Perimenopause

Overview

What is perimenopause?

Perimenopause (also referred to as the menopause transition) is when your body starts transitioning to menopause. During this transition, your ovaries begin producing less hormones, causing your menstrual cycle to become erratic or irregular. At this time, your body is moving toward the end of your reproductive years.

Perimenopause may begin as early as your mid-30s or as late as your mid-50s. Some people are in perimenopause for only a short time. But for many, it lasts four to eight years. The term perimenopause simply describes the time when your cycles are no longer predictable.

Other physical changes and symptoms can occur as your body adjusts to different hormone levels. During perimenopause, your fertility is declining, but you still can become pregnant. The symptoms of perimenopause, the age it starts and how long it lasts will vary between women. You’re out of perimenopause and into menopause once you’ve had 12 consecutive months without a menstrual period.

What is the difference between perimenopause and menopause?

Perimenopause is a transitional time that ends in menopause. Menopause means your periods have ended. When you have no menstrual cycle for a full 12 months, you have officially reached menopause.

Why does perimenopause happen?

Your ovaries begin to produce less estrogen as you age in preparation to stop releasing eggs entirely. Ultimately, your body is preparing to transition to menopause, when you lose the ability to get pregnant. It’s a natural and normal progression in a woman’s reproductive cycle.

At what age does perimenopause begin?

Perimenopause begins about eight to 10 years before menopause. It usually starts in your mid-40s, but it can start earlier. Completing menopause before age 40 is called premature menopause. Some medical conditions or procedures cause early menopause. If there is no medical or surgical cause for premature menopause, it's called primary ovarian insufficiency.

How long does perimenopause last?

The average length of perimenopause is about four years. Some people may only be in this stage for a few months, while others will be in this transition phase for more than four years. If you’ve gone more than 12 months without having a period, you are no longer in perimenopause.

What are the hormonal changes during perimenopause?

The hormonal changes you experience during perimenopause are mostly caused by declining estrogen levels. Your ovaries make estrogen, which plays a vital role in maintaining the reproductive system. Once you enter perimenopause, your estrogen levels start to decrease. As estrogen decreases, it throws off the balance with progesterone, another hormone produces by the ovaries. These two hormones together are responsible for ovulation and menstruation. It’s common for hormone levels to fluctuate during perimenopause — to go up and down like a rollercoaster.

When you reach menopause, your body makes so little estrogen that your ovaries no longer release eggs. At this point, you stop having your period.

What are the first signs of perimenopause?

Generally, the first sign of perimenopause is irregular periods. Most people will go from having fairly predictable menstrual cycles to unpredictable cycles. A lot of people also experience the most common signs of menopause like hot flashes and vaginal dryness (vaginal atrophy) fairly early into the menopause transition.

Symptoms and Causes

What are the symptoms of perimenopause?

Your body has been producing estrogen since puberty. Once your estrogen levels begin to decline, your body has to adjust to the changes in hormones.

The symptoms vary, but most people experience at least one of the following:

  • Irregular periods or skipping periods.
  • Periods that are heavier or lighter than usual.
  • Hot flashes (a sudden feeling of warmth that spreads across your body).
  • Vaginal dryness and discomfort during sex.
  • Urinary urgency (needing to urinate more frequently).
  • Sleep problems (insomnia).
  • Changes in mood like irritability, depression or mood swings.

The length of time you have symptoms of perimenopause can vary between a few months to many years. The decrease in estrogen also can lead to bone thinning or changing cholesterol levels. Continue to have regular checkups with your healthcare provider to keep an eye on your health.

What are periods like during perimenopause?

Your body is producing less of the hormones that help you ovulate, so your periods can become irregular. Your menstrual cycle could become longer or shorter than usual. Your bleeding could also be heavier or lighter than normal. Some people also notice a change in their premenstrual syndrome (PMS) symptoms.

How do I know if changes in my periods are normal perimenopausal symptoms or something to be concerned about?

Irregular periods are common and normal during perimenopause, but other conditions can cause abnormalities in menstrual bleeding. If any of the following situations apply to you, see a healthcare provider to rule out other causes.

  • Your periods are changing to become very heavy or accompanied by blood clots.
  • Your periods last several days longer than usual.
  • You spot or bleed after your period.
  • You experience spotting after sex.
  • Your periods occur closer together.

Potential causes of abnormal bleeding include perimenopausal hormonal imbalances, infection, pregnancy-related bleeding, fibroids, blood-clotting problems, endometrial polyps, miscarriage, taking blood thinners or cancer.

Do you still ovulate during perimenopause?

If you’re still getting a period, even an irregular one, you're still ovulating. Until you haven't menstruated for 12 consecutive months, you should assume your body is still ovulating (releasing eggs).

Diagnosis and Tests

How is perimenopause diagnosed?

