Perimenopause is the transitional phase leading up to menopause, typically beginning in a woman’s mid-40s, though it can range from the late 30s to early 50s. This phase spans the time after changes in the cyclical reproductive hormone pattern until menopause, defined as 12 consecutive months without a period, which occurs at an average between 51 and 52 years of age. Perimenopause duration can greatly range from woman to woman, from a few months to around a decade. This phase is characterized by fluctuating hormone levels that impact nearly every system in the body, including metabolism, cardiovascular health, cognitive function, and emotional well-being. Despite its significant effects, perimenopause is often dismissed, misunderstood or mismanaged in medicine, leaving many women feeling unsupported. Understanding the hormonal shifts and adopting a proactive, integrative approach can empower women to navigate this transition with greater ease and resilience.
Understanding Hormonal Changes and Their Impact on the Body
One of the most notable hormonal changes during early perimenopause is an imbalance between estrogen and progesterone. Estrogen levels are high relative to progesterone and there is an overall decline in progesterone production and therefore reduced tissue exposure to progesterone. This hormonal imbalance can lead to symptoms such as heavy periods, bloating, weight gain (particularly around the midsection), breast tenderness, mood swings, and a higher risk of conditions like uterine fibroids and endometrial hyperplasia. Menstrual cycles often shorten in early perimenopause, while later in perimenopause, the woman may start skipping cycles leading up to her last period.
As progesterone levels decline, women often experience increased anxiety, sleep disturbances (especially sleep maintenance problems), and worsened premenstrual symptoms. This hormone plays a crucial role in calming the nervous system and supporting deep, restorative sleep. Women can experience cyclical night sweats as a result of fluctuating hormones, which can further exacerbate sleep problems. Insulin resistance and blood sugar dysregulation can become more pronounced later in perimenopause, as declining estrogen levels impact glucose metabolism, increasing the likelihood of weight gain, insulin resistance, and diabetes. 1
Other hormones that may play a role in the symptoms include cortisol and thyroid hormones. In a small study, women with increased urine cortisol levels during late menopause transition had more vasomotor symptoms 2. Given the prevalence of thyroid disease among women, and a range of symptoms resulting from a dysregulated thyroid that can mimic some of the symptoms of perimenopause, it is important to note that screening for thyroid disorder and appropriate management, if detected, are crucial. 3
Beyond metabolic and menstrual cycle changes, many women in midlife experience cognitive changes, including challenges with memory, attention and verbal recall. These changes, often referred to as “brain fog,” can lead to concerns about potential cognitive disorders. One potential reason for cognitive shifts is the fluctuation in estrogen levels, which is believed to influence neurotransmitter function and cerebral blood flow. 4 5 Research suggests that estrogen may have a neuroprotective role, supporting cognitive processes such as memory and executive function. Declining and fluctuating estrogen levels can impair verbal fluency, concentration, and task management, ultimately reducing mental clarity and cognitive performance.6
The potential benefits of estrogen therapy in preserving cognitive function remain a subject of debate, largely due to conflicting study results. One explanation is the “timing hypothesis” which posits that estrogen is most neuroprotective when initiated soon after menopause begins, while delayed therapy may not confer the same benefits. 7 8 Additionally, progesterone– a neurosteroid– plays a crucial role in cognitive function, anxiety and mood regulation, as well as in PMS symptom relief . Furthermore, disruptions in estrogen and progesterone balance observed in perimenopause can dysregulate key neurotransmitters such as serotonin, dopamine, and gamma-aminobutyric acid (GABA), increasing the risk of anxiety, depression, and sleep disturbances during perimenopause. 7
Beyond direct hormonal effects, other biological and psychosocial factors also contribute to cognitive and mood changes during perimenopause. Research highlights that chronic stress, sleep disturbances, and metabolic changes can exacerbate symptoms in vulnerable populations, and genetic predispositions may influence susceptibility to mood disorders. Additionally, psychosocial stressors such as caregiving responsibilities, career transitions, and evolving family dynamics can compound emotional distress during this period. 9
These multifaceted influences underscore the complexity of cognitive and mood symptoms in perimenopause, reinforcing the need for a comprehensive approach to management. Given the significant impact of hormonal fluctuations on cognitive and emotional health, it is essential for healthcare professionals to understand, recognize, and address these changes. Providing tailored interventions can help women navigate this transition more effectively improving both mental well-being and quality of life. 10
Fluctuations in estrogen levels during this transition can also influence cardiovascular health. Endogenous estrogen, which has a protective effect on the heart, helps to control cholesterol levels, maintain arterial elasticity, and reduce inflammation. 11 As estrogen levels begin to decline, there is an associated increase in cardiovascular risk factors, including increase in blood pressure and cholesterol levels. Moreover, associated weight gain increases the risk of developing cardiovascular disease in postmenopausal women.12 The combined changes in body composition, along with hormonal disturbances, can lead to increased insulin resistance, abdominal fat and alterations in lipid profiles, further elevating cardiovascular risk and the need to implement preventative treatments when indicated.13
