I am a licensed clinical psychologist and for over a decade I have worked with female-identified clients and non-binary individuals assigned female at birth (AFAB). What remains a driving force behind my clinical practice is the belief that knowledge is power.

It is my hope that in sharing with you what I have learned about perimenopause through a combination of training, clinical practice, and personal experience, that you will be armed with an informative guide for self-advocacy. As you tackle this transitional chapter in your reproductive health, it can be reassuring to feel you are not alone and that others have faced and overcome similar obstacles.

Perimenopause: Biology 101 

If you first heard of the term “perimenopause” in your late night internet searches to make sense of your new and very confusing symptoms, welcome! If this is you, it’s likely you are finding this blog post at 3 am, so while I have your attention, let's start with a quick biology lesson on this stage of your reproductive life.

Menopause is the date on the calendar for when an individual has gone 12 months without a menstrual cycle. This is a natural stage of life and occurs with aging as ovulation becomes irregular, decreases, and ultimately stops altogether once the ovaries significantly reduce estrogen and progesterone production (more on this later). In the U.S., individuals assigned female at birth will reach menopause sometime between age 49 and 52, with the range encompassing earlier menopause for people of color and later menopause for white individuals. The years following menopause are called postmenopause and can come with other physical and mental health challenges associated with aging.

The many years of symptoms prior to menopause is known as perimenopause, or the menopausal transition. Perimenopause can start as early as age 36, but is most commonly experienced around age 45. This post will describe the hormonal changes that occur during perimenopause, the multiple body and organ systems that can experience dysregulation as a result, and symptoms that accompany this chapter in your reproductive story. 

It is important to note that even though the age for menopause is on average early 50s, some individuals can experience perimenopause symptoms for up to decade before reaching menopause. Racial identity also plays a role in this, with people of color experiencing symptoms for 9-10 years while white individuals have on average symptoms for 6.5 years prior to menopause (Sims, 2022). 

The life expectancy for women in the U.S. is about 81 years. This means if we count the menopausal transition, most individuals AFAB will live close to 50% of their lives in perimenopause or postmenopause (Sims, 2022). Unfortunately, this is a stage of life often overlooked in health care settings, and historically ignored and stigmatized in our broader culture, which is reflected in the gaps of medical research and practice regarding menopause. A Mayo Clinic study from 2019 found only 7% of physician residents in family medicine, internal medicine, and obstetrics/gynecology felt confident in providing care to women during menopausal years (Sims, 2022). In that same study, 20% of physicians reported they had not received medical training on menopause. 

As a result, many folks who are seeking out answers, support, and treatment for their symptoms are left to their own devices and responsible for carrying the burden of their own medical care. This is an exhausting process that can leave people feeling defeated, hopeless, and severely isolated in their challenges. 

To share a quote from Dr. Karen Tang, a board-certified gynecologist and surgeon: 

“Just because a biological function can be painful doesn’t mean that pain is acceptable or that you must continue suffering. If you are like most people assigned female at birth, you have almost certainly suffered far more than you should have already.”  (1)

Hormones: They Key Players

Hormones are chemical messengers in your body that are created by glands in your endocrine system. The hormones we will focus on to better understand perimenopause symptoms are estrogen and progesterone.

Estrogen

Produced primarily in the ovaries, this hormone is essential to your mental and physical health as it plays a role in multiple metabolic functions. To simplify for our discussion, here are the main take aways:

• There are 3 types of Estrogen: Estrone (E1), Estradiol (E2), and Estriol (E3)
• E2 is the main female hormone your body produces during your reproductive life and this is what begins to fluctuate during the perimenopause years
• E3 is increased during pregnancy and outside of those times, it remains low and barely detectable 
• E1 is generated from fat tissue and production of this hormone increases during perimenopause and postmenopause; high levels promote inflammation

Why does this matter? 

Low Estradiol (E2) levels contribute to: erratic moods, irritability and anger, restlessness, hot flashes and night sweats, increased anxiety, systemic inflammation, muscle loss, reduced bone density, iron deficient anemia, weight gain, and increased risk of heart disease and osteoporosis

Progresterone

Made in the ovaries, progesterone offers counterbalance for estrogen and increases during the window in your menstrual cycle following ovulation. During perimenopause, as ovulation becomes irregular, you will have cycles where there are menstrual bleeds without ovulation (anovulatory cycles). This can lead to early experiences of “estrogen dominance,” since the absence of progesterone leaves this hormone “unchecked” in your body. Luckily, we also have progesterone produced in our brain, which is important once ovary production stops in postmenopause. 

Why does this matter? 

Low progesterone contributes to: heavier periods, mood swings, “brain fog,” memory loss, heart palpitations, increased risk for ligament injury, and reduced pain tolerance. Since progesterone has pain-diminishing qualities, higher levels can help individuals cope better with intensity of pain and emotional responses to pain. 

Once this hormone level starts to fluctuate, individuals with chronic pain report worsening symptoms and flare ups. One study of fibromyalgia patients found that their reported experiences of pain increased by 25% when progesterone levels were fluctuating. The worst outcomes were reported by individuals with combined low progesterone and high cortisol (Sims, 2022). More on cortisol further into this post. 

Testosterone

Though to a lesser extent, testosterone also plays a role in perimenopause symptoms. In individuals AFAB, testosterone works in conjunction with estrogen and progesterone to promote healthy brain functioning, building muscles and bones, and stimulating sex drive and libido. Your body will continue to produce testosterone, but its functioning becomes dysregulated since the other hormones are in flux. This can make building muscle and bones more difficult, and increased presence of fat tissue can lead to loss of lean muscle tone. 

Cortisol

Cortisol plays a key part in perimenopause symptoms, even though it is not a reproductive hormone. The levels of this stress hormone increase due to dwindling estrogen, responsible for keeping these levels low. Higher levels of cortisol can contribute to poor sleep, weight gain, and build up of visceral fat.   

Summary 

To sum it up, perimenopause is a normal stage of aging that delineates the start of reproductive hormonal fluctuations individuals AFAB experience prior to entering menopause. Because hormonal changes are a key feature of this stage of life, symptoms severely impact an individual's experience, as all organs in the body have hormone receptors. This results in multisystem and multisymptom presentations, which range from weight gain and changes to body composition, poor cognition and “brain fog,” low mood and heightened anxiety, poor sleep, worsening chronic pain, and physiological changes in connective tissue, bones, and muscles. 

For an overview of these symptoms, refer to the summary table below: