Hot flashes, headaches, brain fog — simply put, you just don’t feel like yourself. While the average age of menopause in the U.S. is 51 to 52 years old, most women begin to experience symptoms of hormonal fluctuation anywhere from months to a decade in advance. This transitional phase is known as perimenopause. Perimenopause can be tricky to identify because it may present differently in different people and may mimic other conditions.

“Everybody’s perimenopause is unique; you may not have the same set of symptoms that your best friend has,” says Dr. Mary Rosser, an OB-GYN at New York-Presbyterian/Columbia University Irving Medical Center. “If you’re experiencing symptoms that are not right for you or you feel off, it’s important to see your healthcare provider.”

Health Matters spoke with Dr. Rosser to better understand what’s happening in the body during perimenopause, the signs and symptoms to look out for, and what treatment options are available.

What are some of the most common symptoms of perimenopause?

One of the first signs may be a change in your menstrual cycle; this is different for each individual. Some people may experience a lighter period, and others may experience a heavier one. Their periods may occur farther apart, or more frequently. If you notice any changes in your menstrual cycle, I always suggest writing down those symptoms to keep track.

Some common symptoms include:

• Irregular or skipped periods
• Periods that are heavier or lighter than usual
• Hot flashes and night sweats (also known as vasomotor symptoms)
• Insomnia or difficulty falling and staying asleep
• Low energy and fatigue
• Mood swings and irritability
• Anxiety and depression
• Brain fog, memory loss, or trouble focusing
• Headaches
• Joint pain
• Weight gain
• Low libido, vaginal dryness, and urinary symptoms
• Gastrointestinal changes, such as bloating and constipation
• Hair loss

Menopause and perimenopause symptoms can also mimic other conditions, such as fibroids, anemia, anxiety, depression, and thyroid disorders, among others – so it’s important to see an expert to get evaluated. You should also see a doctor if you experience bleeding for more than seven days, are saturating a pad or tampon every one to two hours or are consistently bleeding twice in the same month.

Can you get pregnant during perimenopause?

Menopause begins when you have had a period for 12 consecutive months. Until then, even during perimenopause, you are still able to become pregnant. During perimenopause, your ovaries are still releasing eggs; it’s just that your menstrual cycle (and ovulation) becomes more irregular.

How long does perimenopause last?

Perimenopause can last anywhere from four to 10 years on average.

What is happening inside the body during perimenopause?

Women have estrogen receptors all over the body; so, as estrogen levels drop during perimenopause, many bodily systems are affected, particularly bone health, heart health, and brain health.

As a result, we experience a whole range of symptoms — from hot flashes because the brain is struggling to regulate body temperature to digestive issues due to hormonal changes in the gut microbiome — as well as increased risk for conditions like osteoporosis, heart disease, and urinary infections increase.

What does treatment for perimenopause look like?

There are both hormonal and non-hormonal options for managing perimenopause. The first step is to meet with your provider to decide which approach is best for you.

Overall, the gold standard is menopause hormone therapy (MHT). This is essentially reintroducing the hormones that you’re losing in perimenopause. There are two main types of menopause hormone therapy: systemic menopause hormone therapy and vaginal estrogen therapy.

• Systemic menopause hormone therapy, also known as whole-body hormone therapy, treats vasomotor symptoms such as sleep and mood. It may be taken orally as a pill or as a transdermal application to the skin in the form of patches, gels, or a vaginal ring. For women who have uteruses, a progestin must be added to prevent overgrowth of the uterine lining (which can lead to hyperplasia or endometrial cancer).
• Vaginal estrogen therapy is applied locally in the form of a vaginal cream, a suppository, or a ring, and usually contains a lower dose of estrogen. It is mainly helpful in treating genitourinary syndrome of menopause (GSM), which includes vaginal dryness and irritation, pain with intercourse, and urinary symptoms of menopause (increased incidence of urinary tract infections, frequent urination, urgency or leakage).

It’s recommended to initiate hormone therapy within 10 years of onset of perimenopause symptoms and up to the age of 60, per The Menopause Society guidelines. That said, this is a rapidly evolving field of medicine, so I always recommend seeing your provider at least once a year so that they can reevaluate and make sure you’re on the best course of treatment for your individual needs.

Some people are unable to take medicines containing estrogen — especially if they’ve had a history of blood clots, stroke, or heart attack, breast cancer, or other estrogen-dependent cancers. In these cases, there are alternatives to menopause hormone therapy, including lifestyle adjustments and other medications that do not contain estrogen. Progesterone-only birth control methods (such as the pill or IUD) can help women manage some perimenopause symptoms without the use of estrogen.

Your doctor may also discuss SSRIs, or selective serotonin reuptake inhibitors, which can reduce vasomotor symptoms, sleep and overall mood and well-being. Gabapentin at bedtime improves both vasomotor symptoms and sleep. Oxybutynin and clonidine are also used in certain circumstances.

Vaginal moisturizers and lubricants can help with dryness, pain, or discomfort caused by GSM. Many women also experience a decline in libido during perimenopause, and topical testosterone gels may be discussed to help with this.

What are some lifestyle tips that can help with perimenopause symptoms?

To support your body during perimenopause, make sure you’re eating a well-balanced, nutritious diet and getting daily cardiovascular exercise, even if it’s as simple as a 20-minute walk. Reducing your intake of alcohol, caffeine, tobacco, and spicy foods may also reduce the risk of hot flashes.

Between night sweats and other sleep disturbances during perimenopause, it can be very difficult to sleep. I usually advise my patients not to stay in bed tossing and turning when they can’t sleep: Get out of bed, sit in a different room, and read, preferably without blue light, until you begin to feel sleepy. Avoiding screens before bed, taking melatonin or magnesium supplements, and setting your thermostat between 60 to 67 degrees (the ideal sleeping temperature), may also help.

As not getting enough sleep can eventually take a toll on mental health, many patients benefit from cognitive behavioral therapy during this time.

Are there any health concerns that different groups should be keeping in mind as they approach perimenopause?

Black women, on average, begin menopause over 8 months sooner than white women, according to the National Institutes of Health — this is significant because earlier menopause is directly linked with increased risk of heart disease and mortality. And on top of that, Black women experience symptoms of perimenopause (particularly vasomotor symptoms, depression, and poor sleep quality) more frequently and intensely.

That’s why it’s incredibly important to find a clinician who listens carefully to your symptoms, so that you can work together to create and tailor an individualized treatment plan.