You don’t always need to see a healthcare provider for a perimenopause diagnosis. Many people notice and tolerate the changes in their bodies without a formal diagnosis. If you have symptoms that interfere with your daily activities, see a healthcare provider.

You should reach out to your healthcare provider right away if you have:

  • Blood clots in menstrual discharge.
  • Spotting between periods.
  • Vaginal bleeding after sex.
  • Emotional symptoms interfering with your ability to function on a daily basis.

What FSH level means perimenopause?

FSH (follicle stimulating hormone) is a hormone produced by the pituitary gland — the gland located at the base of your brain. It stimulates the ovaries to release an egg during ovulation. Testing your FSH level can help confirm menopause has started. A consistently high level of FSH can indicate menopause. However, FSH tests can be misleading because during perimenopause your hormones rise and fall erratically. Certain medications, like birth control pills or hormone therapy, interfere with hormone levels and will affect the results of any hormone tests. Overactive thyroid and high prolactin can also alter those results.

Management and Treatment

Can perimenopause be treated?

There isn’t any treatment to stop perimenopause. Perimenopause is a natural part of life. The “cure” for perimenopause occurs when your periods stop and you enter menopause.

But your healthcare provider may recommend over-the-counter or prescription perimenopause treatment to help ease symptoms. Your provider may recommend:

  • Antidepressants: These medications help with mood swings or depression.
  • Birth control pills. These medications stabilize your hormone levels and typically relieve symptoms.
  • Estrogen therapy: This treatment stabilizes estrogen levels. You may take estrogen therapy as a cream, gel, patch or swallowable pill.
  • Gabapentin (Neurontin®): This medicine is a seizure medication that also relieves hot flashes for some women.
  • Vaginal creams: Your provider can tell you about prescription and over-the-counter options. Treatment can decrease pain related to sex and relieve vaginal dryness.

Your healthcare provider will discuss the risks and benefits of perimenopause treatment with you and recommend the best option based on your needs. Certain lifestyle changes like eating a healthy diet, light exercise and avoiding foods or activities that trigger hot flashes can also help.

What is hormone therapy?

Hormone therapy can help relieve some symptoms of perimenopause. In general, healthcare providers recommend that people who opt to use hormone therapy start it within 10 years of beginning menopause symptoms and use it for less than five years. Estrogen and hormones have been linked to an increased risk of heart problems and some types of breast cancer.

Speak with your healthcare provider to make sure you understand the risks and benefits of hormone therapy as a treatment for perimenopause.

What are the risks of hormone therapy?

Treating perimenopause with hormone therapy can increase your risk for the following conditions:

What can I do to manage my perimenopause symptoms at home?

You may choose to manage perimenopause symptoms at home. To relieve symptoms, you can:

  • Eat a diet full of fruits, vegetables, whole grains, lean protein and healthy fats.
  • Perform weight-bearing exercises like walking, hiking or strength training.
  • Improve sleep hygiene by avoiding screens and doing relaxing activities before bed.
  • Limit alcohol and caffeine.
  • Practice meditation or other stress management techniques.
  • Quit smoking.
  • Lose weight if indicated. Weight loss reduces hot flashes and night sweats and improves your energy level.
Care at Cleveland Clinic

Prevention

What can put you into perimenopause early?

Certain factors are linked to early perimenopause. These include:

  • Smoking or using tobacco products.
  • A family history of early menopause.
  • A history of cancer treatment.
  • If you’ve had your uterus or ovaries removed.

How can I reduce my risk of perimenopause complications?

Irregular periods are the most common symptom of perimenopause. But it’s important to know when to talk to your healthcare provider about your periods. Sometimes, irregular bleeding can point to an underlying problem.

You can lower your risk of complications by seeking treatment when necessary. Talk to your healthcare provider if you:

  • Bleed for more than seven days in a row.
  • Bleed between periods.
  • Change pads or tampons every one to two hours.
  • Have periods more frequently than every 21 days.

Outlook / Prognosis

Are there any health risks associated with perimenopause?

There are health risks associated with menopause, which happens right after perimenopause.

Estrogen plays an important role in preserving your bones. Osteoporosis is a condition where the insides of your bones become less dense and more fragile. This increases your risk for bone fractures. Your healthcare provider may recommend a multivitamin, calcium supplement, extra vitamin D or more weight-bearing exercises.

People in menopause are also at an increased risk for heart disease and other cardiovascular health conditions.

Can I get pregnant if I am in perimenopause?

Yes, you can still become pregnant. You may be less likely to get pregnant during perimenopause, but it's still possible. As long as you have a period, you can still get pregnant. If you want to expand your family during this time, speak with your healthcare provider about your health, fertility and possible fertility treatment options.

