What Is Perimenopause? What Are the Symptoms?

Short Answer

Perimenopause is the natural process that begins before menopause and when the female body transitions from the reproductive period to menopause. During this period, the working order of the ovaries begins to change; Estrogen and progesterone levels may fluctuate rather than decrease steadily.

Due to these hormonal changes, frequent or infrequent menstrual periods, hot flashes, night sweats, sleep problems, mood changes, vaginal dryness and differences in sexual desire may occur.

Since ovulation does not stop completely during perimenopause, pregnancy is still possible. A woman is considered to have reached menopause when she has not had a menstrual period for 12 months without another medical reason.

Highlights

• Perimenopause and menopause are not the same period.
• Perimenopause most often begins in the 40s but may occur earlier or later.
• One of the first noticeable changes is the difference in menstrual cycle.
• Although hot flashes and night sweats are common, they do not occur in every woman.
• Ovulation may become irregular, but pregnancy is possible because it has not stopped completely.
• A single FSH or AMH result does not diagnose perimenopause.
• Not every menstrual irregularity seen in the 40s should be attributed to perimenopause.
• Very heavy bleeding, breakthrough bleeding or bleeding after intercourse should be evaluated separately.
• If symptoms impair quality of life, treatment options appropriate to the individual may be considered.

What is Perimenopause?

Perimenopause literally means “around menopause”. It refers to the years when a woman transitions from the reproductive period to menopause.

In this process, the working order of the ovaries begins to change. In particular, the levels of hormones such as estrogen and progesterone may no longer follow the same pattern every month.

While estrogen levels may be high in one month, they may drop more significantly in another period. While ovulation may occur in some months, it may not occur in others.

Therefore, the symptoms of perimenopause are not constant.

A woman may experience hot flashes for a few months and then not feel this complaint for a long time. Their periods may become frequent for a while, and the intervals may become longer after a few months.

Perimenopause is not a disease. It is one of the natural periods of a woman's life. However, in some women, symptoms can significantly affect daily life, sleep, work performance or sexual life.

In this case, it is not necessary to ignore the complaints by saying "it is menopause process anyway."

What is the Difference Between Perimenopause and Menopause?

These two concepts are often confused with each other.

Perimenopause is the transition period before menopause. The woman may still menstruate and ovulation may continue from time to time.

Menopause is the phase defined by no menstrual period for 12 months without any other reason.

Postmenopause is the period of life after menopause.

In other words, during perimenopause, the woman has not yet entered menopause.

This distinction is especially important in terms of pregnancy planning. Just because your periods have become less frequent does not mean that ovulation has completely stopped.

At What Age Does Perimenopause Begin?

There is no exact age at which perimenopause begins in everyone.

Many women notice the first changes in their 40s. For some women, symptoms may begin in their late 30s.

The age of onset may vary from person to person.

In this process, it is not only the calendar age that is important;

• how menstrual cycle changes,
• whether there are hot flashes or night sweats,
• What is the age of menopause in the family,
• Surgeries related to the ovaries,
• general health status

It is the evaluation of such factors together.

Especially if there are obvious menopausal symptoms or long-term cessation of menstruation before the age of 40, a more detailed evaluation is necessary rather than accepting this as routine perimenopause.

How Long Does Perimenopause Last?

The duration of perimenopause is different for each woman.

For some women, the transition is shorter, while for others it takes several years:

• menstrual irregularity,
• hot flashes,
• night sweats,
• sleep changes

may continue.

For this reason, it is not possible to give an exact period valid for everyone, such as "perimenopause lasts this many years".

Perimenopause is considered to have ended and menopause has occurred when 12 months have passed since the last menstrual bleeding.

However, symptoms such as hot flashes, sleep problems or vaginal dryness may continue after menopause.

What are the first symptoms of perimenopause?

One of the first changes that patients most often notice is the disruption of menstrual cycle.

A woman who has had regular menstrual periods for years:

• her periods come earlier,
• The period between two periods is getting longer,
• Some months you do not have a menstrual period,
• the amount of bleeding has changed

It may make a difference.

However, the first symptom in every woman is not menstrual irregularity.

