Perimenopause Starts Years Before Menopause: Here's What to know

Menopause is a major and inevitable health journey for every person with ovaries and a uterus -- about half of the population. Yet, most people transition through menopause without a clue that there are things you can do and treatments you can seek to improve your quality of life.

When people talk about "going through menopause," they're usually referring to the middle-to-end stages of perimenopause -- a period that spans the last reproductive years when the ovaries start producing less estrogen and progesterone. Erratic or dropping hormone levels during this time cause symptoms such as hot flashes, urinary tract and vaginal problems, menstrual cycle changes, mood shifts and brain fog. 

Once the ovaries stop ovulating and functioning, menstruation stops. You're fully "in menopause" or postmenopausal once you've gone a whole year without a period. The average age of menopause in the US is 51, and perimenopause typically starts in your 40s. 

Despite it being an inevitable health event that affects multiple body systems, shyness around conversations involving reproductive health and confusion over the use of the first line of treatment for menopause -- estrogen therapy -- have left many people in the dark. What's more, research and medical training has a history of ignoring menopause as a factor in health, leaving big gaps in aging care. In recent months, celebrities including Halle Berry and Naomi Watts have made calls to destigmatize and increase awareness of menopause. 

To get the lay of the land, we spoke with experts about identifying the signs of perimenopause, when to go to your doctor, what foods you should include in your diet and more steps to take for transitioning out of your menstruating years as comfortably as possible. 

What is the first sign of perimenopause? 

For most people, perimenopause begins in their 40s, though it may start as early as someone's mid-30s or as late as someone's mid-50s. (Premature ovarian insufficiency, or premature menopause, is uncommon and occurs before age 40.) How long you experience symptoms also varies, as some people will be in perimenopause for several years, while others will only have symptoms for several months. 

Perimenopause may come in stages, with symptoms more noticeable toward the later end when less estrogen is being produced. However, the first signs of perimenopause are typically seen in the menstrual cycle. 

Sign 1: Your menstrual cycles become shorter 

According to Dr. Natalie Crawford, a fertility doctor and co-founder of Fora Fertility in Texas, one of the first perimenopause signs someone will likely notice is shorter menstrual cycles than what's typical for them. (For example, someone who's always had 28- or 29-day menstrual cycles on average may start having 24- or 25-day menstrual cycles as their new norm.) Crawford said this is due to a depleting number of eggs locked in the "vault" (your ovaries), which naturally dwindles over time but gets quite low in number near the end of your reproductive years.

"As the vault gets emptier, you have clinically low threshold and you start to see these period changes," Crawford explained. Factors like being on birth control that suppresses ovulation or not being familiar with the timing of your "regular" cycle, though, will make this typical sign a little tricky to catch, according to Crawford.

For that reason, more dramatic changes in the menstrual cycle that occur as perimenopause progresses are often the first signs people bring up to their doctor. 

Sign 2: Your menstrual cycle becomes irregular and longer  

Periods will often become irregular and longer as your body ovulates less easily and less often. The Mayo Clinic describes irregular periods as the "hallmark" of perimenopause. 

"Your periods get weird, then they don't come as frequently, then you're like, 'Is that it?'" said Dr. Sophia Yen, co-founder and chief medical officer of Pandia Health, a reproductive and hormonal health telemedicine company. Someone could go months without a period, think they're finally in menopause, then get another one, she explained. 

"It's just really stressful for a lot of women," she added. 

You may also experience "flooding," which Yen described as the very heavy bleeding that people often experience in perimenopause. "Spotting," or light bleeding outside of the menstrual part of your cycle, can also happen.

Sign 3: You have symptoms of low estrogen 

Vaginal dryness, urinary tract infections and pain, sleep problems and the infamous "hot flashes" are signs of low estrogen and signs of perimenopause, according to the American College of Obstetricians and Gynecologists. 

Tell your doctor about your symptoms and ask about estrogen therapy  

The menstrual cycle is a window into your overall health -- not just your reproductive organs. So even if you're in your 40s and you think your irregular periods are linked to perimenopause, it's important to rule out a thyroid problem, a nutritional deficiency or another ailment. 

"You want to make sure that change isn't due to some other hormone system," Crawford said. 

But if you're perimenopausal, there are treatments available to relieve symptoms, and you don't need to suffer through. Arguably the gold standard is estrogen therapy. Not only does estrogen help with hot flashes and vaginal and urinary symptoms, but it may also help reduce the risk of osteoporosis and relieve some other symptoms associated with declining estrogen levels.