Osteopenia, osteoporosis, and muscle loss are additional major health concerns associated with menopause and aging. Women start to experience bone loss in their thirties. Estrogen plays a vital role in maintaining osteoclast activity, and as levels drop, women experience accelerated bone loss, which can heighten the risk of fractures. 14 Similarly, estrogen’s decline is associated with a decrease in muscle mass, known as sarcopenia, making resistance training an essential part of maintaining health during this transitional stage as a key driver for prevention. Engaging in resistance training helps improve muscle strength, counteracts age related muscle loss and supports bone density. Alongside physical activity, adequate nutrition including protein, calcium, and vitamin D, and supplemental support as needed, play a crucial role in supporting bone and muscle health. 15 A comprehensive approach that combines resistance training, nutritional support, and medical guidance can help women manage these changes associated with perimenopause, improving both bone and muscle health and enhancing overall well-being. 16
Addressing Metabolic Changes
During perimenopause, hormonal fluctuations—particularly decline in estrogen and progesterone—can impact insulin sensitivity and weight distribution. Estrogen plays a crucial role in enhancing insulin sensitivity; thus, its reduction during the later part of perimenopause may lead to increased insulin resistance and higher blood glucose levels, over time. Consequently, many women experience increased central adiposity during this transition, which is associated with changes in lipid and glucose profiles, further elevating metabolic and cardiovascular risks. 17
Maintaining healthy blood sugar levels is important during perimenopause. While studies suggest that overall weight gain in midlife is more closely related to aging than menopause itself, women often experience increased fat accumulation and shifts in fat distribution, particularly around the abdomen, during the menopause transition. These changes are largely driven by hormonal shifts, including declines in estrogen and progesterone, which can contribute to increased insulin resistance, altered fat metabolism, and changes in energy balance. 18 Since insulin resistance and obesity can perpetuate one another, maintaining metabolic health becomes even more critical. 19 A diet and lifestyle that supports metabolic health can help to mitigate these effects.
Disrupted glucose regulation can also affect neurotransmitters involved in mood regulation, leading to irritability, anxiety, and depression. Increased abdominal fat, coupled with hormonal imbalances like reduced progesterone and increased androgen levels, can further exacerbate these mood disturbances. Energy crashes linked to hypoglycemia (low blood sugar) can contribute to fatigue, a common complaint during perimenopause.20 To address these concerns, a perimenopausal diet should prioritize stable blood sugar control by focusing on low glycemic index foods, incorporating sufficient fiber, and selecting protein-rich options to prevent blood sugar spikes and crashes 21. However, it is important to recognize that diet alone may not fully address metabolic concerns in all women, and personalized interventions based on individual health profiles may be necessary for optimal management.
Nutritional Strategies for Supporting Perimenopause
Implementing targeted nutritional strategies during perimenopause can help to alleviate common symptoms and promote overall health. Consuming high-quality protein sources—such as lean meats, fish, eggs, legumes, and plant-based options—at each meal (approximately 20-30g per meal) supports muscle maintenance and stabilizes blood sugar levels. This approach is especially beneficial during perimenopause because it counteracts age-related muscle loss while supporting blood glucose regulation.21
Incorporating healthy fats, especially omega-3 fatty acids found in fatty fish, walnuts, flaxseeds, and chia seeds, can reduce inflammation and support brain health. Research indicates that omega-3s may improve mood and cognitive function during menopause, addressing symptoms such as anxiety and depression.22
Emphasizing low-glycemic, fiber-rich carbohydrates—including quinoa, lentils, non-starchy vegetables, and berries—can enhance insulin sensitivity and promote metabolic stability. These dietary choices help manage blood sugar fluctuations, which are important during perimenopause to mitigate risks of insulin resistance and associated metabolic disturbances.
Lifestyle
Stress management is another, often overlooked component of perimenopause support. Perceived stress significantly influences self-reported perimenopausal symptoms, with higher stress levels linked to more frequent and severe symptoms, including hot flashes, mood disturbances, and sleep disruptions.23 Chronic stress is thought to worsen symptoms associated with perimenopause by elevating cortisol levels and the downstream effects of this.
Mindfulness-based stress reduction (MBSR), meditation, and deep breathing exercises have been shown to improve mood, reduce anxiety, and enhance sleep quality in perimenopausal women. 24 Additionally, regular physical activity, including strength training, yoga, and aerobic exercise, supports mental well-being by reducing stress, improving mood, and promoting better sleep. 25 Exercise also plays a key role in maintaining bone density, muscle mass, and cardiovascular health, all of which are vital during this transition. 26 Implementing both stress management techniques and consistent movement can significantly improve overall well-being and resilience during perimenopause. It is generally advised that people engage in moderate-intensity aerobic exercise 150-300 minutes per week (or 75 minutes of vigorous-intensity activity) and in strength training 2-4 times per week.
For more information about supplemental, herbal and hormone therapy for perimenopause, see this article.
We encourage any woman experiencing perimenopause symptoms to speak to their doctor about the possibility of perimenopause and available treatment options.
Our team is here to guide and support you every step of the way. We’re committed to providing the personalized care you deserve, helping you move forward with confidence and strength. You have the power to take charge of your health during perimenopause – and we’re here to help you do just that. To learn more about our support services, contact us at 646.627.8000, fill out this form for a complimentary discovery call, or email Bridget@drbojana.com.
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