Perimenopause: What It Is, What It Feels Like, and How We Treat It

Many women expect menopause to begin with hot flashes and missed periods. In reality, the hormonal transition often starts years before the final menstrual period—and some of the earliest symptoms can be surprisingly subtle.

Women in their late 30s and 40s may notice changes in sleep, anxiety, mood, concentration, memory, or joint discomfort while continuing to have regular periods. Because their menstrual cycles have not obviously changed, these symptoms are often attributed to stress, aging, work, parenting, or simply “not sleeping well.”

At our Chicago primary care practice, we take a different approach. We routinely talk with women in their 40s about perimenopause, including both the obvious symptoms and the less-recognized changes that can occur during the menopausal transition.

First, What Exactly Is Menopause?

To understand perimenopause, it helps to first define menopause.

Menopause refers to a woman's final menstrual period and is confirmed after she has gone 12 consecutive months without another period, assuming there is not another explanation for the absence of menstruation.

The average age of natural menopause in the United States is around 51, but the hormonal transition begins well before that point.

What Is Perimenopause?

Perimenopause is the transition leading up to menopause and extending through the final menstrual period. It commonly begins during the 40s, although some women develop symptoms earlier.

During the reproductive years, estrogen and progesterone generally rise and fall in relatively predictable patterns throughout the menstrual cycle. During perimenopause, ovulation becomes less consistent. Progesterone levels drop, while estrogen levels can fluctuate substantially from one cycle, or even one part of a cycle to another.

It is this hormonal variability, rather than simply having a “low estrogen level,” that helps explain why perimenopause can feel so unpredictable.

And importantly, you do not need to have irregular periods to experience symptoms of perimenopause.

The Early Symptoms of Perimenopause Are Easy to Miss

For many women, the first symptoms are not dramatic hot flashes. They are much more subtle.

Women may begin noticing:

• Increased anxiety or feeling unusually overwhelmed

• Irritability or mood changes

• Brain fog or difficulty concentrating

• Problems recalling words, names, or information

• Difficulty falling asleep

• Waking during the night and having trouble falling back asleep

• Changes in energy

• Joint or muscle aches and stiffness

• Headaches or changes in migraines

• Changes in sexual desire

• Changes in menstrual flow or cycle length

As the menopausal transition progresses, symptoms may become more recognizable and can include hot flashes, night sweats, significant sleep disruption, vaginal dryness or discomfort, urinary symptoms, and more pronounced changes in mood.

One of the most important points we emphasize to our patients is that perimenopausal symptoms can occur even while menstrual cycles remain regular.

Why We Discuss Perimenopause Before Menopause

In our practice, we do not believe women should have to wait until their periods stop—or until symptoms become severe—to start discussing menopause care.

When we see women in their 40s, we routinely educate them about symptoms that may signal the beginning of the menopausal transition. For some women, symptoms begin in their late 30s or early 40s. For others, meaningful symptoms may not develop until their late 40s or beyond.

There is no single age at which every woman needs treatment.

There is also no single blood test that reliably tells us whether a woman in her 40s is experiencing perimenopause. Hormone levels can fluctuate considerably during this period, so diagnosis and treatment decisions are generally based on the overall clinical picture: age, symptoms, menstrual history, medical history, and other potential explanations for the symptoms.

How We Treat Perimenopause

Treatment should be individualized.

For women with bothersome symptoms who are appropriate candidates, menopausal hormone therapy can be an extremely effective treatment. Estrogen is the primary hormone used to treat systemic menopausal symptoms. Women who still have a uterus generally also require adequate progesterone or another progestogen to protect the uterine lining.

Depending on the patient, treatment may involve transdermal estrogen, such as an estrogen patch, together with progesterone. Other approaches may be more appropriate depending on whether contraception is still needed, the patient's bleeding pattern, medical history, personal preferences, and specific symptoms.