The first thing that attracts attention in some women is:

• hot flashes,
• night wakings,
• Decrease in sleep quality,
• mood changes,
• vaginal dryness

maybe.

What are the symptoms of perimenopause?

Perimenopause symptoms can be seen in a wide range.

Among the most common complaints:

• Menstrual irregularity
• Hot flashes
• Night sweats
• Difficulty falling asleep or staying asleep
• Mood changes
• Irritability
• Increased anxiety
• Difficulty concentrating
• Feeling of forgetfulness
• Vaginal dryness
• Discomfort during sexual intercourse
• Change in sexual desire
• Palpitation feeling
• Headaches
• Muscle and joint complaints

Available.

Not every woman is expected to have all the symptoms.

While some women experience perimenopause with only mild menstrual changes, in others hot flashes and sleep problems can seriously affect daily life.

How Does Menstrual Pattern Change During Perimenopause?

During perimenopause, ovulation may not occur in the same pattern every month.

As a result, customs:

• more often,
• less frequent,
• longer,
• shorter,
• more intense,
• lighter

It may become.

For example, a woman who has been menstruating every 28 days for years may experience 23-24 day cycles for a while. Later, the menstrual interval may increase to 35-40 days or a menstrual period may be skipped completely.

These changes can be seen in perimenopause.

However, there is an important distinction here:

Not every irregular bleeding seen in the 40s is due to perimenopause.

Is Excessive Bleeding Normal During Perimenopause?

Change in the amount of bleeding may occur in perimenopause, but not every heavy bleeding should be considered a "normal menopause transition".

Especially:

• Bleeding that requires frequent pad or tampon changing,
• Bleeding that lasts longer than seven days,
• spotting or bleeding between periods,
• Bleeding after intercourse,
• Very heavy bleeding after not having a menstrual period for a long time

If present, gynecological evaluation is required.

Because in the same age period:

• uterine fibroids,
• endometrial polyps,
• thickening of the inner lining of the uterus,
• thyroid disorders,
• different hormonal problems

It may also change the bleeding pattern.

It is not enough to simply make a comment during the examination such as "your age is approaching menopause age". The nature of the bleeding and the intrauterine structure should also be evaluated.

How Do Hot Flashes Happen During Perimenopause?

Hot flashes are one of the most well-known symptoms of perimenopause.

Usually begins suddenly and especially:

• face,
• neck,
• chest

It occurs as a feeling of intense warmth felt in the area.

To this:

• sweating,
• facial flushing,
• palpitations sensation

May accompany.

Attacks can last several minutes and in some women may recur many times during the day.

However, not every perimenopausal patient experiences hot flashes. Some women can go through menopause without ever experiencing hot flashes.

What Causes Night Sweats?

Night sweats refer to hot flashes that occur during sleep.

While sweating is mild in some women, it may be significant enough to require changing pajamas or sheets in others.

This situation does not only cause physical discomfort.

Frequent interruption of sleep due to night sweats:

• tiredness during the day,
• difficulty concentrating,
• irritability,
• headache,
• mood changes

It may also increase other complaints such as:

Does Perimenopause Cause Insomnia?

Yes.

Sleep disorders are common complaints during perimenopause.

Woman:

• may have difficulty falling asleep,
• may wake up frequently at night,
• may wake up earlier than normal in the morning,
• His sleep may be interrupted due to night sweats.

However, sleep problems should not be attributed solely to hormones.

Sleep apnea and other causes should also be evaluated, especially if there is significant snoring, a feeling of breathlessness, excessive sleepiness during the day, or long-lasting severe insomnia.

Does Perimenopause Affect Mood?

Some women during perimenopause:

• irritability,
• sudden emotional changes,
• anxiety,
• depression,
• impatience

He can express that he is alive.

It is not correct to say that these changes are caused only by hormones.

In the same period:

• impairment of sleep quality,
• Work and family burdens,
• care responsibilities,
• other seasonal stresses of life

It can also affect mood.

In women with a previous history of depression or anxiety, symptoms may need to be evaluated more closely.

Is There Brain Fog During Perimenopause?

Some women during this period:

• difficulty focusing,
• difficulty finding words,
• feeling of forgetfulness,
• mental slowdown

can survive.

