Before We Begin

Language Matters: This guide is written for a person who was assigned female at birth, identifies as a woman, and uses she/her/hers pronouns.

If you’re reading this, chances are you aren’t quite feeling like yourself and are trying to figure out what’s going on with your body and mind. Your hormones may be starting to shift as you enter the final stages of your reproductive years. If you are still getting periods, this gradual change could be perimenopause, a transitional phase on the road to menopause that will mark the end of fertility and the start of a new chapter in your life. While many women are fearful of the changes, they believe menopause may bring, such as loss of desire or desirability, it can actually present an opportunity to rediscover life’s joys and possibilities. Considering that more than half the people on our planet ovulate, it is remarkable how little most people, including women, know about menopause and perimenopause and the many changes that accompany them. Menopause and perimenopause are a natural part of being a woman, and they are not conditions requiring medical treatment unless symptoms are bothersome. Understanding the signs and changes that often accompany perimenopause and menopause can help you take control of your life and your health.

What is Perimenopause?

The mental, emotional, and physical changes that often start during perimenopause that are distinct from the aging process more generally can be substantial. At first, these symptoms may be subtle, so you may not realize they are connected to hormonal changes. Some, such as moodiness, breast tenderness, and bloating, are similar to symptoms of premenstrual syndrome (PMS), but others may be new to you. These can be wide-ranging and may include:

Perimenopause starts well before menopause, usually around a woman’s mid-40s, but every woman is different-- some start much earlier and some later. In fact, by the time menopause begins, many women have already been experiencing changes for years without recognizing it. Perimenopause occurs when the amount of the primary female hormone, estrogen, produced by your ovaries, decreases. This drop in estrogen causes changes throughout your body.

Meanwhile, low levels of the hormone progesterone cause periods to become irregular, and often heavier and longer (but confusingly, sometimes shorter and lighter). The average length of menopause is 4 years, but it can be as short as a few months or as long as 10 years.

Right before you transition into menopause, there is a further drop in estrogen, and you may start to experience more changes.

How is Perimenopause Different than Menopause?

When you have gone a full year without having a period, you are officially in menopause. The average age at menopause is 51, but every woman is different and some experience menopause earlier than others, including those with a family history of early menopause, smokers, and women who did not have children.

When women first begin to notice changes in their bodies in the months and years leading up to menopause, they are actually in perimenopause. Menopausal symptoms tend to be the same as those for perimenopause except for the irregular periods, which cease at menopause. These symptoms may continue for years beyond the transition to menopause itself.

Changes associated with Perimenopause and Menopause

The mental, emotional, and physical changes that often start during perimenopause that are distinct from the aging process more generally can be substantial. At first, these symptoms may be subtle, so you may not realize they are connected to hormonal changes. Some, such as moodiness, breast tenderness, and bloating, are similar to symptoms of premenstrual syndrome (PMS), but others may be new to you. These can be wide-ranging and may include:

• Weight gain/redistribution of body fat
• Headaches
• Difficulty concentrating and forgetfulness
• Mood swings and irritability
• Depression and/or anxiety
• Sleep disruptions/insomnia
• Reduction in sex drive (libido)
• Vaginal dryness and discomfort during sex
• Changes to vaginal discharge
• Frequent urination and/or urine leakage
• Hot flashes/night sweats
• Changes to skin and hair
• Fatigue
• Muscle aches/joint pain
• Constipation
• Changes to the size and shape of your breasts

These changes are normal, even if uncomfortable. You may experience many or very few of them. One thing to know is that they are treatable, and you don’t need to suffer in silence!

Every woman goes through this phase of life – it is not something anyone should be embarrassed about, although it is not generally something people discussed publicly in the past. Even now, it’s not widely discussed – but it should be. If you are feeling out of sorts or “not yourself”, telling friends and family that you are going through perimenopause or menopause and what that entails could help them understand your needs, and will often result in helpful tips and new friendships with other women who may be going through or have already gone through these changes.

What can you do if you are experiencing uncomfortable changes?

In addition to lifestyle changes and prescription therapies, there are many products available to relieve discomforts of perimenopause and menopause, including natural and over-the-counter (OTC) solutions.

