Illustration by Marta Pucci
Menopause and perimenopause 101
What changes happen in the cycle, when, and why?
Top things to know
Menopause is when menstrual cycles end. The average age at menopause is 51 in Western countries, though ethnicity, behavior, and environment may influence menopause timing.
Perimenopause is the transition into menopause. Menstrual changes start, on average, 4 years prior to menopause, though that’s not the case for everyone.
Lifestyle modifications, medications, and supplements may help with uncomfortable menopause changes.
What is menopause?
Menopause is when someone’s menstrual cycles come to an end, and pregnancy is no longer possible. The word menopause is from the Greek root word men, meaning “month” and pausis meaning pause or cessation.
Menopause is a unique experience—humans are 1 of only 4 species on the planet who experience it (1). For some people, it’s both an ending and a beginning. It can bring a lot of new changes, and for some people it might not feel like much of a change at all.
Menopause is a normal life phase, but can also be induced by surgery, drug treatments, or medication. It technically begins after your last menstrual period, but your healthcare provider will consider you to have reached menopause after 12 months without a period (2).
What is perimenopause?
Perimenopause is the body’s transition into menopause (peri comes from the Greek word for “around”). You may not have heard the term before, because people often confuse perimenopause (the transition period) with menopause (the time after your last period).
Perimenopause can be as short as a few months or last up to 8 years. On average, it lasts around 4–5 years (3-6). During perimenopause, hormone levels fluctuate and then decline, giving rise to new sensations, symptoms, and changes. Experiences of perimenopause vary widely across people and cultures.
Why it’s important to know about menopause and perimenopause
Every woman and person with a cycle who goes through the natural aging process will experience these life stages. Despite this, they are still underrepresented in culture and research.
Knowing what changes are possible can help you identify the transition in yourself. Also, because it’s still possible to have or develop reproductive conditions like polycystic ovary syndrome (PCOS) or endometriosis during perimenopause, it’s important to know what the probable signs of perimenopause are, and what symptoms might be signs of something else.
When does perimenopause start? What is the average age of menopause?
The exact start of perimenopause—the transition into menopause—is hard to pinpoint. One study that tracked women as they transitioned into menopause found that menstrual irregularity began on average between ages 47 and 48. But it can begin much earlier or later. In that same study, of those who were still menstruating at age 45, about 1 in 3 reported menstrual irregularity. At age 52, about 1 in 10 reported that they were still menstruating normally (3). There are other perimenopausal changes and symptoms that may be felt before menstrual irregularity begins, which may help in identifying a different starting point of perimenopause, but more research is needed.
Menopause—when periods actually stop— happens on average at age 51, but most people reach it anywhere between ages 45–55 (3,5,7,8). About 4 in 10 women reach menopause by age 50, 9 in 10 will reach it by age 55 (3).
Menopause is considered “early” when before age 45, and “premature” when it happens before age 40. Premature menopause is also sometimes called primary ovarian insufficiency (POI) or premature ovarian failure (not the greatest of terms). About 1 in 100 people experience premature menopause for non-surgical or chemotherapy-related reasons (8-10).
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Early menopause can be caused or influenced by cigarette smoking, certain medications, chemotherapy, and possibly insulin resistance and type 2 diabetes (10,11).
People who have an oophorectomy (removal of the ovaries) will undergo menopause immediately. Sometimes people who have had a hysterectomy (removal of the uterus) will also experience early menopause, even if their ovaries are not removed (9,11). People who have had menopause induced due to surgery, drug treatments, or medication generally do not experience perimenopause, since there is an abrupt stop to their reproductive function. But people with induced menopause may still experience symptoms of menopause.
How long does menopause last? (How long does perimenopause last?)
You might ask: how long does menopause last? Perimenopause is the transition period, and menopause is the time after your last period.
