Your Perimenopause Handbook

Instead of Sneezy, Sleepy and Happy, you’re living with Bloaty, Headachy and Hot Flashy. Our guide explains how to handle what’s going on

by Stacey Colino
woman image
Photograph: Illustrated by Eduardo Recife

Perimenopause is like puberty in reverse. For the second time in your life, your body is riding a hormonal roller coaster that features highly irregular periods and huge mood swings. But during this particular stretch, instead of cranking up so you can have babies, your ovaries are gearing down for the retirement called menopause (which technically arrives one year after your final period).

Perimenopause, aka the menopausal transition, can last anywhere from four years to 10 and is unnervingly unpredictable. “Some women have normal periods all the way through to their last one, and then that’s it. Others—and this is the classic pattern—have periods that come a week early or a week late for a while, then skip an entire month altogether,” says Margery Gass, MD, executive director of the North American Menopause Society and a consultant at the Cleveland Clinic Center for Specialized Women’s Health. “It’s normal to reach menopause between the ages of 41 and 55, with 51 being the average.” Smokers tend to experience menopause a year sooner than other women; a few heavy-duty exercisers are also on the early side.

The roller-coaster ride to menopause is divided into several passages, and women experience them differently in terms of when each phase starts, how long it lasts and what kinds of symptoms appear. If you’re lucky, symptoms—such as hot flashes, tender breasts, insomnia and headaches—are only a minor bother; if you’re further down the spectrum, you may have days when you feel smacked by a hormonal two-by-four. “Some women are just much more sensitive to the hormonal changes than others are,” notes Nanette Santoro, MD, chair of obstetrics and gynecology at the University of Colorado School of Medicine in Denver.
In other words, perimenopause is uncharted territory, one that this guide is designed to help you navigate. The tools: a map showing where you are now and where you’re heading, plus advice on handling the roller coaster’s curves and dips along the way.

If you’re in the midst of perimenopause, you may wonder how much longer this transition is likely to last. Why getting a heads-up is important: “If you know you’re close to the end and the relief of menopause is coming soon, you may be better able to tolerate symptoms,” explains Santoro. And the opposite is true: “When you realize you’re in the early stages and your symptoms are really unpleasant, you may want to be more aggressive about seeking treatment.”

Now, for the first time, identifying how far you’ve come in the menopausal transition is easy, thanks to a new set of criteria established by an international panel of women’s-health experts. Their findings, published last fall, are called the STRAW + 10 Staging System, with STRAW standing for Stages of Reproductive Aging Workshop. See if you can locate yourself in the following STRAW stages; then you’ll know how much longer you’ll probably be in perimenopause, and you can consult the informational boxes for help with whatever symptoms you’re experiencing.

Stage 1: Late Reproductive Years
A transition before perimenopause, this is the final stage of the baby-making years—a time when your ability to have a child declines rapidly.

Possible symptoms
•Lighter or heavier menstrual bleeding.
•More frequent (that is, shorter) cycles.

Hormonal changes: During days two to five of your cycle (day one is the first day of your period), there’s a larger-than-before jump in your levels of follicle-stimulating hormone (FSH), which stimulates an egg follicle to grow each month. Extremely elevated FSH, which your doctor can determine via a blood test, indicates your ovaries are aging. (See “Can I Still Have a Baby?”)

How long this stage lasts: Quite variable from woman to woman but can continue for up to 9 years.

STAGE 2: Early Menopausal Transition
This is the official beginning of perimenopause.

Possible symptoms
•Your menstrual cycle varies by seven or more days from one cycle to the next.
•An increase in irritability and PMS-like bloating.

Hormonal changes: Your body is making lots of estrogen but less progesterone, explains Steven R. Goldstein, MD, professor of obstetrics and gynecology at New York University’s Langone Medical Center. “It’s the paradox of perimenopause,” he notes. “Estrogen levels go up before they go down.”

How long this stage lasts: Usually 4 or more years.

STAGE 3: Late Menopausal Transition
The second full-fledged phase of perimenopause often occurs at about age 49. Santoro calls it the hot spot, because this is when you may start to be really affected by symptoms.

Possible symptoms
•Hot flashes are common.
•Sleep disturbances get worse.
•Mood changes.
•Skipped periods; you may go 60 days or more without menstruating and you frequently don’t ovulate.

Hormonal changes: There can be dramatic fluctuations in levels of hormones, including estrogen and progesterone, but the overall trend is that estrogen declines. “Ovarian function doesn’t just stop on a dime; it sputters,” Goldstein explains.

How long this stage lasts: Generally 1 to 3 years.

STAGE 4: Early Postmenopause
At this stage, you’ve recently crossed to the other side of menopause; in other words, you’ve gone more than a year without a period.

