Part 2 of our 6-week menopause series
"I'm only 43. It can't be menopause yet, can it?" I hear some version of that question in our Princeton office almost every week. My answer is usually: not menopause yet, but very possibly perimenopause. And knowing the difference can change how you feel about what's happening to your body.
Last week, we talked about hot flashes and night sweats and what actually helps. This week, we're going back a step to the years leading up to menopause.
Perimenopause vs. Menopause: What's the Difference?
Menopause is a single point in time: 12 months in a row without a period. In the United States, the average age of the last period is 51. Perimenopause is the transition leading up to it, when your ovaries' hormone production becomes erratic: estrogen rises and falls unpredictably, and ovulation happens less often.
According to ACOG, perimenopause usually begins in your 40s, but these hormone shifts can start in your late 30s. For some women the transition lasts only a few years. For others it lasts much longer.
Early Signs of Perimenopause
Not everyone gets every symptom, and they can come and go. Here's what to watch for.
Changes in your cycle and bleeding
This is often the first clue. Your cycles may get a little shorter at first, then longer, and you may start skipping periods. Bleeding can become heavier or lighter, and it may last fewer or more days than you're used to. Tracking your periods on a calendar or app is one of the most helpful things you can bring to a visit.
Sleep changes
Trouble falling asleep, waking at 3 a.m., or waking up drenched from night sweats are all common.
Mood changes
Irritability, anxiety, low mood, or feeling "not like yourself" are real and common in perimenopause. The Menopause Society notes that women appear especially vulnerable to depression during perimenopause and the years right after menopause, particularly if they've had depression earlier in life. If your mood is affecting your daily life, that deserves real attention, not a shrug.
Hot flashes and night sweats
Many women assume hot flashes start only after periods stop, but they can begin while you're still having periods. The Menopause Society cites one large U.S. study in which up to 80% of women had these symptoms at some point during the menopause transition.
Brain fog
Forgetting words or names, losing focus, or walking into a room and forgetting why: according to The Menopause Society, 40% to 60% of midlife women report symptoms like these during the transition. These changes are usually mild and within the normal range, and dementia at midlife is very rare.
Vaginal dryness and urinary changes
Falling estrogen can thin the tissues of the vulva, vagina, and bladder, a condition called genitourinary syndrome of menopause (GSM). It can cause dryness, pain with sex, irritation, or urinary symptoms. Many women don't notice GSM until after menopause, but some do earlier. It's very treatable, and we'll cover it in depth later in this series.
Can a Blood Test Tell Me If I'm in Perimenopause?
This is one of the most common questions I get, and the honest answer surprises people: usually, no test is needed, and a single test often isn't reliable.
During perimenopause, hormone levels, including follicle-stimulating hormone (FSH) and estradiol, can swing widely from day to day and month to month. A "normal" FSH level on Tuesday doesn't rule out perimenopause, and a high one doesn't confirm it. That's why the U.K.'s NICE guideline recommends identifying perimenopause without lab tests in otherwise healthy women 45 and older, based on symptoms and cycle changes. NICE recommends an FSH test only in specific situations, such as women 40 to 45 with symptoms and cycle changes, or women under 40 when early menopause is suspected. FSH isn't useful at all if you're on combined hormonal birth control.
Labs still have a place. When symptoms could point to something else, such as thyroid problems, pregnancy, or anemia from heavy bleeding, testing can help sort things out. The point is to test for a reason, not out of routine.
When to Make an Appointment
Changing periods are expected in perimenopause, but some bleeding should always be checked. Schedule a visit if you have:
Heavy bleeding or bleeding that lasts longer than usual
Bleeding between periods or after sex
Any bleeding after you've gone 12 months without a period. This always needs to be evaluated.
Symptoms that are affecting your sleep, work, mood, or relationships
Yes, You Still Need Birth Control
Irregular periods don't mean you can't get pregnant. You can still ovulate during perimenopause, sometimes unpredictably. The Menopause Society advises women who don't want to become pregnant to keep using contraception until menopause is confirmed, 12 months after the final period. Some birth control options can also ease perimenopause symptoms like heavy bleeding or hot flashes.
Treatment Is Personal
There is no one-size-fits-all plan for perimenopause. For some women, understanding what's happening is enough. Others need relief for bleeding, sleep, mood, or hot flashes. Options include:
Hormone therapy or hormonal contraception, chosen based on your health history and goals, not a hard age cutoff
Progesterone, which can help some women, including with sleep, whether or not they have a uterus
Nonhormonal options if hormones aren't right for you. Among the newer medicines, I more often reach for elinzanetant (Lynkuet) than fezolinetant (Veozah), as I explained in last week's post.
Lifestyle support for sleep, movement, and stress
We'll make that decision together, honestly and individually.
You're Not Imagining It
If you've been wondering whether something is changing, trust that instinct. Patients come to us from across southern West Virginia and southwest Virginia, from Beckley and Lewisburg to Peterstown, Giles County, and the Blacksburg and Christiansburg area. Dr. Samantha Snyder, Megan Lingenfelter, PA-C, VaLeah Bradshaw, CNM, and I are here to help you make sense of perimenopause and feel like yourself again.
Summit Women's Health
411 12th Street Ext, Princeton, WV 24740
Next Friday, in week 3: hormone therapy myths vs. evidence.
This post is for general education and isn't a substitute for personal medical advice.
Call 681-282-5591 to schedule an appointment, and we'll make a plan together.
Sources
American College of Obstetricians and Gynecologists. The Menopause Years (patient FAQ). https://www.acog.org/womens-health/faqs/the-menopause-years
American College of Obstetricians and Gynecologists. Perimenopausal Bleeding and Bleeding After Menopause (patient FAQ FAQ162). https://www.acog.org/womens-health/faqs/perimenopausal-bleeding-and-bleeding-after-menopause
The Menopause Society. Perimenopause (patient education). https://menopause.org/patient-education/menopause-topics/perimenopause
National Institute for Health and Care Excellence (NICE). Menopause: identification and management (NG23), Recommendations 1.3.1 to 1.3.6. https://www.nice.org.uk/guidance/ng23/chapter/Recommendations
European Society of Endocrinology. Clinical practice guideline for evaluation and management of menopause and the perimenopause. European Journal of Endocrinology. https://doi.org/10.1093/ejendo/lvaf206
The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. https://doi.org/10.1097/GME.0000000000002028
Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition (SWAN). JAMA Internal Medicine. 2015;175(4):531-539. https://pubmed.ncbi.nlm.nih.gov/25686030/
Study of Women's Health Across the Nation (SWAN). https://www.swanstudy.org/