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What is perimenopause?

Dawn Weinberger headshot By | May 13, 2020
Medically reviewed by Laura K. Grubb, MD, MPH

Many women think of menopause as something they “go through.” Menopause, however, is actually a destination—not a journey. You reach this destination when you have made it through a solid year without a menstrual period. The phase leading up to that point (you know, the one with all the annoying hot flashes, mood swings, and heavy periods) is actually called perimenopause, says Leah Millheiser, MD, clinical assistant professor of obstetrics and gynecology at Stanford University. 

It is the result of fluctuating estrogen levels in the body. “This uneven up and down can wreak havoc on a woman’s body,” says Dr. Millheiser. 

Perimenopause symptoms 

You will have a pretty good idea that you are in the perimenopause phase because the symptoms are quite telling. When you’re perimenopausal, common symptoms include:

  • Hot flashes and night sweats (also known as vasomotor symptoms)
  • Irregular periods
  • Heavy periods
  • Vaginal dryness
  • Breast tenderness
  • Low sex drive
  • Mood changes, feelings of anxiety or depression
  • Bladder problems/incontinence
  • Insomnia or sleep disturbances
  • Weight gain

“The majority of women will experience at least some of these symptoms,” says Dr. Millheiser. 

The severity of the symptoms will vary, and can even vary month by month, she says. One month, for example you could have a totally normal period. The next, you might miss it altogether because that surge of estrogen prevents you from ovulating. Meanwhile, your uterine lining continues to build. The result? Your next period is a very heavy one.

How long does perimenopause last?

These havoc-wreaking menopausal symptoms often start off mild and gradually, but they can also hit suddenly and with great intensity. They can last for a year, or they can last for five or 10 years. The average is 7.4 years, says Mary Jane Minkin, MD, a clinical professor in the department of obstetrics, gynecology and reproductive science at Yale University School of Medicine. How long will they last for you? Unfortunately, there is no way to predict the answer to this question. You really just have to wait and see, Dr. Minkin says.

What is a normal age for perimenopause?

Just like it is impossible to predict how long perimenopause will last, it is also somewhat mysterious as to when exactly perimenopause will begin. If you are in your mid-40s, and are experiencing hot flashes and changes to your menstrual cycle, that could be a sign that hormone levels are changing and perimenopause is underway. However, it could also signify something else, so you’ll want to speak to your doctor to rule out any health issues that need treatment. 

Can older female relatives offer a gauge as to when perimenopause will begin and how long it will last? Sometimes, yes. “[You can] talk to your mom and your aunt because there are familial tendencies,” Dr. Minkin explains. 

Be aware, though, that this is just a gauge. Doctors don’t really know how much of a role familial tendencies play because there isn’t a lot of reliable data on the topic, says Dr. Millheiser. “It is different for every woman,” she says.

What’s a normal age for menopause?

As for actually reaching menopause, the average age is 51, according to the North American Menopause Society—but it is normal for women to reach menopause anytime between the ages of 40 and 58. At this point, your ovaries are no longer releasing eggs and those fluctuating hormones should stabilize. Although some women experience hot flashes throughout menopause, says Dr. Minkin.

How is perimenopause diagnosed?

Perimenopause is a completely natural process, and diagnosis is symptom-based, Dr. Millheiser explains. There are no tests to verify perimenopause; only tests to rule out other conditions that have similar symptoms. For example, if your doctor is not certain your symptoms are the result of perimenopause, a pregnancy test, a blood test, a Pap smear, and/or imaging might be ordered to check for other women’s health problems like uterine fibroids, ovarian cancer, or certain thyroid conditions—especially if you are on the younger side. 

“If a woman is having hot flashes or night sweats and is in her late 40s, I would say there is a pretty good chance she is in perimenopause,” Dr. Millheiser says. “But if you are in your early 40s and are experiencing these symptoms in isolation, you might want to be checked for other conditions.”

The best thing a woman nearing the age range of perimenopause can do, Dr. Millheiser says, is to simply learn to recognize the symptoms of perimenopause so she can face it head on. Treatment is available, and the symptoms can be managed.

