The Musical Dynamics of Perimenopause

The 3-ish Stages of the Menopause Transition

I never understood that “they”¹ say that there are two stages of perimenopause—early and late. I believe that there are at least three stages:

• Early

• Middle (and Later Middle)

• Late

Each stage brings about its own challenges and signs that generally happen in the body.

Let’s create a parallel between music and the perimenopause journey. In music, “dynamics” refers to the volume at which a piece is played. In songs, a typical dynamic goes from soft (the build-up) to louder (crescendo) to resolution (decrescendo).

The perimenopause journey follows a similar pattern: It starts subtly in early perimenopause, reaches a peak in middle and late perimenopause, and then gradually subsides as a woman approaches menopause and beyond. Knowing about this progression can help you feel less anxious about the experience and the changes in your body.

Listen to A Space Odyssey theme to hear this dynamic in action. It's a powerful piece of music.

Where the hell am I?

It’s not necessarily essential to know where exactly you are in the perimenopause transition, and sometimes, you don’t know until you move into the next phase. However, it’s helpful to know roughly so you can understand what to expect next.  

Below are descriptions of each phase. Although some symptoms may show up when they commonly do, that doesn’t mean every symptom will show up accordingly. Every woman’s body is different, and changes happen in their own time. Some women breeze through the menopause transition and some have severe experiences.

This process below also assumes that you aren’t taking menopause hormones. These don’t stop the process, but it may change symptoms. See questions at bottom if you have PCOS, a hysterectomy, taking birth control, using menopause hormones, or went through medical menopause.

Early Perimenopause

🩸…🩸..🩸..🩸.🩸

This is when subtle changes start to happen. Women report that mood changes are usually the first symptom to show up. You may be more anxious than normal, lose interest in things that make you happy, or become angry more often.

You may start to wonder if you should see a doctor because other weird things are happening, too, like an increase in allergies, sleep difficulties, a bit of fatigue, changes in taste, or digestion issues. I had mysteriously more tartar build-up on my teeth daily, and skin tone changes. Your periods may arrive more frequently in this phase. “Consistently shortening period cycles are a reliable indicator” of early perimenopause.²

There are a lot of WTF moments as you try to figure out what’s happening with your body, and you may experience sensations that you’ve never dealt with before, like panic attacks. You may also get more cramping and more breast tenderness.

✔Although perimenopause and menopause are not diseases or a medical condition, they do sometimes set the stage for the development of one. It’s very important during this time that if you experience anything that is concerning to you (or to the others around you), please get checked out by a doctor. Things like chest pain, heart palpitations (rapid heartbeat or skipped beats), insulin sensitivity/blood sugar issues, possible blood clots, and high blood pressure should always be checked out by a doctor. If the doctor tells you, “You’re normal; there’s nothing wrong.” Then you can assume it’s perimenopause related but don’t just assume any symptom is. You should also see your doctor if you are concerned about unusual bleeding to get checked for fibroids or cysts.

Hormonal Play in Early Perimenopause – “And So It Goes” by Billy Joel

During this phase, your progesterone will decline because there will be menstrual cycles in which you don’t ovulate (called anovulation). When you don’t release an egg, you don’t produce a surge of progesterone. Progesterone is your calming hormone so sleep issues may pop into your life. Hello 3am; I see you!

For more information about anovulation, see the Vagtionary entry for “Cracked Period” towards the bottom. In an effort to balance your body, estradiol estrogen will begin to spike higher than normal to try to trigger ovulation; however, this causes breast tenderness and other issues.

If you feel like you’re not feeling like yourself, there are reasons why. See my article Just Not Feeling Like Myself.

Fun fact: “If you’re over 45 and have gone 60 days without a period and you used to cycle normally, you’ve got a 90 percent chance of being menopausal in 4 years.”³

Middle Perimenopause

🩸……🩸…🩸………………🩸……..🩸

This is the phase where symptoms may be showing up in full force. Dr. Mary Claire Haver calls this period the “Zone of Chaos.” You’ll begin getting periods spaced out longer, more days of bleeding, and skipping periods altogether. But, then again, you may get a short period thrown in the mix. It’s a very confusing time. Periods are all over the place, and you start wearing a panty liner just in case it shows up when you least expect it (and we know, it ALWAYS does that).

