Why Perimenopause Is Not About Aging

Perimenopause or “second puberty” is the two to ten years before the final period. It’s different from menopause, which is the life phase that begins one year after the final period. Symptoms, if they occur at all, occur mostly during perimenopause and are temporary.

The normal age for the final period is anywhere from 45 to 55 so the normal age for perimenopause is up to ten years before that—as young as 35. In other words, if you were born before 1984, you could be in perimenopause and yet still be relatively young. That’s why perimenopause is not about aging but is instead about an important (and unavoidable) recalibration of your hormonal system.

The timing of menopause is genetic

As I explain in my new book Hormone Repair Manual, menopause has been around for as long as we’ve been human and is not just an accident of living too long. According to some historians, menopause may even have been the driving force behind the evolution of a longer human lifespan.

You are genetically programmed to achieve menopause at approximately the age your mother or female relatives achieved it. If that’s on the younger end of normal (mid-40s), you’re fine and healthy. It doesn’t mean you’re aging more rapidly than your friends. If, on the other hand, you’re genetically programmed to achieve menopause on the older end of normal (mid-50s), then your perimenopause is happening alongside aging but is not caused by aging.

Finally, if you enter menopause before age 40, it’s the medical condition of premature menopause or primary ovarian insufficiency and is also not about aging.

How to diagnose perimenopause

Menopause (including early menopause) can be diagnosed by two high FSH readings (more than 40 IU/L) at least a month apart.

Perimenopause cannot be diagnosed by FSH or any other lab test. Instead, it’s diagnosed based on age and symptoms. According to Canadian endocrinology professor Jerilynn C Prior, a midlife woman with regular cycles is likely to be in perimenopause if she notices any three of the following nine changes:

  • new-onset heavy and/or longer flow
  • shorter menstrual cycles (25 days or less)
  • new sore, swollen or lumpy breasts
  • new mid-sleep waking
  • increased menstrual cramps
  • onset of night sweats, in particular premenstrually
  • new or markedly increased migraine headaches
  • new or increased premenstrual mood swings
  • weight gain without changes in exercise or eating.

In other words, if you’re older than 35, and have at least three symptoms on this list, you’re likely to be in perimenopause.

What are the hormonal changes of perimenopause?

In the early phases of perimenopause, the biggest change is lower progesterone due to shorter luteal phases and more anovulatory cycles—despite regular periods. Lower progesterone contributes to anxiety, breast pain, heart palpitations, night sweats, frequent migraines and crazy, heavy periods. At the same time that progesterone drops away, estrogen spikes up to three times normal which contributes to irritable mood, breast pain and heavy periods.

Changes of progesterone and estrogen in perimenopause.

👉🏽 Tip: High estrogen symptoms stem both from the direct effects of the hormone and from estrogen’s indirect effects on mast cells and histamine.

The fact that perimenopausal symptoms stem largely from losing progesterone, not estrogen, is why progesterone, not estrogen, can be the better treatment. Also, just as a little reassurance, it is possible to conceive during perimenopause.

For treatment ideas, see Hormone Repair Manual where I discuss my favourite combo of magnesium plus taurine as well as modern body-identical hormone therapy including transdermal estrogen (Estradot) and natural progesterone (Prometrium or Utrogestan).

Also see my blog posts:

45 thoughts on “Why Perimenopause Is Not About Aging”

  1. Everything is so confusing. Is menopause diagnosed by a year without a period, or two high FSA readings? I’m 45 and I have one high FSA reading and that is as much as I have been tested, and irregular periods, just had one, but if I still have a period here and there guess it’s not menopause?

    Does estrogen make any sense at this point? I have tried small amounts. Will 100mg continuous progesterone suppress periods (if my body is still continuing to have them that is)? Can estrogen and progesterone case fake periods if if is not cyclical but continuous? I am so confused about even knowing where I am in perimenopause/menopause or taking hormones for symptoms. I don’t think my periods have been ovulatory for awhile, but probably been having anovulatory periods most of the time since age 43.

    Reply
    • if your cycles are mostly regular, you’re probably in phase 2 of perimenopause (see my book hormone repair manual). In that situation, cyclic progesterone can be helpful. The way many of my patients use it is to use it daily but stop for 10 days from the first day of the flow. It will contribute to somewhat regular withdrawal bleeds. Since you’re mostly anovulatory at this stage, there is no expectation of a regular cycle.

