Perimenopause is the transitional phase leading up to menopause, during which a woman’s ovaries gradually produce lower levels of reproductive hormones, particularly oestrogen and progesterone. This article explains some early symptoms and the importance of early recognition. 

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Perimenopause

Perimenopause affects 80–90% of women, involves a variety of symptoms related to the fluctuation and gradual decline of gonadal hormones. These can include vasomotor symptoms like hot flashes, urogenital changes such as vaginal dryness, and shifts in cognitive function and mood, leading to conditions like memory issues or irritability.

These symptoms can vary in intensity and duration, affecting overall well-being during this transitional period. This period is associated with a mild ovarian hormonal deficiency that leads to anovulation and menstrual disorders, especially menorrhagia, and sometimes obesity. It usually begins in the 40s but can start earlier for some women. Perimenopause is followed by 1 year of amenorrhea. When the follicular number drops below 1000, menopause begins.

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Early Symptoms

Here are some early symptoms of perimenopause that are often missed or misattributed:

1. Irregular periods
2. Hot flashes and night sweats
3. Vaginal dryness or discomfort
4. Weight gain
5. Decreased libido
6. Joint and muscle pain
7. Mood changes
8. Sleep disturbance
9. Brain fog and memory issues
10. Hair fall and dry skin

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1. Irregular Uterine Bleeding in Perimenopause: Understanding the Causes

Irregular uterine bleeding is a common clinical presentation during perimenopause and can be attributed to a variety of causes. These are systematically classified under the PALM-COEIN system, which includes both structural and non-structural aetiologies:

A. Structural causes (PALM):

• Polyp
• Adenomyosis
• Leiomyoma (fibroids)
• Malignancy and hyperplasia

B. Non-structural causes (COEIN):

• Coagulopathy
• Ovulatory dysfunction
• Endometrial causes
• Iatrogenic (e.g., medications, devices)
• Not otherwise classified

During the perimenopausal transition, ovarian activity progressively declines. Because ovulation frequently fails in the early phase, there is no corpus luteum formation and, as a result, no progesterone release. This results in anovulatory cycles, which are typically irregular and unpredictable.

As perimenopause progresses, the development of Graafian follicles also diminishes, leading to a decline in oestrogen production. This reduction in oestrogen eventually causes endometrial atrophy, culminating in the cessation of menstruation—amenorrhea.

The initial evaluation of abnormal uterine bleeding should include a thorough history and physical examination, along with a transvaginal ultrasound to assess the endometrial thickness and rule out structural abnormalities. Depending on the findings and clinical context, further investigations such as saline infusion sonohysterography or endometrial biopsy may be necessary to clarify the diagnosis.

Hormonal treatments used in premenopausal women can also be applied in older women, but the presence of comorbidities and the potential need for future hormone replacement therapy may influence the choice of regimen. When hormonal therapy is ineffective or contraindicated, procedural options such as hysteroscopic polypectomy, endometrial ablation, or uterine artery embolisation can be considered. For women who do not respond to conservative management, hysterectomy remains a reasonable and definitive treatment option.

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2. Hot Flashes and Night Sweats

1. Hot flashes and night sweats are vasomotor symptoms and among the most common complaints during perimenopause.
2. Hot flashes are sudden sensations of heat, usually affecting the upper body, face, and chest, lasting for about 1 to 5 minutes.
3. They are often accompanied by reddened skin, sweating, palpitations, and sometimes followed by chills.
4. Stress, hot weather, spicy foods, alcohol, and caffeine are common triggers.
5. Night sweats refer to episodes of intense sweating during sleep and are frequently associated with sleep disturbances, fatigue, and irritability.
6. Both symptoms are prominent during perimenopause and are primarily caused by fluctuating oestrogen levels, which impact the hypothalamic thermoregulatory centre.
7. The decline in oestrogen narrows the thermoneutral zone, making the body overly responsive to minor temperature variations, thereby leading to vasomotor symptoms.

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3. Vaginal Dryness or Discomfort

Vaginal dryness and discomfort are frequently reported symptoms among perimenopausal women, primarily attributable to declining oestrogen levels. Oestrogen is essential for maintaining the integrity, elasticity, and lubrication of the vaginal epithelium. Its reduction during the perimenopausal transition leads to thinning, decreased moisture, and reduced elasticity of the vaginal tissues—a condition clinically referred to as vaginal atrophy or more broadly as part of the genitourinary syndrome of menopause (GSM).

These changes may manifest as vaginal itching, burning, irritation, dyspareunia (painful intercourse), and an increased risk of urogenital infections. Such symptoms can significantly impair sexual function and overall quality of life. Management strategies include lifestyle modifications—such as regular sexual activity to enhance vaginal blood flow—the use of non-hormonal vaginal moisturisers and lubricants, and local oestrogen therapy, which is highly effective with minimal systemic absorption. In selected cases, non-hormonal options such as vaginal dehydroepiandrosterone (DHEA) or laser-based vaginal rejuvenation therapies may also be considered.