You may be able to reduce or eliminate some discomfort by reducing stress, exercising regularly, eating a healthy and nutritious diet, moderating alcohol, limiting caffeine consumption, and quitting smoking. There are apps that can help with many of these, including some that provide guided meditation, breathing exercises, or gentle bedtime yoga to improve mindfulness, reduce stress, promote calm, and improve sleep.

This is also a good time to practice self-care and focus on things that bring you joy and relaxation such as a calming lavender lotion, journaling, or yoga.

If these do not provide you with adequate relief and you are concerned about how you feel, you should talk candidly with your trusted health or wellness professional.

When appropriate, your health care provider may prescribe hormones, such as estrogen, to relieve general symptoms by normalizing estrogen levels. Estrogen is available in many forms including pills, creams, gels, and skin patches, either OTC or by prescription, depending on the product. Until recently, hormone replacement therapy (HRT) was the most common treatment for hot flashes. However, studies have suggested that HRT may increase the risk of heart disease and breast cancer, therefore, it is currently only recommended for short-term use. There are also more targeted medications such as prescription vaginal creams to alleviate dryness, antidepressants for mood swings, and gabapentin or clonidine for improved sleep and hot flashes. All of these can have possible side effects or risks that you should discuss with your health care provider prior to use.

If you are interested in more natural remedies, there are many options! Every woman is different, so no one thing will work for everyone. You may need to try more than one to get to a comfortable place, but you don’t want to overwhelm your body with multiple new products when you’re already experiencing a change with your hormones, so you may want to start by trying one at a time.

Different products such as medicines and supplements may interact with each other. For instance, soy products can interact with antidepressants and synthetic estrogen, and ginseng can cause insomnia and headaches if you take too much. You should tell your health care provider about any herbal remedies you are using to ensure they don’t interact with any prescription medications.

Some of the natural remedies you may want to look into for relief of physical and mental symptoms include:

• Rhubarb extract, which has been shown to significantly reduce the frequency and severity of hot flashes
• Black cohosh for general menopausal symptoms
• Ginseng to help with mood and the quality and duration of your sleep
• Vitamin D to strengthen your bones and boost mood
• Soy, and other phytoestrogen foods such as tofu and flaxseed to improve hot flashes, night sweats and vaginal dryness
• Wild yam in the form of a topical cream or pill (yam eaten alone may not be as effective as a cream or pill)
• French maritime pine bark extract (Pycnogenol) for hot flashes and other menopause symptoms
• Vitamin E in either vaginal suppository or oil form applied to directly to the vagina may improve lubrication and help with hot flashes

You may also want to consider taking a multi-vitamin for menopausal women if you do not get adequate nutrition from your diet, or a simple OTC stool softener if you suffer from hormone-related constipation.

How will I know I'm perimenopausal?

You don’t need to see a health care provider to get a diagnosis of perimenopause or menopause unless you are seeking medical treatment for discomfort that is interfering with your daily life. Your medical professional can often make the diagnosis of perimenopause based on your symptoms alone. They can also check your hormone levels (follicle-stimulating hormone [FSH] and luteinizing hormone [LH]) with a blood test, but these levels vary day to day so a single test may not be able to confirm your status.

 I feel like I have “brain fog”. Is that a thing, and if so, what can I do about it?

One of the lesser known but very common symptoms of perimenopause and menopause is having trouble focusing or becoming forgetful, for instance not being able to find the right word for a simple household item in the moment you want to say it. If this is happening to you, you are not alone! As many as two-thirds of women experience brain fog. Researchers have linked it to depression and sleep disturbances that accompany hormonal changes, but there is annoyingly little information out there about this unsettling – and temporary – change. It will pass. Getting enough sleep and exercise and eating a healthy diet can help maintain/improve memory, as can quitting smoking. Staying socially and mentally active can also delay age-related (as distinct from hormone-related) memory loss.

What hormonal changes is my body experiencing?

Your ovaries produce 3 main hormones that play different roles in the body, and their levels all change during the perimenopause/menopause process.

