The four stages of perimenopause

The Four Stages of Perimenopause

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. 

What are the four stages of perimenopause?

According to Canadian endocrinologist 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

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:

 
  • 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

Read more about the signs and symptoms of perimenopause.

What's happening to our hormones over the four stages of perimenopause?

As you can see from this image, perimenopause is characterized by lowering progesterone and initially high, fluctuating levels of estrogen. Estrogen 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. Progesterone is only made as a result of ovulation.

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 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.

Symptoms of high, fluctuating estrogen
  • 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.

Symptoms of LOW estrogen
  • 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 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.

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?
  • 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 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, neurotransmitters and inflammation markers to get a full picture.
After testing, you’ll receive a personalised health plan with supplement and diet recommendations from one of our experienced nutritionists with targeted recommendations to improve your symptoms. Read more about testing in perimenopause.

 

2. SUPPORT OVULATION AND PROGESTERONE PRODUCTION

Ways to support healthy and regular ovulation include:
  • Manage stress levels
  • Support good-quality sleep
  • Support ovulation with personalised nutrient support and supplementation
  • Ensure high-quality protein with each meal
  • Remove alcohol

3. BALANCE BLOOD SUGAR

Insulin resistance is highly likely in perimenopause due to the drop in protection from progesterone (and eventually estrogen). 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. 

Learn how to balance your blood sugar, lose weight and more in our Perimenopause Club

4. SPEAK TO YOUR GP ABOUT HORMONE 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. 

It’s important to test your hormones first, before starting any hormone therapy to check which hormones you really need and to ensure you are metabolising your estrogen safely and effectively. We recommend the Advanced Hormone Test for women in perimenopause.

Options for hormone therapy in perimenopause include:

  • Progesterone only hormone therapy
  • Cyclical progesterone
  • Combined estrogen and progesterone

3 KEY TAKEAWAYS

  1. 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.
  2. Everyone’s perimenopause is different but perimenopausal symptoms stem largely from losing progesterone, not estrogen. Hormone therapy (HRT) should be tailored accordingly.
  3. Testing with FUTURE WOMAN can be beneficial in perimenopause to understand your hormone production, hormone balance, hormone metabolism and stress and other contributing factors. 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.

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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