The Sneaky Symptoms of Perimenopause and How We Treat Them
The average age for menopause, defined as the complete stopping of menstruation for a period of 12 months, in the United States is around 52 years old (1). Any age between 45 and 55 is considered normal. However, the symptoms of perimenopause can begin up to a decade before and last for years. This means that people even in their 30s can have symptoms of perimenopause, not knowing that their hormone changes are causing their health concerns. As the body begins to create less hormones, the ride can be rocky for a lot of us. Surprisingly, many of the symptoms of this under-discussed stage of life can be vague and are far more than just the stereotypical hot flashes, changes in bleeds, and night sweats.
As an integrative provider and a woman who is very aware of the insidiousness of these symptoms, I take perimenopause very seriously. Unfortunately, many of my patients have been shrugged off by other providers or told that “this is just the way it is”. I don’t accept that. At. All. So, let’s take a little dive into some symptoms that people may experience during this transition and help bring a little light to the subject.
Musculoskeletal Effects
Nearly 70% of people in perimenopause and menopause will have symptoms involving the bones, joints, and muscles (2). The symptoms can include joint stiffness, muscle aching and fatigue, loss of muscle mass, and loss of bone density. It’s estimated that people lose approximately 10% of their bone mass in perimenopause, with further loss after menstruation stops. Arthritis symptoms increase, inflammation in the joints can increase, and we become more prone to injury (2).
Genitourinary Symptoms
Many patients present with complaints of frequent urinary infections, bacterial vaginosis, and yeast infections. As estrogen levels lower, the pH of the vagina changes, allowing growth of some undesirable bacteria and yeast. The tissues of the vagina, vulva, and labia thin and elasticity decreases. Symptoms like vaginal dryness, pain with penetrative intercourse, and itching can result. Many people begin to lose bladder control, or experience urgency when their bladder is full, and increased frequency of urination.
Cognitive and Mood Changes
Mood changes might be one of the earlier symptoms of perimenopause. From brain fog to flattening of the mood (otherwise known as “anhedonia”), feeling more tearful or angry, or worsening depression, anxiety, and PMS symptoms, hormone levels significantly affect our brains. Perimenopausal and menopausal mood changes can be severe, significantly decreasing the quality of life of the patient going through this transition (3). Many people feel guilty about their lower threshold for frustration, further adding to the mental and emotional burden of perimenopause. I can’t tell you the number of tissues that we go through in my office, with people feeling that they’re failing themselves and their tribe because they’re no longer able to compensate for these changes. If you’re reading this and it resonates with you, please know that you are dealing with something real, and it’s not “just in your head”. Feeling this way is explainable, and not inevitable.
Hot Flashes, Night Sweats, Insomnia, Oh My!
And now we move onto the more stereotypical symptoms of hot flashes and night sweats. Changes in estrogen and progesterone levels can also contribute to insomnia and sleeplessness, with unexplained awakenings and increased nighttime anxiety. For those of us who tended towards being chilly our whole lives, it’s very disconcerting to be walking around outside comfortably in a tank top only to realize it’s 30°.
Changes in Body Weight and Cardio-Metabolic Markers
Nearly 60-70% of menstruating people in midlife experience weight gain, and even for those who don’t gain pounds, they do notice a change in their body shape and fat distribution. I will often notice changes in a patient’s cholesterol panel or blood sugar levels. These changes can point to increased cardiovascular disease risk, and they can cause increases in blood pressure, insulin resistance, and chance of chance of vascular disease that can eventually contribute to heart attacks and stroke (4).
What We Can Do About It
First, it’s most important to identify that these symptoms are caused by changes in the hormones (and acknowledge that this isn’t a “just deal with it” scenario). Once we’ve determined that perimenopause may be contributing to symptoms, we discuss options for treatment together and figure out a plan that works best for each individual.
Assuring proper sleep, nutrition, and exercise are priorities, and the importance of each of these cannot be stressed enough. Sometimes it’s about helping people find a way of eating that works best for them, finding simple ways to add more physical activity to their lives, or giving some ideas and herbal formulas to help with sleep. It’s more than just recipes and work outs - It’s about assuring support for mental health, putting ourselves first and creating space for ourselves in our busy lives.
For my patients to wish to avoid medications, herbal and nutritional supplements can be supportive during this pivotal time. For those open to hormone replacement, we can use carefully selected bioidentical hormone therapies to significantly improve symptoms. Urogenital treatments including localized vaginal estrogens can help alleviate discomfort, while pH-balanced body washes and lubricants can help maintain healthy flora. For stubborn musculoskeletal issues, topical treatments, bodywork, and physical therapy are just some of the modalities that we use to keep everyone as active and pain-free as possible.
There is no one-size-fits-all protocol for addressing perimenopause. Each person comes in with their own story and symptoms, and each person leaves with their own unique plan for feeling better. This transformative time in our lives can feel messy and uncomfortable. Let’s use it as an opportunity to help us pause, listening to ourselves and our bodies as they tell us what we need to thrive.
National Institute on Aging. (2024). What is menopause? U.S. Department of Health and Human Services. https://www.nia.nih.gov/health/menopause/what-menopause
Wright, V. J., Schwartzman, J. D., Itinoche, R., & Wittstein, J. (2024). The musculoskeletal syndrome of menopause. Climacteric, 27(5), 466–472. https://doi.org/10.1080/13697137.2024.2380363
O’Reilly, K., McDermid, F., McInnes, S. & Peters, K. (2024) “I was just a shell”: Mental health concerns for women in perimenopause and menopause. International Journal of Mental Health Nursing, 33, 693–702. Available from: https://doi.org/10.1111/inm.13271
Kodoth, V., Scaccia, S., & Aggarwal, B. (2022). Adverse Changes in Body Composition During the Menopausal Transition and Relation to Cardiovascular Risk: A Contemporary Review. Women's health reports (New Rochelle, N.Y.), 3(1), 573–581. https://doi.org/10.1089/whr.2021.0119