Perimenopause: Changes and Symptoms to Expect

You recently blew out candles to celebrate your 45th birthday, and now you’re dealing with hot flashes, irregular periods and vaginal dryness. Welcome to perimenopause, the time in your life—usually in your 40s—when hormones shift as you approach menopause.

“We define menopause clinically by the fact that a person has stopped menstruating for at least one year,” says UNC Medical Center OB-GYN Rachel Urrutia, MD. “Perimenopause is the time leading up to that, and it’s characterized by hormone levels that are starting to change.”

Perimenopause can last 10 to 12 years, but the worst symptoms are usually in the five years leading up to menopause. Menopause happens when the ovaries no longer have eggs to expel and so ovulation stops. Because ovulation stops, the production of estrogen and progesterone is greatly decreased.

Symptoms of Perimenopause

So what type of changes can you expect?

Dr. Urrutia says the first symptom you may notice, which can occur more than a decade before menopause, is that your cycles get shorter. This means the time between periods is shorter.

“When women are about 43 years old, on average, their cycles will be the shortest length of their life,” Dr. Urrutia says. “When women are closer to menopause, their cycles will commonly become longer and more irregular.”

As you get within five years of menopause, you may begin to have symptoms of estrogen deficiency, such as hot flashes and night sweats.

These symptoms may be more noticeable at different times in your menstrual cycle, typically worsening at the end of your cycle and the beginning of your period, when estrogen levels are already low; they become lower as you move toward menopause, Dr. Urrutia says.

Some women also say they notice a change in mental clarity.

“Some women have changes in their mood around menopause, but others don’t, so it’s not an across-the-board thing,” Dr. Urrutia says.

Another issue women in their 40s may experience related to a change in hormones is that their metabolism shifts.

“A lot of women will notice a small weight gain in their early 40s, like 5 to 10 pounds,” Dr. Urrutia says.

Vaginal dryness is another symptom of perimenopause, and it can get worse over time.

So what can you do to relieve symptoms of perimenopause?

Keep Your Body and Mind Healthy

Maintaining a healthy weight helps mitigate symptoms of perimenopause, as women who are overweight and obese often have worse symptoms.

Dr. Urrutia says cognitive behavioral therapy can help alleviate symptoms. Cognitive behavioral therapy emphasizes the important role of thinking in how you feel and what you do. In other words, the way you perceive a situation is more closely connected to your reaction to it than to the situation itself.

However, Dr. Urrutia says that if you have a mental health disorder, it’s important to get treatment because hormonal changes may worsen symptoms of anxiety and depression.

“Make sure you take care of yourself from a mental health perspective,” she says.

Dr. Urrutia also encourages women to remember that perimenopause is natural, even if it’s not pleasant. She points out the positive outcomes of nearing the end of menstruation.

If you are a parent, you may be adjusting to new routines at home. “The kids are growing up, and maybe you start to have a little more time to yourself, so that is something positive you can focus on,” Dr. Urrutia says.

Consider Hormone Replacement Therapy

Medication can help if your symptoms become overwhelming.

“There are medications for hot flashes and estrogen replacement, but they have side effects, so it’s important you talk to your doctor to see if they are right for you,” Dr. Urrutia says. “The side effects will depend on the type of hormone you take.”

If you still have your uterus, you will take some form of progesterone and an estrogen replacement, because estrogen alone can increase the risk of cancer in the uterus. If you’ve had a hysterectomy, you’ll take only estrogen.

“Estrogen alone can cause an increased risk of blood clots, and the combination of estrogen and progesterone can cause a small increased risk of heart attacks and strokes, especially in women who are at high risk for those conditions,” Dr. Urrutia says, “so that’s a conversation to have with a physician.”

In addition, your risk of breast cancer increases if you take estrogen and progesterone for more than five years. Dr. Urrutia usually recommends using hormone therapy as a temporary “quality-of-life improvement” and trying to wean off the medication after four or five years.

If you do not want to or cannot take hormonal medication to alleviate symptoms, your doctor can prescribe medication that helps with night sweats and hot flashes but does not contain hormones.

“The best thing to do is have a conversation with your provider about your symptoms and your quality of life and the risks and benefits trade-off for taking your medication,” Dr. Urrutia says.

Use Caution with Herbal Supplements

Dr. Urrutia cautions patients about using herbal supplements to treat symptoms.

“Herbal supplements like black cohosh and evening primrose have been studied in menopausal women, and none have shown a benefit for hormonal symptoms,” Dr. Urrutia says. “In addition, many herbal supplements actually have plant-type estrogens in them, which can have medicinal effects. With herbals, we know even less about whether they can be harmful in the long term.”

Sex and Perimenopause

While topical treatments, such as long-lasting lubricants and topical estrogen, can help with vaginal dryness, having regular sex reduces the risk of developing vaginal dryness and pain during intercourse.

“So if women continue to have intercourse, it will actually be more comfortable,” Dr. Urrutia says. “Women who continue to have intercourse into menopause actually, on average, are more satisfied with their sexual function than younger women having intercourse.”

It is important to note that you can still get pregnant during perimenopause, so be sure to use contraception if you want to prevent pregnancy.

If you find sex painful, talk to your provider.

If you’re concerned about perimenopause or menopause, talk to your doctor. If you don’t have one, find a doctor near you.