Perimenopause
Introduction
Perimenopause, literally meaning "around the menopause", refers to the transitional years leading up to and immediately following a woman's final menstrual period. It is the phase during which the ovaries gradually reduce their hormonal activity, producing a period of physical and psychological changes preceding menopause. It begins with a persistent difference in the length of the menstrual cycle by more than seven days and ends after the occurrence of one year of amenorrhea, when menopause is reached.[1][2] The perimenopause consists of two stages: (1) the early transition and (2) the late transition. During the early transition phase, the menstrual cycle is generally regular, with relatively few interruptions. In contrast, in the late transition, the amenorrhea can last up to 60 days until the final menstrual period.[2] For an average woman, the early transition is at the age of 47, the late transition at the age of 49 and the final menstrual period at the age of 51.[2] The fluctuating estrogen levels during perimenopause can cause a wide range of symptoms, including heavy and irregular bleeding, mood and memory changes, decreased libido, vasomotor symptoms and genitourinary symptoms.[1] Perimenopause is a normal part of reproductive aging rather than a disease, although clinically significant symptoms may be coded under ICD-10 (N95.8) or ICD-11 (GA30).[3]
Signs and symptoms
Four core symptoms discussed here are hot flashes, sleep changes, vaginal dryness, and adverse mood. While these are the most commonly discussed perimenopausal symptoms, women may experience many others, and the type and severity of symptoms vary widely among individuals.
Hot Flashes and Night Sweat
Hot Flashes also known as vasomotor symptoms, one of the most common symptoms of perimenopause, are experienced by 30%-70% of premenopausal women.[4][5][2] Although it is likely to be mild in the early transition, it becomes doubled in the late stages. It is one of the major causes of substantial amounts of distress and reduction in the quality of life of women at their premenopausal stage.[6] The duration of hot flashes varies between women, and it can last up to 10 years for some. [7] Women of certain Ethnic backgrounds, including African American women or women with high Body mass index (BMI), are particularly at higher risk for a long duration of hot flashes. Moreover, women who have experienced hot flashes in their earlier stage of perimenopause are more likely to experience prolonged duration of hot flashes.[4][7]
Sleep Changes
Sleep changes are another perimenopausal symptom that can affect the quality of life of women in their early perimenopausal stage. Although women begin to notice sleep changes in their 40s, it becomes worse with the menopausal transition.[2] A study by the Melbourne Midlife Women's Health Project found that the complaint of poor sleep progressed through the Menopause.[8] However, there is no clear consensus on whether these changes in sleep pattern are directly related to menopause or due to estrogen withdrawal or other hormonal changes, or simply related to ageing.[2] The hot flashes at night are one cause of sleep disturbance. In a study, the insomnia rates of women in the perimenopausal stage were 56.6%, while they were 36% for premenopausal women and 50.7% in postmenopausal women.[9]
Vaginal Dryness
Although vaginal dryness or dyspareunia is a common issue reported among postmenopausal women, women in their perimenopausal stage also experience vaginal dryness, even though the Estrogen levels are not consistently low as in postmenopause.[10][11][12] A study also found differences in the reported vaginal dryness, with almost 60% Central American Women reporting vaginal dryness at baseline, while only 21% of Non-Hispanic Caucasian women reported vaginal dryness at baseline. [13] Unlike hot flashes and adverse moods, vaginal dryness and sleep difficulties are less likely to get better without ongoing treatment. [2]
Adverse Mood
Adverse moods reported by women in the perimenopausal stage include depression (mood) and anxiety.[14] [15][2] Studies show that anxiety symptoms mainly appear in the late phase of perimenopause[15] and may lead to the onset of depression.[16] In a study, women with both high anxiety and those with low anxiety scores at baseline tend to become highly anxious as they progress through the perimenopausal stage.[15] A study found that Japanese women who had the lowest prevalence of depressive symptoms at baseline showed a sharp upturn in depressive symptoms similar to Hispanic women over time.[17]
Several factors influence the prevalence of depressive symptoms among women in their perimenopausal stage. These factors include stressful life events, financial strain, low educational attainment, High BMI, and vasomotor symptoms.[17] The depression experienced by women in their perimenopausal stage needs to be distinguished from major depression.
Further symptoms
- Vaginal dryness and genitourinary symptoms
- Urinary incontinence
- Reduced libido
- Cognitive complaints (e.g. "brain fog", memory lapses)[1]
Diagnosis
Diagnosis is primarily clinical, based on age, symptom pattern, and changes in menstrual cyclicity. Hormonal blood tests (such as FSH or estradiol) are generally not recommended for diagnosis in women over 45 with typical symptoms, as hormone levels fluctuate substantially from day to day and even within a single cycle, limiting their diagnostic value.[3][1] Testing may be considered in atypical cases, such as suspected premature ovarian insufficiency in women under 40.
