If you ask a woman about their knowledge of perimenopause and this transitional time of life, you’re likely to get a similar response: “There’s so much I wish I knew.”
Dr. Diana Bitner, FACOG, MSCP, Co-founder and CMO, true. Women’s Health, explained that one of the reasons women feel unprepared for perimenopause is that we traditionally haven’t talked about this phase of life nor screened or prepared women in advance. Another key barrier is health care providers not being given any training or being informed of the intricacies of perimenopause, nor how to talk to women about this phase of life.
“Perimenopause can be complicated; it’s not like pneumonia or a UTI that’s treated by a specific antibiotic,” Dr. Bitner said. “It’s a life phase that needs language and a stepwise approach, which can result in women feeling prepared and knowing what to do when symptoms arise.”
RECOGNIZING SYMPTOMS AND TIMING
While some women can experience sudden menopause with the removal of their ovaries or premature menopause from cancer treatment such as radiation or chemotherapy, perimenopause generally starts in a woman’s early 40s and can last from two to nine years, with an average of four years.
“The initial symptoms tend to be periods which start earlier and are heavier than normal, and night sweats the first few days before menstruation,” Dr. Bitner advised. “If women have had a hysterectomy or have a progesterone-containing IUD, bleeding is not a helpful pattern to use but usually there’s enough pattern to the symptoms to define the phase.”
Early perimenopause, Dr. Bitner explained, is when periods change by more than seven days, early or late, and late perimenopause is when there’s been 60 days without a period, even if the cycles normalize for a period of even months after.
“Symptoms such as hot flashes, night sweats, mood changes, sleep disturbance, and headaches tend to progress as the cycle advances, with the worst few years occurring around the time of your last menstrual period,” Dr. Bitner said. “Despite regular good habits, many women will also experience weight gain, especially in the waist area (belly fat or what’s referred to as the menopot) and a change in sex drive.
“Compared to perimenopause, menopause at least is a set of more consistent symptoms. The night sweats and weight gain, etc., can get even more pronounced, but at least the rollercoaster is done.”
UNDERSTANDING THE PHYSICAL AND MENTAL CHANGES
Many of the women Dr. Bitner sees have said they simply want to know why their symptoms are happening and what they can do to feel better.
“I usually start with talking about what the ovarian hormones do and how the ovary cycles through hormone production during perimenopause,” Dr. Bitner explained, noting that estrogen, progesterone, and testosterone are the key hormones at play. “The ovary starts to sputter, meaning the number of follicles (or baby eggs) drops off and the remaining follicles don’t listen to the brain signals to get ready for a pregnancy. The brain then signals ‘louder’ with a message of high follicle stimulating hormone, making extra estrogen at ovulation.”
These high estrogen symptoms can include significant breast tenderness, acne, being easily brought to tears, feeling bloated, and a higher libido. Alternatively, when estrogen levels fall quicker and earlier, women can experience night sweats, irritability, menstrual migraines, low sex drive, and sugar cravings.
When it comes to the mental aspect of perimenopause, Dr. Bitner explains to patients how the levels and function of brain chemicals (i.e. neurotransmitters such as GABA, serotonin, and norepinephrine) depend on estrogen and progesterone, in addition to sleep, stress levels, and unresolved events.
“When a person isn’t sleeping, she isn’t recovering, leading to her brain chemical function being ‘off,’ meaning there’s not enough in the tank to deal with extra stress,” Dr. Bitner shared, adding this can be a vicious cycle that presents itself very similarly to postpartum depression, PMS, or PMDD. “It’s important for women to know they could be at risk if they’ve experienced these other conditions or have a female relative who has. It’s also critical to prioritize restorative movement such as yoga and walking, and to consider options such as treatment of hot flashes and night sweats, even short-term use of medications for mood, and to give themselves grace when mood changes occur.”
Unfortunately, these emotional symptoms can affect areas of life such as work and relationships.
“I had one patient even get kicked out of a local grocery store because she way overreacted at the checkout register, and other women say they wouldn’t have been divorced or would still be working if they’d gotten help,” Dr. Bitner recalled, emphasizing that women in this time of life just want to feel normal and show up for themselves and their families. “Often just knowing why symptoms occur is helpful so my patients do not feel their body is being taken over by an alien and it is powerful to have validation they are not alone or imagining how bad they feel.”
YOU HAVE THE POWER
Dr. Bitner framed the symptoms of perimenopause as a gift reminding us to get our health in order.
“When perimenopause starts, it’s a time to take stock of your risks for chronic conditions such as obesity, diabetes, osteoporosis, and heart disease,” she said. “Use this time to set goals, understand personal barriers, and develop a health plan to age how you wish. It’s possible and I see it happen every day.”
Dr. Bitner hopes perimenopause can become more commonplace in our everyday conversations, with more support for healthcare providers who are providing safe and evidence-based treatment options, in addition to increased training across the healthcare landscape.
“Workplaces need to embrace the power and wisdom of women in midlife and menopause, and insurance companies need to pay for FDA-approved treatments for menopause,” Dr. Bitner said, stressing that women from all backgrounds need to know they deserve treatment. “Women who are affected by cancer also need to know they have options too, and fear shouldn’t drive the avoidance of learning how to take their bodies back after treatment.”
Written by Sarah Suydam, Managing Editor for West Michigan Woman.
This article originally appeared in the Fall ’26 issue of West Michigan Woman.