The menstrual cycle irregularities of perimenopause last an average of about 4 years, from the beginning of menstrual irregularity to the last period. But it can last anywhere from a few months to ~8 years (3-6). About 1 in 10 people may experience the transition more abruptly, with only a few months of menstrual irregularity. These people also tend to report fewer symptoms like hot flashes (3).
What can affect the age of menopause?
Smoking: yes.
Hormonal birth control: maybe.
Your genetics, environment, and lifestyle may all play a role in how you experience perimenopause, and the timing of perimenopause and menopause. People who reach menopause later in life tend to have shorter transitions (10). Smokers tend to be slightly younger at perimenopause and have shorter transitions, reaching menopause about a year earlier than average. There are likely other differences due to ethnic background and/or related environmental and behavioral factors, but more research is needed on this topic (12).
A person’s pregnancy history and their history of oral contraceptives (OCs) use might delay menopause. Studies on the topic are mixed—some studies have found an association, and others not—and the biological reason why this would be the case (if true) is not fully understood (5,10,13). Although being pregnant and using OCs suppresses ovulation, they don’t suppress the development (and death) of eggs prior to the point of ovulation, so why using OCs would impact timing of menopause is still unclear.
Menopause symptoms & signs: Physical and emotional changes of perimenopause
Perimenopause is whole-body change. It influences everything in your body that involves estrogen and progesterone, along with other hormones and proteins. Some of these changes and symptoms go away after menopause is reached, and others are longer lasting. Some advocates argue that these changes can be felt well before changes show up in the menstrual cycle, but there is little research on this so far.
The changes during perimenopause and after menopause are caused by the decline in the number of eggs in the ovaries. The menstrual cycle is driven, in part, by the development of eggs. This process impacts our levels of estrogen and progesterone, among other hormones. Once the number of eggs in the ovaries decreases beyond the point when reproductive hormone levels can be maintained, changes start to occur.
It can be difficult to know when ovulation will happen during perimenopause, so use reliable contraception if you are having penis-vagina sex. Getting pregnant becomes more difficult during this time, but it’s still possible.
To get an idea of when you’ve entered perimenopause, track changes to your menstrual cycle, and be aware of other common symptoms and changes you might be experiencing.
Common changes and symptoms in perimenopause include:
Hot flashes (aka hot flushes)
Sweating
Disturbed sleep
Changes in mood and anxiety
Increased forgetfulness
Changes in sexual desire
Vaginal dryness and itchiness
Lowered fertility/infertility
Increased abdominal body fat (14-19).
Lasting physical changes to be aware of include loss of bone density, vaginal dryness, changes in urination function, and changes in sexual function (14,20,21).
Fortunately, the end of menstrual cycles also means the end of any negative symptoms you may have experienced during your cycle, like cramps, as well as the risk of unintended pregnancy.
How the menstrual cycle changes before and during perimenopause
1. At first, you may notice that your period arrives slightly earlier each cycle (ie shorter menstrual cycles) and is heavier.
As you approach perimenopause, your hormone levels begin to change. This happens before your periods become unpredictable. For some people, one of the earliest signs of perimenopause is that their periods arrive slightly earlier—meaning that their menstrual cycle shortens, by ~2–4 days This is due to a shortening of the follicular phase (the first part of the menstrual cycle), as ovulation happens more quickly (19,22-25).
(Note: Cycles can also become shorter for other reasons, so don’t assume you’re entering early menopause if your cycle becomes slightly shorter in your 30s. Average cycle length decreases with age, from about 29 days for people in their 20s, to 26 days for those in their 40s (26,27). Cycles can also become shorter due to a shortening of the luteal phase, caused by any factor leading to a decrease in the ovary’s production of progesterone after ovulation (28).)
During perimenopause, less estrogen is produced. But before perimenopause, estrogen levels can actually rise for a while, and progesterone levels typically decrease (19,29). This is what shortens the follicular phase, and may also cause other changes, symptoms, or sensations. You may notice changes to the heaviness of your period during this time. Lower progesterone—with or without higher estrogen—may also lead to heavier periods, which is more common in early perimenopause (19).