• Estrogen: is the primary “female” hormone that stimulates the growth of breast tissue; maintains vaginal blood flow, elasticity and lubrication; causes the uterine lining to thicken during the menstrual cycle; maintain bone density and much more. Estrogen levels generally decline during perimenopause, but they do so irregularly before falling to a very low level. High levels of estrogen can cause breast tenderness, bloating and heavy bleeding, while low levels can result in hot flashes/night sweats, headaches, sleep disruptions, bone loss, vaginal dryness and fatigue that can all contribute to lower libido.
• Progesterone: prepares the lining of the uterus for a fertilized egg and helps maintain early pregnancy. Your body stops producing progesterone when there is no ovulation and after your periods stop at menopause. Low levels of progesterone can cause your periods to be longer, heavier and more irregular during perimenopause.
• Testosterone: is also known as the “male” hormone, but is also important to women’s sexual health, playing a key role in libido, bone density and muscle mass, as well as in the production of estrogen. Testosterone levels change with age, even before perimenopause, peaking in a woman’s 20s and declining slowly thereafter. This may be one reason sex drive can be diminished, although this has not been proven and of course there are ways to combat it if it does.

Hot flashes are terrible! What can I do?

About three-quarters of all women experience hot flashes, often starting during perimenopause and for some, continuing for as much as a decade or more. Nobody knows why this is so common, but there are ways you can try to prevent and/or manage them. To manage hot flashes naturally, you can track them to see what triggers them and try to avoid those triggers.

When you feel one coming on, you can take slow, deep breaths, drink cold water, and use a fan you’ll want to keep nearby. Dressing in layers also helps, as does losing weight if appropriate. There are also some new clothing and bedding options designed specifically to minimize the discomfort associated with the sudden heat/sweat and cold chills that follow. If you want to prevent hot flashes naturally, there are products such as rhubarb extract or black cohosh that work for many women. Prescription medications including low dose birth control pills or hormone therapy are effective but carry risks. There are also other medications that can help, including some antidepressants, epilepsy and blood pressure medicines even if you don’t have these health conditions.

I’m having trouble sleeping and it’s killing me! What can I do?

The low levels of progesterone that happen during perimenopause and menopause make it hard to fall and stay asleep, while low estrogen levels can cause hot flashes (called night sweats when they happen at night), interrupting sleep when they occur. Either of these alone can cause chronic and debilitating fatigue, but when combined with urinary symptoms that can make you get up several times at night to pee, it’s enough to make anyone irritable!

Sometimes, improved sleep can occur just from lifestyle changes, including exercise, limiting screen time near bedtime, practicing good sleep hygiene by keeping the bedroom dark and cool, and avoiding large meals and alcohol before bed (and caffeine after noon). You can also promote relaxation before bed with warm caffeine-free drinks, a hot bath/shower, meditating or light yoga.

As always, you can talk to your trusted health or medical professional about other options, including treatment for hot flashes if that is a primary driver of night awakenings, or bladder problems if appropriate. Your sleep disturbance may also be related to other factors that affect some women at midlife, such as sleep apnea, restless leg syndrome, chronic illness, depression/stress, or even some medications, so you may want to turn to your clinician if lifestyle changes or natural therapies do not provide you with adequate relief. There are also prescription options for insomnia, such as gabapentin, although you may need to manage hot flashes (night sweats) to make sure you can stay asleep.

My joints hurt when I stand up or move. Could this be related to menopause?

Yes. When you reach perimenopause, you may start to notice you feel more aches and pains in your knees, shoulders, neck, elbows, or hands, especially in the morning. This happens to many women because estrogen helps reduce inflammation, so as estrogen levels drop as menopause nears, inflammation can increase.

Keeping active can help tone muscles and reduce body aches, as can switching to more low impact activities such as swimming, yoga, or Pilates instead of running. OTC medicines like ibuprofen can help reduce inflammation, while pain-relieving medications such as acetaminophen can help with discomfort. Unfortunately, unlike some other menopausal changes that are temporary, joint pain may be lasting, so finding lifestyle changes that work for you is your best bet. Many women may also start to experience more frequent, chronic pain, including headaches, fibromyalgia and back pain as their hormones change. There is no need to suffer in silence! While you might get some relief from natural solutions such as massage and acupuncture, you may want to talk to your health care provider about non-addictive pain relief options.

I’m tired all the time.Is this normal if I’m perimenopausal/menopausal?

It can be, and may be related to hormone-related sleep disruptions or to excessive blood loss if you have started having heavier-than-usual periods. Lifestyle changes such as avoiding caffeine and excessive alcohol or large meals before bed and keeping your bedroom cool can help improve sleep. Making efforts to reduce stress along with consistent exercise may help restore energy. If nothing you try helps, you might consult your doctor to see if you may have undiagnosed thyroid disease, as menopausal symptoms such as fatigue, depression, mood swings and sleep disturbances can also be signs of hypothyroidism.

I’m experiencing vaginal dryness that makes sex painful. Is this permanent?

It doesn’t need to be. As the body produces less estrogen, vaginal tissue starts to get drier and thinner, which can result in itching, burning and pain or discomfort. You can use an OTC vaginal moisturizer every few days to keep lubricated and make sex more comfortable. Water-based OTC vaginal lubricants can be used before or during se, can make sexual activity more enjoyable. There are also prescription medications, including hormonal birth control, menopausal hormone therapy, or prescription estrogen cream, gel or ring that can be inserted into the vagina. These estrogen products are not associated with any increased risk of blood clots or stroke and can be used safely.

What is vaginal atrophy, and will it happen to me?

Why doesn’t anybody talk about vaginal atrophy when it happens to so many women? Vaginal atrophy can occur after menopause when the vaginal walls get thinner and less elastic as a result of reduced estrogen. It can result in a shortening and tightening of the vaginal canal, making sex more painful or even impossible. It can also cause distressing urinary symptoms. Fortunately, genitourinary syndrome of menopause (GSM) can often be prevented, and simple, effective treatments are available! Here’s what you need to know: the best way to prevent GSM after menopause is to make sure you have something in your vagina twice a week. Regular sexual activity with or without a partner can help keep your vaginal tissues healthy. If that is not possible or desirable, inserting a dilator or dildo for 5 to 10 minutes twice a week (with lube) can help preserve vaginal elasticity.

My vaginal discharge has changed. Is this normal? Should I be worried?

Vaginal discharge varies throughout a woman’s cycle due to fluctuating hormones associated with ovulation, so when the female hormones drop later in life, it’s perfectly normal for discharge to change also. For most women, this means less vaginal discharge during perimenopause, but all women are different. Lower levels of female hormones can cause the vagina to become thinner, drier, and more easily irritated by soaps or detergents, which may result in additional discharge. Thinning vaginal tissue can make it easier to develop vaginal infections that can result in abnormal discharge, and of course, women of any age can still develop bacterial and yeast infections or STIs. Once you enter menopause, you may want to consider a vaginal moisturizer to prevent irritation, inflammation, and pain during sex. Any amount of bleeding after menopause should prompt a visit to your doctor.

I’m starting to have problems with peeing/urinating. Is this part of menopause/perimenopause too?

Yep. As if all this weren’t enough, many women develop bladder or urinary problems during menopause/perimenopause. This is actually part of the same “genitourinary syndrome of menopause” (GSM) that causes changes to the vulvovaginal area as well as the urethra and bladder. Some women may experience “urinary stress incontinence” when a little pee leaks out when they laugh sneeze, or cough. Some find it hard to hold their urine long enough to get to the bathroom, resulting in “urinary urge incontinence”. Also, many have their sleep disrupted by the need to get up to use the bathroom one or more times at night.

This is caused by dropping estrogen levels, which causes the tissues in the urethra and vagina to lose their elasticity, the lining to thin, and surrounding muscles to weaken. These urinary problems can be treated! You can start by limiting or avoiding caffeine, losing weight if appropriate (extra weight puts more pressure on your bladder), and by exercising your pelvic floor muscles by doing Kegel exercises.

These can be done on your own anywhere (try it anytime you are stopped at a traffic light) or using products such as a yoni egg. If necessary, women with urine leakage can use pads, a urethra cap or a pessary or they can try medications, devices, physical therapy or surgery to treat incontinence.

