Perimenopause: What it is, symptoms, causes, and treatments

As you enter your 40s, it’s common to wonder about the changes your body may start going through. The first major hormonal shift many women experience is called perimenopause. This natural stage begins when your levels of estrogen and progesterone start to fluctuate. Perimenopause is often accompanied by symptoms that are completely normal, but sometimes confusing or disruptive to your everyday life. 

Understanding what perimenopause is, how it shows up, and what you can do about it can help you feel more in control of your health and better prepared for what comes next.

What is perimenopause?

Perimenopause is the transition from your reproductive years into menopause. It typically begins within 10 years of menopause and marks the point when your ovaries gradually stop producing the high levels of estrogen that regulate the menstrual cycle. This causes irregular periods and a host of other symptoms. You’re officially in menopause once you’ve gone 12 consecutive months without a period.

“Every decade brings about some emotional and physical change, but for women, your 40s may pack one of the biggest punches of all,” observes Dr. Sheryl Ross (Dr. Sherry), Chief Medical Officer of Women’s Health for QuickMD. 

According to Dr. Sherry, “The average age for menopause is 51, which means your 40s are prime time for perimenopause to begin. Between the typical 40-something anxieties of shifting relationships (divorce and dealings with hormonal or college-bound teens), self-esteem issues, job challenges and other midlife stresses, your 40s can be challenging enough without the hormonal upheaval. It’s not just life’s stresses that are affecting you emotionally and physically; it’s the beginning of “the change” and it’s called perimenopause.”

Some women barely notice the shift. Others wake up drenched in night sweats or struggle to enjoy intercourse because of vaginal dryness. Although all of these symptoms are a normal part of the process, that doesn’t make them any less frustrating. Fortunately, you’re not alone, and you also have a number of options to help ease the transition from perimenopause into menopause and beyond. 

Who is most likely to experience perimenopause?

As long as you have ovaries, you are fair game for premenopausal symptoms. However,  the age when this transition begins can be much earlier for some women as a result of a few factors, including:

• Cancer treatments: Women who have breast cancer and are receiving chemotherapy may experience perimenopause symptoms earlier than the average woman. Chemotherapy and radiation, especially when focused near the pelvic area, can damage the ovaries and prompt an earlier onset of perimenopause. 
• Smoking: Smoking has been shown to reduce estrogen levels and may cause women to experience perimenopause 1–2 years earlier than average. 
• Being underweight: Women with very low body fat may produce less estrogen, which can disrupt menstrual cycles and mimic early perimenopause. Fat tissue contributes to estrogen production.
• Certain medications: Medications that block estrogen (like tamoxifen, used in breast cancer treatment) can bring on perimenopause symptoms, as can other chemotherapies. 
• Turner syndrome: This genetic condition causes women to be born with underdeveloped ovaries, leading to lower estrogen levels earlier in life. 

When does perimenopause start?

On average, perimenopause begins 8 to 10 years before menopause. Although there is no set answer because every woman’s body and history are unique, most women feel the first stirrings of perimenopause in their mid-40s. However, the transition can start anywhere from your late 30s to early 50s. 

A common point of confusion is whether perimenopause, premature, and early menopause are the same thing. They’re not. Premature menopause occurs when a woman begins having symptoms of perimenopause before the age of 40. It can be the result of primary ovarian insufficiency (POI), a condition that still allows for occasional ovulation and even pregnancy, but with reduced fertility.

Early menopause refers to symptoms that begin before the age of 45, with some women experiencing this change as early as their 30s. Some women choose to get treatment for early menopause to stave off more serious health issues like osteoporosis.

If your symptoms start after 45, it’s perimenopause. Whether you’ll need treatment will depend on the severity of what you experience.

How long does perimenopause last?

Perimenopause can last anywhere from four to eight years, depending on your unique body chemistry. Some women breeze through it in a matter of months, while others experience gradual changes for nearly a decade.

Factors like genetics, lifestyle, medical conditions, and whether you smoke can influence how long the transition lasts.

Causes of perimenopause

The causes of perimenopause center around hormonal changes. Your ovaries make most of the estrogen in your body, so when they struggle to produce the amount that you’re used to, hormone levels begin to fluctuate. This includes both estrogen and progesterone.

But what triggers the ovaries to make less estrogen? There are a few factors that play a role in perimenopause: 

• Aging: This is the most common and natural cause.
• Cancer Treatments: Chemotherapy and radiation can damage ovarian follicles.
• Surgery: Oophorectomy (removal of ovaries) or hysterectomy (removal of uterus) can affect hormone production.
• Smoking: Chemicals in cigarettes damage the ovaries and reduce blood flow to the reproductive organs, which speeds up estrogen loss.

What are the risk factors that increase the likelihood of perimenopause?

Perimenopause is a process that all women go through. However, if you’re worried about experiencing it earlier than what’s considered “normal,” it can be helpful to understand what genetic and lifestyle factors may contribute. These don’t guarantee you’ll experience early or more severe perimenopause, but they do raise the odds:

• Family History: If your mother or sister went through early menopause, you might, too.
• Smoking: Tobacco use affects blood flow to the ovaries. If you smoke, it can damage ovarian follicles and speed up loss. 
• Cancer Treatments: Chemotherapy and radiation therapies can increase the risk of earlier perimenopause.
• Hysterectomy: A hysterectomy involves removing your uterus, but keeps your ovaries intact so that they still produce estrogen. However, this surgery can affect hormone production and trigger earlier perimenopause.
• Oophorectomy: An oophorectomy is a surgery that removes one or both of your ovaries. This directly reduces your estrogen output and typically triggers immediate perimenopause or menopause. 

Symptoms of perimenopause

The hallmark of perimenopause is hormonal fluctuation, which can affect everything from your menstrual cycle to your mental health. Being able to spot the signs of perimenopause as early as possible allows you to begin managing them so that they don’t feel as overwhelming. Some of the most common symptoms of perimenopause you can experience include:

• Hot flashes
• Night sweats
• Irregular periods
• Insomia
• Depression
• Anxiety
• Weight gain or loss
• Bloating
• Poor concentration
• Memory loss
• Heart palpitations
• Vaginal dryness
• Vertigo or dizziness
  

Less common symptoms of perimenopause are:

• Joint pain
• Frozen shoulder
• Ringing in the ears
• Itchy and sensitive skin
• Gum disease
• Electric shock sensations
• Acne
• Burning mouth syndrome
• Nipple discharge
• Urinary tract infections
  

Your estrogen levels aren’t just related to reproductive health. They also help regulate serotonin and other brain chemicals that affect sleep, mood, and stress. When your levels fluctuate or drop unpredictably, you may experience:

• Mood swings
• Increased sensitivity to stress
• Panic attacks
• Irritability
• Reduced desire to interact socially
• Feeling “off” and not like your usual self
  

These symptoms may be made worse by life changes that often coincide with perimenopause, such as caregiving responsibilities, career changes, or personal transitions.

When to seek help

Perimenopause symptoms are a normal part of life, but that doesn’t mean you have to “just deal with” them. If your symptoms are interfering with your daily life, sleep, relationships, or emotional well-being, it might be a good time to reach out for help. 

Stages of perimenopause

There are two main stages of perimenopause: early and late. 

• Early perimenopause typically involves wildly fluctuating hormone levels that lead to irregular periods. You may experience heavier or lighter menstruation, and the cycle can become much shorter or longer than you’re used to. Early perimenopause can last for a few years. 
• Late perimenopause is the final transition before full menopause. You can expect less frequent ovulation and going months without a period before getting it again. Sleep disturbances and hot flashes are more likely during this stage. 
  

Understanding which stage you’re in can help you and your provider anticipate what’s ahead and better plan for symptom management.

Perimenopause diagnosis

You may not need a formal diagnosis to confirm perimenopause. Many providers rely on symptoms and medical history. However, if you’re unsure or want to rule out other conditions, a provider may recommend:

• Blood tests to check estrogen and progesterone levels. However, these levels can fluctuate from day to day. 
• Follicle-Stimulating Hormone (FSH) testing: FSH is a hormone that your pituitary gland (at the base of your brain) makes. This hormone prompts ovulation, and if you have higher levels of it, it can mean your ovaries are slowing down and you’re close to menopause.
• Imaging studies to rule out structural conditions if symptoms like pelvic pain are present.
  

It’s important to note that hormone testing is most helpful in younger women with suspected premature menopause or POI. For women over 45, reporting your symptoms to your provider may be enough to give you a confirmed perimenopause diagnosis. 

Perimenopause treatment

Perimenopause is a normal part of life and aging. As frustrating as the process can be, there’s no “pause” button available. However, there are ways to help manage your symptoms. 

It all depends on your symptoms, medical history, and personal preferences. Just as some women experience more severe premenstrual syndrome symptoms, some can also have more disruptive perimenopause symptoms.

Perimenopause medical treatment options include: 