2. Later, you may have irregular cycles and bleeding changes.
As the number of follicles in your ovaries decreases, ovulation becomes less common, and hormone levels start to fluctuate more and more. Menstrual cycles might become longer, and then progressively more variable—longer and shorter, with menstrual periods that are heavier, lighter, and far less predictable (19,23,30,31).
The heaviness of your period will also fluctuate. Cycles without ovulation may have lighter periods, while periods that come after a long cycle may be long (32). On average, about 6 of the final 10 cycles before menopause are prolonged and anovulatory (where ovulation doesn’t occur) (33). In the 1-2 years before menopause, it’s common for cycles to last more than 5 weeks (31,33).
3. No period, period.
As ovulation becomes rare, your period might go away for months at a time, and then return (6). This phase lasts between 1-3 years for most people, but again, everyone is different (6). Eventually, menopause is reached, and cycles comes to an end, along with the period.
About 1 in 10 people may stop menstruating more abruptly, with much less prolonged irregularity (3).
Menopause treatments: How can I manage symptoms of menopause and perimenopause?
You might have searched for “menopause treatment.” Quick reminder: perimenopause is the transition period before menopause. It is a normal function of the body, but some of the changes it causes can feel uncomfortable, or even rageful.
If you are experiencing symptoms that affect your quality of life, such as hot flashes, vaginal dryness, changes in mood, or difficulty sleeping, seeing a healthcare provider or a perimenopause specialist can be a good idea.
Lifestyle changes for menopause symptoms
There are some simple changes you can make in your lifestyle to help you cope with menopausal symptoms.
Some dietary adjustments may be helpful, (see below and in the supplementation section), but there is no known “menopause diet” to provide guaranteed menopausal symptom relief. Much more research is needed to understand what lifestyle changes may be useful treatments for menopausal symptoms.
Some first steps that may be helpful:
Prepare for hot flashes
Dressing in layers and having cool water and beverages available to you may help with managing hot flashes (21).
Drink in moderation
Drinking less than 1 drink per day probably doesn’t decrease rates of hot flashes, but the effects of drinking higher amounts of alcohol are unclear, and may worsen symptoms—you’ll have to see what’s true for you (34).
Exercise
Exercise has been found to be beneficial for overall wellbeing during and after perimenopause. Studies have also found that exercise, particularly aerobic exercise might reduce hot flashes, though the effect is small if it exists (35). A recent study that looked specifically at resistance training (i.e. lifting weights) also decreased the frequency of hot flashes (36).
Stop smoking
Smoking has been linked to increased hot flashes and night sweats (34).
Maintain a healthy weight
This may help to protect against hot flashes and night sweats, since people with heavier body masses tend towards having more frequent symptoms (34).
Invest in personal lubricant and vaginal moisturizer
These will be helpful for relieving symptoms of vaginal dryness and pain during sex (37,38).
Hormone replacement therapy (HRT) for menopause symptoms
Hormone replacement therapy (HRT), also called hormone therapy, is sometimes prescribed during or after the menopausal transition to help relieve certain symptoms, like hot flashes, night sweats, and vaginal dryness. HRT involves taking synthetic or “bioidentical” forms of estrogen and often synthetic progesterone. “Systemic” HRT goes throughout the whole body and can be taken in several forms, like pill, patch, gels, creams, and sprays. For people who are only experiencing vaginal symptoms, “local” HT used inside the vagina in the form of a cream, ring, or tablet may be recommended (21,39).
Also, data suggest that systemic HRT lowers the risk of osteoporosis, coronary heart disease (CHD) and overall mortality in people who take it around menopause, particularly for those who have had a hysterectomy and use estrogen-only HRT, but more information is needed (39.