This condition is called “brain fog” in everyday language.

Sleep disturbance, intense hot flashes, stress and mood changes can also affect cognitive performance.

However, it is not correct to automatically attribute memory problems that progress significantly or seriously disrupt daily life to perimenopause.

Does Vaginal Dryness Occur During Perimenopause?

Yes.

Changes in estrogen levels can affect the tissues of the vagina and external genital area.

As a result:

• vaginal dryness,
• burning,
• irritation,
• sensitivity,
• pain during sexual intercourse

can be seen.

Some women also have:

• Burning while urinating,
• frequent urination,
• recurrent urinary tract complaints

Complaints such as this may also occur.

It is not correct to interpret these symptoms as "the normal result of menopause, there is nothing to be done". Significant relief can be achieved with appropriate treatments.

Does Perimenopause Affect Sexual Desire?

It may affect, but the direction and severity of the change differ from person to person.

Decrease in sexual desire:

• vaginal dryness,
• pain during sexual intercourse,
• sleeping problem,
• stress,
• hormonal changes,
• partner relationship,
• Drugs used

It can be affected by many factors such as.

For this reason, libido changes should not be explained only as "estrogen decreased."

Can You Gain Weight During Perimenopause?

Changes in body composition may occur during middle age, when perimenopause occurs.

Fat may increase, especially around the abdomen.

However, it is not correct to attribute weight gain only to menopause hormones.

During this period:

• decrease in muscle mass,
• decrease in physical activity,
• sleep disorders,
• eating habits,
• metabolic changes

It also plays an important role.

Therefore, the approach should focus not only on weight loss but also on maintaining muscle mass and overall metabolic health.

Can You Get Pregnant During Perimenopause?

Yes.

This issue is often misunderstood, especially in women whose menstruation begins to become irregular.

During perimenopause, ovulation may become irregular but does not stop completely.

A woman may not ovulate for several months and then ovulate again.

Therefore:

Perimenopause = pregnancy no longer possible

It does not mean.

Women who do not want pregnancy should continue to use appropriate contraception.

Do the chances of pregnancy decrease in perimenopause?

Yes.

Perimenopause often coincides with the years when female fertility decreases significantly with age.

With age:

• ovarian reserve decreases,
• There is a change in egg quality,
• The possibility of obtaining chromosomally healthy embryos may decrease,
• The time it takes to achieve pregnancy may take longer.

However, just because the chance of pregnancy decreases does not mean that it is reset.

The "let's wait a while longer" approach may not always be correct, especially for women in their 40s who want to have children.

How to Follow in Perimenopausal Patients Planning Pregnancy?

Evaluation of women who want to become pregnant is not done only by looking at menstrual irregularity.

Assoc. Prof. Dr. In Nurettin Türktekin's clinical approach, especially in a patient with a pregnancy plan:

• age,
• menstrual pattern,
• Antral follicle count by ultrasound,
• AMH,
• ovulation status,
• uterus and tubes,
• partner's sperm characteristics

They should be evaluated together.

Since time is of the essence, especially in advanced reproductive age, evaluation and treatment options should not be unnecessarily delayed.

Does AMH Decrease During Perimenopause?

Since AMH is related to ovarian reserve, it generally tends to decrease with age.

AMH levels may be quite low during perimenopause.

But AMH alone:

• Does not diagnose perimenopause,
• It does not indicate exactly when menopause will begin,
• It does not alone determine the possibility of natural pregnancy.

For this reason, the AMH result must be interpreted together with age and ultrasound findings.

How is Perimenopause Diagnosed?

The diagnosis of perimenopause is often based on clinical evaluation.

Physician:

• patient's age,
• changes in quantity,
• Symptoms such as hot flashes,
• medical history

evaluates together.

For most women, there is not a single test that must be performed as a "perimenopause test".

A comprehensive hormone panel may not always be necessary, especially in a woman of typical age and with typical symptoms.

Which Hormone Tests Are Performed in Perimenopause?

The same tests are not required for every patient.

According to clinical situation:

• FSH,
• estradiol,
• TSH,
• prolactin,
• pregnancy test

Such investigations can be made.

