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What no one tells you about perimenopause?


Perimenopause is the transitional time around menopause. Menopause is when a woman’s periods stop. It’s marked by changes in the menstrual cycle, along with other physical and emotional symptoms. This time can last 2 to 10 years. During this time, your body:

  • Releases eggs less regularly
  • Produces less estrogen and other hormones
  • Becomes less fertile
  • Has shorter and more irregular menstrual cycles

What causes perimenopause?

Perimenopause is a natural process caused when your ovaries gradually stop working. Ovulation may become erratic and then stop. The menstrual cycle lengthens and flow may become irregular before your final period.

Symptoms are caused by the changing levels of hormones in the body. When estrogen is higher, you may have symptoms like you might have with PMS. When estrogen is low, you may have hot flashes or night sweats. These hormone changes may be mixed with normal cycles.

What are the symptoms of perimenopause?

No two women will experience perimenopause in the same way. These are the most common symptoms:

  • Mood changes
  • Changes in sexual desire
  • Trouble concentrating
  • Headaches
  • Night sweats
  • Hot flashes
  • Vaginal dryness
  • Trouble with sleep
  • Joint and muscle aches
  • Heavy sweating
  • Having to pee often
  • PMS-like symptoms

The symptoms of perimenopause may look like other conditions. Always talk with your healthcare provider for a diagnosis.

How is perimenopause diagnosed?

Sometimes it’s hard to tell if you are having symptoms of perimenopause. Your symptoms, medical history, age, and a physical exam may help your healthcare provider with the diagnosis. You may also have blood tests to measure your hormone levels.

How is perimenopause treated?

Perimenopause does not need to be treated unless symptoms are bothersome. Treatments may include:

  • Hormone therapy using estrogen or estrogen and progestins to level out hormone levels
  • Antidepressants to stabilize moods

Your healthcare provider may suggest other lifestyle changes:

  • Eat a healthy diet with fruits and vegetables and whole grains.
  • Get at least 1,000-1,200 mg of calcium each day through your diet or supplements.
  • Exercise regularly.
  • Find what triggers your hot flashes (for example, alcohol, coffee or tea) by keeping a record.

Discuss the use of other treatments in relieving symptoms with your healthcare provider.

You may hear about herbal supplements that claim to help manage hot flashes. It’s important to remember that the FDA does not regulate these supplements. They are not tested like traditional medicines to prove their effectiveness and safety.

Talk to your healthcare provider before using any herbal supplements.

Key points about perimenopause

  • Perimenopause is the time around menopause when your ovaries gradually stop working.
  • This is a natural process that causes physical and emotional symptoms.
  • It does not need treatment, but treatment can help lessen symptoms.
  • Treatment includes hormones, antidepressants, and lifestyle changes.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down questions you want answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.

Find a Doctor

  • Gynecology and Obstetrics
  • Amenorrhea
  • Abnormal Pap Smear

At Another Johns Hopkins Member Hospital:

  • Howard County General Hospital
  • Sibley Memorial Hospital
  • Suburban Hospital

Find a Treatment Center

Find Additional Treatment Centers at:

  • Howard County General Hospital
  • Sibley Memorial Hospital
  • Suburban Hospital

Crazy Periods, Pimples And ‘Superfeelings.’ Welcome To F-cking Perimenopause

We’re stumbling around in a brain fog, desperate for sleep, furious with our partners, wondering just how much blood it’s possible to lose before dying. Must we white-knuckle it for the next few years?

Kate Rae Updated August 19, 2022

Overhead shot of a stack of books, glasses, and an empty glass of water. Top book on stack says

Illustration, Jeannie Phan.

I love invitations to sunny afternoon barbecues, and so last summer I happily prepped a salad I’d been wanting to try. I carefully sliced the napa cabbage, lovingly roasted the pistachios and was placing it all on a platter when my 11- year-old stepson looked at it skeptically and said, “I don’t think anyone’s going to eat that.” Normally I would have mentally given him the finger and shrugged it off. Oh, but not that day. Mortally wounded, I stormed to my bed, where I spent the next four hours sobbing so hard I gave myself a migraine.

