Perimenopause: The slow shift to menopause

March 30, 2021
A woman in perimenopause enjoys time outside in this photo.
On average, women are age 51 when they enter menopause, which is defined as going a full year without menstruation. Perimenopause typically lasts for five to 10 years. Photo by Getty Images.

The shift into menopause doesn’t happen overnight. In fact, this transition, also known as perimenopause, can take years.

“Perimenopause is the time leading up to when the ovaries cease to function, but it’s not like putting on the brakes,” said Dr. Diane E. Petersen, an OB/GYN with UCHealth Women’s Care Clinics in Steamboat Springs and Craig. “The ovaries start to fail gradually.”

Below, Petersen explains what you can expect through perimenopause and how to treat troublesome symptoms.

A woman’s regular cycle

Petersen describes the menstrual cycle as a “dance” between the brain and the ovaries. Changes in ovarian hormones alert the brain that the ovary is working, while the brain gives instructions on what to do.

A number of hormones are involved: for instance, estrogen and progesterone stimulate the uterus and breasts in preparation for a possible pregnancy, while FSH (follicle stimulating hormone) stimulates the development of eggs.

Approaching menopause

Eventually, this cyclical communication and response start to change.

“The eggs in the ovary gradually decline and when you reach a certain point, some of the eggs aren’t going to respond and develop, so you don’t get estrogen,” Petersen said. “The brain shouts louder and louder, and the FSH gets higher and higher, and eventually the ovary may kick back in. You may get a surge of estrogen because the brain is shouting so loudly, but then it plummets again.”

During perimenopause, swings in hormone levels mean normal menstrual cycles may be followed by times without a cycle or even overlapping cycles.

Symptoms of perimenopause

With dynamic changes in estrogen levels, women may experience symptoms such as emotional changes, difficulty sleeping, hot flashes and acne. “Many women don’t have issues, but for those who do, it can be very disruptive to their quality of life,” Petersen said.

On average, women are age 51 when they enter menopause, which is defined as going a full year without menstruation. Perimenopause typically lasts for five to 10 years.

“Increasingly for women in their 40s, they’ll have a rise in premenstrual dysphoria, or feeling off and irritable, before their menses,” Petersen said.

Treatments to help with perimenopause

Various treatments are available to help women through the symptoms of perimenopause. Some women stay on an oral contraceptive until menopause, which provides steady levels of hormones.

“There are benefits of that: it’s simple, it can control heavy bleeding and it will often take care of those dips in estrogen,” Petersen said. “There is a downside, as it’s an oral estrogen, and as women get older, there are co-morbidities with the pill, such as an increased risk of blood clots in the legs and migraines.”

Petersen’s preferred method of addressing perimenopause symptoms is to give a patient a very small amount of estrogen delivered through a low-dose patch. As the body slowly makes less estrogen through the perimenopausal years, the estrogen dose increases.

“It’s complicated and requires a lot of conversations between the doctor and patient, but when it works, it’s really great,” Petersen said.

An IUD (intrauterine device) that delivers hormones locally can help address issues with heavy periods.

Since the decreased estrogen levels impact the function of neurotransmitters, a low dose of an SSRI (selective serotonin uptake inhibitor) antidepressant may help address cyclical mood changes and hot flashes.

“There shouldn’t be a stigma in using an SSRI,” Petersen said. “The brain cells need to have neurotransmitters, or chemicals that live in between cells and transmit or talk. SSRIs allow that to continue.”

Petersen acknowledges the concern that taking estrogen may contribute to breast cancer, but points out that causes of breast cancer are likely varied and complex.

“We have to make these decisions as intelligently as we can,” Petersen said. “Perimenopausal treatment is tailored to each woman – what she’s feeling, what her family history is, what scares her and keeps her up at night, and what will help her feel better.”

This story first appeared in the Steamboat Pilot & Today.

About the author

Susan Cunningham lives in the Colorado Rocky Mountains with her husband and two daughters. She enjoys science nearly as much as writing: she’s traveled to the bottom of the ocean via submarine to observe life at hydrothermal vents, camped out on an island of birds to study tern behavior, and now spends time in an office writing and analyzing data. She blogs about writing and science at