in perimenopause and continue a few years into the menopause stage. Known as “vasomotor symptoms,” these sudden changes in body temperature are caused by fluctuating hormone levels, especially estrogen. The hormone changes affect how the body regulates temperature.
Beyond hot flashes, perimenopause can contribute to a wide variety of symptoms that women—and their doctors—may not attribute to this transition. Some women sail through menopause with little to no symptoms, while others feel like their bodies have been taken over by an alien. Symptoms can include irregular periods, abnormal bleeding, vaginal dryness, difficulty sleeping, mood swings, brain fog, dry skin or eyes, headaches, joint or muscle pain, frozen shoulder, and hair loss or thinning.
A decline in estrogen can also lead to other health issues that are important to address, Dr. Mandeville said. These include an increase in higher cholesterol and blood pressure, an increased risk of arteriosclerosis (plaque build-up in your arteries), insulin resistance and type 2 diabetes, dementia and bone loss.
“All of these things you don’t feel—they’re just happening. And a lot of those things happen at an accelerated rate in the first few years after you’ve gone into menopause, after your ovaries have stopped working,” Dr. Mandeville explained.
Sleep disruption can be one of the most common and debilitating menopause symptoms, Dr. Maki said. About 40% to 69% of midlife women experience sleep disruption. With menopause, this is typically a type of sleeplessness called “wakefulness after sleep onset,” or WASO. That’s when you want to be sleeping, but you wake up in the middle of the night and can’t fall back asleep.
Mood, menopause and sleep are often interconnected. Anyone who has trouble getting a good night’s sleep knows how it can affect mood. It can also wreak havoc on your ability to focus, stay alert and think. A 2021 study showed that women in perimenopause with more sleep disturbances had more trouble in verbal learning and memory than perimenopausal women who slept better.
Cognitive changes—changes in the brain’s ability to think, remember, concentrate, problem-solve and make decisions—in perimenopause are not solely because of poor sleep, though. Although estrogen is a sex hormone, estrogen is found throughout the body, including in the brain. Studies have shown that a decline in estradiol—the specific type of estrogen the body makes during a person’s reproductive years—may be linked to declines in verbal learning and memory that can be reversed with estrogen treatment. These cognitive challenges are often called “brain fog.” (Learn more about brain fog symptoms.)
Lack of Menopause Training—and Confusion
Not every female will become pregnant, but every female with ovaries will eventually reach menopause, if they live long enough. Despite that, there is very little training or research about this transition, even in obstetrics and gynecology. A 2023 survey in the journal Menopause surveyed ob-gyn residency program directors (who oversee the education of new doctors) about these issues. While 93% strongly agreed that ob-gyn residents in the U.S. should have access to a standardized menopause curriculum, only 31% reported actually having that curriculum. Only 29% of the programs reported that these new ob-gyns had dedicated time assigned to a menopause clinic (where they would see actual patients).
Furthermore, a 2019 survey in the journal Mayo Clinical Proceedings showed that only 6.8% of family medicine, internal medicine, and obstetrics and gynecology residents (doctors in training) said they were adequately prepared to manage menopause in female patients.
One of the reasons health care professionals know little about menopause is the damage done by the Women’s Health Initiative (WHI) study over 20 years ago. Launched in 1991, WHI was intended to improve research into women’s health care. One part of the study focused on menopause. At the time, it was routinely thought that given menopausal women estrogen via hormone therapy (HT)—sometimes called “hormone replacement therapy”—could reduce their risk of heart disease and bone fractures from osteoporosis.
But in 2002, one component of the HT part of the study (women taking estrogen and progesterone) was stopped early because it seemed to show an increased risk of breast cancer, coronary heart disease, stroke and blood clots. Another part of the study in which women took only estrogen was also stopped early, after it appeared that estrogen wasn’t helping heart disease risk but increased the risk of stroke. Because of this, the study authors recommended that HT not be used to prevent heart disease in postmenopausal women.
The outcry was loud and swift. Doctors stopped prescribing HT altogether and women became scared, particularly about the risk of breast cancer. However, the WHI findings were confusing: The study was focused on preventing heart disease in women who were several years into menopause—not treating symptoms in younger, perimenopausal women.
