Perimenopause I
What They Call Hormonal
Perimenopause hormones do not fade. They swing, and they swing hard. What is actually happening, and why one blood test cannot see it.
There were four of them by the window with their coffee. Ten loose minutes before a Monday meeting.
One of them said something about his wife. She had been impossible all weekend. Another added his own. Then somebody said the word.
Hormonal.
They laughed.
I have thought about that laugh for years. It was not cruel. It was the laugh of men who never had to know a thing, and were never made kind by having to know it. A laugh with no cost attached.
Our manager sat at the desk behind them. The only woman at her level in that building.
We all wore tailored clothes. It was that kind of job. Three-piece sets, fitted properly, because the work required them. None of us dressed that way for our own pleasure. They could be quite suffocating.
She stood up. She crossed the floor. She took off her jacket and threw it on the ground in front of them.
Her blouse had no sleeves. Not sleeveless as it was made. Cut out. Someone had taken scissors to a well-tailored blouse and removed the arms at the shoulder, and left the edges raw where the seams had been.
She had been wearing that under the jacket all morning. Sitting in meetings in it. For weeks, maybe. None of us knew. The jacket was exactly the point.
Then she explained it to them, and she explained it well.
She told them about opvliegingen. What it is to be ambushed by your own body in a room where you are the only woman in it. To sit through a client meeting soaked and keep talking. To sleep in ninety-minute pieces for three years and chair a department on that. To be called hormonal by the people whose respect you need to keep your job.
It shut them up. For good, I hope. I do not know.
I was in my twenties. I said nothing, because I had nothing to say. I felt for her more than I had words for at the time, and I stood in awe of her. Society would rather women kept quiet about this. She put it on the floor instead, in front of the people laughing.
I still stand in awe of her.
I am not there yet. This post is not mine. It belongs to her, and to my mother, and to every woman who has quietly taken scissors to her own clothes and put a jacket over the top.
Perimenopause vs menopause, because we use both words wrong
Perimenopause is the transition. It runs for years and it is where nearly everything happens.
Menopause is a single day, named backwards. Twelve months after your final period.
Postmenopause is the rest of your life.
So when a woman says she is going through menopause, she means perimenopause. And when a doctor tells her she is too young for menopause, he can be correct on the definition and still miss what she came in for.
Most women enter perimenopause in their forties. Some start in their late thirties. The final period lands around fifty-one on average, and the transition before it runs for years.
What happens to estrogen in perimenopause
Ask anyone and you will get a dimmer switch. Estrogen fades, a gentle slope down, three or four years, then you are through. The Cleveland Clinic uses that image. So does most of the internet.
The measurements show something else.
FSH moves first
Your ovaries hold a shrinking pool of follicles. Those follicles make inhibin B, and inhibin B is the brake that tells your pituitary to ease off.
That is the first hormonal event of perimenopause. Not a hormone falling. A hormone climbing, years ahead of anything else, while your cycles still look ordinary on a calendar.[1]
Higher FSH means higher estrogen, not lower
FSH tells follicles to grow and make estradiol. Turn that signal up and the follicles you have left get driven harder. They mature faster. They ovulate at a smaller size. The follicular phase shortens, so cycles arrive closer together.
Estradiol does not slide downward. It spikes.
In perimenopause you can produce more estrogen than you did at twenty-five. Not once. Over and over, without warning, then collapsing within days.
Georgina Hale and colleagues at the University of Sydney sampled blood three times a week across full cycles in women aged twenty-one to fifty-five. In the transitional cycles they kept finding a second estradiol rise appearing during the luteal and menstrual phases: an entire out-of-phase follicular wave, running on top of a cycle already in progress. They named them luteal out-of-phase events. LOOP cycles.[2]
Two cycles overlapping inside one body.
Progesterone leaves first, and leaves quietly
Progesterone has one requirement. Ovulation. It comes from the corpus luteum, the structure left behind after an egg is released.
As cycles turn erratic, more of them pass without ovulating or run a short luteal phase. So progesterone drops before estrogen does, and drops further. This is the first hormonal change most women feel, years before anyone mentions menopause to them.
Which leaves years of high, swinging estrogen against almost no progesterone. Heavy bleeding. Sore breasts. Sleep that breaks at three. Anxiety with no subject attached to it.