You’ll think you bought your last box of menstrual products, but nope, not yet. Hot flashes, dry skin, headaches, fatigue, vaginal/urinary changes, burning mouth syndrome, aches and pains and just plain old weird symptoms like itchy ears, frozen shoulder, body odor changes can add to the excitement. Anxiety and depression may still be an issue, as well as feeling rageful at times. Fractures and injuries can start to happen more frequently because estrogen is protective to our muscles, ligaments, tendons, and bones and when it starts to decline we lose that protection.

I heard that there are now 100 symptoms tied to perimenopause. That doesn’t mean you’ll get all of them, but it’s comforting to know that when the weird stuff shows up, you have a possible explanation for it. By now, you’ll realize that you’re in perimenopause because of the traditional symptoms like hot flashes and missed periods.

You may become obsessed with research, discussing symptoms with anyone who will listen, and trying to figure out what is happening inside your body. You may be mad at yourself for not knowing any of this – it’s okay, truly. You’re learning about it now and that’s what matters. And pat yourself on the back, you found the right place to learn.

“Can I Door Dash a pregnancy test? Who broke the thermostat?”

Even when you start skipping periods or getting hot flashes, you may not see the signs for what they are. It’s hard to think of ourselves as getting older, and it’s easy to deny it. When you miss a period, you may panic and think you’re pregnant (which can still happen during this phase, so please plan accordingly). It’s easier to think every thermostat is broken than to come to terms with aging and losing our fertility.  

Hormonal Play in Middle Perimenopause – “Nobody Told Me” (there’d be days like these) by John Lennon

During this phase, your progesterone is very low as you begin to stop ovulating. Your estradiol estrogen is shooting high and low often, even hourly. It can make you feel like you’re nuts, crying one moment and laughing the next. There are other hormones at play here too (See Your Hormones are Pooh) for an explanation.

Your body is confused because your normal hormone pattern is all over the place. It’s trying to re-balance you and is working very hard to do so. I know it feels like you’re body is betraying you, but it’s not. It’s trying to bring you back into equilibrium through a major hormonal transition.

We haven’t talked about testosterone yet. Testosterone can spike during this time in relation to estrogen. Higher testosterone doesn’t necessarily mean you’ll be feeling freaky deaky. There are several factors that affect libido outside of testosterone; more on that in another article later. But what it may mean is extra facial hair, weight gain around the belly, and hair loss.

The symptoms of perimenopause don’t correlate with your hormone levels⁴ I believe that it’s the sudden spikes and sudden crashes of all of the sex hormones that cause the most symptoms. During perimenopause, estrogen levels can rise typically 20-30% higher than during PRE-menopause.⁵ Can you imagine estrogen spiking that much higher quickly and then crashing down suddenly?

Later Middle Perimenopause

🩸……………………..…….🩸………………….🩸…..

By this phase, you’ve figured some things out about perimenopause and menopause, probably implemented some lifestyle changes to try to feel better, maybe started on birth control pills, menopause hormones, or other medications to manage symptoms, and are seeing positive results of those changes.

Some symptoms are easing up a bit, and some are kicking into high gear, like vaginal dryness and urinary symptoms. At this point, your periods are most likely spaced out further and further, and you’re just waiting to get into the 365 days of no periods or blood before reaching menopause.

Hormonal Play in Later Middle Perimenopause – “Waiting is the Hardest Part” by Tom Petty

Progesterone is consistently low now, flatlining close to zero. Estradiol may still spike, but is heading on the decline. At this point, you’re waiting for everything to get better. You may be tired of dealing with period issues like cramping, heavy bleeding, period massacres, spotting, and unexpected bleeding surprises. You may be experiencing brain fog, migraines, and the rest of the things that can appear.

This is the stage I’m in. And, Tom Petty has been visiting me in my dreams.

Late Perimenopause

Late perimenopause, by my definition, is when you’re somewhere in the 365 days with no period. I call this phase “Waiting 365.” You won’t necessarily know if you’ll reach 365 days until you reach 365 days, but when you skip periods for months at a time, it means that you’re getting very close to menopause.

Perimenopause’s motto should be “expect the unexpected,” I’ve heard countless stories from women who’ve reached 11 months of no period to all of a sudden get one. If that happens, you’ll need to reset the clock back to day 1. I know, it sucks!

There’s no medical reason I know of (and I’ve asked around) why they use 365 days as the basis, but that’s the number “they” picked.

I haven’t yet reached this stage, but I did go 157 days in middle perimenopause without a period once before it went back to every month and not getting a period feels very weird. I hate to say it, like really hate to say it, but I missed the monthly clean out.

