What to know about perimenopause and menopause

This article is based on an interview during a live event for Health Lab. Watch the full video above or here.

For many women, the years leading up to menopause can bring unexpected physical and emotional changes, from irregular menstrual cycles and hot flashes to sleep disturbances, brain fog and joint pain.

But despite knowing this, perimenopause, the phase before and after menopause officially occurs and may bring on some of these symptoms, remains new and mostly  misunderstood to many.

John Randolph, M.D., a Professor of Obstetrics and Gynecology and a Reproductive Endocrinologist in Michigan Medicine's Division of Reproductive Endocrinology and Infertility, discusses what you should know about the perimenopause and menopause transitions and how research continues to reshape treatment recommendations for both.

Menopause is an event. Perimenopause is the transition

Although the terms are often used interchangeably, Randolph explains that menopause and perimenopause describe different stages of the reproductive aging process.

"Menopause actually is an event," Randolph said, saying that medically, menopause is defined as a woman's final menstrual period, confirmed after 12 consecutive months without bleeding.

Perimenopause, by contrast, is the yearslong transition leading up to menopause and can often continue for several years after as hormone levels continue to fluctuate.

"It can begin anywhere from four to eight years before bleeding stops," Randolph said.

He compared the transition to puberty because both involve significant hormonal changes that can affect nearly every aspect of the body.

"It's a good way to think about it because the changes can be very unpredictable and difficult to deal with," he said.

Randolph says many questions remain about how perimenopause affects long term health, including cognition, cardiovascular disease and cancer risk.

Much of the current research focuses on whether the menopause transition itself can predict future health outcomes and whether earlier interventions may improve long term health.

"We're learning things all the time," Randolph said.

“We have been studying the menopausal transition for over 30 years and are now increasingly able to associate health outcomes later in life with what happened at midlife.”

What are perimenopause and menopause symptoms?

Hot flashes and night sweats remain the most recognized symptoms of perimenopause, but Randolph says growing research suggests the transition affects much more than temperature regulation.

At any point in the transition, many women can experience vaginal dryness, recurrent urinary tract infections and changes in body composition as body fat shifts toward the abdomen.

Increasing evidence also links perimenopause to symptoms including brain fog, joint pain, dry skin and even itchy ears.

"There are probably a whole host of other symptoms that very well may be associated with this whole change process," Randolph said.

One of the earliest signs is usually changing menstrual cycles; the time between periods may become shorter or irregular, and bleeding is often heavier or more unpredictable before eventually stopping altogether.

But even if heavy bleeding is part of the process, it’s not a symptom to be ignored, Randolph emphasizes.

“Women experiencing persistent heavy periods should seek medical evaluation because excessive blood loss can lead to anemia or signal other conditions such as uterine fibroids,” that can be managed until bleeding stops, he explains.

Likewise, any vaginal bleeding occurring more than one year after menopause should be evaluated promptly. While usually from benign causes, such bleeding has an increasing chance of being a pre-cancer or cancer as the time since menopause increase.

Lifestyle changes may help, but treatment is available

For women with mild symptoms, lifestyle adjustments can often provide relief.

Randolph recommends identifying and avoiding common hot flash triggers, including spicy foods, alcohol and caffeine.

Dressing in layers and staying cool may also help, particularly during warmer months when hot flashes tend to occur more frequently.

Women with more disruptive symptoms, however, should know they have treatment options.

"There are a whole host of medical options that we can consider," Randolph said.

Non-hormonal medications, including certain antidepressants and other medications that act on the brain, may reduce hot flashes and are especially important for women who cannot safely take hormone therapy, such as some breast cancer survivors.

A newer class of medications that targets the brain pathways responsible for hot flashes has also recently become available, although insurance coverage remains limited.

Known as neurokinin receptor antagonists, these drugs are very specific and have been shown to reduce hot flashes without affecting other parts of the body.

Hormone therapy has evolved, and it’s also (been) safe

One of the biggest misconceptions surrounding menopause treatment stems from findings published more than two decades ago at this point.

In 2002, the Women's Health Initiative reported increased risks of blood clots, heart disease and breast cancer among certain women taking oral combined hormone therapy.

The results dramatically changed public perception and physician prescribing practices.

Subsequent research has shown that for many healthy women transitioning through menopause, menopausal hormone therapy actually offers more benefits than risks when prescribed appropriately.

"We have a whole generation of health care providers that were taught that this was something they probably shouldn't prescribe," Randolph said.

And a lot of women unnecessarily suffered because of that.

But he notes that, on top of those findings being sensationalized and overinterpreted, hormonal treatments have also significantly evolved.

Today, hormone therapy is available in multiple forms, including transdermal patches, which research suggests carry markedly fewer clotting risks than oral estrogen for most healthy women.

Rather than using the older term "hormone replacement therapy," Randolph says doctors increasingly use "menopausal hormone therapy" to better reflect that treatment is intended to relieve symptoms rather than replace something considered a deficiency.

Is hormone testing worthwhile?

As menopause content has gained popularity on social media, at-home hormone testing has become increasingly common.

Randolph says decades of research, including Michigan Medicine's participation in the national Study of Women's Health Across the Nation, has shown that hormone levels fluctuate too variably during the transition to reliably predict symptoms or guide treatment.

Instead of focusing on laboratory values, he recommends that your doctor evaluate your symptoms and develop an individualized treatment plan with you to treat them.

"It's better to talk to somebody and figure out what's the best option for managing her particular constellation of symptoms," Randolph said.

How do I find a perimenopause and menopause doctor?

Because menopause education changed significantly after the Women's Health Initiative findings, Randolph acknowledges that not all health care providers feel comfortable prescribing menopause treatments.

He recommends starting with a primary care physician or obstetrician-gynecologist and asking for a referral for additional expertise if that provider is unsure.

Women can also look for clinicians certified by The Menopause Society, formerly known as the North American Menopause Society.

Randolph says that perimenopause is a period of change, and symptoms today may not even look the same a year from now, which is reassuring to hear if you’re struggling through tough symptoms.

Most importantly, though, he encourages women not to dismiss or put off talking with a doctor about those symptoms that are interfering with your quality of life.

"If you have issues, seek out care," Randolph said.

"Be your own advocate and seek to find somebody that can get you answers."

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