What To Expect During Perimenopause—And How To Treat Your Symptoms

When Jerilynn Prior, a professor of endocrinology and metabolism at the University of British Columbia, started to notice herself experiencing a heavy period and sore and lumpy breasts at age 48, she didn’t think much about it—until she got a night sweat. “It finally twigged that I was in perimenopause,” she says. (Yes, even someone who studies women’s hormones didn’t realize they were in perimenopause.)

From irregular cycles, unexplained weight gain and mid-sleep waking, there are many telltale signs you might be in perimenopause, the transition phase before menopause. This major hormonal shift comes with a lot of physical and emotional changes, which can range from irritating to full-on debilitating. Not sure if you’re on the rocky road to menopause? Two menopause experts break it down.

Perimenopause and menopause are not the same thing

“Menopause is a normal life phase for women that starts 12 months after your last menstrual flow,” explains Prior.

Perimenopause, on the other hand, consists of the time leading up to menopause when your hormones are in flux. “If you’re no longer ovulating in a predictable fashion, that’s perimenopause,” says Michelle Jacobson, an obstetrician, gynecologist and menopause specialist at the Women’s College Hospital and Mount Sinai Hospital in Toronto. To further complicate matters, there’s also a lot of overlap between the symptoms of perimenopause and menopause—like hot flashes, night sweats and sleep disturbances—despite being distinct hormonal phases.

“Most women will start experiencing classically perimenopausal symptoms in their 40s,” says Jacobson. Some women might even start experiencing perimenopausal symptoms—like a heavy flow and worsened PMS—10 years before their final period, which for some women means starting perimenopause in their 30s. “It’s still considered normal, albeit early, to go through menopause between 40 and 45,” Jacobson says.

Hot flashes are a classic symptom of perimenopause

An American study published in the National Library of Medicine in 2008 found that 79 percent of perimenopausal women experience hot flashes (or flushes) and night sweats, also called vasomotor symptoms. Hot flashes typically come on quickly and last anywhere from one to five minutes. Their intensity also varies. “It can go all the way from ‘I feel a little hot,’ to ‘I’m a bit sweaty,’ to a tropical rainstorm,” says Prior.

You may feel like your skin is hot, your face and neck can turn red, your heart rate might increase, you may break out into a sweat or chills or even feel anxious. Prior says moments before a hot flash you may feel dizzy, nauseated or even angry—something she experienced during perimenopause.

Related: 5 Ways To Survive Perimenopause

Prior’s research has found that night sweats tend to happen before hot flashes start. The Centre for Menstrual Cycle and Ovulation Research, created by Prior, found that, if a woman is still having regular cycles, night sweats tend to cluster around the time of her period.

According to the Society of Obstetricians and Gynaecologists of Canada (SOGC), there are certain factors that can increase the frequency of hot flashes, including smoking, obesity and consuming alcohol and/or spicy foods. Ethnicity also plays a role in your likelihood of having vasomotor symptoms, with Black women experiencing them more than white women, and Japanese and Chinese women experiencing fewer symptoms.

Common symptoms to look out for

“Perimenopause is very unpredictable,” says Jacobson. “Sometimes you’re making lots of estrogen and sometimes you’re getting long gaps with no estrogen. There’s a really big swing from low to high.”

Because of this roller coaster of hormones, there’s a wide range of symptoms that you might experience, and they can change throughout perimenopause. Aside from the hallmark symptom of hot flashes, it’s common to experience irregular cycles during perimenopause. You might notice a heavier and longer menstrual flow or shorter cycle lengths (less than 25 days). Other new or increased symptoms to look out for include menstrual cramping, premenstrual mood swings, depression, mid-sleep waking, sore or lumpy breasts, migraines, changes in libido, vaginal dryness and weight gain.

Some symptoms that are commonly described by women but are often overlooked include changes in hair or skin and memory problems. Jacobson also says worsening PMS symptoms are very common in perimenopause, but many women don’t realize it.

It’s also possible to go through perimenopause and not experience any noticeable symptoms at all, says Jacobson.

There’s no test to determine if you’re in perimenopause

Unfortunately, there isn’t a hormone test that will tell you if you’re in perimenopause. “Billions of dollars are being spent on antimullerian hormone testing, but it’s not reliable,” says Prior.

She suggests using a diary to track your symptoms, which can vary significantly from one woman to another. “Self-knowledge gives a sense of control, although symptomatic perimenopause is the ultimate in unpredictable,” she says.

Treatments are available to ease symptoms

The good news is you don’t have to suffer. The North American Menopause Society, the International Menopause Society and the SOGC have all extensively reviewed the current literature, and in May 2022, put out guidelines that recommend menopausal hormone therapy (MHT) as the first line of treatment for women suffering from vasomotor symptoms as long as they don’t have any contraindications—like coronary heart disease or breast cancer—to using hormone therapy.

The prescription you receive will depend on your preferences and is individualized to mitigate your personal risk factors, says Jacobson. Estrogen can be taken orally or through the skin (like a patch), while progestin can be taken orally, vaginally or intrauterine. Patients typically see improvements within one to three months, with their doctors reevaluating after a few months to troubleshoot, if necessary, based on side effects or ongoing symptoms.

MHT, or Hormone Replacement Therapy (HRT)—the latter of which is typically used for prematurely menopausal women—got a bad rap thanks to a 2002 study put out by the Women’s Health Initiative (WHI) that linked hormone therapy with elevated health risks including heart disease and breast cancer. The negative results received extensive media coverage, with many women choosing to forgo treatment out of fear.

Like any treatment, there are risks involved in hormone therapy, which is why you need to speak with your healthcare professional to see if it’s the right plan for you.

Related: I Have PMDD. Perimenopause Radically Improved My Life

Jacobson stresses that estrogen should never be taken alone in women who have a uterus or have not undergone a hysterectomy. “Any woman with a uterus who is going to take estrogen also needs to take some form of progestin or endometrial protective agent, to protect herself from developing complications from using only estrogen, like uterine cancer,” she says. But some women may find progesterone/progestin therapy alone helpful.

Prior’s biggest concern around MHT is that the current official clinical guidelines assume both perimenopause and menopause can both be effectively and safely treated with estrogen (alone or with progesterone/progestin). In perimenopause, Prior notes, “estrogen’s the driver of the symptoms, but not because it’s low—because it’s going through huge, huge swings.” She believes in the importance of a balance of both estrogen and progesterone therapy. Prior personally found the use of progesterone on its own to be an effective treatment for symptoms related to her perimenopause, including hot flashes and sleep.

A 2018 study that Prior conducted with 189 women, funded by the Canadian Institutes of Health Research, found that progesterone on its own is effective for perimenopausal night sweats and sleep problems and does not cause depression, as it has been commonly attributed to. The results have been presented internationally, but are not yet published in a peer-reviewed journal.

Jacobson says MHT “usually contains estrogen, but in women who estrogen is contraindicated, but progestin is not, progestins alone can be used (not as effectively).”

When it comes to other symptoms like anxiety or depression, Jacobson says treating mood is a multipronged approach, which might include therapy and mood medications.

No matter what symptoms you’re dealing with, speak with your primary care physician to discuss treatment options. If your family doctor isn’t comfortable or willing to treat your concerns, don’t be afraid to seek out an opinion from a specialist. Perimenopause is a normal phase of life, but it doesn’t need to be painful.