As the ovarian production of estrogen diminishes in midlife and ultimately stops, it is estimated that more than 47 million women worldwide enter the menopause transition annually.

The average American woman will experience menopause between 51 and 52, but the hormonal change can happen anywhere from 45 to 57.

Perimenopause symptoms can start anywhere between two and 10 years before menopause, meaning some women begin seeing symptoms in their 30s. This phase is called perimenopause.

A difficult diagnosis

Physicians define menopause as not experiencing a period for an entire year — for a woman who has regular monthly periods.

“That’s like the old school of thought, and we need to change that narrative,” said Dr. Gunjan Raina, a family medicine physician in Baton Rouge. “If a woman is suffering or she’s having symptoms, we need to start addressing it.”

Dr. Robin Bone is an OB-GYN at Ochsner Health in New Orleans. Since the surge of menopause research, largely guided by patient demand, Bone has studied perimenopause, menopause and postmenopause.

If a woman doesn’t have a period because of an IUD, other forms of birth control, a hysterectomy or more, “we use blood work to define or determine whether or not labs are consistent with menopausal levels,” Bone said.

The ups and downs of estrogen levels trigger menopausal symptoms, according to Bone. So typical blood tests and hormonal levels may not be helpful to physicians to determine a woman’s progression through the process of perimenopause, menopause and postmenopause.

Bone is of the mind that the best way to help patients is to “put the puzzle pieces together” and figure out the cause of the symptoms — whether that be perimenopause, menopause or something else. 

Some symptoms are noticeable, like night sweats and hot flashes. But some may be harder to detect.

Because menopause is identified retroactively, determining whether or not a woman is in that process is difficult. Adding to the confusion is that the process isn’t linear.

“If you would have asked OB-GYNs five years ago, ‘What are the symptoms of menopause?’ They probably would have said: hot flashes, night sweats, trouble sleeping, vaginal dry and osteoporosis,” Bone said. “But now we have at least 35 and some say 65 symptoms of that can be attributed to menopause.”

The common and unknown symptoms

Perimenopause and menopause do not present differently, according to both Bone and Raina. 

Raina, a concierge doctor, treats patients for all of their ailments, including the symptoms of menopause. Raina, however, found that medical school did not prepare her for the complexities and realities women face in menopause.

“It’s almost like they skipped through it,” Raina said. “I had itchy ears for three years, and I didn’t even realize it was related to perimenopause.”

More than 70% of women who go through menopause experience musculoskeletal symptoms and 25% will be affected more acutely by the symptoms during the transition from perimenopause to postmenopause.

“A lot of times, women don’t recognize it because they are just getting older,” Bone said.

According to Bone, doctors are learning that estrogen is an anti-inflammatory hormone. And when the body loses estrogen, as it begins to do in perimenopause, the body’s stem cell production decreases causing less “healing in our muscles, our joints and our bones,” Bone said.

The loss of estrogen due to menopause makes muscles recuperate more slowly.

“Exercise is important, especially strength training or resistance exercises, to help build muscle to start off with good muscle mass,” Bone said.

Here’s a list of the most common perimenopausal and menopausal symptoms:

• Changes in mood
• Irritability
• Insomnia
• Difficulty concentrating
• Brain fog
• Anxiety
• Depression
• Panic attacks
• Decreased libido (sex drive)
• Night sweats
• Hot flashes
• Irregular periods
• Breast tenderness
• Headaches
• Weight gain
• Bloating
• Digestive problems
• Joint pain
• Muscle tension
• Decreased muscle strength/mass
• Dizziness
• Changes in taste
• Burning mouth sensation
• Heart palpitations
• Body odor
• Hair loss
• Brittle nails
• Itchy skin
• Tinnitus
• Bleeding gums
• Tingling extremities
• Electric shocks
• Vaginal dryness
• Urinary urgency/frequency.

Managing the symptoms

Hormone therapy is the most effective treatment for managing menopause symptoms, particularly hot flashes, night sweats and sleep disturbances. However, many women hesitate to use hormone therapy due to safety concerns, according to new Mayo Clinic research.

These concerns may stem from a 2002 study that showed an increased risk of breast cancer, coronary artery disease, stroke and blood clots from specific hormone therapies such as conjugated equine estrogens and medroxyprogesterone acetate.

“The lingering fear caused by the initial Women’s Health Initiative trial results in 2002 has promoted a false belief of a lack of safe options for treating menopause symptoms, Dr. Ekta Kapoor said, a Mayo Clinic endocrinologist and author of the study. “This has most likely affected how health care professionals approach evaluation of menopause symptoms.”

More recent studies have established the relative safety of hormone therapy when started by women in their 50s or those within 10 years of menopause.

“The study was misleading, and because of that, a whole generation of providers in the last 20 years were taught that estrogen was dangerous and causes cancer,” Raina said. “And it’s actually been debunked now.”

Bone, 54, said she would tell her 40-year-old self to do more strength training and more yoga as well as supplement to promote bone health like vitamin K, vitamin D, calcium and magnesium.

“I’m big on resistance training three times a week,” Raina said. “All of these things will help a woman through perimenopause, in addition to being a candidate for hormonal therapy.”