Am I in perimenopause???

Perimenopause and menopause are having a moment - it does not take long before something flashes before your eyeballs making you question whether every physiological sensation may in fact be a sign that you are in perimenopause. Whilst I am happy that women's health is getting some more attention, remembering that there are some generations including my mother's, that had a blackout of information and support during this phase of life, it is important that we do not pathologise this period of life or get caught up with mis/dis - information.

So, whilst I often eye-roll at a lot of content out there, I am pleased to see that research and medical advice is catching up and that women are beginning to get better support to transition through this stage of life. 

One question I get asked a lot in the clinic when someone is experiencing menstrual cycle stuff with other symptoms - am I in perimenopause?

Officially, based on what's called the STRAW +10 criteria, early perimenopause for those that have a uterus, is defined by persistent variability in menstrual cycle length; specifically, a difference of 7 or more days in consecutive cycles, recurring within 10 cycles of first occurring. At first changes might be subtle, like a shorter cycle, fewer days of bleeding, heavier or lighter flow, spotting instead of a period. In other words, cycles continue but become persistently irregular. If a cycle is missed (≥60 days of amenorrhea), this signals the a likely later phase in the menopausal transition, which is often accompanied by consistently elevated FSH (>25 IU/L) and greater symptom burden.

(Harlow et al., 2012)

Menopause itself is defined retrospectively; confirmed 12 months after the final menstruation. The menopausal transition can last anywhere from around 4 to 8 years on average, though individual experience varies considerably.

As noted in the STRAW +10, there are two late reproductive phases (3a and 3b) just before perimenopause, where women may experience symptoms such as worsening PMS. These individuals may have regular cycle lengths to slightly shorter, normal to slightly rising/variable FSH, low AMH, low follicular count. The worsening of PMS symptoms can be a first sign of transition. 

Typically, women enter perimenopause in their 40s, though it is possible to have symptoms earlier. Early menopause is defined by having the last period before the age of 45. If the last period is before the age of 40 this is defined as premature menopause. There is another condition call Premature Ovarian Insufficiency (POI), that looks like early/premature menopause but it is not. For early/premature menopuase or POI - it is important to understand what this means for long term health as well as the support/treatment that is available (more to come on this in another blog).

Beyond physiology - the broader implications of this period of life to consider include:

• Associated symptoms of menopause transition can impact the quality of life of women and all those with ovaries

• The impact on workplace performance impacts both personal and societal financial outcomes.

• Some symptoms may be a sign of future health risks for some women (e.g. vasomotor symptoms and sleep issues may be associated with increased risk of bone and cardiovascular risk; vasomotor symptoms and depression may be associated with increased risk for cognitive decline) 

• Geographical location and ethnicity influence the prevalence of varying symptoms. 

• Individual factors such mental health, stress & trauma, metabolic health and socioeconomic status may considerably worsen the experience of menopause.

• Potential for significant influence on interpersonal relationships and family structure.

Importantly - perimenopause and menopause are not pathologies but a natural transitional stage of life. Some women will transition without too much distress or needing too much support. If the changes do not interfere with quality of life and your daily functioning, support may not be necessary.

However, for many women, the symptoms experienced during this season of life can impact day to day life and quality of life. For these women, research and clinical evidence suggest that support is well indicated and that early and comprehensive management improves both short-term symptoms and long-term health outcomes.

When bleeding changes raise a red flag

Many changes in the menstrual cycle are normal but some changes can be unsettling and impact quality of life. If you have any of the following changes in bleeding/cycles for more than 2 cycles, it is a good idea to chat with your GP and see an ob/gyn for evaluation:

• bleeding that soaks through one or more tampons or pads every hour

• bleeding that lasts more than 7 days

• flooding or gushing when you stand up

• passing large blood clots the size of a quarter or larger

• bleeding or spotting after sexual intercourse

• bleeding between cycles

• cycles longer than 35 days or shorter than 21

What is actually happening in this phase of life?

As we age, so do our ovaries. This impacts our hormones produced by the ovaries as well as from other sites in the body. Before estrogen does its decline, it rollercoasters often resulting in ‘high estrogen-like’ symptoms such as heavier bleeding, breast pain, mood symptoms/anxiety. This is compounded by the declining progesterone from poor ovulatory cycles. 

(Hardringham, 2025) 

These changes in hormones impact more than just our reproductive system and this is because our hormones play important roles throughout our body.

This image shows how estrogen functions in different parts of the body...

(Farkas et al, 2022)

(Monteleone et al., 2018)

With estrogen having wide multi-systemic functions - it makes sense that individuals can experience multi-systemic symptoms during perimenopause/post-menopause. This is where things can get a little messy, however, as many of these symptoms can be related to other things going on and not necessarily perimenopause. It is therefore, important to discuss your symptoms in context with a practitioner who can look at the big picture, rule out possible other causes, and support your individual needs. 

What else might contribute to timing and earlier onset

Other things that may be relevant to when you might go through menopause is family history. Knowing when your mother went through menopause can be helpful. Other factors that can influence the timing of perimenopause include trauma/stress, health conditions, smoking, other chemical exposure, ethnicity, & short menstrual cycles.

The take away….

We do have guidelines that can help us determine whether you are in perimenopause. If you are not feeling yourself, it is always worth talking to your doctor. Tracking your cycle & symptoms can be a helpful way to identify with a practitioner what you are experiencing as well as the patterns that may be happening to get a holistic picture. You can download this tracker linked below or use one of the many apps available to help you. Hormone blood tests are not necessary to determine whether someone is in perimenopause or prescribe support such as HRT but they can be a helpful way to assess what is actually going on with your hormones and provide more personalised comprehensive support.

Perimenopause Symptom Tracker.pdf

Download PDF • 302KB

Key hormone blood tests that can be helpful and the days to test them if you are still cycling:

Day 2 of your cycle test (second day of full menstruation):

• FSH

• LH

• E2

• Prolactin

• Free testosterone

• DHEA

  
  

Day 21 of your cycle test or 7 days post-ovulation: 

• Free T (including SHBG)

A Point on Differential Diagnosis

As mentioned above, there can be other things that result in missed/irregular periods as well as other symptoms that can be associated with perimenopause. I am brining this up because in the age of social media and dr. google - it is very easy to self-diagnose and possibly incorrectly. There are other reasons we may be experiencing our symptoms. PCOS for example can result in metabolic changes, weight changes, irregular/missed cycles. Other conditions that need careful consideration - especially if someone is younger than 40 - include hypothalamic amenorrhea and primary ovarian insufficiency. Thyroid issues can also lead to period changes, metabolic changes, poor temperature regulation, reduced libido. Not only are there possible other contributing factors that may need to be considered or at least ruled out - it can be more than one thing at once. For me personally - I have a thyroid condition and had primary ovarian insufficiency that likely kicked off my perimenopause early - both needed to be addressed.

The point is - whilst, yes, a range of symptoms can be perimenopause - they can also be other things and it is important to look at whole picture and assess what is really going on - identifying other potential contributors that may require different or additional support.

...More posts to come on how to support yourself through this phase of life. 

If you are wanting some more support,

--> stay tuned to our weekly newsletters this month focused on perimenopause.

--> join our fireside chat at 12pm nz time on Saturday May 30th. Subscribers get free access.

--> for more 1:1 support schedule a free vitality strategy call to discuss pathways of support.