What to expect in Perimenopause

using a hot water bottle to relieve cramping

Period pain / Photo: Esther Simpson (cc)

What to Expect in Perimenopause

By OBOS Menopause Contributors | October 15, 2011


At midlife, women transition from their reproductive years to the natural end of monthly menstrual cycles. This transition — called perimenopause — usually begins in the 40s and ends by the early 50s, although any age from the late 30s to 60 can be normal. It can be difficult to know whether you’ve entered perimenopause, because the hormonal fluctuations begin while menstrual periods are still regular.

Perimenopause can last anywhere from one to 10 years. During this time, the ovaries function erratically and hormonal fluctuations may bring about a range of changes, including hot flashes, night sweats, sleep disturbances, and heavy menstrual bleeding. Other signs of perimenopause can include memory changes, urinary changes, vaginal changes, and shifts in sexual desire and satisfaction.

Some women breeze through the transition. For many others, the hormonal changes create a range of mild discomforts. And for about 20 percent of women, the hormones fluctuate wildly and unpredictably, and spiking and falling estrogen and declining progesterone cause one or more years of nausea, migraines, weight gain, sore breasts, severe night sweats, and/or sleep trouble. For this group, perimenopause can be enormously disruptive both physically and emotionally.

Perimenopause can sometimes be managed through self-help approaches such as meditation, yoga, relaxation, regular exercise, healthful food, enough sleep, and support from family and friends. When perimenopause is particularly difficult, a combination of non-medical and medical solutions may be helpful.

Health care providers who are well informed about perimenopause can be important partners in thinking through the options. This article presents what is known about the risks and benefits of different approaches so you can choose what works best for you.


Premenstrual Syndrome (PMS)

Some women report more severe premenstrual discomforts (PMS) during early perimenopause, when cycles are still regular, such as swollen or tender breasts, water retention (bloating), anxiety, sleep disruption, or irritation.

Whether you have had such discomforts for years or are just beginning to have them now, you can typically look forward to relief later in perimenopause, when your periods become irregular, and certainly by postmenopause, when the hormones level out. (For more information on menstrual discomforts such as mood changes and severe cramps, see Physical and Emotional Challenges Through the Menstrual Cycle.)

Menstrual Cycle Changes

One common menstrual change in early perimenopause is shorter cycles, usually averaging two or three days less than usual but sometimes lasting only two or three weeks. It can feel as though you’re starting a period when the last one has barely ended. In later perimenopause, you may skip a period entirely, only to have it followed by an especially heavy one. Occasionally, menstrual periods will be skipped for several months, then return as regular as clockwork.

The hormonal ups and downs of perimenopause can be the cause of almost any imaginable bleeding pattern. When estrogen is lower, the uterine lining gets thinner, causing the flow to be lighter or to last fewer days. And when estrogen is high in relation to progesterone (sometimes connected with irregular ovulation), bleeding can be heavier and periods may last longer.

Menstrual irregularities are a normal part of this stage in a woman’s life. If you and your health care provider decide that efforts should be made to regulate your cycles at this time, be aware that while oral contraceptives are sometimes prescribed for menstrual irregularities, the use of progesterone alone can be a milder intervention.

Progesterone can be used to manage the imbalance of estrogen and progesterone. A clinician can prescribe progesterone or its synthetic cousins, progestins, to be taken the last 14 days of the cycle. This replaces the progesterone that would normally be secreted in an ovulatory cycle and helps to create a more regular bleeding pattern.

Abnormally Heavy Bleeding

About 25 percent of women have heavy bleeding (sometimes called hypermenorrhea, menorrhagia, or flooding) during perimenopause. Some women’s menstrual flow during perimenopause is so heavy that even supersized tampons or pads cannot contain it. If you are repeatedly bleeding heavily, you may become anemic from blood loss. During a heavy flow you may feel faint when sitting or standing. This means your blood volume is decreased; try drinking salty liquids such as tomato or V8 juice or soup. Taking an over-the-counter NSAID such as ibuprofen every four to six hours during heavy flow will decrease the period blood loss by 25 to 45 percent.

Don’t ignore heavy or prolonged bleeding — see your health care provider if it persists. Your provider can monitor your blood count and iron levels. Iron pills can replace losses and help avoid or treat anemia.

Other medical treatment may include progesterone therapy or the progestin-releasing Mirena IUD, which is known to reduce menstrual bleeding. If your health care provider suggests hysterectomy as a solution to very heavy bleeding during perimenopause, you may want to try other less invasive approaches first. Removal of the uterus is an irreversible step with many effects.

Heavy bleeding during perimenopause may be due to the estrogen-progesterone imbalance. Also, polyps (small, noncancerous tissue growths that can occur in the lining of the uterus) can increase during perimenopause and can cause bleeding. Fibroid growth during perimenopause can sometimes cause heavy bleeding, especially when the fibroid grows into the uterine cavity.

If very heavy bleeding persists despite treatment, your provider should test for possible causes of abnormal bleeding. (Learn more about the causes of abnormal uterine bleeding as well as the pros and cons of various treatment options.)

Hot Flashes and Night Sweats

Hot flashes are legendary signs of perimenopause and for some women can continue well into postmenopause, though 20 to 30 percent of women never have them at all. A woman experiencing a hot flash will suddenly feel warm, then very hot and sweaty, and sometimes experience a cold chill afterward. For detailed information on hot flashes and strategies for reducing discomforts, see Hot Flashes and Night Sweats.

Sleep Disturbances

Many women in both perimenopause and postmenopause experience sleep disturbances. Most commonly, a woman will fall asleep without a problem, then wake up in the early-morning hours and have difficulty getting back to sleep. For detailed information on sleep problems and tips for addressing them, see Sleep Disturbances.

Vaginal Changes

As estrogen and progesterone levels decline in late perimenopause and postmenopause, vaginal walls frequently become thinner, drier, and less flexible and more prone to tears and cracks. This can lead to irritation and difficulties with penetration. For information on how to address these issues, see Dealing with Vaginal Dryness.

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