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    • and in answer to your question about estrogen. If there are symptoms of significant hot flashes or memory loss, then low-dose (25 mcg) transdermal estrogen can also be helpful.

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      • thanks. I don’t know if my periods are that regular, I missed a period and then some before the latest. In the past year I have also skipped a period before as well, and one month bled twice 2 weeks apart. I have minor hot flashes, sometimes severe insomnia, I feel sweaty but don’t really sweat that much, sometime heart palpitations, panic flashes at night, weepiness, depression. I stopped taking estrogen for now as I was on the lowest dose of divagel, but my breast gets sore if I take it too long, my breasts were even feeling sore on 100 mg natural progesterone by itself (without estrogen) sometimes even though it is a godsend for my sleep and I really want to take it for that as otherwise I struggle to sleep. I also take magnesium citrate and taurine. I just can’t get my hormones right.

        Reply
  2. Hi Lara, i was taking Prometrium orally continuously for nearly a month and was loving the benefits until I started to suffer from migraines, insomnia and night-time panic attacks. Can taking Prometrium vaginally prevent these unwanted side-effects? And can you still gain the benefits? My body seemed to love the progesterone until it got to high.

    Reply
    • yes, taking progesterone vaginally can reduce side effects.
      Another option is to take a lower dose or for fewer days. For example, 5 days per week.

      Reply
  3. Hi Lara, I’m 48 and have typical symptoms of low progesterone (shorter cycle, heavy periods, migraine, worsen PMS particularly anxiety and heart palpitations). I started on continuous Prometrium and it was working so well for me (reduced anxiety, reduced heart palpitations). However, after about a month it started to give me a migraine, insomnia and night-time panic attacks. Could I get the benefits of progesterone without the side effects by taking the Prometrium vaginally and cyclical instead of orally? Thank-you ☺️❤️

    Reply
    • Yes, taking it vaginally is an option (see my other comment). Also, taking it fewer days such as 5 days per week or cyclically (2 weeks on, 2 weeks off) or

      Reply
  4. I have tried to get my doctor to give me progesterone but he just looks at me in shock. My FSH was 42 and he said it’s menopause. Does it mean Im near menopause? My mom and aunts were 52. I am 45 and still cycle but my periods are crazy.
    Also tried to talk about insuline resistance and he thinks I’m hypochondriac!

    Reply
    • The simplest strategy is to accept the script for an estrogen patch and Prometrium (progesterone) — which most doctors are happy to prescribe. And then start by using only the progesterone.

      Reply
  5. Hi, I read your book “Hormone Repair Manual” and I was hoping to read of those cases when oral micronized progesterone does not help with sleep as in women like me. I am 55 and in full menopause. I tried up to 300mg and didn’t even feel any drowsiness. As per your recommendation, I am taking Glycine, Magnesium, Melatonin, Taurine. The progesterone did get rid of hot flashes. Thank you!

    Reply
    • yes, about 1 in 10 women do not get the nice tranquillizing effect from progesterone.
      If nothing else has worked for sleep, it can be worth trying estrogen (a 25-mcg patch together with Prometrium). But check with your doctor, of course.

      Reply
  6. Dear Dr. Briden!
    Thank you for sharing all these helpful Information.
    Your blog made me stop taking the pill after decades, 6years ago.

    Im getting 50 in December.

    By just hitting age 49 my doctor made a saliva test which stated a estrogen dominance. Progesteron was too low.
    I am on micronized natural progesteron ( made by a pharmacie from yams) since december 2020.
    Started with 50 mg and meant to add up to 200 mg every cycle.

    My cycle before micronized
    Prog. was just 21-23 days long but still completely regular!

    With 150 mg prog it was
    28 days. Than with 200 mg it is really long ( 42 days..) or I doesn t blood at all.
    I am still on 200 mg and had my Last period
    start of march. My gyn said I should stop progesteron after 30 days and start again on the 7 th day ( if period doesn t come).
    Normally should pause when I get the period and start again with progesteron on day 7 of cycle.
    Is this just coimcidence that my period comes that ‚ late‘ or don t come at all, or is my body mixed up because of progesteron 200 mg- maybe too much?
    Gyn days 200 mg are not much.
    I take the capsul vaginal.