That is not a deficiency. That is a ratio coming apart.
And the swinging is itself the symptom
Estrogen receptors sit throughout your brain. Temperature regulation, mood, sleep architecture, memory.
Those systems do not need estrogen high. They need it predictable.
A brain calibrated to a steady signal cannot settle on a moving one. The hot flush is a thermostat that lost its reference point.
Hormonal, then. Accurate as a description. Backwards as an insult.
Move the slider across the whole transition and watch the shape of it.
The Perimenopause Hormone Arc
Twelve years around the final period. FSH climbing, estradiol turning violent, progesterone leaving early. Stylised from measured population patterns, not a forecast for any one woman.
The stress part, and the story you have been told about it
There is a version of this circulating that I want to correct, because it is everywhere and it is wrong.
The story goes: chronic stress makes your body steal pregnenolone to build cortisol, so less remains for progesterone. The pregnenolone steal.
It is a tidy story. It is not how steroid synthesis works. Pregnenolone gets made inside the mitochondria of the cells that use it. There is no shared tap to divert.
The real mechanism runs through your brain, and it is worse.
Stress does not steal your progesterone. It cancels the ovulation that would have made it.
Now put that on top of a transition where ovulation is already becoming unreliable. Two forces, pushing the same direction, on the hormone that was already leaving first. This is why I keep saying the cortisol work and the perimenopause work belong in the same conversation.
Why your estrogen "looks fine" on a blood test
Look at that estradiol line again. Now imagine drawing blood on one morning and calling that number your hormonal status.
The same woman in the same month can look postmenopausal on a Tuesday and twenty-eight on a Friday. FSH swings too before it settles high.
This is why researchers stage the transition by bleeding patterns rather than blood tests. The staging system they use, built by Siobán Harlow's group at the University of Michigan with an international panel, reads what your cycles do.[1] Not what one draw says.
So when a woman with three years of broken sleep is told her estrogen looks fine, the result is often true and almost meaningless.
She goes home believing the problem is her.
How long does perimenopause last
Clinical guidance used to say six months to two years. Many women still get told some version of that.
Then SWAN, the Study of Women's Health Across the Nation, followed women through the transition across a median of thirteen visits each and measured it. Nancy Avis at Wake Forest published the numbers in 2015.[3]
7.4 years.
That is the median duration of frequent hot flushes and night sweats. They continued a median of 4.5 years after the final period. Black women in the cohort carried them longest of all.[3]
Sit with the size of that gap. Women were told two years, lived seven, and drew the only conclusion available to them. Something had gone wrong with them specifically.
My manager had been in it long enough to redesign her wardrobe around it. Nobody had told her how long she should expect to be doing that.
The perimenopause symptoms nobody names
The transition arrives and gets sorted into departments. Joints to physiotherapy. Palpitations to cardiology. Low mood to the GP, returning as an antidepressant. Recurrent urinary infections to urology. Dry eyes to the optician. Each clinician looking at one system, in a woman between forty-two and fifty-five, with nobody joining it up.
Estrogen receptors are not confined to the reproductive tract. They sit in bone, blood vessels, skin, bladder and urethra, gut, joints, eyes, and throughout the brain. Make that signal erratic and the effects show up everywhere at once, in the specialties least likely to be thinking about ovaries.
And then the ones that never make any list:
The specific quality of the fatigue, which is not sleepiness. It is a flatness that sleep does not repair.
The word that will not arrive. Tip-of-tongue, estrogen-linked, and frightening in a particular way if you have watched a parent lose language.
Skin that changes texture, and itches with nothing on it.
A body that responds to the same food and the same training in a way it did not last year.
Below: tell it what your cycles are doing, then tap what you have. Orientation, not diagnosis.
Where Are You In It?
The published staging criteria[1] read bleeding patterns first. Symptoms come second. Both, in the order clinicians should be using them.
Why so little of this is known
A decade-long event that reaches every woman who lives long enough, and this is the map we have.
Some of that is difficulty. The transition is long, it gets defined in retrospect, and its central feature is variability, which is the one thing a single measurement cannot capture. When Harlow's panel built the staging framework they published seven outstanding research priorities alongside it.[1] They wrote the gaps into the founding document.
Some of it is training. Menopause takes up very little room in most medical curricula, which produces clinicians who are sympathetic and unequipped. Women arrive with a decade of symptoms and leave with a referral to whichever specialty owns their loudest one.