When my family came home from the barbecue (where people did, in fact, happily eat the salad, just FYI), my worried husband softly (and, let’s agree here, oh-so-bravely) came into the room to see if I was okay. “I just…maybe we should…do you think it could be…can we maybe…is it possible that….”

“ARE YOU SUGGESTING I MIGHT BE GETTING MY PERIOD?!” I, well, snarled is the only word I can use here. I checked my Clue app just to prove him wrong, and…huh, what do you know…. Overnight, my usually mild PMS crabbiness had taken things up a notch, turning into something bigger. With claws. And I felt a sudden need to resurrect arguments from years ago. P.S., Why the hell is there a backpack in the middle of the hall? So this is 47?

Well, welcome to f-cking perimenopause, a.k.a. perif-ckingmenopause. It’s not a syndrome or an illness. It’s the stage of life leading up to menopause, which only officially happens once you’ve gone a full year without a period—the North American average is age 51—unless it’s caused by surgical removal of the ovaries.

Basically, in the buildup to “The Change” (as our grandmothers quietly called it), our ovaries are going out of business and firing all their employees, and they’re not going gracefully, taking down your sleep, your moods, your sex life and your skin as they storm out of the building. And BTW, it can all start in your 30s and last up to a decade. But while our grandmothers had to just grit their teeth and suck it up, propriety is now thankfully out the window, and we can actually talk about what the hell is happening to us.

Okay, so what is going on?

Our two main hormones—estrogen and progesterone—made their dramatic entrance when we hit puberty, and now the old ovary factory where they’re made is winding things down, so all that hormonal upheaval you went through during your early teens is happening again, in reverse. Only now, instead of worrying about math class and sorting your scented pens, you’ve got adult stressors, including aging parents, a demanding career and maybe even hormonal teens of your own. Sure, some women’s estrogen and progesterone elegantly and gradually slip away, holding hands like sleeping otters. Then there are the rest of us, whose hormones crash and dip and swoop like a couple of fighting rabid bats. (Experts don’t know why some women have an easier time of it, though lifestyle may play a role.)

With its perplexing symptoms and unbearably long timeline, perimenopause is the most complex life stage we’ll go through, says JoAnn Pinkerton, an ob-gyn in Charlottesville, Virginia, and the executive director of the North American Menopause Society, a non-profit that provides resources to health-care professionals and women. Estimates have 80 percent of us experiencing insomnia; 70 percent, irritability; and 20 percent, depression (and yeah, obviously you can have more than one symptom at a time). That’s a lot of us going through a rough time. But on a positive note: There’s a truckload of help out there.

Periods on the loose

Feeling like your periods are a bit boring? Great news! Sure, during perimenopause, your periods can get lighter and less frequent, but they can suddenly go rogue and last for 12 days and come every 13 days—and they can get heavy. Like really, really heavy.

For 47-year-old Jane, who works in publishing in Toronto, they became set-an-alarm-for-every-hour-in-the-night heavy, walk-down-the-street-and-feel-like-your-water-burst heavy. (The medical term for these superperiods is menorrhagia, which means your flow is 80 millilitres, or 16 soaked pads or tampons per period. An average flow is 30 millilitres, or two tablespoons.) An ultrasound revealed Jane had a polyp (which are more likely to develop in your 40s and 50s), and once that was removed, things calmed down a bit. But still, she says, “I have to plan long drives, vacations and cottage visits according to my period schedule—sleeping on someone else’s white sheets while I’m menstruating is out of the question.”

For menorrhagia that occurs during perimenopause, we can mostly thank a hormone imbalance, namely low progesterone. It is estrogen’s designated driver, the friend who steps in when things are getting out of hand. But as progesterone naturally declines in perimenopause, estrogen can get unruly. One of progesterone’s jobs is to keep tabs on our uterine lining—without progesterone that lining will thicken and grow unabated throughout the month.

If you’re a candidate for the pill, it might be a good option—the added progestin (a synthetic form of progesterone) will help even out your periods. Hormonal IUDs like Mirena or Jaydess that deliver progestin and suppress ovulation are a possibility too, although Pinkerton cautions that some women experience an adjustment period that can involve spotting and cramps for a few months. A bonus with both options is that birth control is taken off your to-do list. (You can still get pregnant when you’re in peri.) If your uterus is wreaking havoc, make sure to discuss next steps with your doctor. You also want to keep an eye on your iron levels and supplement if needed.

