Perimenopause vs. Menopause: How Do They Differ?

Madeline Miller, 45, was at her Wednesday night book club discussing the main character’s hot flashes when someone casually remarked, “Oh, she’s clearly in perimenopause.” Miller was momentarily stunned silent. “Perimenopause?” she recalls thinking. “I thought it was just menopause. You know, that thing where your period stops, you get hot flashes, and then life moves on.”

Miller didn’t realize it at the time, but she was a member of two clubs: her book club and the “Nobody Taught Me About Perimenopause vs. Menopause” club.

Like puberty and pregnancy, perimenopause and menopause are pivotal milestones in a woman’s life. But while puberty and pregnancy are both taught in school and openly discussed in the media, women often feel left on their own to navigate the menopausal transition, which includes:

• Perimenopause: The years preceding menopause, marked by declining production of estrogen and progesterone from the ovaries
• Menopause: A moment in time that marks the end of a woman’s menstrual cycle, occurring after 12 consecutive months without a period
• Post-menopause: The rest of a woman’s life after she hits menopause

At Midi, we’re excited to help you understand how to distinguish menopause vs perimenopause. Because even though the two words are often used interchangeably, they’re not the same, and understanding the difference can help you better understand your symptoms and take control of your health. If you’ve ever wondered, “What is perimenopause? What’s the difference between perimenopause and menopause?” We've got you.

What Is Perimenopause?

Perimenopause is a years-long transitional phase that typically starts in a woman’s 40s, characterized by fluctuating hormones and fewer and fewer periods. It’s been called “the change before the change,” “the rocky road to menopause,” “puberty in reverse,” or, as Miller quipped during book club, “Wait - so there’s a pregame to menopause?!” 

The peri in perimenopause comes from the Greek word for around or near, reflecting the fact that perimenopause is the four to six years leading up to menopause. (That’s the average; it can be shorter or as long as 10 years.) 

Here’s what’s happening: In your prime reproductive years, your ovaries pump out estrogen and progesterone on a reasonably reliable, predictable monthly schedule. In perimenopause, these hardworking twin organs begin to gradually downshift. But rather than do so with any sort of regularity, the ovaries like to throw curveballs, kicking out different amounts of estrogen month after month (though generally maintaining an overall downward trend.)

“In perimenopause, you’re still ovulating and still have your period, but can have all of the symptoms typically associated with ‘menopause,’ including hot flashes, night sweats, midsection weight gain, bone loss, vaginal dryness, and more,” explains Midi medical director and clinician Christy Beyer, MD. As for why symptoms of perimenopause occur throughout the body, and not just in the regions typically associated with estrogen (like the vagina and breasts), the answer lies in the fact that estrogen receptors are located everywhere—in the brain, heart, bones, skin, and more, helping these organs thrive. When estrogen starts to drop, or fluctuate, there is diminished signaling throughout all estrogen receptors. An exhaustive (and often exhausting!) laundry list of perimenopausal symptoms can result.

Symptoms of Perimenopause

Irregular Menstrual Cycles

For many women, wonky periods are the first sign of perimenopause, reflecting irregular ovulation as estrogen starts fluctuating and declining. Periods may become more or less frequent, heavier or lighter, and may be accompanied by breast tenderness and other PMS symptoms. In the later stages of perimenopause, the time between usually stretches out even more. 

Hot Flashes and Night Sweats

Estrogen influences the hypothalamus, the brain’s temperature-regulating hub. As levels spike and dip in perimenopause, the hypothalamus becomes more sensitive to even minor changes in body temperature. It responds by trying to cool you down, even if you’re not hot. 75% of women experience hot flashes and night sweats (vasomotor symptoms in medical speak) in midlife.

Insomnia

Almost 50% of perimenopausal women report poor sleep, according to the Study of Women's Health Across the Nation (SWAN). Besides night sweats keeping you up, perimenopausal hormone fluctuations can directly impact the sleep-wake cycle. You’re also more prone to age-related sleep conditions like sleep apnea and restless leg syndrome; joint pain and body aches; and frequent nighttime urination, none of which are conducive to sleep.

Mood Changes

Estrogen influences the production, release, and receptor activity of neurotransmitters like dopamine and serotonin, which can affect mood and emotional regulation. As estrogen ebbs and flows, so does mood. Up to 70% of women experience emotional volatility throughout the menopause transition, including mood swings, anxiety, depression, feelings of chronic overwhelm or irritation, and anger.

Vaginal Dryness, Uncomfortable Sex, and an MIA Libido

Your vaginal tissue is rich with estrogen receptors. Estrogen helps keep everything lubricated and pliable. As estrogen naturally dwindles during perimenopause, these tissues can become dry, thin, and irritation-prone. As a result, you may notice vaginal itching and burning, painful intercourse, and an increase in urinary tract infections (estrogen also helps protect the skin lining the bladder and urethra). 

Nearly 80% of post-menopausal women report low sex drive, likely due to the gradual drop in testosterone—“the hormone of desire.” By the time you hit menopause, your testosterone levels are less than half of what they were at age 30.

