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The menopausal transition, or perimenopause, is associated with profound reproductive and hormonal changes. These changes have been well chronicled and matched with concomitant symptoms. The pattern of appearance of menopausal symptoms and their natural history have become increasingly clear thanks to the conduct of several long-term, longitudinal cohort studies that have examined many aspects of women's biology and psychology through this time of life. Menopausal symptoms are highly prevalent; they are sufficiently bothersome to drive almost 90% of women to seek out their healthcare provider for advice on how to cope.1 The classic symptom of menopause is the hot flash, which is experienced by most women, and is moderately to severely problematic for about 1/3 of women. While most women will have an experience of hot flashes limited to just a year or two, others will experience them for a decade or more, and a small proportion of women will never be free of them. Poor sleep becomes more common in perimenopausal women not only in association with the menopausal transition but also in relation to aging. Depressed mood and increased anxiety also increase during the transition, with an abrupt rise in prevalence as women approach the later stages of the menopausal transition and have longer bouts of amenorrhea. These common symptoms often interact with one another such that depressed women tend to experience worse hot flashes along with worse sleep. As women enter the latter stages of the transition, vaginal dryness and dyspareunia also become more likely, affecting about 1/3 of the population. Unlike hot flashes, mood issues, and sleep, vaginal symptoms will not go away without treatment. Clinical approaches to these problems often involve hormone therapy, which can be safely given to most perimenopausal women on a short-term basis. Therapeutic strategies that are nonhormonal and behavioral can also be deployed.


Women in perimenopause have at least some of what are called vasomotor symptoms (VMS). These may include:

Hot flashes

Breast tenderness

Worse premenstrual syndrome

Lower sex drive


Irregular periods

Vaginal dryness; discomfort during sex

Urine leakage when coughing or sneezing

Urinary urgency (an urgent need to urinate more frequently)

Mood swings

Trouble sleeping


Perimenopause is a natural process caused when your ovaries gradually stop working. Ovulation may become erratic and then stop. The menstrual cycle lengthens and flow may become irregular before your final period. Symptoms are caused by the changing levels of hormones in the body.

Risk factors

Menopause is a normal phase in life. But it may occur earlier in some women than in others. Although not always conclusive, some evidence suggests that certain factors may make it more likely that you start perimenopause at an earlier age, including:

Smoking. The onset of menopause occurs 1 to 2 years earlier in women who smoke than in women who don't smoke.

Family history. Women with a family history of early menopause may experience early menopause themselves.

Cancer treatment. Treatment for cancer with chemotherapy or pelvic radiation therapy has been linked to early menopause.

Hysterectomy. A hysterectomy that removes your uterus, but not your ovaries, usually doesn't cause menopause. Although you no longer have periods, your ovaries still produce estrogen. But such surgery may cause menopause to occur earlier than average. Also, if you have one ovary removed, the remaining ovary might stop working sooner than expected.

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Irregular periods are the most common symptom of perimenopause. But it’s important to know when to talk to your healthcare provider about your periods. Sometimes, irregular bleeding can point to an underlying problem.

You can lower your risk of complications by seeking treatment when necessary. Talk to your healthcare provider if you:

Bleed for more than seven days in a row.

Bleed between periods.

Change pads or tampons every one to two hours.

Have periods more frequently than every 21 days.


Certain factors are linked to early perimenopause. These include:

Smoking or using tobacco products.

A family history of early menopause.

A history of cancer treatment.

If you’ve had your uterus or ovaries removed.