Systemic HRT also carries risks, including an increased chance of developing breast cancer, stroke, and blood clots (39-41). Risks vary by whether your form of HRT contains a progestin or not (39). Also, the risk of negative effects increases when people begin taking it after menopause, particularly 10 or more years from menopausal onset (39,40). The U.S. Federal Drug Administration (FDA) currently recommends that people who choose HRT take it “at the lowest dose that helps and for the shortest time” (41).
(We have a whole article on HRT and different risks here.)
During perimenopause, some healthcare providers may also suggest using hormonal contraceptives to help manage abnormal bleeding and some other symptoms. Hormonal contraceptives can also help prevent unintended pregnancies, which are still possible during perimenopause.
Non-hormonal medications for menopause symptoms
Certain medications that are primarily used to treat depression, high blood pressure, and seizures—SSRIs, SSNRIs, clonodine, and gabapentin—have been found to also be effective in reducing hot flashes, although they may be less effective than HRT (21).
There is also a type of medication called selective estrogen receptor modulators (SERMs) which are non-hormonal, but have effects similar to estrogen on certain parts of the body. One SERM, Ospemifene, is approved to treat painful sex caused by vaginal dryness (21,42).
Similarly, a combination medication containing estrogen and a SERM, called Duavee, is used to treat hot flashes and prevent osteoporosis (weakened bones due to low density) (43).
These medications can have unwanted side effects, so it's important to have a discussion with your healthcare provider about benefits and risks.
Alternative and “natural” treatments and supplements for menopause symptoms
There is no scientific consensus on the benefits or risks of any complementary or alternative treatment for menopausal symptoms. Many small trials may show individual benefits, but when data from multiple studies is analysed together the results are difficult to draw conclusions from (44). This important area of research is greatly underfunded, leaving people to test things on their own, or take other routes.
Some examples of treatments that have been explored:
Acupuncture for perimenopause and menopause
Acupuncture treatments seems to provide little to no effect on menopausal symptoms, though for some people it may be better than no treatment at all.
Body mindfulness for perimenopause and menopause
Body mindfulness therapies like relaxation and breathing techniques may be helpful at providing some relief for hot flashes and are not harmful to try.
Supplements for perimenopause and menopause
Plant and dietary supplements have mixed and unclear results, including Black cohosh (Actaea racemosa/Cimicifuga racemosa) a popular herb often prescribed for menopausal symptoms is not effective at relieving hot flashes. Phytoestrogens such as those found in soy may provide some benefit to relieving hot flashes and vaginal dryness, but no do help with night sweats (44-50). We’ll be writing more on current “natural” approaches to perimenopause symptom treatment.
Using dietary supplements can also have negative side effects, and some supplements may interact with other medications, so speak with your healthcare provider before treating your perimenopausal symptoms with supplements.
When should I see a healthcare provider?
During perimenopause and menopause, talk to your healthcare provider if:
You are concerned about the heaviness or length of your period
You begin to bleed between periods, especially if you have a history of polycystic ovary syndrome (PCOS), are higher weight, have a family history of uterine cancer, or have taken estrogen-only hormone therapy or certain medications to prevent breast cancer .
You experience any spotting or bleeding after reaching full menopause
You experience bleeding during penetrative sex (2,51,52)
Abnormal bleeding during perimenopause
Although changes in bleeding are to be expected during perimenopause, some bleeding changes may be caused by abnormal changes to your endometrium (i.e. the lining of your uterus). If the endometrium becomes too thick and irregular, it can develop into cancer, but this can usually be prevented if caught early (2).
Abnormal bleeding after menopause
In some cases, bleeding continues after menopause. It is easy to mistake this type of bleeding for symptoms of perimenopause, which may mislead someone to think they have not reached full-menopause when they actually have.
Any spotting or bleeding after menopause is abnormal and should be checked out by a healthcare provider (2). Spotting or bleeding after menopause can be caused by a medical condition, such as uterine polyps (2). Uterine polyps are growths on the inside lining of the uterus (the endometrium), and become more common with age (53).