Other equally significant signs of perimenopause include (but are not limited to):

• Brain fog, difficulty concentrating 
• Weight gain, especially in the midsection
• Bone loss, usually occurring under the radar 
• Skin changes (acne, crepey skin, wrinkling, discoloration)
• Fatigue
• Bloating and other digestive issues
• Achy joints

After several years of perimenopause, you’ll reach the point where at least 60 days pass between periods. This indicates your estrogen levels have diminished significantly. You’ve officially entered late-stage perimenopause and are nearly at the finish line (yay!). 

Some women find relief as their symptoms subside during the latter part of perimenopause, while others are hit with an uptick. Regardless, your periods will stop altogether sooner rather than later. When you’ve gone 12 consecutive months without bleeding, you’ve officially hit menopause.

What Is Menopause?

Menopause signals the end of your menstrual cycles or your ability to conceive a child, and it arrives with a whimper, not a bang. “The diagnosis of menopause is done in retrospect,” says Dr. Beyer. “You look back in time and realize you haven’t had a period in 12 months.”  

Every day, 6,000 American women hit menopause—that’s 1.3 million a year. The average U.S. woman enters menopause at age 51, with a general range of about 45 to 55

Counterintuitive as it may sound, menopause is technically a single point in time: The day marking 12 period-free midlife months. The years and decades following menopause are actually considered post-menopause. 

Gone are the erratic estrogen and progesterone swings that typified perimenopause. Instead, hormone levels remain low and start to stabilize. The upside is that as the body begins to adjust to its new hormonal normal, some women find their symptoms of perimenopause improve. Brain fog, for instance, often starts to lift, cognitive sharpness rebounding to pre-perimenopause levels.

Some women also feel relief crossing the menopause finish line because it means no more worrying about pregnancy (unpredictable ovulation and period in perimenopause have been behind many an unexpected pregnancy), as well as an end to unpredictable periods. (Buh-bye, pads and tampons!)

Still, the same hormonal shifts behind your perimenopausal night sweats, foggy memory, and parched libido also stand poised to target your heart, brain, and other organs, often leading to chronic health conditions.

Potential Health Problems After Menopause

Heart Disease

Hormone receptors in the heart and blood vessels rely on estrogen to keep cholesterol levels in check and blood vessels open and supple, allowing for healthy blood flow–key reasons women in their 20s, 30s, and 40s tend to have better cardiac health on the whole, than men of similar age. Once estrogen drops and stays down post-menopause, women’s cardiac risks jump. Without the protection of anti-inflammatory, cardioprotective estrogen, arteries stiffen within a year of one’s final menstrual period. The weight gain, stress, and dip in exercise that so often occurs in midlife further drives heart disease risk.  

Osteoporosis

Estrogen is highly protective of bone, helping maintain skeletal strength and bone density during the reproductive years. Bone loss starts in perimenopause but ramps up after menopause; women can lose up to 20% of their bone mass in the first five to seven years post-menopause, predisposing them to osteoporosis and fractures. 

Dementia

Two-thirds of all individuals with Alzheimer’s disease are women and 60% of patients with Alzheimer's are post-menopausal women. Once again, post-menopausal estrogen depletion is thought to be a primary culprit, triggering metabolic and structural changes in the brain that can pave the way to cognitive decline.

How Do You Know If You’re in Menopause vs Perimenopause? 

There’s no simple test confirming perimenopause status, although when combined with measurements of your symptoms testing hormone levels can provide information to help guide your decision making on where you are in your journey. 

Your clinician will often draw blood to measure estrogen and follicle stimulating hormone (FSH) levels, the latter of which triggers the growth of eggs in the ovaries in preparation for ovulation and tends to start rising about six years before menopause. This rise occurs because as perimenopause progresses and the number of eggs in the ovaries falls, the body tries even harder to stimulate the eggs that remain. At Midi, for patients who want it, we also test levels of AMH (Anti-Müllerian Hormone), estradiol, and testosterone. But while elevated levels of FSH (>30 mIU/mL) and estradiol levels <20 pg/mL suggest menopause has occurred, they don’t give much intel regarding perimenopause. More often, these blood tests end up leaving women feeling gaslit and unseen.

“So many patients come to me saying, ‘My doctor tested my FSH and said my labs are normal, so I’m not in perimenopause,’” Dr. Beyer says. “But FSH levels fluctuate throughout your menstrual cycle. Your levels could look absolutely normal depending on when your blood was drawn. So people get very confused because they’re told they’re not perimenopausal based on a blood draw, when really, they are.” At Midi, we allow symptoms to guide our care, not just numbers.

As for menopause, women don’t usually need a test to tell them they’ve reached that milestone. If you haven’t had a period in 12 consecutive months, Dr. Beyer points out, you know.

There’s an easier, cheaper, more reliable way to tell you’re in perimenopause: If you’re in your mid-to-late 40s or early 50s, still getting your period (even if it’s wildly irregular), and have any of the symptoms of perimenopause mentioned in this story, ​“You’re in perimenopause,” Dr. Beyer says. 