Premenstrual moodiness—or, perhaps one should keep one’s thoughts on salad to oneself

“I call these our superfeeling times,” says Agnes Wainman, a registered psychologist in London, Ont. That’s a very nice way to describe the emotional train wreck PMS can bring on. She recommends tracking your moods and cycles using an app. Once you get a sense of when your superfeeling times are, plan accordingly and clear the decks as much as possible. “Now is not the time to overschedule or have difficult conversations or try to solve big problems,” says Wainman. No confronting your mother-in-law over a perceived slight or talking to your co-worker about his throat clearing. And take a break from social media if you need to. “The last thing you need is to see someone making star-shaped sandwiches for her kids before heading to the gym with the #bosslady hashtag,” she says.

When it comes to getting support from trusted friends, a doctor or a therapist, don’t wait until you’ve hit the wall. “Recognize when you’re running head first toward it and reach out,” she says.

Treatment options are individualized and can include talk therapy, anti-depressants and hormonal replacement therapy (HRT). It’s crucial to track to see if your symptoms are worsening, too. It could be that your PMS has become PMDD (premenstrual dysphoric disorder), a rare and severe form of PMS that can affect your ability to work or care for your children. “PMDD can be very complex and requires an attentive doctor,” says Pinkerton.

Many women in perimenopause also experience the dreaded brain fog (I originally wrote “brian fog” here, and I leave that for you as supporting evidence). For all of us who laughed at our moms for putting their keys in the freezer, well, who’s laughing now?

Wait, so now I can’t sleep, either?

Swoopy hormone levels, increased anxiety and occasional night sweats can mean sleep gets tricky during perimenopause, too. “I’ll wake up in the night and start thinking about something not important, and it’s like a skipping record I can’t move past,” is how Alex, 49, describes most of her time in bed. “I’m just ruminating all night and a foggy mess the next day.” A visit to her doctor yielded a prescription for Ativan, which she takes when she needs a solid night’s sleep, because, as we all know, insomnia exacerbates every other problem we’re having. “If sleep isn’t going well, nothing is going well,” says Wainman. (I call my own restless nights “skin-strippingly bad,” leaving me to tackle the next day without any armour.)

“A lack of sleep leads to a lack of ability to cope,” agrees Pinkerton, who suggests examining your sleep hygiene. (You’re not still looking at your phone in bed, are you?) “I tend to encourage women to avoid sleep aids, which can be addictive, though you and your doctor may decide their benefits outweigh the risks,” she says.

Did I accidentally line my vagina with cotton balls?

At 56, Karen is just now learning about perimenopause, and the upheaval of her 40s is finally making a lot more sense. “I honestly just thought I was going crazy.” Her marriage ended in that time, and one of the contributing factors was a sharp plunge in her libido, brought on partly by vaginal dryness and the ensuing painful sex. “I had no idea what was going on or why. I considered lube, but a friend told me that was ‘just for porn stars.’”

The good news is that intervention for dryness (which can be caused by low estrogen levels) is pretty simple—vitamin E oil can help, or you can use an over-the-counter vaginal moisturizer (look for Replens or Zestica). And if you feel up to having intercourse or using toys, please do reach for the lube. (Karen’s new boyfriend just casually showed up with a bottle early in their relationship. Her one-word review: “Whoa.”) There are two main types—water-based, which are safe to use with toys and condoms but can dry out quickly, and silicone-based, which stay slippery longer but will damage any silicone toys. If you’re prone to yeast infections, look for one that’s glycerine-free.

On an emotional level, losing your natural ability to lubricate may come with some complicated feelings, too. “You—and your partner—might worry that you’re no longer attracted to them or that sex is never going to be pleasurable again,” says Wainman. “Remember, though, that lubrication isn’t the only way to tell if you’re turned on and means nothing about the quality of the sex—or of your body.” Keep communicating with your partner about what’s going on for you and what you need. “It’s not just one conversation,” she says.