Possible symptoms
•During the first part of this phase, hot flashes and night sweats are likely to worsen or start.
•Toward the end of this phase, most menopausal symptoms recede, though hot flashes may continue for several years and vaginal dryness and thinning become more common.

Hormonal changes: After your period finally ends, estrogen and progesterone decline to very low levels.

How long this stage lasts: First part: 2 years. Remaining part: 3 to 6 years.

Even if you’re not a good candidate for HT (see “Should You Take Hormones?”), that doesn’t mean you must put up with symptoms that interfere with your life or disrupt your sleep, says Andrew Kaunitz, MD, professor in and associate chairman of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine–Jacksonville. While they’re not as effective as HT, a number of therapies can help assuage your discomfort. And remember: How you feel now is not necessarily how you will feel in two years. Unlike many other things in life, hot flashes and other perimenopausal concerns will get better as you age.
Here’s the latest on managing your symptoms.

SYMPTOM: Hot Flashes and Night Sweats
An estimated 75 percent of women experience hot flashes during the menopausal transition, and for about a quarter of those affected, the internal temperature shifts are seriously distressing. Night sweats—hot flashes that occur while you’re sleeping—are also very common; these two discomforts are classified as vasomotor symptoms. Interestingly, during menopause, obese women are more likely to get hot flashes because the fat tissue makes their bodies warmer; after menopause, obesity is protective because the fat tissue produces a small amount of estrogen, which may prevent hot flashes.

How to Handle

Practice slow, deep breathing What’s called “paced respiration” can make a hot flash feel less intense while you’re experiencing it. At the onset of a temperature rise, “don’t fight it—breathe deeply through it, similar to what you might have done during childbirth, and the flash won’t be as bad,” says Carol Landau, PhD, clinical professor of psychiatry and medicine at the Alpert Medical School at Brown University and coauthor of The New Truth About Menopause.“The breathing helps dial down your physiological arousal.” (For a demonstration, go to

If you consistently employ paced respiration, it even has a preventive effect. A 2005 study found that women who practiced breathing that way experienced almost 50 percent fewer episodes. Here’s the best way to practice: Sit in a quiet, comfortable spot. As you breathe, keep your rib cage still and lower and raise your diaphragm to fill and empty your lungs. Inhale for five seconds, pushing your stomach muscles out, then exhale for five seconds, pulling your stomach muscles in and up. Landau suggests following this technique, which is recommended by the North American Menopause Society, 10 to 15 minutes twice a day.

Break a sweat regularly Aerobic exercise reduces hot flashes in many women (though for some, a cardiovascular workout may worsen the symptoms). Women who have a strong physiological reaction to stress (for instance, their blood pressure temporarily rises when they are anxious) are especially prone to experiencing vasomotor symptoms, notes Steriani Elavsky, PhD, assistant professor of kinesiology at Pennsylvania State University. One benefit of regular aerobic exercise is that it can help you become less affected by stress, which in turn can make you less susceptible to hot flashes and night sweats. Although no one has yet determined the optimal exercise prescription, government guidelines recommend getting 150 minutes of moderate intensity or 75 minutes of high-intensity aerobic exercise a week.

Take certain antidepressants While not nearly as effective as hormone therapy, some antidepressants have been shown to reduce the frequency and severity of hot flashes. Among the most widely used are the selective serotonin reuptake inhibitor (SSRI) Paxil and the serotonin-norepinephrine reuptake inhibitor (SNRI) Effexor XR. Used off-label, the antiseizure drug gabapentin, which you take three times a day, can also moderate hot flashes.

Try acupuncture In a recent Turkish study, the severity of hot flashes declined in women who received acupuncture twice a week for 10 weeks—findings that jibe with earlier research. Although it’s not clear why this traditional Chinese medicine technique might cool you off, the study at the Ankara Training and Research Hospital did find heightened levels of estradiol, a form of estrogen, in women who underwent a series of acupuncture sessions. “Typically, patients register a change in severity and frequency after the first few treatments,” says Arya Nielsen, PhD, director of the acupuncture fellowship program for inpatient care at Beth Israel Medical Center’s Department of Integrative Medicine in New York City. “Once hot flashes are gone or manageable, then it is recommended that you have maintenance treatments—for instance, every other week or once a month—until you no longer need them.”

Experiment with eating soy Soy contains phytoestrogens—plant compounds that are chemically similar to estrogen—and for that reason, many researchers have hypothesized that consuming these foods or their extracts (isoflavones) reduces hot flashes. While studies have been inconsistent, one large, recent analysis in Menopausefound that in women who took soy isoflavones, the frequency of hot flashes was reduced by 21 percent more than in those taking a placebo; the severity of the hot flashes was reduced by 26 percent more than in the placebo group. If you want to try the soy approach, eat two servings of soy products a day, which translates into seven ounces of tofu, a half cup of edamame or two cups of soy milk. “Three months on soy should be enough to see a substantial effect,” says Melissa Melby, PhD, biological-medical anthropologist at the University of Delaware in Newark and a coauthor of the Menopausestudy.