And some of it is 2002. When the first Women's Health Initiative results were announced, prescribing collapsed worldwide within months. The corrections came later, about the age of the women studied, the formulations used, the timing of initiation, absolute rather than relative risk, and none of them travelled as far as the headline. Hormone therapy is undersold, underused, and often only offered after menopause has already fully occurred. A generation of women got nothing, and a generation of doctors trained during the silence that followed.
Underneath all of it sits the thing that was operating by the window that Monday. There is a long habit of treating the female midlife body as a comic subject rather than a research subject. Symptoms get attributed to stress, to depression, to getting older. Neither of those constitutes a clinical response.
You do not fund what you find funny.
What the evidence actually supports
Now the useful part, and I want to do it honestly, which means telling you what does not work as plainly as what does.
In 2023 The Menopause Society reviewed the non-hormonal literature and graded every option by evidence quality.[5] Reading it is uncomfortable, because much of what women get handed did not survive the review.
Sorted By What The Evidence Says
The first two groups are about hot flushes and night sweats. The third answers a different question, and the difference matters.
The two that almost nobody gets offered
Cognitive behavioural therapy and clinical hypnosis both carry Level I evidence for hot flushes, the same tier as the prescription options.[5] Not because the flushes are imagined. The physiology is real. What changes is the arousal and the dread wrapped around each episode, and that turns out to alter how much they cost you. Neither gets mentioned in a ten-minute appointment.
The ones that do not work, so you can stop failing at them
Paced breathing. Cooling techniques. Avoiding triggers. Yoga. Mindfulness. Relaxation. Supplements and herbal remedies. Soy and soy extracts. Acupuncture. All reviewed. None recommended for hot flushes.[5]
I include this because women get handed these lists again and again, and when the flushes continue, the failure lands on them. It was never a failure. The interventions were not strong enough for the job.
And the conversation worth having
The same statement is unambiguous that hormone therapy remains the most effective treatment for hot flushes and night sweats, and should be considered for women within ten years of their final period.[5] Whether it suits you depends on your own history and risk, and that belongs with a clinician who knows both. What a blog post can tell you is that the conversation is legitimate, and being waved off before you have it is not a clinical judgement.
Blood sugar, and why it belongs in a post about hormones
This is the section I most wanted to get right, because generic advice does the most damage here.
Something specific happens to metabolism in this window, and ageing alone does not account for it. Insulin resistance rises across the transition faster than chronological age explains, driven in part by fat redistributing into the abdomen. After perimenopause women carry roughly twice the cardiovascular risk they did before, independent of age.[6]
And the detail that changes what you would do: post-meal glucose control slips before fasting glucose moves. Fasting numbers shift last. So a normal fasting glucose during the transition is not the reassurance it looks like[6], and almost nobody measures the thing that moves first.
Meanwhile the composition underneath the number on your scale is changing. SWAN tracked it with DXA rather than bathroom scales. Gail Greendale's group at UCLA found that around two years before the final period, the rate of fat gain doubles and lean mass starts to fall. Weight climbs in a straight line through all of it, with no acceleration at the transition at all.[4]
Fat arrives. Muscle leaves. The scale reports nothing, because the two cancel out.
Which explains the thing women describe over and over and get disbelieved about. The weight is the same. The body is not.
So, specifically
Lift for the tissue, not for the flushes. Resistance work is the one intervention that opposes the lean-mass loss starting around two years before your final period. And the honesty this requires: the same evidence review found exercise does not reduce hot flushes.[5] Both are true at once. Train because muscle is leaving, not because someone promised it would cool you down.
Protect the post-meal window. If post-meal control slips first, that is where the attention pays. Protein and fibre before the starch, and a ten-minute walk afterwards, both blunt the rise. This is about the shape of a meal, not its size, and about adding rather than removing.
Spread protein across the day instead of stacking it into dinner. Muscle protein synthesis responds to distribution, and this is the decade where lean mass stops being automatic.
Treat sleep as a lever, not a symptom. Sleep predicts both mood and metabolic health across this window, and the transition carries a higher risk of depression than the years before it.[6] Sleep is not the thing you fix last, once everything else is handled. It sits upstream of the rest.