It is important not to completely ignore the possibility of pregnancy, especially in a patient with menstrual irregularities.

Thyroid disorders can also cause symptoms that may mimic perimenopause, such as menstrual changes, palpitations, sweating or mood changes.

Does a Single FSH Result Indicate Perimenopause?

Not always.

Since hormone levels fluctuate during perimenopause, FSH levels that may be high on one day may be different on another period.

Therefore, looking at just one hormone result:

“You have definitely entered menopause.”

or

“Menopause is still years away.”

Commenting like this is often not correct.

Clinical history and menstrual cycle should be evaluated together with laboratory results.

Are Perimenopause and Early Menopause the Same Thing?

No.

Perimenopause is the transition period before natural menopause.

Early menopause is when menopause occurs earlier than the expected age range.

Especially if symptoms such as marked irregularity or cessation of menstrual periods, hot flashes and night sweats occur before the age of 40, additional evaluation may be required for primary ovarian failure.

This distinction is especially:

• bone health,
• cardiovascular health,
• fertility

It is important for

Is Perimenopause Treated?

Since perimenopause is a natural life period, it is not a "disease that needs to be treated."

But the symptoms can be treated.

Purpose of treatment:

• Reducing hot flashes,
• Improving sleep quality,
• To relieve vaginal complaints,
• controlling heavy bleeding,
• improving quality of life

maybe.

Since each woman's symptoms and health history are different, treatment should also be individualized.

Is Hormone Therapy Used in Perimenopause?

Hormone therapy may be considered in suitable women.

Especially:

• pronounced hot flashes,
• night sweats,
• Vasomotor symptoms that disrupt sleep quality

Menopausal hormone therapy may be one of the effective options for women with this condition.

In women with a uterus, systemic estrogen therapy is usually planned together with an appropriate progestogen therapy that will protect the uterine lining.

However, hormone therapy is not suitable for everyone.

When deciding:

• age,
• personal and family history,
• breast diseases,
• clotting history,
• cardiovascular risks,
• bleeding characteristics

They should be evaluated together.

Are there options for women who do not want to use hormone therapy?

Yes.

Some non-hormonal treatment options may be considered for women for whom hormone therapy is not suitable or who do not want to use hormones.

Which treatment is chosen depends on the main complaint.

For example, the approach used for hot flashes is not the same as the treatment used for vaginal dryness.

For this reason, there is no such approach as "one medicine for perimenopause".

Are Herbal Products Safe During Perimenopause?

“Herbal” does not automatically mean safe.

Some supplements sold for menopause symptoms:

• It may interact with the medications used,
• may have an effect on the liver,
• It may not be suitable for some hormone-sensitive diseases.

For this reason, it would be better to use regular medications or supplements in consultation with a physician if there is a significant health problem.

How to Treat Vaginal Dryness

In mild vaginal dryness:

• vaginal moisturizers,
• Suitable lubricants during sexual intercourse

It may help.

If complaints are significant, local vaginal treatments can be considered in suitable patients.

It is important to undergo an examination, especially if there is pain, burning or recurrent urinary tract complaints during sexual intercourse.

What Should the Lifestyle Be During Perimenopause?

Perimenopause should not be seen as a period in which only hot flashes are managed.

This period is also important for long-term women's health.

Especially:

• regular walking,
• resistance exercises,
• Adequate protein consumption,
• balanced diet,
• healthy body weight,
• stay away from smoking,
• sleep pattern

It is important.

Resistance exercises and adequate nutrition can especially help maintain muscle and bone health.

Is Birth Control Necessary During Perimenopause?

Yes, if pregnancy is not desired.

Infrequent periods does not mean that ovulation has ended.

Therefore, if a woman whose perimenopause symptoms begin does not want pregnancy, she should continue appropriate contraception.

Some birth control methods may also be used in eligible women:

• Reducing heavy menstrual bleeding,
• controlling menstrual cycle

It may provide additional advantages such as

Which bleeding should not be ignored as perimenopause?

In clinical evaluation, the following situations should especially be taken into account:

• non-menstrual bleeding,
• Bleeding after intercourse,
• increasingly intense bleeding,
• Menstruations that cause significant anemia,
• Unexpected heavy bleeding after a long period of absence of menstruation.

