One of the cruel ironies of middle age is that, as our kids need us less and our parents need us more, our own bodies begin to revolt. This isn’t the menopause of hot flashes, sitcom moms, and what your Nana might have called “the change.” It’s something subtler but equally acute: perimenopause. Have a strange zit, crime scene periods, or persistently free-floating rage? I’m talking to you.
If you identify as a woman over 35 or so, you’ve probably felt it. You eat a cheeseburger and regret it. You wake up at 4 a.m. for no apparent reason. You’re irritable. Your skin looks like a Hot Pocket. Your cramps make you weep. Because this constellation of symptoms is ill-defined and could apply to any number of woes, from stress to fibroids, we just accept it.
High school friends and I actually have a thread named “perimenopause hell” where we swap complaints: bad cramps, bad skin, bad moods. Another friend vented about bloating woes over dinner last week. Three more of us looked up knowingly. It wasn’t the foie gras. “Perimenopause,” we said in unison.
Menopause is the natural cessation of ovarian function and menstruation; it usually happens around 51. Perimenopause is more amorphous. It happens in the years leading up to this transition, as estrogen begins to decrease, roughly around age 47. And while menopause begins once you’ve gone 12 months without a period, perimenopause is less concrete.
It is beginning to have a moment, though. On TikTok, for example, the hashtag #perimenopause has 461.4 million views. But a hashtag on a social media platform that also teaches teens how to make origami pancakes does not a medical movement make.
As such, I spoke to Dr. Tara Iyer, physician with Brigham and Women’s Menopause and Midlife Clinic, for actual answers. Here’s what to know.
Why is perimenopause still a mystery for many women?
Honestly, because I think that there are a lot of providers who probably aren’t that comfortable with the space, in particular. Previously, it hasn’t really been associated with terrible health outcomes — terrible being relative, because certainly a lot of women would call their symptoms terrible. But it’s not on par with some of the things that doctors classically think about: really severe cancer, cardiovascular disease, heart attacks.
More recently, the American Heart Association came out with a scientific statement saying that menopause itself is a risk factor for cardiovascular disease. We’ve had data for several years saying that there are big metabolic consequences that start in perimenopause. The most significant progression is in perimenopause. That’s really the time we need to start talking to our patients more about preventive care. Now, it’s really being more adopted as general knowledge, but it takes time for that to trickle to your general practitioner.
What’s going on in our bodies during perimenopause, and what are the potential health consequences?
During perimenopause, you start to have less frequent ovulation. Over time, your ovarian function slowly declines, and there’s a steep decline during perimenopause. That’s why you might end up skipping periods. You might ovulate or you might not. You certainly have big hormonal fluctuations during this time.
There are times where estrogen is through the roof, so you might get periods more frequently. You might have more bleeding or more significant PMS-type symptoms than before, then go a month with no bleeding. You might get what we classically associate with menopause: hot flashes and night sweats. Your sleep might start to be disturbed. You might have vaginal dryness, changes in libido, changes in mood — and it goes on like that until your last menstrual period. Over time, estrogen is waxing and waning, until you get to the point where it’s just low lows.
Estrogen has profound effects on the body. It affects almost every organ system. Estrogen loss leads to a lot of different symptoms. There are at least 40 symptoms that I would associate with menopause. It really is more than just hot flashes and night sweats. It’s more than just vaginal dryness, it’s more than just sleep disturbance.
There are things that you can’t see. If you go through menopause before 45, it’s associated with an increased risk of cardiovascular disease and osteoporosis. In many women, depending on the cause of early menopause, there’s an increased risk of dementia at the same time. We’re learning more about that now.
People tend to have worsening lipid profiles, increased total cholesterol, increased LDL cholesterol, increased total adipose tissue [body fat], and changes to body composition; a 4.5-pound gain on average for most women. You also tend to have more weight around the midsection. There’s also a worsening or increased prevalence of metabolic syndrome during perimenopause.
That sounds scary. What is it?
Metabolic syndrome has multiple components, but it really encompasses factors that are reflective of a woman’s overall metabolic health: waist circumference, triglyceride levels, HDL cholesterol, blood pressure, and fasting glucose.
Should we be on certain drugs? Is there a diet to mitigate the effects?
One of the most important things is optimizing your metabolic health at this age, or ideally prior: things like making sure you’re getting enough physical activity, hitting your steps each day. For cardiovascular health, the recommendation is at least 150 minutes of moderate exercise a week, and adding in some strength training is helpful. In terms of diet, make sure you’re eating whole unprocessed foods and prioritizing getting enough protein so that you have the building blocks to keep the muscle you do have and maintaining your lean muscle mass.
Let’s go through what’s normal and what’s not. My friends and I compare symptoms, and it’s easy to throw everything under this perimenopause umbrella. So: digestion.
There are so many things that can impact digestion. Certainly, we can see changes that are hormonally related. Many women, during their period, might have diarrhea or food cravings. With hormones fluctuating, you may have more severe symptoms during perimenopause, especially at the beginning of perimenopause. As you lose estrogen, gut motility does decrease. There’s a little bit of evidence that potentially you might have more constipation as you lose estrogen.
Brain fog: middle age or perimenopause?
I hear about brain fog regularly in my practice multiple times a day, every single day. It absolutely is a symptom of perimenopause. Not even just brain fog, but a lot of executive function issues, such as word-finding issues, for example.
We certainly don’t have an exact biochemical reason for what causes brain fog in some people but not others. We do know that estrogen has myriad effects on the brain. And there’s more and more research at this point looking into estrogen and its effects on cognition and its impact on dementia and dementia risk down the line.
Last one — and this is something that’s important for women to understand. We’re at an age where periods start to change. But we also hear that these symptoms could be things like ovarian cancer. How do we know if symptoms aren’t a normal part of aging?
That would need to be evaluated per individual. Bring it up with your gynecologist at your regular preventive care visits. Most people as they go through perimenopause will tend to experience more frequent periods and a shorter duration, and then start skipping periods until they have their last period.
If you’re having really heavy bleeding, it might be indicative of other things. You could have fibroids that those high levels of estrogen are spiking and stimulating, or an endometrial polyp that needs evaluation and removal. You could have an over-proliferation or growth of the lining of the uterus that needs a biopsy to make sure that it’s not anything abnormal. There are a lot of things that might be occurring, and some of it may be very consistent with perimenopause.
Is there anything that would prompt an immediate call? What’s abnormal?
Really severe, heavy bleeding. It’s more about quantity than anything else. This might be a little graphic for the column, but if you’re soaking through a pad or a tampon or having to change it more frequently than every one to two hours. Are you having big, huge blood clots? Are you feeling faint, dizzy, or having chest pain because you’ve lost too much blood?
I know some women get hormone therapy, but you also hear about cardiac risks. Talk to me about that.
In young women — and most perimenopausal women would be quite young — and women [under the age of 60 and/or within 10 years of menopause], benefits far outweigh the risks, especially in terms of cardiovascular health.
We know the risks go up for cardiovascular health during perimenopause and certainly at menopause. Menopause is a risk factor for cardiovascular health. Women who take hormone therapy in several studies tend to have a lower cardiovascular disease risk and lower cardiovascular disease mortality. There are actually cardiovascular benefits from taking hormone therapy.
The risks that people associate with it are typically blood clot and stroke. Those risks are rare and are slightly higher in oral medication. There have been several studies to show that transdermal medications do not carry those risks. That’s not every single study, but the vast majority of evidence points to transdermal being much safer.
Before I let you go: What do you wish more women knew about perimenopause?
You don’t have to suffer through it. Many women come into my office potentially after being told by other providers or having conversations with their friends thinking this is normal, and everyone goes through it — that this is their lot in life to suffer as a woman. You don’t have to suffer. You should see a specialist.
There’s a lot more information on social media now. Women are so desperate. Sometimes their symptoms are so severe that they will take whatever they can get. Make sure that you get your information from a health care provider who is using evidence-based medicine, because there’s absolutely a lot of non-evidence-based medicine out there.
Are there any online resources you do trust?
The expert organization governing menopause, generally speaking, is the North American Menopause Society. It’s a good way to find a provider, and the website also has a lot of resources. Resources through that organization are evidence-based.
Interview has been edited and condensed.