Ask for the measurements that move early. Fasting glucose is a late indicator here. It is reasonable to ask about post-meal or longer-window measures instead, and to ask what your own baseline is rather than whether you land inside a reference range built on somebody else's body.
Back to the jacket
I went looking, over the years, for what happened to her. I never found out. She left that company before I did.
What I keep is the sound of it. Not the speech. The jacket hitting the floor, four men going quiet, and a woman standing in a ruined blouse explaining her own endocrinology to people who had been laughing at it ninety seconds earlier.
She should not have had to. That is the part I cannot put down. She became her own case study, in her own workplace, in front of her own staff, because the science that would have explained her had not been done, and the culture that could have spared her had decided her body was funny.
Every woman in this runs an unfunded study with one participant. She keeps the notes herself. She reports the findings to nobody, because the last time she mentioned it somebody laughed, or told her the bloods were normal, or said it was just her age.
My mother is somewhere on the far side of this now. When I read the SWAN numbers I thought about how many years she spent without anyone telling her the shape of what she was inside. Seven years is not a phase. Seven years is a period of a life.
You are not too much. You are not failing at something that should be easy. You are inside the most volatile hormonal passage of your life, with less evidence behind you than almost any other stage of human physiology, and you are still getting up and going to work.
Put the jacket down whenever you are ready. And when a woman near you puts hers down first, be the one who looks.
The perimenopause series
- Perimenopause hormones explained. You are here.
- Perimenopause and sleep: why you wake at three, and what progesterone withdrawal has to do with it. Coming next.
- Perimenopause, brain fog and ADHD: when the strategies that always worked stop working. Coming after that.
For the women reading
Take this one thing with you: your hormones in perimenopause are not low. They are unstable. Instability is a different problem with different answers, and if the story you have been given is that your body is running out, that story will not explain what you are living and it will not help you decide what to do about it.
Bring specifics to your appointments, because specifics survive a ten-minute slot in a way that I do not feel like myself does not. How many months of broken sleep. What the bleeding actually does. When the flushes come. What changed first. And if you are told your bloods are normal, it is fair to ask what a single measurement can tell anyone about a hormone that swings this much.
None of this is medical advice, and no article knows your history. It is here so you can walk in already knowing what is happening inside you, and so nobody gets to hand you the word hormonal as though it were an explanation.
References
- Harlow, S. D., Gass, M., Hall, J. E., Lobo, R., Maki, P., Rebar, R. W., Sherman, S., Sluss, P. M., & de Villiers, T. J. (2012). Executive summary of the Stages of Reproductive Aging Workshop + 10: Addressing the unfinished agenda of staging reproductive aging. The Journal of Clinical Endocrinology & Metabolism, 97(4), 1159–1168. https://doi.org/10.1210/jc.2011-3362
- Hale, G. E., Hughes, C. L., Burger, H. G., Robertson, D. M., & Fraser, I. S. (2009). Atypical estradiol secretion and ovulation patterns caused by luteal out-of-phase (LOOP) events underlying irregular ovulatory menstrual cycles in the menopausal transition. Menopause, 16(1), 50–59. https://doi.org/10.1097/gme.0b013e31817ee0c2
- Avis, N. E., Crawford, S. L., Greendale, G., Bromberger, J. T., Everson-Rose, S. A., Gold, E. B., Hess, R., Joffe, H., Kravitz, H. M., Tepper, P. G., & Thurston, R. C. (2015). Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Internal Medicine, 175(4), 531–539. https://doi.org/10.1001/jamainternmed.2014.8063
- Greendale, G. A., Sternfeld, B., Huang, M., Han, W., Karvonen-Gutierrez, C., Ruppert, K., Cauley, J. A., Finkelstein, J. S., Jiang, S.-F., & Karlamangla, A. S. (2019). Changes in body composition and weight during the menopause transition. JCI Insight, 4(5), e124865. https://doi.org/10.1172/jci.insight.124865
- The North American Menopause Society. (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 30(6), 573–590. https://doi.org/10.1097/GME.0000000000002200
- Rivaya Salvadores, C., Boytar, A., Gillen, J. B., & Kirkham, A. A. (2026). Women’s midlife: A nexus of depression, insulin resistance, and opportunity for lifestyle intervention. Journal of Women’s Health, 35(2), 109–111. https://doi.org/10.1177/15409996251393035