Look, It’s Probably Perimenopause

An interview with Dr Yael Swica, by Karen Russo, originally published on Hello Gloria.

Perimenopause, meaning “around menopause,” is nature’s allegedly gentle fade to the end of women’s menstrual cycle. But the vagueness around “around” is confusing, and the transition is often anything but gentle.

Not too long ago, when I thought about menopause, I recalled watching movies where women stick their heads into refrigerators to cool down during hot flashes. Other than that, I was pretty clueless as to what to expect. Or when to expect it. And I was definitely unaware about the term perimenopause, the distinction between them, or that I was experiencing perimenopause.

I was having more frequent migraines — which I have had since I was a child but for the life of me could not find any new triggers — interrupted and unsatisfying sleep, and inconsistent periods which stopped and started with an unregulated intensity. I was also at a constant base level of “tired” despite attempts at an earlier bedtime,  and found it difficult to concentrate during the day.

Symptoms such as mine all point to perimenopause, according to Dr. Yael Swica, Assistant Clinical Professor of Medicine, Division of Family Medicine, College of Physicians and Surgeons at Columbia University.

“None of my friends were complaining about any symptoms related to perimenopause — never mind using the term “perimenopause.” ”

“Aside from the ‘classic’ symptoms of hot flashes and night sweats, many women experience increased anxiety, depression, poorer sleep, worsening migraine headaches, difficulties with executive functioning and concentration, worsening PMS symptoms, hair loss, increasing bladder irritability or more frequent urinary tract infections, low libido, vulvar irritation, and dryness or pain with vaginal sex. These symptoms can build gradually or be intermittent, and can begin while a woman is still having regular menstrual cycles — which can be very confusing for women and also for their doctors,” says Dr. Swica. “How can these symptoms be due to menopause if a woman is still having regular cycles? The symptoms must be due to something else, like a thyroid, adrenal, autoimmune, or psychiatric disorder.  However, menopause, like puberty, is a multi-year process. During that process, women can experience many unpleasant and even disabling symptoms. The transition to, and away from, fertility does not happen overnight.  Fortunately, we now know more and have effective options for treating the problems women face as they move through the perimenopausal transition.”

None of my friends were complaining about any symptoms related to perimenopause — never mind using the term “perimenopause.” But when I speak with women my age and older, they often share that they suffer from several of these issues. For me, the larger question becomes: Why is no one talking about this? Why, with so much information available to us, does everything feel so unexpected? “Most women don’t want to believe what’s happening to their bodies,” says Dr. Swica. “The changes are not signs of arrival, but of departure.”

I have a theory that this is related to us being disconnected from our elders, removed from family members like grandmothers and great aunts who may have shared these experiences — or at least gave us some warning of what to expect.

“Aging is of course associated with death, but more pertinent to day-to-day reality, though, is its relationship to shame. Many women feel shame when they notice signs of aging.”

Dr. Swica believes that much of the lack of discussion is about the stigma around aging.

“Aging is of course associated with death, but more pertinent to day-to-day reality, though, is its relationship to shame. Many women feel shame when they notice signs of aging. When we age, we lose our sexual appeal. In a culture that prizes attractiveness above all else and whose economy is in no small part driven by the desire to increase and preserve attractiveness, the status of women is by definition lowered by menopause. Now we can discuss the problems with the male gaze and how it informs (and forms) female sense of self, but the fact remains that many women experience shame over the impending and inexorable changes that occur with the menopausal transition. In general, people don’t like to discuss things that make them experience shame.”

For many women, the signs of perimenopause can be confusing, discouraging, and dismissed. Here is what to pay attention to when you’re in your late 30s to mid 40s, which is around the time many of symptoms begin:

1.Watch for whacky cycles

“For perimenopause, women should notice that the length of their cycle becomes less regular,” says Dr. Joann Manson, professor of medicine at Harvard Medical School and chief of the division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital. “The cycles might become shorter and then longer, then back to shorter for a while, and hormone levels will also fluctuate between high and low. This variability in cycle length and hormone levels is due to inconsistent ovulation – you’re ovulating in some cycles but not others.” You may have several years of irregular cycles in your early to mid to late 40s, sometimes starting even earlier.

“Cycle lengths may be three weeks or shorter, then six weeks or longer. The cycle length and hormone levels can be variable for quite a while and may be associated with intermittent hot flashes and night sweats even before the final menstrual period.

You are in complete menopause when you have gone without a period for 12 straight months. Dr. Manson adds that, if you miss two cycles in a row, there’s a good chance that you will miss the next ten. In other words, menopause might be headed your way sooner than you realize.

2. Not everyone has hot flashes

Many perimenopausal women suffer from disrupted sleep, which may be triggered by “temperature changes” rather than hot flashes. These temperature changes, flushes, sweating followed by chills, fluctuating hormones, awakenings during the night, night sweats … all can affect quality of life.

“Sleep disruptions can contribute to difficulty concentrating, brain fog, and mood swings,” adds Dr. Manson. “Around 75 percent of women will have some symptoms of hot flashes or night sweats during the perimenopause or menopause, of those only 15 to 20 percent will have moderate-to-severe night sweats or hot flashes.”

3. HRT is not for everyone

“Only about 15 to 20 percent of women are appropriate candidates for menopausal Hormone Therapy (HT)  based on the severity of the symptoms,” says Dr. Manson. 

She explains that most women do not need estrogen therapy to manage perimenopause. “Usually patients receive hormone therapy for moderate to severe hot flashes and night sweats that disturb sleep, interfere with daily activities, and/or impair quality of life.

Another treatment option for some women who have not reached menopause is low-dose hormonal or oral contraception (a much lower dose than a typical oral contraceptive), which can help with hot flashes and to regulate periods during perimenopause. Women in their early to mid forties may want to ask their doctor if they are a candidate for this medication.

4. There are things you can do to help yourself

Simple changes can make a big difference when it comes to symptoms. 

For hot flashes, for example, try lowering the thermostat, especially at night. And wear layered clothing. During perimenopause, the thermostat in the brain can become altered and you may become more sensitive to temperature changes, both hot and cold. (Personally, I find that I often seek out cooler spots or shade, even though everyone around me seems completely comfortable with the temperature. Lately, I find myself saying I feel “overheated” and after speaking with Dr. Manson, it’s nice to know that this is all part of the biological process.)

These days, we hear a lot about “sleep hygiene,” which is extremely important for perimenopause. To improve the quality of your sleep, have a cool room and try to reduce the amount of blue light from screens. Some hot flashes can be traced to coffee, alcohol, or spicy foods. Dr. Manson recommends keeping a diary to track your triggers. 

“There aren’t many over-the-counter remedies that have been rigorously tested and shown to be effective,” says Dr. Manson, who adds that for some women, incorporating a little soy or soy milk to our diet may be enough to lower your hot-flash risk. (“This is NOT effective for all women,” she emphasizes.)

5. More helpful resources, if you need them

What do you do if you’re going through this and need help? There is so much information available that it is often hard to know where to begin. 

Dr. Manson recommends the North American Menopause Society at, which has a section dedicated to perimenopause. They include a directory where you can search for local healthcare providers who specialize in perimenopause.

Other high-quality resources include the Mayo Clinic and Harvard University. Dr. Manson is a specialist for the menopause center at