Symptom Management
Menopausal hormone therapy is commonly used as a treatment for women who experience symptoms of perimenopause such as hot flashes, sleep disturbance, vaginal dryness and mood changes, and can improve the quality of life.[2][1] Women who experience irregular bleeding may benefit from oral contraceptives and it can also meet the contraceptive needs as pregnancy can occur during perimenopause.[1]
Non-hormonal pharmacological options
- SSRIs and SNRIs for mood symptoms and hot flashes
- Gabapentin and clonidine for vasomotor symptoms
- NK3 receptor antagonists (e.g. fezolinetant), a newer targeted class for hot flashes
Non-pharmacological approaches
- Cognitive behavioral therapy (CBT) for insomnia, mood, and hot flashes[18]
- Weight-bearing and resistance exercise for bone health
- Regular cardiovascular exercise
- Dietary adjustments and weight management
- Stress management techniques
- Avoidance of common triggers such as caffeine, alcohol, and spicy foods
Society and culture
Historically, there has been limited public and clinical information about menopause and the perimenopausal transition, and awareness of perimenopause specifically remains low, although it is a life stage that all women who reach midlife will eventually go through — nearly half the world's population.
Public discussion has expanded in recent years, with growing attention to its impact on quality of life and on workplace participation.[19] Several countries and employers have begun introducing menopause-related workplace policies, including flexible working arrangements, and awareness training.[20]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Lega, Iliana C.; Jacobson, Michelle (2024-10-15). "Perimenopause". Canadian Medical Association Journal. 196 (34): E1169. doi:10.1503/cmaj.240337. ISSN 0820-3946. PMC 11482657 Check
|pmc=value (help). PMID 39406411 Check|pmid=value (help). - ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Santoro, Nanette (2016). "Perimenopause: From Research to Practice". Journal of Women's Health. 25 (4): 332–339. doi:10.1089/jwh.2015.5556. ISSN 1540-9996. PMC 4834516. PMID 26653408.
- ↑ 3.0 3.1 "Menopause: identification and management". www.nice.org.uk. 2015-11-12. Retrieved 2026-06-02.
- ↑ 4.0 4.1 Avis, Nancy E.; Crawford, Sybil L.; Greendale, Gail; Bromberger, Joyce T.; Everson-Rose, Susan A.; Gold, Ellen B.; Hess, Rachel; Joffe, Hadine; Kravitz, Howard M.; Tepper, Ping G.; Thurston, Rebecca C. (2015-04-01). "Duration of Menopausal Vasomotor Symptoms Over the Menopause Transition". JAMA Internal Medicine. 175 (4): 531–539. doi:10.1001/jamainternmed.2014.8063. ISSN 2168-6106. PMC 4433164. PMID 25686030.
- ↑ Reed, Susan D.; Lampe, Johanna W.; Qu, Conghui; Copeland, Wade K.; Gundersen, Gabrielle; Fuller, Sharon; Newton, Katherine M. (2014). "Premenopausal vasomotor symptoms in an ethnically diverse population". Menopause. 21 (2): 153–158. doi:10.1097/GME.0b013e3182952228. ISSN 1072-3714. PMID 23760434.
- ↑ Utian, Wulf H (2005). "Psychosocial and socioeconomic burden of vasomotor symptoms in menopause: A comprehensive review". Health and Quality of Life Outcomes. 3 (1). doi:10.1186/1477-7525-3-47. ISSN 1477-7525. PMC 1190205. PMID 16083502. Unknown parameter
|article-number=ignored (help) - ↑ 7.0 7.1 Freeman, Ellen W.; Sammel, Mary D.; Lin, Hui; Liu, Ziyue; Gracia, Clarisa R. (2011). "Duration of Menopausal Hot Flushes and Associated Risk Factors". Obstetrics & Gynecology. 117 (5): 1095–1104. doi:10.1097/AOG.0b013e318214f0de. ISSN 0029-7844. PMC 3085137. PMID 21508748.
- ↑ Dennerstein, Lorraine; Lehert, Philippe; Guthrie, Janet R.; Burger, Henry G. (2007). "Modeling women's health during the menopausal transition: a longitudinal analysis". Menopause. 14 (1): 53–62. doi:10.1097/01.gme.0000229574.67376.ba. ISSN 1072-3714. PMID 17023873.
