The four stages of perimenopause

The Four Stages of Perimenopause

Everything you need to know about the four stages of perimenopause.

Article highlights

  • What the four stages of perimenopause are.
  • How our symptoms can change over the four stages and why.
  • What we can do to support the four stages of perimenopause.

What does it mean to be in perimenopause?

Perimenopause is the stage leading up to menopause when our hormone system is recalibrating. It’s sometimes referred to as our second puberty because of the hormonal changes that happen in the body. Because of this shift, this is the stage, rather than menopause, when we’re most likely to experience symptoms. 

What are the four stages of perimenopause?

According to Professor Jerilynn Prior, perimenopause can happen over four stages.

  1. Very early perimenopause, when periods are still regular.
  2. Early menopause transition, from the onset of irregular periods.
  3. Late menopause transition, from the first cycle of more than 60 days.
  4. Late perimenopause, which is 12 months from your final period.
Signs & Symptoms of Perimenopause

What are the common symptoms of perimenopause? 

Everyone’s perimenopause is different but perimenopausal symptoms stem largely from losing progesterone, not oestrogen. The most commonly reported symptoms include:

  • Cycle changes: Heavier periods, longer periods, shorter cycles, irregular cycles
  • Physical changes: Weight gain, sore breasts, changes in libido, vaginal dryness
  • Sleep changes: More frequent waking, difficulty getting to sleep, insomnia
  • Mood changes: More frequent mood changes, irritability, rage and increased PMS
  • Vasomotor changes: Onset of night sweats, hot flushes
  • New allergy symptoms: Hayfever-type symptoms or the onset of new allergies

You can read more about the signs and symptoms of perimenopause here.

What is happening to our hormones over the four stages?

As you can see from this image, perimenopause is characterized by lowering progesterone and initially high, fluctuating levels of oestrogen. Oestrogen lowers (but still fluctuates) as we approach menopause. 

Stage 1: Early perimenopause

Our cycle is likely still regular but we could have sporadic ovulation/more anovulatory cycles and therefore lower progesterone. 

Symptoms OF low progesterone
  • Migraines
  • Sleep disturbance
  • Heavy and painful periods
  • Mood changes
  • Breast pain
  • Irritable mood
  • Histamine-related symptoms
  • Headaches

Stage 2: Early menopause transition

This is when our cycles are starting to become more irregular and can vary in length, sometimes by more than 6 or 7 days. We are likely to have low progesterone and high, fluctuating oestrogen. This means that when oestrogen drops, it not only has further to fall but it can also drop to lower than what we’re used to. Such a drop in oestrogen can trigger symptoms such as hot flashes and night sweats or they can worsen if we’re already experiencing them.

Symptoms of high, fluctuating oestrogen
  • Heavy and painful periods
  • Breast pain
  • Irritable mood
  • Histamine-related symptoms
  • Hot flushes and night sweats
  • Mood issues
  • Vaginal dryness
  • Aches and pains
  • Abdominal weight gain
  • More cervical mucus
  • Increased irritability
  • Poor sleep

Stage 3: Late menopause transition

This is when we start missing periods and we have our first cycle that’s longer than 60 days. Symptoms of high oestrogen can start to ease because we’re starting to lose oestrogen – even though it might still be fluctuating. As a result, breast pain could ease but night sweats and hot flashes could get worse.

Symptoms of low oestrogen
  • Hot flushes and night sweats
  • Mood and sleep issues
  • Vaginal dryness
  • Aches and pains
  • Abdominal weight gain – one of the reasons for this is we naturally become more insulin resistant and as we lose progesterone and oestrogen we can have a relative androgen excess, which can itself drive insulin resistance (which in turn can drive up androgens!)

Stage 4: Late Perimenopause

This is when our periods are likely over and we’ve stopped ovulating, but 12 months haven’t gone by yet so we haven’t officially reached menopause. We likely have low oestrogen and therefore symptoms of high and fluctuating oestrogen are easing – so our mood and sleep might be stabilising, although hot flashes can continue for a while after.

What can we do to support the four stages of perimenopause?

Supporting perimenopause is very individual but there are some things we can all do to to make for a smoother transition to menopause.

1. Support ovulation and progesterone production
How?
  • Manage stress levels
  • Support good-quality sleep
  • Support ovulation with nutrient support
  • Ensure high-quality protein with each meal
  • Remove alcohol
2. Balance blood sugar & reverse insulin resistance
Why?

Insulin resistance is highly likely in perimenopause due to the drop in protection from progesterone (and eventually oestrogen). Insulin resistance is the most common cause of weight gain in perimenopause. Reversing insulin resistance and balancing blood sugar can improve nearly all perimenopausal symptoms. 

How?
  • Prioritise protein at every meal but especially breakfast
  • Eat three balanced meals a day and avoid snacking
  • Reduce sugar and simple carbohydrates
3. Speak to your GP about hormone therapy

During perimenopause, as you have discovered, it is not all about oestrogen. In fact, initially it is all about the low progesterone. Therefore your hormone therapy should not just be all about the oestrogen, especially in earlier perimenopause when you likely have high oestrogen. 

Here are some ways that hormone therapy can be used in perimenopause:
  • Progesterone only hormone therapy
  • Cyclical progesterone
  • Combined oestrogen and progesterone

Top three takeaways from this article

  1. There are four stages of perimenopause: very early perimenopause, early menopause transition, late menopause transition and late perimenopause.
  2. Perimenopause symptoms can change depending on what stage you are in.
  3. Everyone’s perimenopause is different but perimenopausal symptoms stem largely from losing progesterone, not oestrogen. Hormone therapy (HRT) can be helpful to support these changes.

References

JC Prior. 2011. Progesterone for Symptomatic Perimenopause Treatment – Progesterone politics, physiology and potential for perimenopause. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987489/ 

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