Why am I gaining weight?

Many women find they are gaining weight around menopause, or that their clothes no longer fit the same even if their weight has remained stable or if they have not changed their diet or exercise regimen. This can happen because the female metabolism slows down, burning about 200 calories a day less at age 50 and around 400 fewer calories a day lby age 60 than in earlier decades. Reducing caloric intake can be helpful but pairing fewer calories with strength training and weight bearing exercise is even better because it can help reduce the risk of osteoporosis and cardiovascular disease while building muscles that can burn more calories.

I’ve had more headaches since I started having perimenopausal symptoms. Are they related?

Hormones can play a role in headaches, particularly in women who have a history of headaches around their periods (menstrual migraines). Fortunately, these headaches generally stop when menopause is reached and hormone levels are consistent, and they can be easily treated with nonprescription pain therapies such as ibuprofen. More serious headaches may require medical assistance.

Can I get pregnant when I am perimenopausal?

Until you actually go into menopause, throughout the time you are perimenopausal, you are still ovulating (even if only sporadically), so you can still get pregnant. If you do not want to become pregnant and are sexually active, you should use some form of birth control until you are in menopause. If you are trying to get pregnant during perimenopause, your dropping estrogen levels can make that more challenging, but there are fertility treatments that can help.

Once you have entered menopause, you cannot get pregnant, but you can still get sexually transmitted infections (STIs), so you will still want to use a condom or dental dam when you have sex if your partner(s) has not been tested. In fact, because there is less natural vaginal lubricant after menopause, it may be easier to get STIs from unprotected sex due to the small cuts or tears that can occur during sexual activity.

When should I call a doctor?

While heavy bleeding can be a normal sign of perimenopause, you should consult a medical professional If you experience blood clots during your period or spotting/bleeding between periods, bleeding after sex, or periods that are much shorter or longer or heavier than usual to rule out hormone problems, endometriosis, pregnancy, fibroids, blood clotting problems or, rarely, cancer.

The hormonal changes that result in menopause can also lead to other changes in your body, such as higher levels of cholesterol (putting postmenopausal women at higher risk of high blood pressure, heart disease and stroke) and a loss of bone density (putting postmenopausal women at higher risk of osteoporosis), so it’s important to keep up your annual physical exams. At your annual visit, your health care provider can evaluate your overall health and recommend testing as needed.

What is induced menopause? Can I do that and skip perimenopause?

Not without a major medical intervention for an indicated cause. Induced menopause is when a woman stops having periods due to a medical procedure, such as hysterectomy (removal of the uterus), oophorectomy (removal of the ovaries), or treatment for conditions such as cancer. When this happens, a woman may still experience menopausal symptoms the same as other women.

What changes can I expect to my skin and what can I do to look youthful?

Menopause also causes changes to your skin. Your body stops making as much collagen, you lose some fat under your skin, and your skin’s elasticity drops. Hormonal changes can cause sagging, especially around the jawline, neck, and cheeks, along with fine lines and wrinkles. Fortunately, there are some steps you can take, such as staying hydrated. Drink water and use a hydrating moisturizer with hyaluronic acid or glycerin and a minimum of SPF 30 (Sun Protection Factor) to your face, neck, and hands along with a body lotion you can apply all. You should also eat a diet rich in antioxidants and phytoestrogens, and step-up weight-bearing exercise to counteract the loss in muscle that comes with age to support your skin from the inside out.

Oh no, my hair is getting thinner! Does menopause also affect hair?

It can, although the good news is it tends to be more subtle in women than in men. When estrogen and progesterone drop, hair grows more slowly and becomes thinner. A decrease in these hormones also triggers an increase in male hormones that shrink hair follicles, sometimes resulting in hair loss on the head and can also result in the development of facial “peach fuzz” and small sprouts of hair on the chin.

Fortunately, most women who experience hair loss will notice thinning hair rather than bald spots. Hair may also fall out in clumps during brushing or showering. Your health care provider can conduct diagnostic blood tests to help rule out other causes of hair loss, such as a thyroid imbalance and can review any medications you are taking that could be having this side effect.

I’m not interested in sex. When will I feel like myself again?

With all the changes that come with dropping hormone levels, many women feel less interested in sex during perimenopause and into menopause than they did at other points in their lives. This can be due to many things, such as weight gain/self-image, sleep deprivation, discomfort during sex, or changes in mood. While having sex might be the last thing from your mind, it is worth considering that the female orgasm can boost feel-good chemicals in your body leading to better sleep! It can also tone your pelvic floor, reducing genitourinary problems and keeping the vagina supple and moist. With a partner, sex can also be a great form of exercise, burning off calories and warding off heart disease.

The important thing to know is that low libido need not be a permanent state. If you aren’t feeling like yourself and would like to find your mojo, The Body Agency can help with our carefully curated collection of natural products to de-stress, energize, rejuvenate, and excite.

I just don't feel sexy anymore...

So...yeah. This can happen at times in a woman’s life, and perimenopause/menopause is a prime candidate. Some of this may be due to body changes related to aging or menopause specifically. For instance, many women find it harder to easily maintain a comfortable weight once they hit menopause due to changes in their metabolism even with the same amount of exercise and caloric intake. Your body may also shift where it holds weight, often shifting into the belly area, so your shape can change in ways you may not have experienced before. Your self- image can play an important role in your outlook, so it’s important to learn to love yourself as you are. Body positivity means accepting and feeling confident in the body you have despite what may be considered by some to be flaws, and not beating yourself up over changes that are a normal part of aging.

When these changes coincide with hormonal changes that cause sleep deprivation, depression and/or mood shifts, it wouldn’t be surprising not to feel like a sex goddess. Rest assured; your sexual partner(s) isn’t as critical of your body as you are. This is a good opportunity to indulge yourself in clothing including bras, panties and sleepwear that bring you joy and make you feel good. Speaking of feeling good, when was the last time you read a book or watched a movie with hot scenes that gave you sexy thoughts? Perimenopause and menopause will change your body but it’s not the end of sex and sexuality – far from it! There are many things you can try to light your fire if your libido has dropped. Have fun experimenting with them and don’t despair. You can also ask your health and wellness provider if they have any suggestions beyond date night – that’s a good place to start but it’s only the beginning (and if that’s their only suggestion, you might find another provider).

I’ve heard women can be unpredictable and irritable. Will this happen to me?

First, it’s important to be understand there is a difference between perimenopause, when symptoms traditionally associated with menopause begin, and menopause itself – although many of the symptoms are the same. Second, it’s not surprising that women starting perimenopause may be irritable or have mood swings because they may be operating on reduced sleep and be experiencing physical discomfort. However, it is also true that hormonal changes associated with “the change” can cause mood swings including crying spells, but also depression and anxiety, which can affect behavior. Some women also report feeling rage over small things, which can also be caused by a temporary hormone imbalance. To be your best, be kind to yourself with a healthy lifestyle and cut yourself a break. It can be helpful to open up to the people in your lives, so they understand what you are going through, and they know they are not necessarily driving your behavior. They need to know that what you are going through can be really hard! This goes double for your partner if you have one. However, if your outlook is affecting friends and family or is distressing to you, it may be time to talk to a medical professional to see if you could benefit from treatment for hormone-related anxiety or depression.

What comes after menopause?

While some feel some sadness at the passing of their fertile years and what that represents, menopause is an opportunity for new beginnings. Many women report feeling much freer from judgment in both their everyday lives and sexually, with a new willingness to go outside their comfort zone, and greater openness to pursuing their own sexual fulfillment. Only you know what’s right for you! The Body Agency can help by providing ideas and access to tried-and-true products used by women around the world to help you feel your best.

The Body Agency is Here For You

We hope this guide has touched on all the topics you need to know about perimenopause and menopause– but if it hasn’t, email us here so we can address your questions in future updates.

Remember, no matter what the issue, you have options! So be kind to yourself, and really tune into your body and needs – this will allow you to find solutions that will enable you to thrive at every age. The Body Agency is here for you and your family

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