SYMPTOM: Irregular Periods
It’s common for your periods to come erratically during perimenopause.

How to Handle

Rule out pregnancy If there’s any possibility that you have conceived, take an over-the-counter pregnancy test to find out. If you miss two periods in a row, take a second test, even if the first one came out negative, says Goldstein (you may have tried it too early).

Try low-dose contraceptives if  erratic bleeding patterns are driving you crazy But be warned: Doctors will typically steer you away from taking oral contraceptives if you have a history of blood clots, heart disease, breast cancer or endometrial cancer or if you smoke and are over 35. In those cases, your physician may recommend a 14-day course of progestin (synthetic progesterone). Another option, the Mirena IUD—a soft, flexible IUD that releases small amounts of progestin into your uterus—can end heavy periods as well as provide contraception for up to five years, after which point it loses its effectiveness.

SYMPTOM: Mood Changes
Moodiness, edginess or irritability (à la PMS) is common among perimenopausal women. “It’s not about feeling sad as much as it’s about having changeable moods,” says Landau. In addition, there’s something of a domino effect: Hot flashes can trigger sleep disturbances, which can leave you feeling moody or irritable during the day.

How to Handle

Get enough vitamin D The “sunshine vitamin” is increasingly linked to improved mood, Landau says. New research from the University of Minnesota found that women who consumed less than 400 IU of vitamin D daily (that’s the government’s daily requirement) had significantly lower scores on mental-health quality-of-life measures than those who consumed more than 400 IU per day. If you suspect you’re running low, talk to your doctor about taking daily D supplements.

Try cognitive behavioral therapy (CBT) This type of short-term treatment can change the way you respond to events. For example, if you’re having a night sweat, a CBT technique could help you avoid having the kind of anxious reaction (“I’ll never get back to sleep!”) that makes the situation worse. A new CBT protocol, done both in group therapy and as an individual self-help practice, was recently shown to be effective at reducing the negative impact of hot flashes and night sweats (while not necessarily reducing the symptoms themselves). That specific program is currently available only in the U.K., but for those who live on this side of the pond, “a clinical psychologist who works with physical health problems could provide treatment to reduce stress and help women manage symptoms,” says clinical psychologist Myra Hunter, PhD, a professor at King’s College London who helped develop the protocol.

SYMPTOM: Breast Tenderness
If your breasts frequently feel swollen and achy, it could be because you’re not ovulating regularly, which means you might be exposed to abnormal hormone levels, says Jan L. Shifren, MD, director of the Vincent Menopause Program at Massachusetts General Hospital in Boston. Breast pain can be bothersome, but rest assured: It’s rarely a sign of breast cancer.

How to Handle

If you can stand it, try cold packs Putting them on your achy breasts can provide relief, Shifren says. Anything cold should do the trick; try bags of frozen peas.

Weigh the Pros and Cons of diuretics They remove fluid from your system. Ask your health care provider about them if tenderness is really bothering you.

SYMPTOM: Forgetfulness or Difficulty Remembering
You walk into a room only to forget what it was you came for. You have trouble paying attention or focusing on what you’re supposed to be doing. More likely than not, this brain fog is due to hormonal changes, sleep disturbances, depression or stress overload—not Alzheimer’s.

Consume caffeine It will give you a mental boost, Landau says, but don’t drink it all day long, or you’ll just get edgy.

Say new facts out loud In a study of women ages 40 to 60, those who complained of memory issues tended to do more poorly on tests of “working memory,” which is the ability to hold data, such as a restaurant bill, in your head and then manipulate it—for example, by calculating a tip. If this sounds familiar, here’s advice from lead study author Miriam Weber, PhD, assistant professor of neurology at the University of Rochester Medical Center: “When someone gives you a new piece of information, you may grasp it better if you repeat it back to the person speaking.”

Consider taking atomoxetine (Strattera) If you’re really being driven around the bend by perimenopausal brain fog, says Santoro, this nonstimulant drug, often used to treat adult attention deficit disorder (ADD), can help. In a recent study involving healthy perimenopausal women without adult ADD who were having memory and concentration problems, researchers at the University of Pennsylvania found that taking this drug daily was associated with significant improvements in short-term memory, attention and concentration.

SYMPTOM: Insomnia
Up to 40 percent of perimenopausal women experience disrupted slumber, according to sleep experts. If you’ve always had trouble falling asleep or staying asleep, that’s likely to get worse during perimenopause. “The erratic production of estrogen often exacerbates women’s original tendencies,” Goldstein says.