"Estrogen is good for the blood, brain and bone," Yen said.

Different types of estrogen therapy 

Estrogen therapy, or hormone replacement therapy, got a bad name due to a large study that's been highly criticized and now largely seen as flawed. While not suitable or safe for everyone, hormone therapy is considered an effective treatment for many, relieving symptoms like hot flashes, night sweats and vaginal dryness, especially when started younger as opposed to many years after menopause. 

Systemic estrogen therapy is given throughout the whole body in the form of a pill, patch or gel, while local estrogen therapy in the form of a cream, ring or tablet can treat vaginal dryness. Progestin is sometimes given as well as a combined therapy. 

Importantly, you don't need to wait until your periods have officially stopped and you're postmenopausal to inquire about estrogen or hormonal therapy. In fact, according to Yen, it may be in your best interest to ask and start it sooner in your perimenopausal journey, as long as it's deemed safe based on your health history, and you've discussed the benefits and risks with a health care provider you trust.

"The way I look at menopause is running out of gas," and estrogen is the gas, Yen explained. As opposed to waiting until the tank is completely empty, Yen said some people may even use birth control as a way to help level off the hormone levels that are going up and down in perimenopause. Then, when menopause arrives, you can move up to the strong stuff (hormone replacement therapy). 

Eat the right nutrients and consider phytoestrogen foods

According to Johns Hopkins Medicine, your daily intake of calcium should go from 1,000 mg of calcium daily to 1,200 mg once you've gone through menopause. Once again, this is due to the lack of estrogen. You also need to make sure you're consuming enough vitamin D, as that aids in bone health. 

If eating a well-rounded diet won't cut it, you can consider a supplement or a multivitamin made for women in their 50s and up. But because too much vitamin D or calcium can cause problems, it's best to run any plans for a supplement or daily vitamin by your doctor to make sure you're choosing the right one for your needs. 

Beyond the healthy bone basics (making sure you're getting enough vitamin D and calcium), there may be other ways to eat to set yourself up for a healthier menopause transition. Hormonal changes that come with menopause may put you a higher risk for chronic health conditions, like heart disease, so reducing sugar intake and choosing whole, nutritious foods will have a positive impact on your overall health. 

And according to information from Zoe, a nutrition science company, some of the foods that are notoriously "heart healthy," such as the Mediterranean diet, may also help reduce menopause symptoms such as hot flashes when compared with people who don't follow as plant-focused diet. 

What's more, foods that contain phytoestrogens may help level off hormones and dipping estrogen levels. According to the Cleveland Clinic, some foods that have phytoestrogens include: 

• Soy products, including soy milk and tofu 
• Berries 
• Carrots 
• Apples 
• Wheat
• Oats and barley 
• Lentils 
• Dried beans 
• Sesame seeds
• Rice 
• Alfalfa

If you see any phytoestrogen supplements online, or any supplement marketed as being for menopause, always check with your doctor or a health professional who knows your health history before taking one, as supplements would contain more phytoestrogen than what's typical in food. This means that phytoestrogen supplements may carry a risk for estrogen side effects, potentially making them risky for people with a history of blood clots, some cancers and more. 

Adjust your exercise routine 

Being physically active is important during all stages of life, including perimenopause and menopause. However, in menopausal women, the focus is "not aerobic exercise, but muscle-building exercise," Yen said, as it can help with bone strength. 

As you age, you can modify or strengthen your workouts to meet your body's needs with cardio, strength training and exercises to improve balance. 

Try your best to optimize your sleep

Many people report sleep disruption as a main symptom of perimenopause and menopause. For those who get hot flashes (about 75% of women at some point), they're often worse at night. Hormonal fluctuations can lead to restlessness and contribute to night sweats. Hormonal therapy, then, may improve some people's sleep.

For general tips for sleeping cool, practice good sleep hygiene by avoiding or limiting caffeine and alcohol, sticking to a sleep schedule, and keeping your bedroom temperature cool. You can also invest in cooling sheets or a cooling mattress. 

However, it may be changes in the brain that are associated with night sweats -- rather than the heat itself -- that keep people up, according to Johns Hopkins Medicine. Also, falling hormone levels can also increase the risk of sleep apnea -- a big disruptor of sleep. If you're struggling to sleep at night, reach out to a doctor, advocate for yourself and share how you've been feeling. If your concerns aren't being addressed by your primary care doctor, find someone who specializes in women's health. You can also search for a menopause practitioner near you.