If you are in your 40s and your periods have started to change, your sleep is worse and your mood is shorter than it used to be, you may be in perimenopause. Many people in Raleigh, Durham, Chapel Hill and Cary reach this stage while they are also raising kids, caring for parents and running a job. That is a lot to carry while your hormones shift.
This guide explains what perimenopause is, what the symptoms look like, which everyday changes have the most support, and where hormone therapy fits. It is general education, not medical advice. Your own doctor is the right person to sort out what is going on in your body.
What is perimenopause?
Perimenopause is the transition before menopause, when your ovaries make less estrogen and progesterone and the levels rise and fall unevenly.13 Mayo Clinic says many of the changes you notice are caused by lower estrogen.3 Menopause is the point when your periods have stopped for 12 months in a row, and perimenopause is over at that point.3
The National Institute on Aging (NIA) says menopause is not a disease. It is a normal part of aging for women.1 Some women have no symptoms or only mild ones. Others have many symptoms that can be severe.5
You may also hear it called the menopausal transition. The words mean the same stretch of time.13
When does perimenopause start, and how long does it last?
Perimenopause often starts in the mid-40s. Cleveland Clinic says it may begin as early as the mid-30s or as late as the mid-50s.2 The NIA says most women begin the transition between ages 45 and 55, and the average age of menopause in the United States is 52.1 ACOG puts the average age at 51.5
How long it lasts varies. Cleveland Clinic gives an average of about four years, and says it can last up to eight.2 The NIA says symptoms can last between two and eight years, and that timing is highly variable.1
Some things can bring it on earlier. Mayo Clinic lists smoking, which it says brings menopause 1 to 2 years earlier, a family history of early menopause, cancer therapy such as chemotherapy or pelvic radiation, and some surgeries on the uterus or ovaries.3 Mayo Clinic also notes that thyroid disease and some autoimmune conditions may make early menopause more likely.3
There is no single test that says "you are in perimenopause." The NIA says your doctor will often ask about your age, symptoms and family history. A blood test for hormone levels may be used in some cases, for example if periods stopped at an early age.1
What are the most common symptoms?
The most common signs are changes in your period, hot flashes and night sweats, sleep problems, and mood changes. The list below comes from Mayo Clinic, Cleveland Clinic, the NIA and The Menopause Society. You may have a few of these, many of them, or none.1234
| What you may notice | What it can look like |
|---|---|
| Cycle changes | Periods that are longer, shorter, lighter, heavier or skipped. Mayo Clinic says a cycle length that is consistently different by seven days or more may mean early perimenopause, and 60 days or more between periods suggests late perimenopause.3 |
| Hot flashes and night sweats | A sudden feeling of heat in the face and upper body. The Menopause Society says up to 80% of women have them at some point in the transition, and each one usually lasts 1 to 5 minutes.4 |
| Sleep problems | Trouble falling asleep or waking early. Mayo Clinic says sleep changes can happen even without hot flashes or night sweats.3 |
| Mood changes | Irritability, mood swings or a higher risk of depression. Mayo Clinic says people who have had depression or anxiety before are also at higher risk.3 |
| Brain fog | Forgetfulness and trouble focusing. The Menopause Society says 40 to 60 percent of midlife women report such symptoms, and that the changes are typically mild.4 |
| Body changes | The NIA says your waist could get larger, you could lose muscle and gain fat, and joints and muscles could feel stiff and achy.1 |
| Vaginal and bladder changes | Dryness, pain during sex, and leaking or urgency. Mayo Clinic links these to lower estrogen.3 |
Fatigue sits on top of many of these. Night sweats can wake you, and ACOG says they may leave you feeling tired and sluggish the next day.5 If tiredness is your main complaint, read our guide to perimenopause fatigue. Tiredness has other causes too, which we cover in why women feel always tired.
Not every change at midlife comes from hormones. The NIA says some changes may be part of aging rather than directly related to menopause.1 Stress is also real at this age. If you wonder whether stress hormones are to blame for how you feel, our article on high cortisol symptoms in women separates the medical condition from the social media label.
What lifestyle changes can help?
The health groups quoted below suggest regular sleep habits, regular movement that includes strength work, balanced meals, less alcohol and some way to unwind. None of these removes symptoms for everyone, and the evidence behind each one differs. They are a reasonable base, and they work alongside whatever your doctor suggests.
Sleep. The NIA suggests a regular sleep schedule, a bedtime routine, a comfortable bedroom temperature, no caffeine late in the day, and no screens in the bedroom. It also says alcohol will not help you sleep, because even small amounts make it harder to stay asleep.7 If those changes are not enough, the NIA says cognitive behavioral therapy for insomnia has been shown to help sleep in women with menopausal symptoms. Ask your doctor about it.7 The NIA also notes that night sweats and low mood can both disrupt sleep, so easing them may help sleep too.7
Movement and strength. Cleveland Clinic suggests weight-bearing exercise such as walking, hiking or strength training.2 ACOG says regular exercise slows bone loss, and that bone loss speeds up in the first 4 to 8 years after menopause.5 The CDC says adults who are not active can work up to 150 minutes a week of moderate activity, and that muscle-strengthening activities help you keep muscle mass and strength.10
Food. Cleveland Clinic suggests plenty of fruits, vegetables, whole grains, lean protein and healthy fats.2 ACOG adds that a balanced diet with enough calcium and vitamin D helps keep bones strong.5 The Menopause Society says that for women who carry extra weight, losing as little as 3% of body weight can improve health markers such as cholesterol.4
Alcohol and caffeine. The NIA says avoiding alcohol, spicy foods and caffeine may help hot flashes, because these can make menopausal symptoms worse.6 The Menopause Society is more cautious. It lists trigger avoidance among measures that have limited solid data.9 A fair way to use this: notice your own triggers and keep a short log, rather than cutting everything at once.