“In women who are less than 60 years old or within 10 years of their last menstrual cycle, hormone therapy is more beneficial than it is risky in most candidates.”
Over the past two decades, menopause experts have tried to explain how deeply flawed the messaging and reaction to the studies were—some have declared the study itself flawed. But the damage was done, as an entire generation of women could not access HT for their perimenopausal and menopausal symptoms.
“We have walked those [WHI menopause] studies back,” Dr. Mandeville said. “What we have found is that in women who are less than 60 years old or within 10 years of their last menstrual cycle, hormone therapy is more beneficial than it is risky in most candidates.”
The risks of heart attack, stroke, blood clots and breast cancer with HT is very, very small, Dr. Mandeville said. The women in the WHI studies were much older than the age of perimenopausal and early menopausal women, which skewed the results.
HT is now approved and regulated by the U.S. Food and Drug Administration (FDA) to treat menopause symptoms. Guidelines from the American College of Obstetricians and Gynecologists and other leading medical societies recommend HT for the management of menopausal symptoms.
Avoid Compounded Bioidenticals
Surrounding the confusion over HT, there has been a lot of marketing—and promotions by celebrities and influencers—around so-called “bioidentical hormones,” sometimes called “organic” or “natural” hormones. These bioidenticals are made in labs, and the “natural” ingredients are no longer in their natural form after they are processed. They are often compounded, or mixed, by compounding pharmacists.
Compounded bioidenticals are not regulated or recommended by the FDA, and most menopause experts warn against taking them. “It’s critically important to avoid bioidentical hormone therapy,” Dr. Maki said. “Compounded bioidentical hormone therapy is not safe.”
Dr. Mandeville explained: “You might not know the purity of the medicine, the safety of it, the efficacy of it. So, you’re at the behest of the compounder to hope that they’re doing everything in a standardized fashion.”
Hormone Therapy Is Safe for Most Women
Lifestyle changes can sometimes help reduce menopause symptoms—and are important for overall health too. These include eating a healthy diet, managing weight, not smoking, and getting regular physical activity. But despite living a healthy lifestyle, some women still suffer from a variety of disruptive daily symptoms.
Today, HT is considered safe and effective to treat hot flashes, night sweats and other symptoms in most women. In addition, if started within 10 years of the final menstrual period or before age 60, HT can improve all those other “symptoms” you don’t feel or see that Dr. Mandeville mentioned. “Hormone therapy can keep your bones strong and decrease risks such as cardiovascular disease, type 2 diabetes and dementia,” she said.
“We need to talk more and more about why, in a non-stigma way, and let women know that there are safe and effective treatment options for them as they navigate this midlife transition.”
Women with a uterus should take both estrogen and progesterone; the progesterone prevents the uterus from thickening, decreasing the risk of endometrial cancer. Women without a uterus can take estrogen alone.
There is a small increased risk of blood clots if you take estrogen pills. Instead, consider taking estrogen as a patch, cream or gel.
You may be able to continue HT safely for several years, which is good news for women who continue to experience bothersome menopause-related symptoms long-term. Studies have shown that up to 40% of women in their 60s and 10–15% in their 70s continue to have hot flashes. Women older than 65 can continue HT with appropriate counseling and risk assessment, advises The Menopause Society (formerly the North American Menopause Society, or NAMS), a leading nonprofit dedicated to understanding menopause and educating health care practitioners. A 2024 retrospective study showed that it was not unusual for women to continue to benefit from HT up to age 80.
Women with menopause symptoms who are feeling dismissed or ignored by their doctors—or told to try unregulated bioidenticals first—can seek out other doctors who are menopause experts. The Menopause Society certifies health care professionals who have demonstrated a higher level of expertise in menopause. These practitioners earn the credential Menopause Society Certified Practitioner (MSCP). Women can visit the society’s website for advice on finding a clinician and to search its database for credentialed menopause professionals in their area.
“Menopause is a natural transition. It is not a disease,” Dr. Mandeville said.
However, it’s clear that many women experience a variety of bothersome symptoms that impact their daily quality of life and well-being as their body transitions into this phase.
“Women are not feeling well, and they don’t know why,” Dr. Mandeville said. “We need to talk more and more about why, in a non-stigma way, and let women know that there are safe and effective treatment options for them as they navigate this midlife transition.”
