Why we need to talk about perimenopause

As a former marketing executive, Kerri Devine spent her entire career responding to crises. So it was a shock to everyone—herself included—when one day, in her mid-40s, she had a complete meltdown in the middle of a craft store. It was so bad that she left with a mild concussion (don’t ask). “But I never even thought about going to a doctor for it,” she says. She just chalked it up to stress and the insomnia and anxiety she’d been dealing with for years. Until a friend suggested it could be something else entirely.

Most of us are familiar with—and getting more comfortable with—the idea of menopause thanks in no small part to the way pop culture has embraced the previously hushed-up “life change”. (See: an entire plotline in Sex and the City 2 and candid commentary by A-listers like Gwyneth Paltrow and Oprah.) But its precursor, perimenopause, not so much. A recent study found that 60 per cent of women over the age of 40 said they felt “not informed at all” on the topic, even though it can be a years-long, mind- and body-altering event.

"Perimenopause usually arrives in a woman’s mid-40s (although sometimes as early as mid-30s), when the body’s levels of estrogen and progesterone start fluctuating," explains Samantha M Dunham, MD, co-director of the Center for Midlife Health and Menopause at NYU Langone Health. It typically lasts four to eight years and ends when you officially hit menopause, signaled by a full year without a period.

“It’s a totally normal chapter in a woman’s life,” says Dr Dunham. Yet many people only find out it’s a thing at all once they’re hit with one or more strange or sudden symptoms that even their physicians may struggle to explain. Because, as is so often the case with women’s health-related issues, peri- menopause has stayed under the radar for far too long. Here’s what it’s time to finally understand.

It’s actually no mystery why it’s a mystery

First things first: Perimenopause can be really freaking hard to identify, both by those going through it and doctors trying to diagnose it. One reason: Everyone experiences it differently. Many people get hot flashes. Others get insomnia. Some have to pee, like, all the time. (Look down and to the right for a long—but not even totally comprehensive—list of other symptoms. Yeah.)

Kate Little, a social media manager, says her two biggest indicators were night sweats and irritability. “I’m not a sweaty person—I barely need to shower after the gym—but I’d wake up absolutely soaked,” she says of entering perimenopause when she was 45. “I was also full of rage all the time. I hated my husband, and I had no idea why.” Like Kate, 40 per cent of people in perimenopause experience mood instability, and many go through physical and mental symptoms at the same time.

Irregularities in your period are the clearest sign, says Emily Hu, MD, MSCP, an ob-gyn at Bay Area Obstetrics and Gynecology and California Pacific Medical Center and the medical director at Evernow. But even those may be tricky to spot. Apart from appearing in other reproductive health conditions, cycle irregularities can be disguised by things like birth control.

And, of course, almost none of these symptoms are unique to perimenopause. The truth is you could develop, say, depression or migraines at any point in your life, for a multitude of reasons. Even hot flashes can be caused by other factors like thyroid issues or medication side effects. Plus, there’s no one test for perimenopause, meaning your doctor might (a) dismiss your symptoms, (b) assume they’re related to something else, (c) send you on an expensive and time-consuming wild goose chase, or (d) all of the above. (Cue: “I love being a woman!”)

Compounding it all is the fact that even though people have been going through this since the dawn of time, no one has ever prioritised perimenopause awareness or education. Not even for doctors. Most are undereducated on the topic because a lot of med schools only teach a single one- to two-hour lecture on it, says Stephanie Faubion, MD, director of the Mayo Clinic Center for Women’s Health and the medical director of the North American Menopause Society. And it certainly wasn’t covered in middle school sex ed or high school health class. That’s a big problem for so many reasons but especially concerning given that more and more women are choosing to have children later in life, when they may be simultaneously starting to go through perimenopause.

The more you know!

There’s no one-size-fits-all answer to perimenopause because at the end of the day, it’s not really a “problem” but a process that will run its course. That’s not to say that it can’t get uncomfortable—or that you should just muddle through it. Healthy lifestyle adjustments and treatments for many symptoms exist. Antidepressants can help with depression and hot flashes, and low-dose birth control can tackle mood fluctuations and night sweats (oh, the irony of starting contraceptives as you leave your most fertile years behind). So can hormone therapies. “My doctor prescribed me progesterone, and within three weeks, I was a completely different person,” remembers Kerri. Kate also received hormone therapy to increase her progesterone levels. “I’m so much better on the other side,” she says. “I just wish I had known what was happening sooner.”

The hope is that, like menopause, perimenopause gets a sustained moment in the social, cultural, and medical spotlight. Because, as Dr Faubion says, “You can’t go looking for resources if you don’t know what the issue is.” Dr. Dunham, for one, is feeling optimistic: “Younger generations are bringing up uncomfortable topics in a way we’ve never seen before. We don’t have to suffer in silence. And we’re all more empowered for it.”

This piece originally appeared in the print edition of November/December 2023 Cosmopolitan USA.