In my clinical practice, I work daily with clients seeking answers and symptom relief from the disruptions they experience during perimenopause. 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. 

If you have questions about perimenopause and want to better understand how these changes occur and what to look out for as far as symptoms, click here for Part I and Part II in our series on perimenopause.

Lifestyle Changes to Consider During Perimenopause 

The Menopause Society (1) lists these lifestyle measures with protective health benefits for women over age 40: 

• Following a Mediterranean diet & increasing dietary intake of omega-3 fatty acids
• Reducing cardiovascular risk factors such as high blood pressure, diabetes, and high cholesterol 
• Maintaining an extensive social network 
• Remaining physically and mentally active 
• Consuming alcohol only in moderation 
• Not smoking 

Nutrition & Gut Health

As noted above, healthcare professionals agree that a Mediterranean diet supports overall health and longevity goals for adults over age 40, including those in the menopausal transition. In addition, research findings showed that higher dietary fiber intake was linked to lower rates of depression during premenopause and perimenopause (Corinna, 2021). 

What you eat can have significant impacts on your gut health. A healthy microbiome has an impact on brain health, your sleep, and your immune function (Sims, 2022). The gut-brain axis helps us understand why poor nutrition can worsen perimenopausal symptoms, including brain fog, weight gain, and poor mood regulation. Foods rich in micronutrients can support better gut health. These foods include: berries, vegetables, nuts, seeds, beans, dark chocolate, and olive oil (Sims, 2022). Also, be mindful of not skipping meals or using diets that promote calorie restriction. Undereating (which we’ve written about here)  can lead to worsening hormonal fluctuations, GI symptoms, fatigue, and anxiety.   

Overall, when addressing your nutritional needs, knowing your vitamin levels can help with appropriate changes to your diet, including use of supplements to address any deficiencies. Blood tests can help identify common vitamin deficiencies that can mimic or worsen perimenopause symptoms. For more robust diet changes, it is best practice to work with a registered dietitian. 

Adaptogens

In traditional medicine, adaptogens have been used for thousands of years (Sims, 2022). Adoptagens are plants and herbs that work by targeting your neuroendocrine system to increase your body’s resistance to stress. For perimenopause support, there are two main types of adaptogens, organized by the response they trigger in your body: calming and stimulating. 

Some of the most commonly used adaptogens for perimenopause support include (15): 

• 
  Stimulating Adaptogens: Maca Root, Rhodiola Rosea, and Schisandra
• Calming Adaptogens: Ashwagandha and Holy Basil 

Work with your healthcare providers to explore if adaptogens could be a good option for you in perimenopause symptom management. 

Movement & Exercise

Researchers have found that during perimenopause, it is important to integrate movement and exercise into your daily routine. In particular, adding exercise that includes cardiovascular training, strength training, and plyometrics. These 3 types of exercises support heart-health, building lean muscle mass, and building bone density. 

According to Dr. Stacy Sims (15), an exercise physiologist and nutrition scientist, these are the recommended exercises for symptom management and improving quality of life and longevity during perimenopause:

• 
  Cardiovascular Training: high-intensity sprint interval training sessions (e.g., Tabata) while walking/jogging or cycling 
• Strength Training: train with heavy weights, in six reps or less, and use compound lifts (e.g., squats, deadlifts, and chest presses)
• Plyometrics (“Jump Training”): use jumping exercises in different directions to support bone health (e.g., squat jump, jumping jacks, side hops, mountain climbers)

For those newer to exercise and fitness, or those with a history of overexercise, it can be helpful to use a personal trainer or fitness coach to build the best movement plan for you. Though these services can be costly, some more affordable options include finding community recreation centers with group fitness classes or group training opportunities. 

Treatment Options During Perimenopause 

Holistic Therapies

Aromatic massage therapy has been shown to support stress reduction and symptom relief during perimenopause. In particular, “massage therapy carried out in the back area is recommended to reduce menopausal symptoms” (Listiana et al, 2022). Additional research shows added benefits of aromatherapy: “Aromatic massage with lavender, clary sage, jasmine, and rose dissolved in almond oil was effective in easing somatic menopausal symptoms” (Said et al, 2022). Other holistic therapies shown to decrease insomnia and depression in women during perimenopause and postmenopause include: “reflexology, yoga, walking and aromatherapy massage” (Lialy et al, 2023). 

Finding a Certified Menopause Practitioner

For many of us, the most difficult part of seeking support for perimenopause is knowing where to start. Accessing good quality medical care can be challenging, especially when you feel overwhelmed and exhausted to begin with. The good news is that there are many healthcare professionals that are equipped to work with you in navigating the menopausal transition and beyond. 

The Menopause Society has made this search easier by listing a full glossary of professional credentials and a search engine to find a provider to meet your needs. This includes listing providers that offer telehealth services to increase access to communities that are typically underserved. 

As a first step, begin to track your symptoms in preparation for your first appointment. List any changes you have observed, including your sleep, energy, focus, mood, pain, and body changes. For a helpful summary of symptoms, read Part I in our series on perimenopause or use this menopause information sheet from The Australian Menopause Society. 

Remember to make note of the interventions and lifestyle modifications you have already tried, over-the-counter medications or supplements you have taken (how much and when), and information regarding your menstrual cycles (e.g., how long in between periods, how long do periods last, any change in heavy bleeding, spotting in between cycles). You may need more than an initial appointment to review your reproductive health history and address all your concerns. Be persistent and find a provider that is willing to offer you additional appointments and collaboratively build a treatment plan.

As a result of her work interviewing individuals AFAB navigating healthcare in the U.S., author Maya Dusenbery offers the following advice: “Listen to your body. Trust that you know when something is wrong. Don’t second-guess yourself; get a second opinion” (16). 

Blood Tests 

Unfortunately, there are currently no blood tests that can confirm an individual is in perimenopause. Since there are other conditions that mimic symptoms that perimenopausal individuals experience, blood tests can be helpful to uncover other potential health issues. For example, thyroid and adrenal conditions, diabetes, and even some reproductive cancers. Blood tests can also be helpful in identifying underlying issues such as vitamin deficiencies and low iron/anemia, which also lead to fatigue and other symptoms common during perimenopause (Sims, 2022).   

During the later stages of perimenopause, blood tests can help to predict how close someone is to reaching menopause. Blood tests to measure your anti-Mullerian hormone (AMH) levels and follicle-stimulating hormones (FSH) levels can be a fairly reliable indicator of menopause (Sims, 2022). Low AMH levels (under 10pg/ml) signal likelihood of a final period within the next year from testing. A high FSH (30 mlU/ml or above) and the absence of a menstrual period for one year confirms someone has reached menopause (Sims, 2022). 

MHT (Menopausal Hormone Therapy) 

Current best practice for perimenopause support includes a treatment called Menopausal Hormone Therapy:

“At the most basic level, hormone therapy replaces female hormones, primarily estrogen and progestogens, that are lost during the menopause transition. Hormone therapy is FDA-approved as a first-line therapy for the relief of bothersome hot flashes and is shown to be the most effective treatment. In particular, the benefits particularly outweigh the risks for HT when used in early menopause to relieve vasomotor symptoms (VMS), hot flashes, night sweats, and sleep disturbances.” (4)

These treatments focus on the main hormones that fluctuate during perimenopause, estrogen and progesterone, and to a lesser extent, testosterone. There are several different ways these treatments are administered, ranging from topical (creams and gels), oral (pills), injections, transdermal (patches), and for localized treatments vaginal rings and suppositories. To learn more about menopausal hormone therapy, click here for a resource on Deciding about Hormone Therapy Use. 

Physical Therapy

Working with a physical therapist can provide support in mitigating symptoms relating to chronic pain (muscles, joints) as well as genitorurinary syndrome of menopause. In particular, pelvic floor muscle training (PFMT)--also known as kegel exercises–can help with prolapse prevention and incontinence, as well as addressing sexual dysfunction and pain during vaginal intercourse. 

Surgical Interventions

In some cases, perimenopause can lead to debilitating symptoms that significantly impair someone’s functioning, cause clinical distress, or otherwise reduce that person’s quality of life. For example, heavy bleeding that cannot be controlled via MHT or other therapies can lead to severe chronic fatigue and exhaustion, iron deficiency anemia, intense pelvic and abdominal pain, chronic back pain, and cardiovascular strain. In these cases,and when there are increased risk factors for reproductive cancers, individuals might consider with their medical provider to explore surgical interventions. Some of the most common surgeries performed by OB/GYNs in response to worsening perimenopause symptoms include:   

• Endometrial Ablation
• Hysterectomy
• Oophorectomy

Psychiatry 

A primary determinant of how perimenopause will impact mood and anxiety symptoms is related to an individual’s psychiatric history. For those who have previously experienced mood episodes (Major Depressive Disorder or Bipolar Disorder) and anxiety disorders, perimenopause can be a vulnerable time for worsening symptom severity. Perimenopause can increase the risk for those  individuals to experience severe mental illness, including paranoid ideation, dissociation, extremely low self-esteem, and aggression and rage (7). 

Current best practices for addressing mental health symptoms during perimenopause include concurrent use of MHT and psychiatric medications. The following nonhormone medications have been found to effectively treat symptoms during perimenopause: 

• SSRIs/SNRIs: paroxetine, escitalopram, citalopram, venlafaxine
• Fezolinetant 
• Gabapentin 
• Oxybutynin 

For those experiencing other reproductive health concerns, such as fertility issues, premenstrual dysphoric disorder (PMDD), polycystic ovarian syndrome (PCOS), endometriosis, as well as those planning a pregnancy, currently pregnant, or in postpartum, more specialized support might be warranted. Learning about providers in your area that specialize in Reproductive Psychiatry could be a helpful next step. 

Psychotherapy

Therapy and counseling can offer individuals evidence-based treatments, social support, education, and connection to community resources during perimenopause. The Menopause Society lists Cognitive Behavioral Therapy (CBT) as a recommended treatment for perimenopause. 

“Cognitive Behavioral Therapy (CBT) is one of the most widely used and researched treatments for a variety of mental health concerns. This evidence-based treatment focuses on the relationship between and impact of thoughts, feelings, and behaviors. CBT is one of the most effective forms of therapy, with evidence supporting its effectiveness with treating anxiety, depression, OCD, and trauma-related conditions.” (12)

Additionally, given perimenopause and postmenopause are associated with elevated risk of developing insomnia, it may be helpful to consider psychotherapy for insomnia. You can read more about insomnia and effective treatment in our Insomnia: A Chronic Problem with Quick Treatment blog post or read about our Insomnia Specialty Clinic. 

Similarly, perimenopause and postmenopause are associated with increased experiences of chronic pain. Fortunately, there are effective forms of psychotherapy to help with managing chronic pain. You can read more about chronic pain in our Living Well with Chronic Pain blog post and can also read about our Chronic Pain Specialty Clinic.

Conclusion

You’ve made it to the end of our series! You have successfully taken steps to educate yourself in better meeting your healthcare needs during perimenopause. As you continue in your self-advocacy journey, it is important to seek out social support. Navigating complex health concerns can be an isolating experience, and not every provider you meet along the way will be equipped to offer you effective treatments or appropriate interventions. Do not let yourself get discouraged. Lean on your resilience, your perseverance, and your support network. 

If you don’t have social support, this is an important stage of life to begin making connections and building community so you can cope with the challenges of aging, while preserving or improving your quality of life. 

At Aviva Psychology Services, we have many providers that work with clients of all ages, genders, and backgrounds to build a healthier sense of self, including tools for managing issues of perimenopause. If you would like to learn more about how the psychologists at Aviva could help, we encourage you to reach out to our practice. You can get connected with a psychologist by filling out the Request an Appointment form.   

Sources & Recommended Reading:

1. Menopause Topics: Mental Health https://menopause.org/patient-education/menopause-topics/mental-health
   
   
2. The Menopause Society: Nonhormone Treatments for Hot Flashes and Night Sweats https://menopause.org/wp-content/uploads/default-document-library/nonhormone-treatment-menonote_f5afc19f-211e-4c1f-8a04-b2d558c6fa66.pdf
   
   
3. The Menopause Society: Perimenopause https://menopause.org/patient-education/menopause-topics/perimenopause
   
   
4. Menopause Topics: Hormone Therapy https://menopause.org/patient-education/menopause-topics/hormone-therapy 
   
   
5. The Menopause Society: Deciding about Hormone Therapy Use https://menopause.org/wp-content/uploads/default-document-library/MenoNote-Deciding-About-HT-2025.pdf
   
   
6. The Menopause Society: Genitourinary Syndrome of Menopause. https://menopause.org/wp-content/uploads/for-women/MenoNote-GSM.pdf
   
   
7. Article: Severe Mental Illness and the Perimenopause (2024) S. Behrman & C. Crockett  https://www.cambridge.org/core/journals/bjpsych-bulletin/article/severe-mental-illness-and-the-perimenopause/8D072AACBCD3C7888C173B36635C08C3
   
   
8. Article: Massage Therapy to Relieve Menopausal Symptoms: A Systematic Review (2022) Listiana et al; https://jurnal.unimus.ac.id/index.php/jur_bid/article/view/5434 
   
   
9. Article: Effects of different physiotherapy modalities on insomnia and depression in perimenopausal, menopausal, and post-menopausal women: a systematic review (2023) Lialy et al; https://link.springer.com/article/10.1186/s12905-023-02515-9 
   
   
10. Article: Effect of Aromatic Massage on Somatic Problems among a Cohort of Menopausal Women (2022) Said et al; https://www.eepublisher.com/index.php/ebnr/article/view/245 
    
    
11. Article: Efficacy and safety of Withania somnifera (Ashwagandha) in the management of menopausal symptoms (2026) Balkrishna et al; https://www.sciencedirect.com/science/article/pii/S2950199725003386 
    
    
12. What is Cognitive Behavioral Therapy? A Boston Guide to CBT (2026) Allison Karthaus  https://www.avivapsych.com/what-is-cognitive-behavioral-therapy-a-boston-guide-to-cbt 
    
    
13. Corinna, Heather (2021) What Fresh Hell is This? Perimenopause, Menopause, Other Indignities, and You
    
    
14. Karen Tang, MD, MPH (2024) It’s Not Hysteria: Everything You Need to Know About Your Reproductive Health (But Were Never Told)
     
15. Stacy Sims, PhD & Selene Yeager (2022) Next Level: Your Guide to Kicking Ass, Feeling Great, & Crushing Goals Through Menopause and Beyond
    
    
16. Maya Dusenberry (2018) Doing Harm: The Trust About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick