When Does Perimenopause Start? Understanding the First Signs

Perimenopause is sometimes called second puberty, or puberty in reverse. Perimenopause and puberty are both times for significant changes in a woman's body (assigned female at birth), both physical and emotional changes. Perimenopause is characterized by more hormonal fluctuations than puberty which tends to be a hormonal rise. Perimenopause also has an overall decline in hormones. While puberty and perimenopause are different, they are both times for big changes and a time of transition.

Perimenopause Age

Perimenopause is the phase of time before menopause and it can vary in length. Most women enter perimenopause in their late 30s to early 40s and it typically lasts 7-10 years. Some women can experience symptoms earlier or later, making the perimenopause age range between 30 and 60.

Perimenopause isn’t about aging; it is about a recalibration of your hormonal system. When you enter menopause isn’t caused by aging, it is something that you are genetically programmed to enter around a specific time. You can look at when your mother and other female relatives entered menopause and get an idea of when to expect entering menopause. There are certain factors that can impact your predetermined menopausal age such as smoking, number of pregnancies, etc

Perimenopause Period Changes

Perimenopause starts with changes in the menstrual cycle. In the early stages of perimenopause, the menstrual cycle length begins to vary by as much as 7 days from your normal cycle. For example, if you typically have a 28-day cycle, the next cycle could be 21 days. In the later stages of perimenopause, you start to see two or more missed periods in a year. Perimenopause can last anywhere from 2-15 years, so there is quite a bit of variation. Typically, perimenopause lasts 4-8 years.

Early Signs of perimenopause

While menstrual cycle changes are an obvious common early sign of perimenopause, other early signs can be subtle. It is common for symptoms to be mild and come and go in early perimenopause, making their hormonal connection less obvious. Women may think their symptoms are caused by aging, stress, etc but are actually from hormonal fluctuations.

Perimenopause Symptoms

Hot flashes and night sweats are well known menopause/perimenopause symptoms but there are some lesser-known symptoms seen in perimenopause. Tinnitus (ringing in ears), frozen shoulder, itchy ears, and hay fever are some “under the radar” type symptoms. Some perimenopause symptoms include:

Physical:

• Hot flashes
• Night sweats
• Weight gain and/or changes in body composition
• Breast tenderness
• Joint pain, body aches (frozen shoulder is common)
• Headaches
• Heart palpitations
• Itchy skin, skin crawling sensation
• Thinning hair
• Dry skin
• Increased allergies, new allergies
• Itchy ears, ear canal itching
• Dry mouth, burning tongue

Mental Health/Mood/Brain:

• Trouble falling asleep and staying asleep
• Difficulty concentrating, brain fog
• Memory issues
• Increased or new anxiety
• Increased or new depression
• New or worsening ADHD symptoms
• Mood swings
• Increased irritability
• Vertigo, dizziness

Pelvic/Sexual:

• Libido changes
• Vaginal dryness, vaginal itching
• Urinary leakage
• UTIs
• Pain during intercourse

Perimenopause Timeline

• Premenopause (before perimenopause): predictable menstrual cycles (generally)
• Perimenopause transition: Subtle changes in your menstrual cycle start happening and new or changing hormonal symptoms
• Early perimenopause: Periods are happening 1 week early or late. Hormonal symptoms are more noticeable
• Late perimenopause: Time between your periods increases, skipped periods, etc. Hormonal symptoms become more intense and frequent.
• Menopause: confirmed after 12 consecutive months of no menstrual bleeding. Menopause officially is one day.
• Post menopause: The time after perimenopause until the end of life

Hormonal Changes in Perimenopause

Perimenopause is characterized by erratic fluctuations rather than a steady decline in hormones, primarily driven by dwindling ovarian function. Progesterone typically decreases first. This decrease in progesterone is because of shorter luteal phases and more frequent anovulatory cycles. What is an anovulatory cycle? It means that you are not ovulating or releasing an egg. It is ovulation that allows for the production of progesterone. No ovulation, no progesterone. So, in perimenopause as there is less ovulation happening, progesterone levels decline. This is happening more frequently as women enter late perimenopause, with even less ovulation and skipped periods.

Progesterone is the “period lightening” hormone, so as progesterone declines, periods can become heavier or can last for longer. Progesterone receptors are located in so many places in the body, which is why the perimenopausal symptoms are varied. Less progesterone contributes to anxiety, breast pain, and sleep changes.

Initially in perimenopause there is often 2-3 times more estrogen than is normal, and there are erratic shifts in the estrogen dropping and increasing again. This erratic up and down of hormones can lead to perimenopausal symptoms such as night sweats, and mood changes. As perimenopause progresses, we see declining levels of estrogen.

Diagnosing Perimenopause

There isn’t really a lab test to officially diagnose perimenopause. If you are in your late 30s and have typical perimenopause symptoms, then you are likely in perimenopause. Hormones are wildly fluctuating at this time so hormone tests are rarely informative or conclusive. Hormonal testing can, and still will be done, but not to diagnose perimenopause. Lab testing to look at things that could mimic perimenopause are useful. Some lab testing that I will run with my patients include glucose and insulin testing, vitamin D, nutrients (vitamin B12, ferritin), thyroid testing, and more.

If you have any questions about whether or not you are in perimenopause or you would like help feeling yourself again, please reach out for an appointment.