How Can You Tell If You're in Perimenopause?
And your other perimenopause questions, answered.
A few months ago, I asked in the Now What chat for you to share health questions you’d like me to answer here. One that I got over and over again was this:
How the hell can I tell if I’m in perimenopause?
So, in celebration of World Menopause Day, I interviewed two Menopause Society Certified Practitioners to find out: Karen Adams, a Clinical Professor of Obstetrics and Gynecology at Stanford University, who directs the Stanford Program in Menopause & Healthy Aging and hosts a brand new Stanford menopause podcast, and Sharan Abdul-Rahman, an OB-GYN in Philadelphia who hosts the Black Women’s Health podcast.
I asked them alllllllllllll the perimenopause questions I could think of, and here’s what I learned. There’s a lot, so I’ve split this explainer into two installments. Today, I’m covering what perimenopause is, when it typically starts, how to tell if you are in it (versus just, like, super stressed), how to find good menopause doctors, whether IUDs or birth control pills can prevent symptoms, and more. Next time, I’ll delve into the science on how to manage it.
What happens during perimenopause?
To answer this question, I’m going to have delve a little into reproductive biology. But bear with me, because it’s interesting.
Before a person enters perimenopause, each menstrual cycle starts when their brain sends a hormonal message — mainly using follicle-stimulating hormone (FSH) — to their ovaries, telling them to start maturing a small group of egg follicles. These follicles then release estradiol (a key form of estrogen), which supports many essential bodily functions, including mood, bone health, body temperature, libido and sleep.
As the follicles develop, one becomes “dominant”, and it produces most of the estradiol in that cycle. The rising estradiol triggers a surge in LH — luteinizing hormone — from the brain, prompting that follicle to ovulate, or release an egg. After that, either pregnancy or a menstrual period follows.
As people age, though, several changes occur within the ovaries. The total number of follicles declines, and the remaining follicles become less sensitive to the brain’s hormonal cues. When the brain sends its monthly signal to start maturing a group of follicles, a few things can then happen:
Sometimes the ovary doesn’t respond, and no ovulation occurs, leading to a missed or delayed period and no estradiol release.
Sometimes the ovary responds sluggishly, so ovulation and the estradiol rise happen later than usual.
Sometimes the ovary recruits fewer or less efficient follicles, so overall they release less estradiol, even if ovulation occurs on schedule.
These changes — fewer follicles, weaker responses, uneven hormone production, and less estradiol overall — set the stage for the hormonal ups and downs of perimenopause.
“You don’t know, from day to day, how you’re going to feel,” Dr. Adams said. “Everything gets more unpredictable — sleep and mood and libido and periods — and that’s why it’s so challenging.”
Then what’s menopause / post-menopause? What happens to your hormones after you’ve officially gone through menopause?
A person has gone through menopause when a full year has passed since their last period. Technically, menopause itself only lasts one day — the day the person hits that one-year mark — and then after that, they are considered post-menopausal.
When that happens, a person has much less circulating estrogen in their body than before, but their hormones don’t fluctuate. “There’s not that unpredictable stuff that happens in perimenopause,” Dr. Adams said.
If a person has had a hysterectomy or is on a form of birth control in which they never have periods, then determining whether they’ve gone through menopause can be trickier. (In truth, menopause isn’t really defined by a lack of periods, Dr. Abdul-Rahman said — it’s when a person has no functioning egg follicles left. But it’s easier to track periods than count egg follicles.) In this situation, to figure out if a person has gone through menopause, a doctor might administer a blood test for, say, Anti-Müllerian hormone, which is an indirect measure of ovarian function.
When does perimenopause usually start?
It varies, but the average age at which a person passes menopause is 51, and before that, perimenopause typically lasts about seven (!!!!) years. So it’s common for people to start perimenopause in their late 30s or early 40s. “It’s not unusual to be having perimenopausal symptoms that early,” Dr. Adams said.
How can you tell if you’re in perimenopause? How can you tell if your anxiety, insomnia, or mood swings are due to perimenopause, versus …. just, well, life craziness? And is it possible to be in perimenopause even if you’re still having regular periods?