Hormonal Play in Late Perimenopause – “Closer to Fine” by Indigo Girls

As long as you aren’t on menopause hormones, your estradiol estrogen and progesterone are very low at this point. You’re just waiting for the magical 365th day when rainbows appear and unicorns fly across the sky.

Menopause

—You made it! You went 365 days without a period or seeing blood. Have a party! Donate your unused menstrual products! Throw out your period underwear and buy some sexy stuff!

Following menopause, it can take up to 5 years for the majority of symptoms to settle down such as hot flashes, night sweats, brain fog, aches and pains.⁶ However, vaginal and urinary symptoms may continue to get worse if you haven’t addressed them with an intervention already.

✔If you see any blood after this point, it’s vital that you let your doctor know. Don’t freak out yet; there are reasons why this could happen that don’t indicate that something is wrong (like getting Covid), but you’ll still want to let your doctor know in order to evaluate the situation.

Hormonal Play in Menopause – “Keep Chasing Stars” by Skinny Dipp

Estradiol and progesterone have flatlined to basically zero the further out from menopause you are. Testosterone starts to decline gradually in the years following menopause. This decline is not considered a part of the perimenopause process, but rather of aging.⁷

Where’s the good news, you ask? Your body has thought of everything so once you reach menopause, it makes a different type of estrogen called estrone in your adrenal glands and fat tissue. It’s not as powerful or protective as estradiol, but your body doesn’t leave you with nothing. This is a piece of info that I never see mentioned online, only medical journals. If you still have your ovaries, it will continue to make a tiny bit of estradiol.⁸

Note: The average age in the US is now 52.

Questions???

How does being on menopause hormone therapy (previously called HRT) affect all of this?

Although adding hormones helps many symptoms and helps prevent osteoporosis, it does not prevent menopause. You may still get periods while taking it if you start it in the perimenopause transition. You can have spotting when taking it which my GYN tells me resets me back to day 1 of waiting the 365 days. Use hormones as a tool in your menopause toolbox if you decide to use it, but continue to work on including lifestyle changes. We still have aging to consider.

How does taking birth control pills affect this?

Perimenopause women are frequently given birth control pills (which are different than menopause hormones) to help with heavy bleeding and to manage peri symptoms. Birth control does not stop menopause. The menopause transition will continue happening behind the scenes, the pills will mask a lot of the symptoms.

You won’t know if you’re menopausal yet until you go off of birth control. I suggest working with your doctor on this. Doctors will usually take you off birth control pills in your early 50s because they want to check if you’re menopausal and because oral contraceptives increase the risks of blood clots the older you are on them.⁹

How does having a hysterectomy affect all of this?

If you had your ovaries removed (oophorectomy) at the time of your hysterectomy or separately, you’ll be in menopause immediately.¹⁰ Instead of a gradual decline of your hormones over years, your body will no longer be able to make any of the hormones the ovaries produce - estradiol, progesterone, and testosterone - following surgery.

Menopause symptoms, such as hot flashes and others, may occur immediately after surgery. If you’re interested in menopause hormones, please ask your doctor to discuss menopause hormone options with you to see if they are a right fit. Some women have asked their doctor to put an estrogen patch on them in the surgical suite to try to lessen the shock to their system and prevent menopause symptom discomfort.

If your ovaries are still in place, they will continue making hormones (may be slightly less)¹¹ until you go through perimenopause and then menopause.

If your uterus has been removed, you won’t have to deal with skipping periods, heavy bleeding, or too frequent periods. If your cervix has been left in place, you may have some spotting occasionally, which is best discussed with your doctor.¹²

How does having an endometrial ablation affect this?

When you have an ablation, you will no longer get periods, so you aren’t able to use them as a guide to when you’ve reached menopause. Some women don’t care to know when they’ve reached menopause, and that’s your choice, but if this is something that you’d like guidance on, please work with your physician.

How does PCOS affect this?

Polycystic Ovarian Syndrome causes irregular cycles. However, your cycles may become more regular as you enter perimenopause.¹³ Look for the classic tell-tale symptoms of perimenopause hot flashes, night sweats, and vaginal discomfort/dryness. It’s important to work with a physician if you have PCOS. The Menopause Society website can refer you to a physician who specializes in menopause care (US, Canada, UK, and international).

How does medical menopause affect this?