When your periods are irregular, you may be more likely to get pregnant unexpectedly. If you don’t want to expand your family at this age, continue using birth control until your healthcare provider tells you it’s safe to stop. Continue to practice safe sex to prevent sexually transmitted diseases (STDs) throughout your life.

Living With

What questions should I ask my doctor?

Discuss your perimenopause symptoms with your healthcare provider. It might help to keep a journal of your menstrual cycles including when they start and stop and the amount of bleeding.

Some questions you should ask are:

  • Are these symptoms of perimenopause?
  • What can I do to relieve my symptoms?
  • How long do you think I will have these symptoms?
  • Would hormone therapy be an option for me?
  • Do I need to start taking medication or vitamins?
  • Are there any tests that should be done?
  • Can I still become pregnant?

When should I call my doctor?

If your perimenopausal symptoms are unbearable or interfering with your quality of life, it might be time to contact your healthcare provider. They may be able to offer support or recommend a treatment to reduce the intensity of your symptoms.

Can perimenopause affect my sex life?

Possibly. Certain symptoms of perimenopause like vaginal dryness and discomfort during sex can make having sex less desirable. Vaginal lubricants can be used to help dryness. Speak with your healthcare provider if you have issues with a decreased sex drive so they can recommend ways to help you.

Should I be on birth control during perimenopause?

Yes. If you do not want to become pregnant, you should use birth control during perimenopause. Even if you are getting your period every few months, you are still ovulating those months. Since it’s not possible to predict when you are ovulating, you should use birth control until you haven’t gotten a period for at least 12 months.

Does perimenopause affect my sleep?

Yes, perimenopause can affect your sleep. Some women in perimenopause experience insomnia and interrupted sleep due to night sweats or other menopausal symptoms.

What do hot flashes feel like during perimenopause?

A hot flash feels like a sudden warmth all over your body. It is often accompanied by sweating and a red, flushed face. Hot flashes are caused by low estrogen levels and can last months or years.

Why am I gaining weight during perimenopause?

The shift in hormones slows down your metabolism. It’s very common for women in perimenopause to gain weight once their estrogen levels start to decline. Maintaining a healthy diet and regular exercise can help prevent weight gain during the transition to menopause.

A note from Cleveland Clinic

Perimenopause is the transition to menopause. During perimenopause, you may start having menopause-like symptoms, such as hot flashes, mood swings or vaginal dryness. Most perimenopause symptoms are manageable. But if you need help managing symptoms, medications and other treatments are available. Perimenopause ends when you’ve had no period for a full year. At that point, you enter menopause.

Last reviewed by a Cleveland Clinic medical professional on 10/05/2021.

References

  • U.S. Department of Health and Human Services, Office on Women’s Health. Menopause. (https://www.womenshealth.gov/menopause/) Accessed 10/12/2021.
  • The American College of Obstetricians and Gynecologists. The Menopause Years. (https://www.acog.org/Patients/FAQs/The-Menopause-Years) Accessed 10/12/2021.
  • The American College of Obstetricians and Gynecologists. Hormone Therapy: Resource Overview. (https://www.acog.org/Womens-Health/Hormone-Therapy?IsMobileSet=false) Accessed 10/12/2021.
  • U.S. Food and Drug Administration. Menopause. (https://www.fda.gov/consumers/womens-health-topics/menopause) Accessed 10/12/2021.
  • The North American Menopause Society. Hormone Therapy and Menopause FAQs. (http://www.menopause.org/for-women/expert-answers-to-frequently-asked-questions-about-menopause/hormone-therapy-menopause-faqs) Accessed 10/12/2021.
  • Santoro N, Sutton-Tyrrell K. The SWAN song: Study of Women's Health Across the Nation's recurring themes. (https://pubmed.ncbi.nlm.nih.gov/21961710/) Obstet Gynecol Clin North Am. 2011;38(3):417-423. doi:10.1016/j.ogc.2011.05.001. Accessed 10/12/2021.
  • North American Menopause Society. How Do I Know When I’m in Menopause. (https://www.menopause.org/for-women/menopauseflashes/menopause-symptoms-and-treatments/how-do-i-know-when-i'm-in-menopause-) Accessed 10/12/2021.
  • North American Menopause Society. Menopause 101: A Primer for the Perimenopausal. (https://www.menopause.org/for-women/menopauseflashes/menopause-symptoms-and-treatments/menopause-101-a-primer-for-the-perimenopausal) Accessed 10/12/2021.
  • National Institute on Aging. AgePage: Menopause. (https://order.nia.nih.gov/sites/default/files/2018-09/menopause.pdf?_gl=1*9a9qbw*_ga*NTEwMDMwNjgyLjE2MjMxODE3NzA.*_ga_TK3CE80DBZ*MTYyNzMwODYzNi4xLjEuMTYyNzMwODk3MS41OQ..) Accessed 10/12/2021.

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