• Menopause hormone therapy (MHT): MHT restores declining estrogen (and sometimes progesterone). It can improve hot flashes, vaginal dryness, sleep, and bone health. It’s best when started early in the transition. Depending on your personal medical history, family medical history, and what you feel comfortable with, the benefits may outweigh any risks. Having an honest conversation with your provider can help you better understand what option is best for you.
• Antidepressants (SSRIs/SNRIs): Certain antidepressants, including selective serotonin reuptake inhibitors (SSRIs), are effective at managing hot flashes, night sweats, and mood swings. 
• Birth control pills: Oral and injectable contraceptives can regulate periods, reduce hot flashes, and help prevent an unplanned pregnancy if you’re still ovulating.
• Gabapentin: Originally for seizures, this medication can reduce hot flashes and night sweats.
• Fezolinetant (Veozah): A non-hormonal treatment that targets the brain’s temperature regulation center, Veozah can be an option for women who can’t or don’t want to take hormones.
• Oxybutynin: This is a medication usually used to treat overactive bladder issues, but it can also assist in managing hot flashes. 
• Vaginal estrogen creams: If you experience vaginal dryness that prevents you from enjoying sex or makes it painful, your provider can offer vaginal creams that enhance lubrication. 
• Cognitive behavioral therapy (CBT): Speaking with a licensed therapist can help reframe negative thoughts around symptoms and provide tools to cope emotionally.
• Supplements: Natural remedies like lemon balm and black cohosh may help ease perimenopause symptoms, but should be discussed with a provider to avoid interactions with any other medications you take. 

At-home treatments and lifestyle changes

Sometimes, the symptoms of perimenopause can feel overwhelming. But small changes can make a big difference. Here are a few helpful tips to help you manage your perimenopause symptoms and take back control during this period. 

• Take stock of your nutrition: “A diet focused on fresh fruits, vegetables, whole grains and fish, with limited alcohol intake and little red meat (similar to the Mediterranean diet) not only benefits your heart, it improves cognitive function,” recommends Dr. Sherry. “The Mediterranean diet is associated with the highest life expectancy and lowest heart disease rate and is proven to help menopausal symptoms.” Some foods, like soy beans and chickpeas, contain compounds that mimic estrogen. Adding these to your diet can be helpful.
• Reduce alcohol intake: Alcohol causes your blood vessels to widen, which can trigger hot flashes. Limit your drinking to reduce hot flashes and improve sleep. 

• Staying Hydrated: Hot flashes and night sweats can drain you of the fluids you need, which can worsen symptoms and even cause you to feel nauseous. 
• Exercising: Weight gain is an issue that bothers many women when they enter perimenopause, but you can help offset that with exercise. Exercise improves metabolism, breathing, energy, and emotional stability. Better yet, Dr. Sherry offers that, “it makes you feel more confident and helps ease the stress of perimenopause symptoms.” Aim for 30 minutes of exercise, three to five times per week. Exercises can include strength training with weights or bodyweight exercises like yoga and pilates. This can help support bone health and help ward off osteoporosis. Use a fitness tracker like a Fitbit or Apple Watch to help you stay motivated. 
• Maintain a healthy weight: Symptoms can get worse if you’re significantly overweight. Finding ways of balancing your meals with your activity levels can make it a bit easier to reach a healthy-for-you weight. 
• Set good sleeping habits: One of the most frequent issues women have when they’re going through perimenopause is insomnia. To help you get a better night’s sleep, avoid screens at least one hour before bed, keep your room cool and dark, and wear breathable fabrics to sleep. 
• Use a fan: If you struggle to work or to rest because of hot flashes, keeping a fan by your desk or bed that you can point directly at yourself is a good way to manage this symptom. 
• Dress in layers: Wearing multiple layers isn’t just a fashion statement. It can also give you more options to regulate your temperature. Removing a hoodie or blazer, or layering a camisole under a blouse, can help you stay fresher and cooler. Plus, it can reduce the anxiety of worrying about visibly sweating through your shirt if you’ve had a hot flash. 
• Quit smoking: Tobacco products cause inflammation throughout your body, which only makes perimenopause symptoms more pronounced. Nicotine causes your blood vessels to narrow, contributing to more severe night sweats and hot flashes. It can also worsen mood swings. Women who quit smoking at least five years before menopause have fewer and less intense symptoms. “If you smoke, just stop,” observes Dr. Sherry. “If not for the fact that smoking increases the risk of heart disease, stroke, lung cancer, and death, but because it makes hot flashes more frequent and severe during perimenopause.”
• Seek out support and stress reduction: Although relaxation techniques won’t stop the symptoms, they can help you manage the stress that they can cause. Meditation, journaling, and mindfulness exercises are all helpful ways to help calm your mind. Cognitive behavioral therapy (CBT) can also help give you more strategic ways to sort through the jumble of feelings associated with perimenopause. Additionally, joining a support group (online or in-person) can help you to feel less alone with what you’re going through.

Is perimenopause preventable?

No, perimenopause is not preventable—it’s a normal stage in a woman’s life. However, certain lifestyle choices may delay its onset or reduce the intensity of symptoms.

One of the biggest factors that you can control is smoking. The chemicals in tobacco products hurt the follicles in your ovaries, which are what hold and develop eggs. Smoking can cause reduced ovarian function, which can easily jumpstart perimenopause.

Most of the other factors that impact your chances of experiencing early perimenopause are outside of your control. These can include family history, surgical removal of your ovaries or uterus, cancer treatments, and genetic conditions.