    I had and have NO
    , bad sleep, no dry
    vaginal skin, ..
    I just suffered Pms emotional issues ( always had), and felt very exhausted/ tired.
    Now I am even more tired – hardly get out of bed, gain weight/ fat
    All this ( exactely since december 2020 when I started
    progesteron..
    All worse.
    I am frustrated.
    I did not change diet or life and sleep routines and feel worse.

    Doctor said Progesteron is one piece of mosaic NOT helping
    with not gaining ( belly fat) and feeling more energy.
    Could you recommend what to do? What happens with me?
    Thank you,
    Mia

    P.S. I have also ADHD
    Thank you for giving me a clue what to do or ask the gny.
    I told her all about worse effects and she kind of says all normal you are in perimenopause and Shows me diagramms of fading hormones.
    But why is all worse since I take supplement ‚ against‘ issues I did not have ( BEFORE the progesteron capsules).
    I am
    confused!

    Reply
    • Short answer, progesterone should feel good. As in, it should relieve a symptom such as night sweats, headaches, or heavy periods. If progesterone doesn’t feel good — if it doesn’t help with symptoms — then there’s no reason to take it.

      Most of my patients who use progesterone take a 100 mg capsule orally at bedtime. Which helps sleep and does not cause grogginess the next day. If they are still having periods, then they stop it for 1-2 weeks from the first day of the menstrual flow. If they are not having periods, then they take it every day.

      Taking progesterone during perimenopause can alter the timing of bleeds but that is not usually anything to worry about, because by 49, most cycles are anovulatory anyway. As in, they’re bleeds — not proper menstrual cycles. So there’s no expectation for regularity.

      Reply
  7. My experiences as a girl/teen/woman have been wholly different than my mother’s. I started my period at 10, had horrendously painful periods during which I routinely vomited and had to be put on birth control pills to manage the symptoms. When I was pregnant, both labors stalled out, and I had C-sections. As an early 40s woman, I have now been experiencing perimenopausal symptoms for about two years now, only to worsen to the point where I connected the dots and am now on HRT.

    My mother had smooth pregnancies and deliveries (no C-sections), never had menstrual cramps and claims to have entered menopause at age 58 with no problems or symptoms.

    Reply
  8. Yes! Can totally relate to this. Sore breasts, fluid retention, mild all-day headaches, constipation prior to periods, painful periods. I have IBS and endometriosis and terrible gut issues like bloating and gas. I always have had gut issues all my life…super frustrating and embarrassing. But the worst thing that really gets to me is the weight gain that came on and doesn’t want to go even though I have the most ridiculous healthy diet and plenty of sleep. How the heck do I deal with any of this?? This has been going on now for the last probably 5 years- certainly increased in the last 3. I’ll be 47yrs next week.

    Reply
    • As I explain in my new book, the later phases of perimenopause are associated with a shift to insulin resistance, testosterone dominance, and weight gain. The first step is to identify insulin resistance, and then if you have it, work to reverse it. If you don’t have insulin resistance, successful weight loss is about supporting mitochondria, building muscle, and maybe taking estrogen.

      My book also has strategies for headaches, breast pain etc.

      Reply
  9. Lara, thank you for the info! I have a question about the perimenopause symptoms. I’m 40 years old – my mother went through menopause when she was 47 or 48 – and breastfeeding a 16-months-old. Until 2 months ago, I also bottlefed and my cycle was very regular with no other symptoms. In late March I went through a rough patch at work (home office) and couldn’t be bothered with the bottles anymore and went back to only breastfeeding (plus solids of course). Since then I’ve nursed my kid about 3-5 times a day and 4-8 times a night. In the past weeks I developed these symptoms: very short cycle (24 days), heavy and dark period bleeding, more menstrual cramping, more migraines, weight gain (5 pounds out of nowhere and I’m pretty slim). Could that be caused by the increased breastfeeding or do you think it’s perimenopause? I’d be pretty disappointed because we were planning on trying for another kid in about half a year… Thanks a lot in advance!