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4. Perimenopausal Weight Gain and Hormonal Dysregulation

During the perimenopausal transition, progesterone is typically the first hormone to exhibit a significant decline due to reduced corpus luteum activity in anovulatory cycles. This reduction can lead to premenstrual fluid retention and increased extracellular water volume, resulting in subjective bloating and weight fluctuations. At the same time, oestrogen levels start to wildly fluctuate and eventually decline. Oestradiol, the most potent form of oestrogen, plays a crucial role in lipid metabolism, adipocyte distribution, and glucose homeostasis. Declining oestradiol levels impair lipolysis, promote visceral adiposity, and negatively affect insulin receptor sensitivity. This hormonal imbalance, particularly the oestrogen-to-progesterone ratio, can dysregulate the hypothalamic-pituitary-gonadal (HPG) axis, leading to secondary metabolic disturbances.

Moreover, perimenopause is often associated with:

• Increased insulin resistance
• Reduced basal metabolic rate (BMR)
• Altered lean body mass to fat ratio
• Reduced mitochondrial efficiency

These hormonal changes can slow down metabolism, increase belly fat, and reduce the body’s sensitivity to insulin, leading to higher blood sugar levels and more fat storage. At the same time, poor sleep, stress, certain medications like antidepressants or sleep aids, and changes in body composition (more fat, less muscle) can all add to weight gain. Together, these changes create the ideal conditions for putting on weight during perimenopause.

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Decreased Libido

During perimenopause, many women experience a decrease in libido, which is often linked to falling levels of oestrogen, progesterone, and sometimes testosterone—all of which play a role in sexual desire, arousal, and overall mood. Lower oestrogen can lead to vaginal dryness, discomfort during sex, and reduced blood flow to sexual organs, making intimacy less pleasurable. In addition to changing nerve function, a hypoestrogenic state may cause a delayed clitoral reaction time and a delayed or nonexistent orgasmic response.

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Joint and Muscle Pain

1. Oestrogen plays a protective role in musculoskeletal health by modulating inflammatory pathways and maintaining bone density.
2. It exerts anti-inflammatory effects through the inhibition of pro-inflammatory cytokines and supports the preservation of cartilage integrity. When oestrogen levels decline during perimenopause and menopause, there is an increase in systemic inflammation, which can contribute to the progression of osteoporosis and osteoarthritis. T
3. he reduction in oestrogen also accelerates bone resorption, leading to decreased bone mineral density and an elevated risk of fractures.
4. Additionally, the loss of oestrogen’s anti-inflammatory properties may exacerbate joint stiffness, swelling, and pain, making physical movement more difficult and uncomfortable.
5. Along with dietary and lifestyle changes, hormone replacement treatment, or HRT, can help lower the inflammation causing joint discomfort.

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Mood Swings and Sleep Disturbance

Oestrogen influences several key areas of the brain, such as the prefrontal cortex (involved in decision-making and planning), the hippocampus (important for memory and learning), and the amygdala (which helps regulate emotions and stress responses). As oestrogen levels shift during perimenopause, many women experience difficulties with concentration, emotional regulation, and mental clarity. Fluctuations in oestradiol can affect brain chemicals like dopamine, serotonin, and norepinephrine, potentially leading to mood swings, memory lapses, and disrupted sleep.

Sleep disturbances are common in perimenopausal women, including insomnia, sleep apnea, and restless leg syndrome. Oestrogen and progesterone fluctuations impair the quality of sleep, and vasomotor symptoms such as hot flashes make sleep worse. Changes in the circadian rhythm, decreased melatonin production, and age-related physiological changes also contribute to these sleep issues.

First-line therapy should be non-pharmacological; depending on the patient's unique needs and risk factors, hormone therapy or non-hormonal pharmacological treatments may be considered.  The initial approach to management should prioritise non-pharmacological strategies. If symptoms persist or are more severe, hormone therapy or non-hormonal medications may be tailored to the patient’s individual needs, preferences, and risk factors.

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Hair Fall and Dry Skin

1. The primary cause of hair loss during perimenopause is hormonal imbalance, specifically the decline in oestrogen and progesterone levels.
2. These hormones play a key role in maintaining the hair in the anagen (growth) phase, promoting healthy hair growth and density.
3. As their levels decrease, the hair growth cycle shortens, leading to slower growth and increased hair thinning.
4. Concurrently, the relative increase in androgens, particularly testosterone, can contribute to androgenic alopecia, also known as female pattern hair loss.
5. This condition is characterised by progressive thinning of hair, especially in the frontal, temporal, and crown regions of the scalp.
6. Collagen content is reduced, causing skin to wrinkle.
7. The idea of "feminine forever" pertains to oestrogen creams that postpone the ageing-related changes in the skin.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Nikita is an Assistant Professor in the OBGY department at SMMCHRI in Chennai.