Less natural lubricant can be a sign of thinning vaginal walls and skin, and it can affect more than your sex life—it can cause discomfort and itching, and the skin can tear more easily, making you susceptible to infections. It’s all part of what’s called the genitourinary syndrome of menopause, which includes vaginal and bladder symptoms. “There are many therapies to help, including locally applied estrogen creams,” says Pinkerton. “But if women don’t tell their provider about their symptoms and providers don’t ask—which is common—then the vaginal problems worsen.” As awkward as it might feel, it’s up to you to start the discussion.

Oh, yes, a huge breakout is exactly what I need right now, thanks

For Sarah, 47, perimenopause is going after her skin. “I really love it when a pimple crops up, like right in the middle of a frown line. My daughter said, ‘Mom, the pimples make you look like a teenager,’ so at least there’s that?”

Add a newly sprung chin hair to that wrinkle and pimple party, and you’ve got the perimenopausal trifecta, says Julia Carroll, a Toronto dermatologist. “Hormonal acne classically presents as a ‘beard’ of acne on your jawline, chin and neck, plus life just kind of catches up to our skin at this time.”

One option for tackling acne and wrinkles at the same time is retinol, made from vitamin A. “It can cause some peeling, so you want to make sure you’re using the right formulation for your skin,” says Carroll. Your dermatologist can help you find the correct one, or try a non-prescription option, available in formulations ranging from 0.25% to 1%.

Carroll also recommends spironolactone, a prescription oral medication, which works by blocking some hormones—specifically androgens, which can surge at this time—that cause acne. It’s used in higher doses to lower blood pressure, which can be a bonus for your heart health but means you should be monitored by a doctor while you’re taking it. It might take a few months to see a difference.

You may have also noticed an increase in skin tags, as well as some waxy, stuck-on bumps called seborrheic keratoses. They most commonly crop up on areas that don’t see the sun, like under your breasts or arms and on your trunk. “It’s so ingrained in us to see our doctor if we get new moles, which is totally important,” Carroll says. “The good news is that these ones are harmless. We can always remove them, but they’ll probably come back.”

We’re going to get through this

When it feels like life is collapsing, it’s always a good idea to go back to the cornerstones of our health: sleep, food, exercise and stress. Tweaking all of those has helped me. I’ve gotten more on top of my sleep thanks to a weighted blanket and melatonin. I’ve cut down on sugar because it’s been making me feel weird. I adopted a smiley dog who wags her tail every time I walk into the room and gets me walking. I started taking different classes—pottery to get me out of my head; stand-up to make me laugh again. And there have been a lot of conversations with my husband and kids about emotional labour and how I need to feel taken care of—especially during my superfeeling times. I’m not at the HRT stage yet, but I have zero qualms about talking to my doctor if and when things start getting tricky again.

Transitions are, by nature, incredibly uncomfortable. And this is a big one. We all have to keep talking and sharing information as we move along the conveyor belt. Just as we’d check in with a new mom to see how she’s faring, let’s make sure to keep tabs on one another at this tricky stage, too.

Posted August 2019, updated August 2022.

The Weird Perimenopause Symptoms No One Tells You About

Weird Perimenopause Symptoms

The signs of perimenopause differ from woman to woman. Even many OB-GYNs aren’t as familiar with the hormone fluctuations marking the end of fertility as perhaps they should be. To add to the confusion, the symptoms of both perimenopause and early menopause often overlap in women as early as their 30s or as late as their 50s. From strange itches to brittle nails, there are weird perimenopause symptoms you might never have heard about that are actually totally normal!

Rapid Heartbeat

Woman Talking with Doctor

Hormone fluctuations can bring with it heartbeat fluctuations. At first, that fluttery feeling in your chest can be startling. Some women also experience them as a sudden, pounding heartbeat, with a bit of an adrenaline burst thrown in!

Naturally, anything having to do with your heart provokes anxiety. If you’re concerned, go in for a physical, especially if you’re overdue. In general, however, if you don’t pass out and the feeling passes after a few minutes, occasional palpitations are probably just part of your transitional experience.