How to Handle

Try mindful meditation A Massachusetts study that involved eight weeks of training in mindfulness-based stress reduction found that following this widely available relaxation technique significantly reduced sleep disturbances among women in late perimenopause and early postmenopause. It also helped them feel less bothered by hot flashes. For more info, click on “The Stress Reduction Program” at the site of the Center for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts Medical School (

Take Benadryl “If you have trouble falling asleep, this antihistamine works surprisingly well and is very safe,” Shifren says.
Go for stronger medicine If your sleep troubles persist, talk to your doctor about whether you might benefit from gabapentin, which has a sedating effect (and also helps with hot flashes) or a prescription aid such as Ambien.

SYMPTOM: Headaches
If you’ve suffered menstrual migraines in the past or you’re prone to headaches in general, be prepared. “In perimenopause, the rise and fall of estrogen levels can cause headaches to become more frequent,” Goldstein says.

How to Handle

Identify triggers Alcohol, certain foods, weather changes, stress or other factors can all play a part. Avoid or mitigate them by, for example, practicing relaxation techniques.

• Consider the strategic use of estrogen For some women with perimenopausal migraines, “intermittent treatment with estrogen around their periods can be a godsend,” Santoro says. “And in the late transition, estrogen patches can sometimes wipe out headaches altogether.”

It’s important to remember that from your early forties into your early fifties, not everything that makes you feel bad can be blamed on perimenopause. “At times, health care professionals may attribute many symptoms to perimenopause and not investigate other possibilities,” says Shifren.

“The biggest potential for harm is if a doctor minimizes a cardiac symptom like heart palpitations and attributes it to perimenopause without thinking much about it,” notes Santoro. Symptoms to watch for:

Hot flashes that begin while you’re taking HT or oral contraceptives They’re probably not due to the hormonal changes of perimenopause, Shifren says. They could, in fact, be signs of a thyroid disorder, diabetes or another medical condition, which your doctor can test for. 

Superheavy bleeding If you’re soaking through pads or tampons at a much faster rate than ever before, this could be a sign of endometrial hyperplasia, a condition in which the lining of the uterus becomes too thick, explains Shif-ren. The excess bleeding could also be due to uterine polyps, fibroids, a thyroid disorder or an infection.

Schedule an appointment with your OB-GYN to find out what’s going on.

Signs of depression or an anxiety disorder Seek medical attention if you regularly have low energy or severe fatigue; worries so severe, you’re having trouble functioning; or other mental issues. Women who have a history of depression are up to five times as likely to be diagnosed with major depression from early perimenopause until postmenopause, says a recent review of the medical literature. If you had postpartum depression or suffer from extreme PMS (premenstrual dysphoric disorder, or PMDD), “you’re also more likely to become clinically depressed at this time,” Landau says.

Heart palpitations accompanied by other symptoms If you’re simultaneously experiencing weakness, breathing trouble or a squeezing sensation in your chest, heart palpitations may be linked to a thyroid problem, a heart condition or panic disorder. See a cardiologist for a full evaluation, including an ECG, and also have your thyroid-stimulating hormone measured. If you’ve developed an arrhythmia (erratic heartbeat), a variety of medications and procedures can treat it.

Tenderness in just one breast, not both This, along with a symptom such as a discharge from the nipple or redness or visible swelling in one breast, can be a sign of an infection or another breast problem. Schedule a visit to your doctor.

Happy 366th day of not menstruating! You can now be sure you’ve had your last period and are officially in menopause. At that point you’ll finally be free—of tampons, pads, premenstrual water retention, menstrual cramps and crazy bleeding patterns. Besides being able to wear white any time you like, you’ll experience other benefits in menopause. “There’s less vaginal discharge, the pain from cramping and endometriosis goes away, and fibroids in the uterus stop growing and shrink,” notes Gass. Plus, you no longer need birth control.

Cognitively and emotionally, you’ll reach a more peaceful equilibrium. Brain fog: gone. The mood roller coaster: gone. Mental clarity: It’s back!

At this point in their lives, many women experience what’s referred to as postmenopausal zest. This new energy and clarity partly stems from the absence of perimenopausal symptoms; you’ll feel better than you have in years. But there’s more going on, experts say. Notes OB-GYN Christiane Northrup, author of The Wisdom of Menopause: “Our bodies, minds and lives are set up so our best times start after 50.” Give yourself permission to explore who you are and how you want to live during the next chapter of your life. “It’s time to start putting yourself first,” Northrup says.

Next: How to Find a Perimenopause Specialist in Your Area

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First Published Fri, 2012-06-01 09:10

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