Perimenopause: The Symptoms, the Treatment, and the Mindset

I woke up one morning and felt like a different person. My lower back was stiff and my joints ached; I couldn’t get out of bed. I wondered if I was getting sick, but when the symptoms didn’t go away, I started to get concerned.

I had been dealing with left hip pain for months, which got so intense I could no longer workout. I had been to multiple doctors and done lots of imaging (including an x-ray that told me I had osteoarthritis, an ultrasound that showed I had trochanteric bursitis, and an MRI that was normal). I even finished a course of physical therapy, but nothing seemed to help until I got treated with osteopathic manipulation therapy (a hands-on treatment that moves the body to release tension, discomfort, and treats a variety of conditions). Finally I felt some relief.

Soon other symptoms started to arise. The most worrisome was my chest discomfort. Every few days, I felt like I couldn’t take a deep breath that lasted a few hours. I thought it was due to anxiety, a feeling that was becoming more frequent. It reminded me of the all-or-nothing feeling I had when my son was sick with cancer. I started to get angry and irritable often. Everything was annoying and I no longer had the patience or the let-it-go mentality I used to.

To top it all off, I had difficulty putting my thoughts together. Once sharp and quick on my feet, now I would read an article and had to pause before explaining it to others, trying to remember what it was I was saying. I was having difficulty finding words, and what I soon realized was brain fog, similar to how I had felt right after pregnancy. That’s when I put it all together—could this be perimenopause?

The symptoms of perimenopause are vast and varied and can mimic many other medical conditions. We all know about the usual hot flashes, night sweats, menstrual changes, and difficulty sleeping (often waking up around 3am). But it can also present as a multitude of other symptoms, described by many trailblazing doctors and scientists who are studying this very important transition in all women’s lives. Dr. Vonda Wright (an orthopedic surgeon) created the term the Musculoskeletal Syndrome of Menopause to encompass symptoms of arthralgia (body pain, with aching and stiffness), frozen shoulder, sarcopenia (muscle loss), osteopenia and osteoporosis, osteoarthritis, joint pain, and tendon and ligament issues. Dr. Lisa Mosconi (a neuroscientist) shares her insight and research on the cognitive changes that happen, including brain fog, trouble with focusing and concentration, word retrieval, and memory lapses. She also discusses the mood changes, irritability, depression, anxiety, and changes in emotional regulation. Dr. Rachel Rubin (a urologist and sexual medicine specialist), among many others, sheds light on the Genitourinary Syndrome of Menopause, which include symptoms such as decreased libido, vaginal dryness and irritation, dyspareunia (pain with sex), urinary symptoms like urgency, increased frequency, and recurrent UTIs. And then there is fatigue, headaches, breast tenderness, weight gain (particularly increased abdominal and visceral fat), hair thinning, heart palpitations, skin and scalp itchiness and many more.

Perimenopausal shifts can start up to ten years before menopause (which is officially 12 months without a menstrual period). Since menopause usually begins between the ages of 45 and 55 for most, with the average age around 51 years old, this means women can be feeling the changes even in their mid thirties, a time many are still experiencing pregnancy and having children. We often say we are just feeling “hormonal” without realizing the truth behind that common phrase, and that there is something we can now do about it.

Menopausal hormone therapy (MHT as it is now called) is widely available and understood to be a very helpful tool that many women can use to manage many of these symptoms. The Women’s Health Initiative study done in 2002 claimed hormone therapy for postmenopausal women could increase the risk of breast cancer, stroke, and blood clots, but was found to be limited and not completely true. The study focused on postmenopausal women ages 50-79, with a majority of them 10-20 years past their hormone shift, and did not include perimenopause at all. Only one form of estrogen and progesterone was used—an oral and synthetic formulation that passes through the liver, which increases the risk of side effects. Now, we have many different ways to deliver estrogen and progesterone (oral, topical, vaginal) in forms more closely related to our natural hormone. The doses of progesterone and estrogen used in MHT are lower than the amount found in contraceptive hormone therapy like birth control pills, and are considered safe for long term use. Although the WHI study only used estrogen and progesterone, we now sometimes use testosterone to support sexual function, mood fluctuations, low energy, and decreased muscle tone, but levels need to be monitored since overdosing can cause irreversible symptoms like voice deepening and clitoral enlargement.

For those who prefer not to use hormones or have contraindications to their use, or don’t find full relief from MHT, there are many alternatives, including herbs and supplements, lifestyle changes, acupuncture, pelvic floor physical therapy, and osteopathic manipulation therapy. Eating enough protein, complex carbohydrates, healthy fats and fiber built around the concept of an anti-inflammatory diet can help us maintain our muscle mass, strengthen our bones, and reduce the inflammation that contributes to many of the symptoms. Movement (especially resistance training, weight bearing exercises, and aerobic activity) can improve our mental health, cardiovascular system, bones, and so much more. Cognitive behavioral therapy for insomnia (or CBTi—a treatment that focuses on sleep restriction while addressing the thoughts, behaviors, and habits that contribute to insomnia), is one of the best tools to help with sleep issues. Taking the time to practice self care, participating in mindfulness practices, building a community of friends and family are also important during this special transition.

So I started on my journey to feeling like myself again. I focused on getting the full eight hours of sleep a night, went outside more often to feel the healing benefits of nature, and added weight bearing exercises to my aerobic activity. I walked away from things when I was feeling annoyed or irritated, and shut my mouth until the storm in my head passed. And I tried out many new herbs and supplements to find what worked for me. I felt reassured that my body was just adjusting to the fluctuation in my hormones and that many of these symptoms would one day improve after the transition. I also felt empowered that I could do something about the effects of hormonal loss to make my body stronger and healthier for my future self. For now, I recognized that this was the new me, accepted the symptoms, even embraced them with curiosity, as if a child, and learned ways to cope.

This content is provided for general informational and educational purposes only. It is not intended as, and should not be interpreted as, medical advice, diagnosis, or treatment.

Recommended reading

My top 3:

The New Perimenopause by Dr. Mary Claire Haver

The Menopause Brain by Dr. Lisa Mosconi

Hormone Intelligence by Dr. Aviva Romm

Other helpful reads:

The Galveston Diet by Dr. Mary Claire Haver

The New Menopause by Dr. Mary Claire Haver

Brain Food by Dr. Lisa Mosconi

Unbreakable by Dr. Vonda Wright

You are Not Broken by Dr. Kelly Casperson

Estrogen Matters by Dr. Avrum Bluming and Dr. Carol Tavris

Grown Women Talk by Dr. Sharon Malone

Recommended websites:

Mary Claire Haver, MD: https://thepauselife.com

Aviva Romm, MD: https://avivaromm.com

Rachel Rubin, MD: https://www.rachelrubinmd.com

Lisa Mosconi, PhD: https://www.lisamosconi.com

Heather Hirsch, MD: https://heatherhirschmd.com

Vonda Wright, MD: https://www.drvondawright.com

Kelly Casperson, MD: https://kellycaspersonmd.com/clinic

Sharone Malone, MD: https://www.drsharonmalone.com

Dr. Grobel is a concierge primary care physician at CrescendoMD in Portola Valley, California, and a board-certified family physician with a fellowship in Family and Integrative Medicine (ABFM). She specializes in whole-person, relationship-based primary care that combines evidence-based medicine with a focus on prevention, lifestyle, and overall well-being, and concierge primary care for individuals and families across the San Francisco Peninsula, including Atherton, Woodside, Menlo Park, Palo Alto, and Los Altos.