    Reply
    • Check with your doctor to rule out thyroid and other factors. Beyond that, yes, it could be perimenopause, which is pretty normal at 40. But you can still conceive in perimenopause.

      Reply
      • Thank you for your reply! Thyroid function is excellent, had it tested – and a host of other things, too – just before all this started, about 2 months ago.
        I know it’s technically possible to conceive in perimenopause, but if this really is perimenopause, I’m afraid I’ll be on my very last menstrual cycle before the year is up, at the rate that I’m going.
        Can I ask you again if my symptoms – which look like low progesterone symptoms to me, right? – could be caused by the frequent breastfeeding? I’d sleep a lot easier if this was the case. Thank you!

        Reply
  10. Hi Lara,

    Can you tell me why taking a bio identical HRT makes my hair shed consistently more than when I went through menopause?

    Thanks in advance

    Reply
  11. I’ve heard that later onset of menopause is associated with longer total life. Is this true? Im late thirties and just got my cycle working well for me, so I’m actually hoping to keep it around for as long as possible!

    Reply
    • There is a correlation, yes. Starting periods later, or going through menopause later are both associated with a slightly longer life expectancy. It’s a correlation so doesn’t necessarily mean that later menopauses causes a longer lifespan. It could just be that the same genes lead to both later menopause and longer lifespan. Unfortunately, the timing of menopause is largely genetic so there’s nothing we can do about it.

      Reply
  12. My periods just stopped suddenly at age 45. I really feel that’s too young for me, my mother was 51. Why was there no gradual slow down if that was menopause? Doesn’t seem right.

    Reply
    • what does your doctor say? Is it definitely menopause? As in, have you had two high FSH readings at least a month apart?

      Reply
      • Have not had the 2 FSH readings, only had 1 from which they did pronounce menopause. I just feel like something else is wrong for periods to so abruptly stop.

        Reply
  13. Hi Lara
    I’m 49 and have none of those symptoms. But I would have thought by my age I am definitely in peri menopause- is that right ?

    Reply
    • Perimenopause is the 2 to 10 years before the final period, so you could be a) still a few years from your final period, and/or b) having the shorter 2-year symptom picture, or c) having an easy transition with no symptoms. At some point, you should start to see an irregular cycle.

      Reply
      • If it is C would there be any reason to take progesterone or estrogen as I transition into menopause or would it not be necessary ? Thanks

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  14. Hi Lara,

    I’m 43 and my periods suddenly stopped last September 2020 after years of heavy periods since my teens. Since then I’ve had mood swings, more brain fog, stress, hair loss, sleep problems and cramps and twinges. I tried some progesterone cream for 10 days because I couldn’t sleep which I stopped for two days and now I’m having a bleed. Was it the wrong thing to use? Did the progesterone cream when stopped start the bleed? It didn’t help much with sleep. I have Hashimoto’s hypothyroid. I’ve got both your books. Haven’t finished reading the second one yet. I would really appreciate your opinion. Thanks.

    Reply
  15. I don’t think the age of your mother’s menopause has much to do with it. My mother hit menopause in her late 50s and, by her account, had no symptoms. I am in my early 40s and went through hell before finally getting HRT.

    Reply
  16. Im 44 and have all those symptomps. Very heavy periods that bio identical progesterone didn’t make much difference. Now on mini pill to stop the periods completely. Would it be ok to still take the bio identical progesterone along side of the mini pill? It does wonders to my skin and hair. Is anyone doing it like that? Thanks

    Reply
    • Yes, it is possible to combine progesterone with a progestin. In general, I would say the better plan is progesterone plus the hormonal IUD rather than the mini-pill. Mainly because the hormonal IUD is effective at a much lower dose of progestin.

      Reply
  17. Dear Dr. Briden, I am 49 years old and have all those symptoms, I read about your combination and got a little confused about using transdermal estrogen as I guess what I need is just progesterone as I have what is commonly called predominance estrogenic due to symptoms, I’m right ?.

    Another question is about the iodine, unfortunately I had my thyroid removed due to multiple benign nodules (I had Hashimoto’s) and I would like to know the dose of iodine that I should take for breast swelling that is increasing every month and is becoming very very painful I actually had two episodes this month and there was no pain pill that could help me. In fact, I thought it was a heart problem.