- ↑ Ohayon, Maurice M. (2006-06-26). "Severe Hot Flashes Are Associated With Chronic Insomnia". Archives of Internal Medicine. 166 (12): 1262–1268. doi:10.1001/archinte.166.12.1262. ISSN 0003-9926. PMID 16801508.
- ↑ Barnabei, V (2002). "Menopausal symptoms in older women and the effects of treatment with hormone therapy". Obstetrics & Gynecology. 100 (6): 1209–1218. doi:10.1016/S0029-7844(02)02369-4. PMID 12468165.
- ↑ Pastore, Lisa M.; Carter, Rachel A.; Hulka, Barbara S.; Wells, Ellen (2004). "Self-reported urogenital symptoms in postmenopausal women: Women's Health Initiative". Maturitas. 49 (4): 292–303. doi:10.1016/j.maturitas.2004.06.019. PMID 15531125.
- ↑ Santoro, Nanette; Komi, Janne (2009-08-01). "Prevalence and Impact of Vaginal Symptoms Among Postmenopausal Women". The Journal of Sexual Medicine. 6 (8): 2133–2142. doi:10.1111/j.1743-6109.2009.01335.x. ISSN 1743-6109. PMID 19493278.
- ↑ Green, R.; Polotsky, A. J.; Wildman, R. P.; McGinn, A. P.; Lin, J.; Derby, C.; Johnston, J.; Ram, K. T.; Crandall, C. J.; Thurston, R.; Gold, E.; Weiss, G.; Santoro, N. (2010). "Menopausal symptoms within a Hispanic cohort: SWAN, the Study of Women's Health Across the Nation". Climacteric. 13 (4): 376–384. doi:10.3109/13697130903528272. ISSN 1369-7137. PMC 3268678. PMID 20136411.
- ↑ Bromberger, Joyce T.; Matthews, Karen A; Schott, Laura L.; Brockwell, Sarah; Avis, Nancy E.; Kravitz, Howard M.; Everson-Rose, Susan A.; Gold, Ellen B.; Sowers, MaryFran; Randolph, John F. (2007). "Depressive symptoms during the menopausal transition: The Study of Women's Health Across the Nation (SWAN)". Journal of Affective Disorders. 103 (1–3): 267–272. doi:10.1016/j.jad.2007.01.034. PMC 2048765. PMID 17331589.
- ↑ 15.0 15.1 15.2 Bromberger, Joyce T.; Kravitz, Howard M.; Chang, Yuefang; Randolph, John F.; Avis, Nancy E.; Gold, Ellen B.; Matthews, Karen A. (2013). "Does risk for anxiety increase during the menopausal transition? Study of Women's Health Across the Nation". Menopause. 20 (5): 488–495. doi:10.1097/gme.0b013e3182730599. ISSN 1072-3714. PMC 3641149. PMID 23615639.
- ↑ Kravitz, H. M.; Schott, L. L.; Joffe, H.; Cyranowski, J. M.; Bromberger, J. T. (2014). "Do anxiety symptoms predict major depressive disorder in midlife women? The Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS)". Psychological Medicine. 44 (12): 2593–2602. doi:10.1017/S0033291714000075. ISSN 0033-2917. PMC 4135380. PMID 24467997.
- ↑ 17.0 17.1 Bromberger, Joyce T.; Kravitz, Howard M. (2011). "Mood and Menopause: Findings from the Study of Women's Health Across the Nation (SWAN) over 10 Years". Obstetrics and Gynecology Clinics of North America. 38 (3): 609–625. doi:10.1016/j.ogc.2011.05.011. PMC 3197240. PMID 21961723.
- ↑ New Collective, Author (2023-06-01). "The 2023 nonhormone therapy position statement of The North American Menopause Society". Menopause (New York, N.Y.). 30 (6): 573–590. doi:10.1097/GME.0000000000002200. ISSN 1530-0374. PMID 37252752 Check
|pmid=value (help). - ↑ Hickey, Martha; LaCroix, Andrea Z.; Doust, Jennifer; Mishra, Gita D.; Sivakami, Muthusamy; Garlick, Deborah; Hunter, Myra S. (2024-03-09). "An empowerment model for managing menopause". The Lancet. 403 (10430): 947–957. doi:10.1016/S0140-6736(23)02799-X. ISSN 0140-6736. PMID 38458214 Check
|pmid=value (help). - ↑ New Collective, Author (2024-09-01). "Menopause and the workplace: consensus recommendations from The Menopause Society". Menopause (New York, N.Y.). 31 (9): 741–749. doi:10.1097/GME.0000000000002415. ISSN 1530-0374. PMID 39186451 Check
|pmid=value (help).
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