Perimenopause explained – beyond hot flushes
Perimenopause is the natural transition leading up to menopause where our hormones start to shift and our ovaries gradually begin to wind down. It can begin as early as your late 30s but for most women, symptom onset is your mid to late 40s. Perimenopause can last several years, and can feel like our body is entering a whole new chapter, sometimes bringing changes you weren’t quite expecting or prepared for.
For a lot of women – perimenopause arrives when you are in the thick of raising a family and caring for aging parents. You are stressed out of your mind and feel like all the balls you’ve been juggling in the air start to fall. From a naturopathic perspective, we recognise perimenopause as a time when your body needs extra support, and there many things we can do to help manage the transition.
Common signs of perimenopause
Every woman's experience of perimenopause is different, but common signs include irregular or changing periods – sometimes getting heavier and more frequent, while for others getting thinner with an increase in time between cycles. Hot flushes, night sweats and brain fog are fairly common, while low mood, anxiety and fatigue are often misdiagnosed. Some women can also see changes in libido and an increase in weight especially around the middle.
What's Happening in the Body
As the ovaries become less consistent in releasing eggs, ovulation becomes irregular. Progesterone, the hormone produced after ovulation, tends to fall first, while estrogen, can swing between very high and very low. This changing balance can affect sleep, mood, temperature regulation and metabolism.
The impact of stress
The body's stress response runs through the hypothalamic-pituitary-adrenal (HPA) axis, which signals the release of cortisol. Both progesterone and estrogen can influence how the brain responds to stress. Progesterone is converted in the brain into allopregnanolone, which enhances the calming effect of neurotransmitters like gamma butyric acid (GABA). As ovulation becomes irregular, progesterone falls, so there is less calming signalling. This can show up as anxiety, restlessness, a feeling of "wired but tired" and increased sensitivity to stress – you might find yourself blowing off the handle at a sock laying on the floor and wondering where that rage came from – well – its elevated cortisol and low progesterone.
Estrogen also influences mood-related chemical messengers like serotonin and dopamine. It supports serotonin production, increases receptor availability and slows its breakdown. When estrogen drops, serotonin signalling becomes less stable, which is linked to low mood, irritability and anxiety. Dopamine affects motivation, focus and reward. Fluctuations in estrogen can contribute to brain fog, low motivation and reduced pleasure.
In a nutshell – the fluctuations in our hormones, leads to changes in the signalling of our neurotransmitters – which impacts our moods and emotions and can make us feel up one day and down the next.
Perimenopause and metabolism
I often hear patients explaining they feel that despite the amount of exercise they are doing or how healthy they try to be with their diet, they feel like they are gaining weight during perimenopause. This is because estrogen helps regulate insulin sensitivity and where fat is stored in our body. As estrogen levels fluctuate and fall in perimenopause, many women become less responsive to insulin, causing blood sugar irregularities, sweets cravings and weight gain around the abdomen more likely. Poor sleep, high stress and excess cortisol mentioned earlier can add to this by increasing appetite and encouraging fat storage.
We also see a shift in body-fat distribution during the menopausal transition. Fat tends to move away from the hips and thighs, where it is more commonly stored during the reproductive years, towards a more central, abdominal pattern. Visceral fat — the fat stored around the internal organs — is metabolically active and is associated with greater insulin resistance and inflammation.
As we age, we naturally tend to lose muscle mass and strength unless we actively work to maintain them. If muscle is lost without being replaced through resistance or weight-bearing exercise and adequate protein intake, our total daily energy expenditure can gradually decrease. This means that the same diet and exercise routine that previously maintained our weight may no longer produce quite the same result.
A note on alcohol
Alcohol can alter hormone metabolism and impair liver function which can reduce the body's ability to process and excrete hormones effectively. Alcohol can also increase circulating estrogen. This leads to cascading impact on perimenopause symptoms and can be particularly problematic for mood regulation and hot flushes, as alcohol causes vasodilation, making flushes more noticeable.
Alcohol directly impact:
Sleep: alcohol directly disrupts sleep architecture, preventing deep restorative REM sleep and increased waking during the night. Perimenopause itself can disrupt sleep through night sweats, anxiety and hormonal fluctuations, creating a cycle where poor sleep makes appetite and metabolic regulation more challenging
Gut Microbiome: diversity in the gut microbiome is particularly important during perimenopause to help stablise mood and digestion – alcohol is a disruptor, and
Stress response: Alcohol reduces GABA, our calming neurotransmitter, which effects our nervous system can contribute to feeling more anxious, wired or fatigued the following day.
Liver health: Metabolism of alcohol changes during perimenopause due to reduced liver enzymes and changes in hormones. Alcohol can be more concentrated in the blood stream leading to increased risk of fatty liver, inflammation and poor metabolism.
While it may feel like that glass of wine is giving your a reprieve from your daily stressors and fluctuating emotions - its actually adding fuel to the fire and is going to leave your worse off.
A whole-person approach
Naturopaths look at the whole person, their environment, diet and lifestyle to understand the driving factors impacting perimenopausal symptoms. We see the connection between all body systems and how changes in hormone levels have an impact.
The goal during perimenopause is about changing strategy – recognising that your body is going through a transition and aiming to give yourself the tools to maintain balance. This includes prioritising protein and fibre-rich whole foods, supporting stable blood sugar, maintaining and building muscle through resistance training, getting enough sleep, managing stress the best you can and being mindful of alcohol.
Naturopaths can support with herbal medicines specifically indicated for hormonal imbalances your nervous system and adrenal system as well as nutritional supplements and dietary planning to ensure you can feel your best, not worse, during this natural transition.