Ultrasonography and, when necessary, intrauterine evaluations may be considered in these patients.

Additional procedures such as hysteroscopy or endometrium sampling may also be evaluated depending on the patient's age, bleeding characteristics and accompanying risk factors.

Is Bleeding After Menopause Normal?

No.

New vaginal bleeding that occurs after a woman has not had a menstrual period for 12 months is not considered a routine menstrual bleeding.

Post-menopausal bleeding:

• Thinning of vaginal tissues,
• polyps,
• intrauterine changes,
• different gynecological conditions

It may depend.

For this reason, post-menopausal bleeding should be evaluated by a gynecologist and obstetrician.

When to Consult a Gynecologist?

Assessment is useful in the following situations:

• very heavy menstrual bleeding,
• breakthrough bleeding,
• Bleeding after intercourse,
• absence of menstruation for months,
• Hot flashes that disrupt daily life,
• Serious night sweats and sleep problems,
• significant vaginal dryness or pain during intercourse,
• Symptoms of menopause before the age of 40,
• pregnancy desire,
• prolonged or significant mood changes.

Any new bleeding, especially after menopause, should be evaluated.

Common Mistakes

“If perimenopause has started, I can no longer get pregnant.”

Wrong. Ovulation may continue, albeit irregularly.

“Perimenopause and menopause are the same thing.”

Wrong. Perimenopause is the transition period before menopause.

“If there are no hot flashes, there is no perimenopause.”

Wrong. Hot flashes do not occur in every woman.

“Any menstrual irregularity after the age of 40 is normal.”

Wrong. fibroids, polyps or different hormonal problems can also change bleeding.

“A single high FSH result means definitive menopause.”

Not always. Hormones may fluctuate during perimenopause.

“AMH shows exactly when menopause will occur.”

No. AMH can provide information about ovarian reserve, but it does not determine the exact time of menopause.

“Hormone therapy is harmful to everyone.”

Wrong. It may be effective and beneficial in suitable patients. Risk-benefit evaluation should be made individually.

“Herbal menopause products have no side effects.”

Wrong. Herbal products may also have side effects and drug interactions.

Assoc. Prof. Dr. Nurettin Türktekin's Evaluation

Perimenopause is a natural period of a woman's life; However, one of the most important points in clinical evaluation is not to automatically attribute every complaint that occurs in this age group to hormonal changes.

Especially in women who experience menstrual irregularities or heavy bleeding, age is not the only consideration. Ultrasound findings, intrauterine structure, the presence of fibroid or polyp and, when necessary, hormonal reasons are evaluated together.

The approach is different for women who want to become pregnant. Ovulation may continue even if perimenopause symptoms have begun; However, time becomes more important as fertility may decrease with age. In these patients, a personalized road map should be created by evaluating ovarian reserve indicators such as age, AMH and antral follicle count, tubes, uterine structure and sperm characteristics.

In women whose complaints affect daily life, it is a more accurate approach to evaluate treatment options appropriate to the nature of the symptoms and the person's health history, rather than saying "it is normal at this age".

Conclusion

Perimenopause is a natural process in which the female body transitions from the reproductive period to menopause. During this period, due to fluctuation in hormone levels, menstrual irregularities, hot flashes, night sweats, sleep problems, vaginal dryness and mood changes may occur.

However, not every woman experiences this process in the same way.

While the symptoms are quite mild in some women, sleep, work life, sexual life and general quality of life may be significantly affected in others.

It is not right to attribute every change in menstrual cycle only to perimenopause. Gynecological evaluation should be performed in cases such as very heavy bleeding, breakthrough bleeding, post-intercourse bleeding or post-menopausal bleeding.

Since ovulation does not stop completely during perimenopause, pregnancy is still possible. Not to delay the evaluation due to the effect of age on fertility in women who want to become pregnant; For women who do not want pregnancy, it is important to continue appropriate protection.

If symptoms affect daily life, the goal of treatment is not to stop the menopause transition, but to create a personalized approach that preserves the woman's quality of life and is appropriate to her health history.