Medical menopause is when your ovaries are shut down for medical reasons, such as with cancer treatment. Medical menopause can be permanent or temporary. If temporary, this means you’ll go through menopause again once your ovaries are ready to call it quits.

Should I get my hormone levels tested?

The Menopause Society does not recommend testing your sex hormone levels in perimenopause. When you get your blood drawn for a test, the result only tells you at that one moment in time what your hormone levels are. Hormonal levels do not correlate with symptoms.¹⁴ They probably changed by the time you got home. Furthermore, “doctors don’t treat hormone levels, they treat symptoms.”¹⁵

If you’re on menopause hormone therapy and you already achieved menopause, your doctor may test your estradiol to make sure you’re in the optimal range if you’re having symptoms. Outside of the optimal range may mean you’re having hot flashes (too low estradiol) or breast tenderness (too high estradiol).¹⁶

I have a question about something you wrote?

I’m happy to chat about something I’ve written. If you’re a subscriber, you can leave a comment or reply to any of my email newsletters. If you aren’t a subscriber, you’ll need a Substack account to post a comment.

Be well, stay cool…

Disclaimer, Content Use Policy, and Privacy Policy

1. Who are “they?” They are the 2001 Stages of Reproductive Aging Workshop (sponsored by the National Institute on Aging, the Office of Research on Women’s Health, The Menopause Society, The American Society for Reproductive Medicine, the International Menopause Society, and The Endocrine Society), which proposed the “official” stages of ovarian aging. What I call “early perimenopause” they define as “late reproductive stage -3a.” While medically this may be correct, practically, what it does is to put women who are dealing with perimenopause symptoms like subtle changes to their menstrual cycle and variable FSH levels into “no man's land.” According to this classification system, a woman wouldn’t be identified as starting the menopause transition yet and, I believe, would cause unnecessary stress as she tries to figure out what is going on with her body. Being told, “Oh, that may be the start of perimenopause,” is far more comforting and helpful in clueing her in, especially now that we have community support for women entering it. It’s all-inclusive and welcoming. But who am I to disagree?

2. Cunningham, A.C., Pal, L., Wickham, A.P. et al. Chronicling menstrual cycle patterns across the reproductive lifespan with real-world data. Sci Rep 14, 10172 (2024). https://doi.org/10.1038/s41598-024-60373-3

3. Dunn, Jancee. Hot and Bothered. Penguin, 2023. Quoting Dr. Nanette Santoro in the Washington Post (pg 54 in book).

4. Lisa Mosconi, PhD. The Menopause Brain. Penguin, 2024. Dr. Mosconi is now researching her theory further that the density of your brain’s estrogen receptors may correlate with symptoms and can be measurable. Mosconi, L., Nerattini, M., Matthews, D.C. et al. In vivo brain estrogen receptor density by neuroendocrine aging and relationships with cognition and symptomatology. Sci Rep 14, 12680 (2024). https://doi.org/10.1038/s41598-024-62820-7 This is exciting new research as of June 2024 which has taken her 5 years to release.

5. “What Is Perimenopause?” News-Medical.net, 19 Dec. 2022, www.news-medical.net/health/What-is-Perimenopause.aspx#:~:text=During%20perimenopause%2C%20estrogen%20levels%20are.

6. Heather Hirsch, MD. Top menopause physician online.

7. Dr Felice Gersh and Dr. Mary Jane Minkin. Both are top menopause physicians you can find online.

8. Dr. Mosconi’s Live Instagram Lecture hosted by My Alloy on 6/27/2024. You can find the recording on the My Alloy page on Instagram.

9. Solymoss S. Risk of venous thromboembolism with oral contraceptives. CMAJ. 2011 Dec 13;183(18):E1278-9. doi: 10.1503/cmaj.111614. Epub 2011 Nov 7. PMID: 22065358; PMCID: PMC3255133.

10. Healthline, What Fills the Space After a Hysterectomy, March 2023

11. Healthline, What Fills the Space After a Hysterectomy, March 2023

12. Healthline, What Fills the Space After a Hysterectomy, March 2023

13. Atlanta Women’s Obstetrics and Gynecology, awog.org

14. Dr. Mosconi’s Live Instagram Lecture hosted by My Alloy on 6/27/2024. You can find the recording on the My Alloy page on Instagram. Her book is The Menopause Brain.

15. As explained to me by Dr. Mary Susan Scanlon, an MD certified by The Menopause Society.

16. Dr. Mary Jane Minkin in a lecture with My Alloy on 6/27/2024.