Stress. The CDC lists simple steps such as deep breathing, stretching, spending time outdoors, connecting with people you trust, and getting enough sleep.11 Cleveland Clinic also suggests stress management such as meditation.2
If you try one thing first, pick the one that is easiest to keep. I start people with one change, not ten.
What about hormone therapy?
Hormone therapy is an option many women ask about, and the decision is one to make with your own doctor. Nothing here is a recommendation for or against it. The aim is to show you what the major medical groups say so you can have a better conversation.
What it is. ACOG explains that hormone therapy means estrogen and, if you still have a uterus, a progestin to lower the risk of uterine cancer from estrogen alone.5 It comes as pills, patches, gels, sprays, and vaginal products.5
What it can do. ACOG says systemic estrogen therapy has been shown to be the best option for relieving hot flashes and night sweats, and that systemic estrogen protects against the bone loss of early menopause.5 The Menopause Society calls it FDA-approved as a first-line therapy for bothersome hot flashes and says the benefits outweigh the risks most clearly when it is used in early menopause.8
What the risks are. The NIA lists increased risk of heart attack, stroke, blood clots, breast cancer, gallbladder disease and dementia, and says the risks vary by age and by whether you have had a hysterectomy.6 ACOG describes some of these as small increased risks, and says patches and other forms not taken by mouth may carry less clot risk than pills.5 The Menopause Society says the risk of breast cancer usually does not rise until after about 5 years with estrogen plus progestogen.8
Timing matters. In 2002, an NIH-funded study called the Women's Health Initiative was stopped early over higher risks, which made many women wary.6 The NIA says later research found younger women have less risk and more potential benefit than that study suggested, and that most of the harm was seen in women over 60.6 The Menopause Society says experts agree it helps moderate to severe symptoms when started within 10 years of menopause onset or under age 60.8
Who should not use it. The Menopause Society says women with breast cancer, uterine cancer, unexplained uterine bleeding, liver disease, a history of blood clots or cardiovascular disease generally should not use it.8 That is one reason your own history matters.
If you do not want hormones. The Menopause Society says two nonhormone medicines are approved by the FDA for hot flashes, a low dose of paroxetine and fezolinetant. It also lists low-risk measures such as weight loss, cognitive behavioral therapy and clinical hypnosis for hot flashes.9 We go through herbs, supplements and other options, with what the evidence does and does not show, in natural remedies for menopause.
The NIA says to discuss your symptoms, family and medical history, and preferences with your doctor, and to see your doctor every year to review your plan.1 If you decide to start hormone therapy, the NIA says it should be used at the lowest dose and for the shortest time it stays effective, with a doctor involved.6
What does a naturopathic conversation cover?
A naturopathic conversation looks at the whole of your daily life, not only your hormones. I look at what the garden around you needs: the Soil (food), the Roots (stress), the Rhythm (sleep and energy), the Ground (time outside and movement) and the Circle (the people around you). The goal is to find patterns you can bring to your own doctor and one change you can keep.
It works alongside your doctor, not in place of your doctor. I never ask anyone to stop a medicine. If you take hormone therapy, a thyroid medicine or anything else, any change in it is between you and the doctor who prescribed it.
In practice that can mean writing down for two weeks when you sleep, when hot flashes hit, what you eat and drink, and how your energy moves through the day. The NIA suggests the same idea: note what triggers your hot flashes and how much they bother you, so you can make better decisions about managing them.6 That log is also useful at a doctor's visit.
To see which part of daily life to look at first, you can take the Garden Check-in. It takes about three minutes. If you would like to talk it through, read about a naturopathic consultation.
When should you see your own doctor?
See your own doctor if symptoms are unbearable or get in the way of your life, and see them promptly for unusual bleeding. Cleveland Clinic advises seeing a provider to rule out other causes of bleeding if any of these apply:2
- You change pads or tampons every one to two hours.
- Your periods are very heavy or contain large blood clots.
- Your periods last several days longer than usual.
- You have spotting or bleeding between periods, or bleeding after sex.
- Your periods come less than 21 days apart.
Mayo Clinic adds one more. If you go 12 months without a period and then start bleeding, talk to your healthcare professional right away, because this could be a sign of a health issue.3 ACOG says changes in bleeding are normal in perimenopause, and still should be reported to your health care professional, since abnormal bleeding may be a sign of a problem.5
Also talk with your doctor if low mood does not lift, if sleep stays poor for weeks, or if you are not sure whether your symptoms come from perimenopause or something else. Our guide to perimenopause fatigue covers what your doctor may check.
Emergency, call 911: chest pain, severe shortness of breath, fainting, or bleeding that soaks through your clothes and will not slow down.
Crisis, call or text 988: if low mood comes with thoughts of harming yourself, call or text 988, the 988 Suicide & Crisis Lifeline. It is free and open all day and every day.11 If your life is in danger, call 911.
This page is for education. It does not replace advice from your own doctor.