Understanding Perimenopause: What to Expect

Author: Dr. Caledonia Buckheit, M.D.

Perimenopause is the transitional phase leading up to menopause. It is marked by fluctuating hormone levels and changes in menstrual cycle patterns. On average, perimenopause lasts 3.8 to 6.25 years, though for some women it can stretch to a decade or longer (1-3). The timing and duration vary greatly, influenced by genetics, lifestyle, and individual ovarian function.

Early Signs and Stages

The first signs of perimenopause often include subtle changes in the menstrual cycle along with symptoms such as mood swings, sleep disruption, hot flashes, or heavier periods.

• Early perimenopause: cycles remain regular, but symptoms appear (sometimes called “compensated ovarian failure”).
• Mid perimenopause: cycles become irregular, with variable lengths and occasional missed periods.
• Late perimenopause: cycles become increasingly spaced, with three or more missed periods per year (2-4).

Perimenopause officially ends once menstruation has stopped for 12 consecutive months. At that point, a woman is considered menopausal, though many symptoms may persist (3).

Common Symptoms

Symptoms during perimenopause often come and go, reflecting the underlying hormonal shifts. The most frequent include:

• Vasomotor symptoms: hot flashes and night sweats.
• Genitourinary changes: vaginal dryness, discomfort, or urinary changes.
• Other complaints: sleep disruption, mood changes, and heavier or unpredictable bleeding (2-3, 5-6).

The severity and frequency of these symptoms can fluctuate over time, adding to the unpredictability of this transition.

Skin and Hair Changes

In addition to hot flashes and mood shifts, many women notice visible changes to their skin and hair during perimenopause. Estrogen levels gradually decline, while testosterone remains relatively stable. This relative increase in testosterone can lead to several dermatologic concerns:

• Acne breakouts, often around the chin and jawline.
• Unwanted facial hair growth (hirsutism).
• Hair shedding or thinning, particularly along the scalp.

At the same time, estrogen’s protective role in maintaining collagen and skin hydration diminishes, which may contribute to dryness, fine lines, and a reduction in skin elasticity. Together, these changes can significantly impact how women feel about their appearance and may be an early motivator for seeking medical guidance.

Treatment Options During Perimenopause

The good news is that there are effective treatments available to help manage perimenopausal symptoms.

• Hormone Therapy (HT): Menopause hormone therapy—estrogen with or without progesterone, depending on whether a woman has a uterus—remains the most effective treatment for hot flashes, night sweats, sleep disturbance, and genitourinary changes.
• Hormonal Birth Control: For women in earlier stages of perimenopause, hormonal contraceptives (the pill, patch, or ring) not only regulate cycles and reduce heavy bleeding, but also improve vasomotor symptoms and acne. Importantly, many women in perimenopause still need contraception. Just because periods are irregular does not mean pregnancy is impossible. Birth control can provide both symptom relief and reliable contraception during this stage.
• Non-hormonal strategies: For women who cannot or prefer not to use hormones, there are additional options—including certain antidepressants, lifestyle adjustments, and targeted treatments for specific symptoms (such as topical therapies for vaginal dryness).

Choosing the right approach depends on an individual’s symptoms, health history, and personal preferences.

Why Individualized Care Matters

Both the American Heart Association and the North American Menopause Society emphasize that no two women experience perimenopause in the same way. Because of this, individualized assessment and management are key to ensuring quality of life during the transition (7-8).

Key Takeaway

Perimenopause is a prolonged, highly variable process that can last several years. Symptoms may come and go, sometimes with long stretches of stability in between. Beyond menstrual changes, women may experience hot flashes, sleep disruption, mood shifts, skin and hair changes, and genitourinary symptoms. Hormone therapy—including both traditional menopause HT and hormonal contraceptives—remains the most effective management strategy, and contraception is still important until menopause is confirmed. Recognizing these patterns and knowing that effective treatments exist can help women navigate this transition with confidence.

References

1. Bastian LA, Smith CM, Nanda K. Is This Woman Perimenopausal? JAMA. 2003;289(7):895-902. doi:10.1001/jama.289.7.895.
2. Santoro N, Roeca C, Peters BA, Neal-Perry G. The Menopause Transition: Signs, Symptoms, and Management Options. J Clin Endocrinol Metab. 2021;106(1):1-15. doi:10.1210/clinem/dgaa764.
3. Crandall CJ, Mehta JM, Manson JE. Management of Menopausal Symptoms: A Review. JAMA. 2023;329(5):405-420. doi:10.1001/jama.2022.24140.
4. Verrilli L, Berga SL. What Every Gynecologist Should Know About Perimenopause. Clin Obstet Gynecol. 2020;63(4):720-734. doi:10.1097/GRF.0000000000000578.
5. Islam RM, Bond M, Ghalebeigi A, et al. Prevalence and Severity of Symptoms Across the Menopause Transition: Cross-Sectional Findings From the Australian Women’s Midlife Years (AMY) Study. Lancet Diabetes Endocrinol. 2025;S2213-8587(25)00138-X. doi:10.1016/S2213-8587(25)00138-X.
6. Bastian LA, Smith CM, Nanda K. Is This Woman Perimenopausal? JAMA. 2003;289(7):895-902. doi:10.1001/jama.289.7.895.
7. El Khoudary SR, Aggarwal B, Beckie TM, et al. Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association. Circulation. 2020;142(25):e506-e532. doi:10.1161/CIR.0000000000000912.
8. Stuenkel CA, Santoro NF, Laughlin-Tommaso SK, et al. NAMS 2019 Pre-Meeting Symposium, September 2019, Chicago Illinois: The Perimenopause. Menopause. 2020;27(7):735-745. doi:10.1097/GME.0000000000001571.