The Ups and Downs of Perimenopause


Perimenopause is a confusing time as there is a lot of variation of when and what can happen. Often referred to as “second puberty,” it is used to describe the 2-12 year time period that precedes menopause (the absence of a menstrual cycle for 12 consecutive months).  It can range from as early as age 35 to as late as age 59.  Though cycles may remain regular, there are definitive hormonal changes that occur. 

A normal menstrual cycle is marked by ovulation (the release of an egg), followed by menstruation 2 weeks later. In the first half of the cycle, there is increased production of estrogen, with progesterone  predominating post-ovulation. Both hormones are needed for optimal health as their actions balance each other out. A normal cycle typically occurs every 21-35 days and can last between 2-7 days, with an overall fluid loss of approx. 15-80 mL (or 1-5 Tbsp).

Ovulation is necessary not only for successful pregnancy, it is also key as it leads to the production of the cycle’s second important hormone—progesterone.  During perimenopause, ovulation happens in more sporadically, so progesterone is on a steady decline. Simultaneously, estrogen levels fluctuate wildly, with dramatic highs and lows, which leads to very unpredictable levels and ratios of both estrogen and progesterone.

Though we think of estrogen and progesterone primarily as reproductive hormones, there are receptors on many different types of tissues – including your heart, lungs, brain, breasts, bones to name a few. Both estrogen and progesterone have many functions, which is why there are so many symptoms that accompany this time of hormonal flux.


Irregular periods. Irregular ovulation can alter the length of time between periods and amount of flow. You may also experience random spotting or skip cycles altogether.

Hot flashes/night sweats. Hot flashes and night sweats are perhaps the most common symptom, with varying intensity, length and frequency. Often, they are triggered by dietary and lifestyle factors such as stress, alcohol intake and tobacco use.

Vaginal dryness and thinning. Vaginal tissues are susceptible to becoming thinner, drier and less elastic due the decrease in estrogen. For some, this can make intercourse painful. Sometimes, there is also an increased susceptibility to vaginal infections, urinary tract infections, and urinary incontinence.

Skin changes. Changes such as brown spots, dryness, easy bruising, and increased wrinkling may occur. Collagen is a key component of skin, and it is estimated that 30 percent of skin collagen is lost during the first five years after menopause.

Fatigue/sleep disturbance. Sleep is often affected by hot flashes and/or night sweats. Since progesterone is calming to the nervous system and can act as a brain neurotransmitter, its decline can also contribute to sleep problems and lowered ability to deal with stress.

Decreased libido is often reported during perimenopause which may be attributed to decreased estrogen levels, changes in mood and/or stress resilience.

Depression, anxiety and/or mood swings. Estrogen increases serotonin and the number of serotonin receptors in the brain, which can influence the experience of depression/anxiety/mood swings. Lowered levels of progesterone typically result in increased feelings of anger and irritability.

Bone loss is caused by declining estrogen levels, and can increase your risk of osteoporosis and bone fractures.

Changing lipid profiles. Decreasing estrogen levels may lead to unfavorable changes in your blood cholesterol levels, including an increase in low-density lipoprotein (LDL) cholesterol — the “bad” cholesterol — which contributes to an increased risk of heart disease. At the same time, high-density lipoprotein (HDL) cholesterol — the “good” cholesterol — decreases in many women as they age. Other symptoms associated with perimenopause can include: changes in memory and cognition, scalp hair loss, facial hair growth, acne, palpitations, nausea, and headaches.

Doesn’t sound like much fun, right? Don’t worry, there is hope. There are a number of supportive therapies and strategies available to help transition through this phase of life more comfortably. Here are a few suggestions to get you started:

Nutrition and diet. This is truly a time to renegotiate your relationship with sugar and starchy carbohydrates, especially processed foods for optimal body composition and blood lipids. Avoid excessive alcohol (no more than 4 servings/week), center meals around whole foods such as meats, vegetables (that grow above the ground) and healthy fats like olive oil and avocadoes, with the addition of whole grains/legumes/root vegetables as condiments to round out the meal.

Manage stress. Re-evaluate your commitments (and cut back where you can) and supplement magnesium, a very calming mineral that soothes your nervous system. Not only does it facilitate better sleep, improves insulin and thyroid function, as well as as activates vitamin D for better bone density¹, for many women, magnesium on its own helps to soothe hot flashes by 50%.

Exercise regularly. Exercise will help with stress management, reduce the intensity and severity of hot flashes, increase your endorphin production for improved mental health and depending on the kind of activity, improve bone density (we’re talking weights here) and body composition.

Despite the physiology, is it really possible to age the same, or even better, with the same energy and vitality of your younger years? Absolutely. The big difference is now you need to pay closer attention and more importantly, take care of yourself. Women are known for putting the needs of others ahead of themselves (hmmm….traits that are really needed to raise a family). Women spend 1/3 of their lives in menopause, which is why supporting our health through this phase is so essential. For many women, this time of life is very empowering, as the focus of life moves away from childbearing/childrearing and becomes more about finding one’s path/voice/calling. Getting older is a chance to live life on your own terms – embrace it!


  1. Uwitonze, A. M., & Razzaque, M. S. (2018). Role of magnesium in vitamin D activation and function. J Am Osteopath Assoc118(3), 181-189.
Tasleem Kassam