There is a special anxiety that comes with changes to your period in your mid-forties. Every deviation from your usual pattern can feel like a sign of the menopause transition, also known as perimenopause. Many women spend months or years wondering if they have started this phase.
Unfortunately, early perimenopause is marked by uncertainty. The transition occurs in fits and starts, not all at once. In contrast, menopause itself is just a single moment: the point 12 months after a person's last period. It is only diagnosed retrospectively, well after the ovaries have stopped producing estrogen, the hormone that drives the menstrual cycle.
Knowing whether you have entered perimenopause can be very helpful. If symptoms are disrupting work or relationships, a diagnosis opens the door to treatment. Here is what you need to know.
What Does Perimenopause Look Like?
On average, perimenopause begins around age 47. A changing menstrual cycle usually signals its arrival. According to Nanette Santoro, a professor of obstetrics and gynecology at the University of Colorado Anschutz School of Medicine, the biggest change women notice is skipping a cycle.
The first symptoms start an average of four years before the last period, but this varies greatly. Periods may begin changing months or even a decade before menopause. During early perimenopause, periods become irregular, often occurring late or early by at least a week. Flow may be lighter or heavier, and about 40% of women experience hot flashes.
Later in perimenopause, periods become even less frequent, sometimes as much as two months apart. Hot flashes peak at this stage, affecting about 80% of women. Additional symptoms often include depression, sleep disturbances, and genital and bladder issues like vaginal dryness, vulvar burning, or itching.
The root cause of these symptoms is declining estrogen levels. After decades of releasing estrogen on a regular schedule, the ovaries begin to slow down in midlife. This leads to less estrogen in the body at less predictable intervals. Lower estrogen reduces menstrual flow because it helps grow the uterine lining. Estrogen also regulates the nervous system parts that control temperature and sleep, so dwindling levels cause hot flashes and sleep problems. It also maintains elasticity and blood flow in the genitals, leading to reduced lubrication and sensation.
If your periods have stopped due to hysterectomy, chemotherapy, use of a hormonal IUD, or other conditions, you may not notice flow changes. However, other symptoms will still be apparent. In such cases, a blood test can be useful.
How Do I Know If I'm in Perimenopause?
If your symptoms are typical and you are over 45, a clinician can usually diagnose perimenopause without tests. Santoro explains, 'If you're 49 and telling me you have hot flashes or certain changes, I don't need a blood test to tell you this is perimenopause.'
Estrogen tests exist, but they are not very informative because estrogen levels fluctuate wildly during perimenopause. A normal result might catch an upswing, while a low level could be normal at other times. Lauren Streicher, a professor of obstetrics and gynecology at Northwestern University, says these tests are accurate but not useful for diagnosis.
Blood tests can help if symptoms are atypical or occur earlier than expected. Thyroid problems and diabetes can also start in midlife and cause cycle irregularity, hot flashes, and mood swings. For confusing scenarios, such as having an IUD with ambiguous symptoms, a test for anti-Mullerian hormone can estimate egg count and help determine proximity to menopause, but it is not useful for all ages.
Several companies sell at-home hormone test kits, but both Streicher and Santoro agree they are not reliable enough to be useful.
I Think I'm in Perimenopause – Do I Need to Do Anything?
If you have core menopause symptoms, see a menopause specialist about treatment. Hormonal and non-hormonal therapies are available but underprescribed. An OB-GYN with menopause expertise or a primary care clinician trained in treating menopause symptoms can help determine the best approach.
Lifestyle basics become especially important in midlife. Santoro recommends getting good sleep, quitting smoking, exercising regularly, and eating healthy, high-fiber foods. Additionally, get checked for common midlife conditions like high cholesterol, high blood pressure, and diabetes. As Santoro notes, 'If you have hypertension in your family and inherited those genes, they are coming after you at this time of life.'
