Everything you need to know about the four stages of perimenopause. We interview our resident perimenopause expert, Sophie Elletson, lead nutritionist at FUTURE WOMAN.
What is 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.Â
If you’re experiencing symptoms but aren’t sure what stage you’re in, testing your hormones is the best way to find out. Our Advanced Hormone Test provides clear insights into your hormone levels, giving you the answers you need to take control of your symptoms.
What Are the Four Stages of Perimenopause?
According to Canadian endocrinologist Professor Jerilynn Prior, perimenopause can happen over four stages.
- Very early perimenopause, when periods are still regular.
- Early menopause transition, from the onset of irregular periods.
- Late menopause transition, from the first cycle of more than 60 days.
- Late perimenopause, which is 12 months from your final period.
Common Symptoms in the Four Stages of Perimenopause
Everyone’s perimenopause is different but perimenopausal symptoms stem largely from losing progesterone, not estrogen. The most commonly reported symptoms include:Â
- Cycle changes: Heavier periods, longer periods, shorter cycles, irregular cycles
- Physical changes:Â 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
What's Happening to Our Hormones over the Four Stages of Perimenopause?
As you can see from this image below, perimenopause is characterised by lowering progesterone and initially high, fluctuating levels of estrogen. Estrogen does lower eventually (but still fluctuates), but only as we approach menopause.Â
This surprises many of our clients! As often the conversation around perimenopause and menopause focuses around low estrogen levels. However, you are more likely to struggle with high estrogen symptoms until the later stages of perimenopause.
Stage 1: Early Perimenopause
Our cycle is likely still regular but we could have sporadic ovulation/more anovulatory cycles and therefore lower progesterone. Progesterone is only made as a result of ovulation.
Testing your progesterone levels during this stage is crucial, as well as markers for inflammation and oxidative stress which can provide insights into egg quality and reserve. Our Advanced Hormone Test assesses all these markers and more, allowing for targeted support before symptoms worsen.Â
It’s important to note that the best time to test progesterone is 5-7 days after ovulation.Â
Symptoms of low progesterone:
- Anxiety
- Shorter cycles
- Sleep disturbance
- Heavy and painful periods
- Headaches and migraines
- Breast pain
- PMS
- Histamine-related symptoms
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.Â
We are likely to have low progesterone and high, fluctuating estrogen. This means that when estrogen 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 estrogen can trigger symptoms such as hot flashes and night sweats or they can worsen if we’re already experiencing them.
At this stage, testing progesterone levels and estrogen levels is key, but also estrogen metabolism. When estrogen levels are high and fluctuating we want to make sure that we’re metabolising our estrogen safely – poor estrogen metabolism can worsen symptoms of perimenopause. You can test all these markers and more in our Advanced Hormone Test, which comes with a personalised healthplan with supplement, diet and lifestyle recommendations tailored to you and your results.Â
Symptoms of high, fluctuating estrogen (or poor estrogen metabolism):
- 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 estrogen can start to ease because we’re starting to lose estrogen – even though it might still be fluctuating. As a result, breast pain could ease but night sweats and hot flashes could get worse.
In this phase we’re also interested in testing progesterone, estrogen and estrogen metabolism, as well as other markers for things like stress, inflammation and insulin resistance which can be exposed by dropping hormone levels. You can test all these markers and more in our Advanced Hormone Test, which comes with a personalised healthplan with supplement, diet and lifestyle recommendations tailored to you and your results.Â
Symptoms of low estrogen:
- Hot flushes and night sweats
- Mood and sleep issues
- Vaginal drynessÂ
- 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 estrogen 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 estrogen and therefore symptoms of high and fluctuating estrogen are easing – so our mood and sleep might be stabilising, although hot flashes can continue for a while after.
Testing estrogen and progesterone can be helpful in pinpointing this stage, but also we’re interested in markers for stress, inflammation and insulin resistance which can worsen with lower hormone levels. You can test all these markers and more in our Advanced Hormone Test, which comes with a personalised healthplan with supplement, diet and lifestyle recommendations tailored to you and your results.Â
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Check your perimenopause symptoms now
How Can We Support Ourselves in 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. Test, Don't Guess
During perimenopause, our clients find our Advanced Hormone Test to be hugely beneficial, as it provides insights into the following key areas of hormone health:
- Hormone production: how much estrogen or progesterone am I making? Which stage of perimenopause am I in?
- Hormone balance: are my hormones in balance, for example is my progesterone higher than my estrogen?
- Hormone metabolism: am I metabolising estrogen safely? This is extremely important to find out in the early stages of perimenpause as estrogen levels are surging, as well as before starting any estrogen hormone therapy, and can reduce breast cancer risk.
- Stress and other contributing factors: is anything else contributing to my symptoms? We test for stress hormones, nutrients, gut health, insulin resistance, neurotransmitters and inflammation markers to get a full picture.
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2. Consider BioIdentical Hormone Replacement Therapy
During perimenopause, as you have discovered, it is not all about estrogen. In fact, initially it is all about the low progesterone. Therefore your hormone therapy should not just be all about the estrogen, especially in earlier perimenopause when you likely have high estrogen.Â
It’s important to test your hormones first, before starting any hormone therapy in order to:
- Check which hormones you really need and in what dosage
- Confirm the best format (for example, oral progesterone is not recommended if you have IBS or IBD)
- Ensure you are metabolising your estrogen safely and effectively
In order to assess this, we recommend the Advanced Hormone Test for women in perimenopause who are considering starting HRT. You can also join the waitlist for our FUTURE WOMAN bHRT clinic, opening soon.
3 KEY TAKEAWAYS
- There are four stages of perimenopause: very early perimenopause, early menopause transition, late menopause transition and late perimenopause. Perimenopause symptoms can change depending on what stage you are in.
- Everyone’s perimenopause is different but perimenopausal symptoms stem largely from losing progesterone, not estrogen. Hormone therapy (HRT) should be tailored accordingly.
- Testing with FUTURE WOMAN can be beneficial in perimenopause to understand which stage of perimenopause you’re in, whether you’re metabolising your estrogen safely, and if other factors are at play such as stress, inflammation, poor gut health and insulin resistance. It can also be helpful if you’re on or considering HRT. We recommend our Advanced Hormone Test for women in perimenopause and menopause, which comes with a personalised health plan included.
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/Â