Treatment and Prevention Options 

The “perimenopause vs menopause symptoms” debate isn’t nearly as important as knowing that symptom relief exists.

Dr. Beyer encourages women to track their menstrual cycles in a journal or app, along with symptoms like moodiness, insomnia, fatigue, and breast tenderness. This can help you and your provider identify patterns—“Oh, my periods are now happening every six weeks”—-that may help direct you towards different treatments.

Hormone Replacement Therapy (HRT)

Supplemental estrogen (combined with progesterone for women who still have a uterus) can ease many of the moderate-to-severe symptoms of perimenopause and menopause. The name is a tad misleading because you’re not replacing any hormones in your body so much as you’re giving them a little boost. “It’s so powerful that adding back just a tiny percentage of the hormones your body made during your peak reproductive years is all you need to gain so many benefits,” says Midi’s Chief Medical Officer Kathleen Jordan, MD. Many experts now use the terms Hormone Therapy (HT) or Menopause Hormone Therapy (MHT) instead of HRT, and it’s available as a patch, pill, cream, or gel. 

Besides cooling hot flashes, lubricating dry vaginal tissues, and easing the throb of painful joints, HRT works behind the scenes to help protect the heart, bones, and other organs from long-term health complications associated with menopause. Women who start HT within 10 years of their last period can lower their future risk of heart disease, bone loss, and diabetes. (Starting HRT before age 60 or within 10 years of menopause is also thought to minimize small but not insignificant risks such as blood clots.)

HRT is safe for most women when used appropriately, according to The Menopause Society. Your doctor or Midi clinician can help you determine if you’re a good candidate and determine the optimal dose, method, and schedule. (Your clinician may discourage hormonal menopausal treatments if you have a history of stroke, blood clots, heart or liver problems, hormone-sensitive cancer, or have unexplained vaginal bleeding.)

Historically, women were told to stop HRT once they turned 65, even if it meant a resurgence of bothersome symptoms. But with the proper counseling and risk assessment, it’s possible to continue HRT past age 65 safely. In an analysis of more than 100 HRT users over age 65, continuing HRT after 65 did not increase the risk of strokes, heart attack, or uterine cancer, although some adverse effects, like postmenopausal bleeding, did occur. The most common reasons these women opted to continue HRT past age 65? Hot flashes, chronic pain and arthritis, and a desire for an improved quality of life.

At Midi, we believe women should experience about an 80% improvement in symptoms. If, after your first few months, that’s not yet ringing true and your symptoms still interfere with daily life, we can tweak your prescription until you get there.

Note: If a woman has her ovaries surgically removed (as part of cancer treatment or prevention, for instance) before her body has naturally reached menopause, she will be immediately thrust into menopause. Symptoms like hot flashes occur suddenly and are often more severe. Surgical menopause is also tied to increased rates of heart disease, dementia, sexual dysfunction, and more. These women are almost universally counseled to immediately start HRT to help ease symptoms and mitigate long-term risks. 

Hormonal Birth Control

Birth control pills are another option for some perimenopausal women, pulling double-duty by easing symptoms while guarding against unplanned pregnancy. Also called oral contraceptives, they can help regulate periods and lighten heavy perimenopausal flows. 

Natural Remedies

At Midi, we utilize a holistic approach to wellness that considers supplements, botanicals, exercise, dietary changes, and other lifestyle adjustments in concert with hormonal and non-hormonal prescription medications. Depending on your age, symptoms, personal and family risk factors, you might receive recommendations to experiment with vaginal lubricants or moisturizers; try magnesium glycinate or valerian for sleep; use a GLP-1 medication like semaglutide for weight loss; and more. 

For Miller, her bookclub-turned-biology lesson “led to simultaneous feelings of relief and validation, along with puzzlement” about why she’d never learned the word perimenopause, or that there was a difference between perimenopause and menopause. It prompted her to schedule an appointment with her doctor to help get her night sweats—which she now realized were perimenopausal in nature—under control. “When I named my experiences, I stopped feeling like I was unraveling and started seeing myself as navigating through a typical yet bothersome biological process….Like, ‘Okay, my body is doing its thing. Now how do I work with it instead of just feeling like I’m at its mercy?’”

The Takeaway

• Perimenopause is the midlife phase paving the way to menopause, which marks the end of the reproductive years. Everything after that is considered post-menopause.
• During perimenopause, your body will experience significant hormone fluctuations, particularly estrogen, that can trigger symptoms that impact brain functioning, temperature regulation (leading to hot flashes and night sweats), sleep, sex drive, and more.
• Once you hit menopause, estrogen levels remain low. This can bring symptom relief for some women, but not all. At the same time, it elevates long-term risks for heart disease, osteoporosis, dementia, and other medical conditions.
• Treatment for the symptoms of perimenopause exists, and certain hormonal, non-hormonal, and lifestyle strategies can help mitigate some of the health risks associated with menopause. Understanding the key differences between perimenopause vs menopause can empower you to seek help for symptom relief and help you feel less alone.