    What do you think of yam cream ?, I don’t know if I can get utrogestan in my country.
    Last question, isn’t taurine an ingredient in a popular drink (redbull) that causes heart attacks? Forgive my ignorance, I would greatly appreciate your answers to my questions.

    Reply
    • In general, what works best is progesterone-alone while you’re still cycling. And then (if needed), add estrogen during phase 4 of perimenopause (after the final period), when estrogen drops. See hormone repair manual for more information.

      As for iodine, since you have Hashimoto’s, you’ll likely need to stay below 500 mcg. I discuss dose in the book.

      Progesterone cream (not wild yam cream) can be helpful, yes, but not as good a progesterone capsule.

      Finally, re: taurine in energy drinks, it’s put there for its calming effect — ie. to offset the stimulating effect of the caffeine.

      Reply
      • what country are you in? As far as I’m aware, body-identical progesterone capsules are available in every country.

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  18. Super helpful! I started having perimenopause symptoms around 36. At 41, I now haven’t had a normal period in about a year, with only a few months of minor spotting for about 24-48 hours. My mom was wrapped up with menopause around 43. Is what I’m experiencing “normal” or would this be considered premature menopause, and is there anything I should be worried about or monitoring? Thanks so much!

    Reply
    • 41 is a little young for periods to have stopped entirely. Check with your doctor to make sure it’s that and not something else. And she may offer you hormone therapy, which might be worth doing. See my book hormone repair manual for a discussion of why the best and safest type of hormone therapy is an estrogen patch plus Prometrium or Utrogestan capsule.

      Reply
  19. Hi Lara! First off.. Thank you for devoting your life to helping women know their bodies and what natural things we can do to not go utterly insane from hormonal changes. I only wish I came across your work 7 years ago. I’m grateful though that your work has guided and helped me the last year and a half.

    I have both your books and I’ve tried almost your full protocol (magnesium, taurine, B’s, glycine, get my protein throughout the day, no dairy or wheat or sugar, I’ve eliminated soy – a new allergy I didn’t know I had – I’ve dropped 25 pounds of extra weight, and I’m walking 3-6 times a week and lift light weights 3 times a week). I also take dedicated grass fed beef kidney to help with raging allergies that developed 7 years ago (probably from a drop in progesterone from severe prolonged stress) but haven’t tried GABA or Progesterone.

    I’m still getting sad/depressed throughout my cycle (which averages 26 days), some allergy symptoms and have very low energy. The sadness used to be horrifically intense but still lingers, is unpredictable and interfering with my day/work/mood, etc. My blood work, including thyroid panel and CRP is all normal, though I tend to have slightly elevated neutrophils and low lymphocytes – my GP has always said it’s from stress or allergies. I’ve lowered my stress the best I can.

    I’m wanting to try micronized progesterone (which I know you say is better for PMDD) but have several hurdles.. I can’t seem to convince my GYN of my low progesterone symptoms, let alone to test my progesterone levels, in order to get an Rx for it. So I feel like cream is my only option.

    What I’m finding in creams is that they are either made from soy or from Wild Yam. I, of course cannot take any of the soy options but am wanting to try the wild yam creams.

    It dawned on me though that DHEA supplements are also made from Wild Yam. Wouldn’t that mean then that DHEA supplements would have the same effect as the progesterone creams and/or micronized progesterone? (I’m still unable to find what micronized progesterone is made from.). Yet I also read in some places that DHEA can have a testosterone effect on women. So confusing.

    Would love your thoughts on using DHEA supplements to help with low progesterone and if so what dosing would look like.

    Reply
    • First, a DHEA supplement cannot increase progesterone in the body. So, if you want to try progesterone, I guess a cream is your only option. The other thing to keep in mind is that although doctors are usually reluctant to prescribe progesterone to relieve premenstrual mood, they are often willing to prescribe it for heavy periods. Do you also have heavy periods? If so, see the section in hormone repair manual called “how to speak with your doctor about progesterone for heavy periods.”

      Finally, think about some of the other PMDD treatments I discuss in the book including higher dose iodine and vitamin B6. and maybe Vitex and SAM-e.

      Reply

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