“Preparation with knowledge is so important,” she says, explaining that many women spend years suffering with symptoms of perimenopause simply because they don’t realize exactly what is going on. “If these symptoms are starting to [disrupt] your quality of life, you really need to talk to your doctor about it.”

Perimenopause treatment options 

The treatments your doctor recommends will depend on the symptoms that are most bothersome to you, says Sally Rafie, Pharm.D., founder of Birth Control Pharmacist

Medication

Some women, for example, struggle most with hot flashes and night sweats. In these cases, a low-dose birth control pill or patch, or some other type of hormone therapy (one that delivers estrogen locally), like a vaginal ring, a topical gel, or an insert—such as estradiol — is the gold standard. Hormone therapy may not be safe for everyone and you should discuss risks with your provider if you have:

  • A history of heart disease or risk factors, such as high cholesterol
  • A family or personal history of breast cancer
  • High levels of triglycerides, a type of fat in your blood
  • A family history of gallbladder disease
  • Liver disease
  • A history of stroke or blood clots

You can find a list of approved hormone therapies here

Other options include antidepressants—such as a low dose selective serotonin uptake inhibitor (SSRI)—for women who don’t respond to hormone therapy. Gabapentin, a medication normally used to treat seizures, is a potential option for women who are unable to use estrogen due to other health conditions (like migraine), Dr. Rafie says.

RELATED: The best birth control pill for you

Over-the-counter treatments

If vaginal dryness and/or pain during sex is the primary concern, non-hormonal local therapies like vaginal moisturizers and lubricants, are a great place to start, says Dr. Rafie. Examples include Replens and Astroglide, which are available over the counter. 

And if everything is bothering you? Yes, you can use these treatments in conjunction with one another. Side effects are minimal or nonexistent. However, if you choose to take low-dose birth control pills it is entirely possible you won’t even recognize that perimenopause is happening.

“I think women need to realize that if they are on hormonal birth control pills it may mask symptoms of perimenopause,” she says. “That could be a good thing, but [some women] really want to know what is going on [with their bodies].”

Alternative therapies 

As for natural and herbal therapies (like red clover, black cohosh, or soy), Dr. Rafie urges women to discuss the use of such supplements with their healthcare providers because a) data is mixed and b) the industry is not regulated by the Food and Drug Administration, meaning that safety and effectiveness have not been proven. According to the National Institutes of Health Office of Dietary Supplements, some studies have indicated that black cohosh, specifically, can actually worsen the frequency and severity of hot flashes.

“With [alternative therapies] it is always a risk/benefit analysis that every individual, with the help of their healthcare provider, should look at carefully [before using],” Dr. Rafie says. 

Simple lifestyle changes can be quite beneficial as well. Dr. Minkin recommends dressing in layers to alleviate the discomfort of vasomotor symptoms like hot flashes and night sweats. She also suggests paying attention to potential triggers. For example, some women find that red wine and/or spicy foods increase the frequency and duration of hot flashes, so they eliminate (or reduce the consumption of) those items from their diets, she says.

Dr. Minkin also emphasizes the importance of maintaining a healthy body weight during perimenopause and beyond because excess weight is a contraindication to a whole host of health problems. 

“Good nutrition and exercise [will] help, there’s no question about it,” she says, adding that it is typical for a woman to gain between 5-8 pounds during the perimenopause phase—even with a healthy diet and plenty of exercise—thanks again to those hormonal changes.

Can women get pregnant during perimenopause?

Even if you don’t need or want to take low-dose birth control pills to help with hot flashes, there may be one significant benefit to using them during perimenopause—contraception. Because, yes, you can get pregnant during perimenopause.

It all goes back to the unpredictable menstrual cycles that occur during this time, she says. In other words, you might not know exactly when, or if, you are ovulating. The quality of the eggs, and therefore the odds of getting pregnant, are diminished, of course (less than a 5% chance according to the American Society for Reproductive Medicine)—but the possibility remains.

“People certainly aren’t as fertile as they were when they were 22, but they still are fertile until they go that magic year without a period,” Dr. Minkin explains.

And if oral contraceptives  aren’t for you? That’s okay. Just be sure to use some sort of contraception. “I have personally delivered three babies to 47-year-old women,” Dr. Minkin says.