Hormone therapy is the most effective treatment available for menopausal hot flashes and night sweats. It can also improve associated sleep disruption and other symptoms in appropriately selected patients. Systemic estrogen also helps prevent the accelerated bone loss that occurs around menopause.

Hormone therapy is not appropriate for everyone, however. Before recommending treatment, we review the patient's medical history, cardiovascular and blood-clot risk, cancer history, abnormal bleeding, medications, and other relevant factors. Nonhormonal treatments are also available for women who cannot or prefer not to use hormone therapy.

Our philosophy is straightforward: treatment should be based on symptoms, risks, goals, and quality of life—not on waiting for a woman to reach a particular age or to go 12 months without a period.

What About Brain Fog, Anxiety, and Mood Changes?

These are some of the symptoms women find most frustrating.

Changes in concentration, memory, sleep, anxiety, and mood are common during the menopausal transition. Hormonal fluctuations may contribute directly, while hot flashes and disrupted sleep can make these symptoms substantially worse.

When these symptoms occur, we look at the entire picture rather than automatically assuming that a new psychiatric medication is the only answer.

For some women whose mood or cognitive complaints accompany other menopausal symptoms, treating the underlying menopausal symptoms can substantially improve how they feel. Other women may benefit from treatment directed specifically toward anxiety, depression, ADHD, insomnia, or another condition.

Hormone therapy should not, however, be prescribed solely for the purpose of preventing dementia. Current evidence does not establish menopausal hormone therapy as a dementia-prevention treatment.

Hormone Therapy and Long-Term Health

The decision to use hormone therapy is primarily about treating symptoms and improving quality of life, but menopause is also an important time to think about long-term health.

Estrogen therapy helps prevent bone loss while it is being used and can reduce fracture risk in appropriately selected women. This is particularly relevant because bone loss accelerates around and after menopause.

At the same time, maintaining muscle through resistance training, getting adequate protein, addressing vitamin D or calcium needs when appropriate, maintaining cardiovascular fitness, controlling blood pressure and cholesterol, avoiding smoking, and maintaining good metabolic health remain important parts of healthy aging.

We therefore think of perimenopause care as more than simply prescribing hormones. It is an opportunity to look at the woman's overall health and build a plan for the decades ahead.

What About Testosterone?

Testosterone deserves a separate discussion because it should not simply be considered another component of routine menopausal hormone therapy.

Women naturally produce testosterone and other androgens, and androgen levels change with age. However, there is considerable variation among women, and a blood testosterone level by itself does not define a universal “testosterone deficiency syndrome” in women.

The strongest evidence for testosterone therapy in women is for carefully selected women experiencing persistent, distressing low sexual desire—particularly hypoactive sexual desire disorder—after other contributing factors have been evaluated.

Testosterone is not currently considered a routine treatment for general perimenopausal symptoms such as fatigue, brain fog, weight gain, or loss of bone density. When we consider testosterone therapy, we evaluate symptoms, medications, sexual health, other possible causes, relevant laboratory testing, and the potential benefits and risks before deciding whether treatment is appropriate.

You Don't Have to Wait Until Menopause to Ask for Help

One of the biggest misconceptions about menopause care is that treatment begins after periods stop.

For many women, the years before menopause are actually when symptoms begin affecting sleep, mood, cognition, relationships, exercise, and day-to-day quality of life.

If you are in your late 30s, 40s, or early 50s and have noticed unexplained changes in sleep, anxiety, mood, concentration, menstrual cycles, hot flashes, night sweats, sexual health, or other symptoms, perimenopause may be part of the explanation.

At our Chicago primary care practice, we regularly evaluate and treat women experiencing perimenopause and menopause symptoms. Our goal is to identify symptoms early, rule out other causes when appropriate, and develop an individualized treatment plan based on your health, preferences, and goals.

If you are looking for perimenopause treatment, menopause treatment, or hormone therapy in Chicago, contact our office to schedule a complimentary consultation. We would be happy to discuss what you are experiencing, review your options, and determine how we may be able to help.