Crazy-Heavy Periods, Super-Light Periods and Everything in Between

For the average woman in her teens to late 40s, a typical menstrual cycle will include a few days of mild to moderate PMS symptoms, followed by several days of bleeding. But once you enter perimenopause, all bets are off. You might go several months without a period or have them much closer together than normal.

Some of your periods might look more like spotting. Others might involve such a heavy flow, with large clots, that you wonder if your stash of feminine hygiene products will hold out.

If you go about two months without a period, you’re considered in late perimenopause. Once you reach the 12-month milestone, you’ve probably reached menopause. That can be disconcerting if you weren’t expecting to reach that stage so soon. The good news? Those unpredictable periods, as well as any intense PMS symptoms, will now be behind you.

Embarrassing Leaks

Unfortunately, incontinence isn’t just for old people. A bit of leaking can actually start making itself known during perimenopause. That’s because hormonal changes make your bladder walls less toned. That means that not only will sneezing trigger a leak, but even not getting to the toilet quickly enough can make for an uncomfortable situation. If you’re a swimmer or a lover of long baths, you may notice leaking as you emerge from the water.

Protective pads or undergarments offer immediate protection. Longer term, add Kegel exercises to tone up your pelvic muscles. If you’ve never done them, Kegels are performed by tightening up your pelvic muscles for a couple of seconds, releasing them, then tightening them again — for about 10 repetitions. If you’re not sure if you’re clenching the right muscles, try to stop the flow of urine when you’re seated at the toilet. Those are the same muscles you want to hold and release while doing Kegels. Work up to about 10 reps, five times a day.

Uncomfortable Sex

There’s often discussion about older women and vaginal dryness, but the related problems can actually start much earlier. Vaginal tissue may already be thinning during perimenopause. They also lose their elasticity. These factors, as well as the possible diminishing of lubrication, can add up to pain during intercourse.

Kegels can help with this problem as well by offering much-needed toning. Lubrication products can also be helpful during sex. And don’t be too shy to ask your partner to help you experiment with more comfortable positions. Variety is the spice of life, after all!

Feeling “Deflated”

We hear a lot about sagging breasts as we age, but decreased estrogen also leads to breasts that aren’t as full as they once were. Some women may even go down a cup size.

If the flattening is really pronounced, you may feel better with padded cups. Otherwise, simply shopping at a store which offers customized bra measurements can make a world of difference. It may cost a bit more, but the result is much more comfortable, and flattering, undergarments.

Itchy Boobs

Hormone fluctuations can cause itching everywhere. But many women experience the sensations in their nipples and breasts for the first time during perimenopause. The delicate skin of your breasts, especially when you’re wearing a constricting bra, is naturally prone to irritation.

Oatmeal-based moisturizers can help. In addition, try to eat more citrus and other Vitamin C foods. This nutrient helps repair and heal irritated skin.

Brittle Nails

Fish Oil Pill

Lowered estrogen often has a dehydrating effect on the whole body. Among the unexpected effects? Ridged, brittle nails that tend to split more easily. The dryness will also tend to make the nails seem cloudier, and less pinkish.

Supplements like biotin and fish oil pills can be helpful in strengthening nails. Include more fish in your diet, too, and ease off the salty junk foods to minimize the dehydration!

Thinning Hair

Decreased estrogen also tends to suck the moisture out of your hair. This translates to thinning, split ends and breakage. If you’re finding more hair in your hairbrush than normal—or more strands pull away when you undo your messy bun—you’re probably experiencing perimenopausal-related hair changes.

So what should your “mane” strategy be? Think gentle. Look for mild shampoos and enriching conditioners. In addition, upgrade to a natural-bristle brush and a good-quality, wide-toothed comb. Don’t brush your hair when it’s wet, and be gentle when brushing or combing dry hair. In addition, use hair accessories that don’t snag and pull. Soft, metal-free bands and ribbons are best.

For many women who are only beginning to enter their perimenopausal years, unusual perimenopause symptoms like heart palpitations or hair loss might trigger fear of serious illness. But chances are, these lesser-known perimenopause symptoms are just part of your personal reaction to hormonal changes.

If possible, begin to track all of your physical changes, including your menstrual cycle, and ask your doctor about any perimenopause symptoms that concern you.

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