What is perimenopause, really?
Perimenopause is a time in a woman's life where ovarian function becomes a bit less predictable. It's the phase before menopause, and it is a time when many women don't quite know what is "wrong," but nothing feels right.
Perimenopause is not caused by a single hormone level dropping. Perimenopause is when there is hormonal variability, and this is where it becomes difficult to "diagnose."
Remember, it is a transition phase, so oestrogen levels don't suddenly drop, they fluctuate. Your periods often become shorter or erratic because progesterone levels tend to decline earlier. Ovulation becomes inconsistent.
This hormonal variability is where the symptoms often begin. It is a phase no one prepares you for and is not well understood.
This is not because it is rare. It happens to every single woman.
You feel unprepared partly because there is not enough research in women's health, and it is a part of a woman's life that no one really spoke about until recently. Even doctors and gynaecologists will admit menopause is a subject we weren't well trained on, and this needs to change.
Perimenopause starts quietly and long before anything shows up on a blood test.
Many women in their late 30s to mid-40s begin to feel off, yet they are told they are fine. It's a time when doctors often reach for antidepressants, because why would it be perimenopause when all their bloods are fine? Technically they are, but clinically things have shifted.
What we need to remember about blood results
This is one of the most important concepts to understand.
Standard blood tests provide a snapshot of hormone levels at a single point in time. However, perimenopause is a transition, and hormones are often fluctuating.
Perimenopause is a dynamic process.
- Oestrogen levels may be normal today, low tomorrow, and high the next week
- Progesterone may only appear low if ovulation didn't occur that cycle
- Cycle timing significantly alters interpretation, and cycle variability does too
So a single "normal" result does not rule out perimenopause. And this is why a thorough history is so important. Remember, doctors need to treat the patient, not the blood results in front of them.
Early signs and symptoms, often ignored
Subtle cycle changes (which could indicate fluctuating progesterone - often the first to change)
- Slightly shorter or longer cycles
- Heavier or lighter bleeding
- More pronounced PMS
Unexplained mood shifts and difficulty concentrating
- Increased anxiety
- Brain fog
- Feeling overwhelmed
Energy and recovery declining
- Experiencing unexplained fatigue
- Reduced ability to recover after training
- Afternoon energy slumps
Sleep changes
- Waking at 2-4am
- Difficulty falling asleep
- Lighter sleep
Body composition changes
- Increased fat in the abdominal region, despite no changes to lifestyle
- Reduced muscle mass despite similar training
Skin and hair
- Dry skin
- Thinning hair or texture changes
Libido changes
- Reduced desire to have intercourse
- Fluctuating libido
- Vaginal dryness
How do hormones play a role?
Often, the first key driver early on is a decline in progesterone.
Remember, progesterone relies on ovulation. So as ovulation becomes less consistent:
- Progesterone levels decline
- Oestrogen becomes relatively "unopposed"
This imbalance of hormones can lead to:
- Anxiety (progesterone is your calming hormone, and now there is less)
- Sleep disruption (progesterone also supports sleep)
- Heavier periods (progesterone counteracts the build-up of the endometrium)
- Breast tenderness (unopposed oestrogen)
At the same time, fluctuations in oestrogen can cause:
- Mood swings
- Brain fog (low oestrogen)
- Water retention
- Fat redistribution
So it's not necessarily a deficiency state initially. It is a dysregulation state. An imbalance state.
Why is this phase so frustrating?
It is because women feel like nothing is right.
Yet:
- Their blood labs look fine
- They are told it's stress and are prescribed anti-anxiety medication
- Or that they are "too young" for perimenopause
And yes, stress absolutely plays a role, and it often interacts with underlying hormonal shifts.
This is why a purely lab-based approach falls completely short.
So understand this
Perimenopause is not a sudden event.
It is a gradual transition and you are right in thinking something is off.
If you feel like something has shifted, even if your blood tests are "normal," it's worth listening to that.
Because in this phase, your symptoms are often way ahead of your labs.
And that's exactly where good medicine begins.