Written and edited by Sarah Bonza MD, MPH, FAAFP, MSCP, DipABLM, NBC-HWC

Four women of different ages — Medical guidelines often address menopause but overlook perimenopause, contributing to delayed recognition and suboptimal care.

Perimenopause is a complex and widely misunderstood transition period in a woman's life, yet it represents a critical window for preventive health and symptom management. Despite affecting millions globally, many women do not recognize their symptoms as perimenopausal, and physicians often lack adequate training to diagnose and support this stage.

The pioneering work of Lara Briden ND urges a more nuanced, individualized approach rooted in evidence and compassion, emphasizing the importance of understanding the four stages of perimenopause.

Understanding Perimenopause: A Silent Transition

Perimenopause is the interval leading up to menopause, typically beginning in the mid-40s, but sometimes as early as late-30s. According to the Stages of Reproductive Aging Workshop (STRAW+10), reproductive aging progresses along a spectrum of menstrual changes and hormone fluctuations.

Women frequently experience perplexing symptoms—irregular periods, mood shifts, fatigue, sleep disruptions—long before the final menstrual period. Yet, both women and clinicians often miss the link between these symptoms and an underlying hormonal transition.

Infographic showing hormone changes across four perimenopause stages — Each stage of perimenopause is marked by distinct menstrual and hormonal shifts, accompanied by variable symptoms.

Why Physicians and Patients Miss Perimenopause

Many women are surprised to learn they are in perimenopause, believing symptoms require medical investigation unrelated to hormones. The stigma and silence around menopause, inadequate training in medical curricula, and limited access to evidence-based information create confusion and frustration.

Medical guidelines often address menopause but overlook perimenopause, contributing to delayed recognition and suboptimal care. The diversity of symptoms, coupled with societal influences and misinformation, complicates the landscape for accurate diagnosis and management.

Four Stages of Perimenopause

Drawing from the STRAW+10 framework, perimenopause can be divided into four dynamic stages.[1] Each stage is marked by distinct menstrual and hormonal shifts, accompanied by variable symptoms.

1. Very Early Perimenopause

Cycle regularity persists, but subtle changes in menstrual flow and premenstrual symptoms may emerge.
Symptoms: New onset of premenstrual mood swings, breast tenderness, insomnia, and heavier flow.
Biologically, there is increased cycle sensitivity to stress and declining progesterone, even as estrogen peaks remain robust.
Many women do not connect these changes to perimenopause, as cycles may remain predictably timed.[2]

2. Early Perimenopause

Characterized by persistent changes in menstrual cycle length exceeding 7 days, such as cycles that shorten or lengthen unexpectedly.
Symptoms broaden to include hot flashes, night sweats, anxiety, brain fog, and new allergic responses.
Hormonal landscape shows wider swings in estrogen and increasing frequency of anovulatory cycles.
Sleep disturbances and mood instability intensify; some women report exacerbation of migraines or joint pains.[3]

3. Late Perimenopause

Defined by intervals of amenorrhea (two or more skipped cycles) longer than 60 days.
Symptoms: More prolonged periods of hormone deficiency, unpredictable heavy bleeding, vasomotor symptoms peak, and pronounced mood changes.
Estrogen and progesterone levels decline more sharply, amplifying risks for metabolic syndrome, bone loss, and urogenital symptoms.
Psychological resilience, lifestyle, and expectations greatly influence symptom severity and adjustment to this phase.[4]

4. Final Stage—Menopause Transition

The final year after the last menstrual period (12 months of amenorrhea), culminating in menopause.

Symptom burden may shift, with gradual improvement of vasomotor imbalances.
Persistent hypoestrogenism leads to increased risk of cardiovascular disease, osteoporosis, and genitourinary changes.
Need for ongoing contraception ends, but management of long-term health risks and quality of life remains crucial.[5]

A chart that explains common symptoms across the menopausal transition — Common symptoms across the menopausal transition

Core Symptoms Across Stages

While vasomotor symptoms like hot flashes and night sweats are most widely recognized, perimenopause affects nearly every system:

Cognitive: Brain fog, memory lapses, reduced focus.
Mood: Anxiety, depression, irritability, emotional volatility.
Sleep: Insomnia, disturbed sleep architecture.
Urogenital: Vaginal dryness, sexual discomfort, bladder changes.
Musculoskeletal: Joint pain, muscle aches, reduced physical stamina.
Metabolic: Worsening cholesterol profiles, insulin resistance, central weight gain.
Menstrual: Irregularity, heavy/prolonged bleeding, skipped cycles.

Why Evidence-Based Care Matters

Perimenopause is easily mistaken for thyroid dysfunction, psychiatric conditions, or other medical issues, resulting in unnecessary workups or missed opportunities for early intervention. Evidence shows hormone therapy, lifestyle changes—including whole food plant-based diets, physical activity, and stress reduction—are foundational for managing symptoms and long-term risks.

Non-pharmacologic interventions, such as cognitive behavioral therapy, tai chi, yoga, and resilience training, have scientific backing for symptom reduction and quality of life improvement.

Gaps in Physician Education

Despite robust research, many clinicians feel ill-prepared to address perimenopause due to:

Limited formal education on perimenopausal diagnosis and management.
Absence of standardized global guidelines focused specifically on perimenopause.
Cultural norms that minimize women’s symptoms and other biases in research and clinical care.
Over-reliance on lab markers, despite STRAW+10 advising that perimenopause is a clinical diagnosis, especially after age 40.

A female doctor meeting with her female patient — Perimenopause is easily mistaken for thyroid dysfunction, psychiatric conditions, or other medical issues, resulting in unnecessary workups or missed opportunities for early intervention.

Overcoming Silence: What Women Need to Know

Preparation for perimenopause is possible and necessary. Women benefit from education on tracking cycles, understanding symptom variability, and accessing evidence-based resources. Individual and cultural attitudes strongly shape experience and symptom severity; proactive self-care and informed expectations reduce distress.

Women should expect:

Their experience may be unique; symptoms and timing vary widely.
Clinicians may not have all the answers, but demand compassionate, science-based care and referral as needed.
Many symptoms can be meaningfully addressed—early education and lifestyle change are key.

At Bonza Health, menopausal and perimenopausal women receive comprehensive, evidence-based support grounded in lifestyle medicine and personalized care. Recommendations always prioritize individual symptom tracking and self-awareness, empowering women to understand their own health patterns and transitions.

Bonza Health’s Signature Recommendations

Encouragement to track symptoms with digital or paper tools, highlighting changes in sleep, mood, menstrual cycles, and overall vitality.
Whole food, plant-based nutrition is the foundation, emphasizing phytoestrogens, micronutrients, and gut health—each shown to support hormonal balance and overall wellbeing.
Judicious prescribing of FDA-approved hormone therapy when clinically indicated, focusing on symptom relief, preventive care, and long-term safety.
Integration of lifestyle interventions such as physical activity, stress management, and heart rate variability monitoring to safeguard cardiovascular and metabolic health.
Promotion of mental wellness strategies, including mindfulness, purposeful community engagement, and resilience-building habits.
Commitment to ongoing physician education and advocacy for broader recognition of diverse menopause experiences to improve research and clinical care for all women.

Every protocol at Bonza Health—b-cut (weight loss), b-cool (hot flashes/night sweats), b-clear (brain fog), b-calm (mood), and b-charged (libido/fatigue)—is designed to meet women where they are in their journey and address both symptoms and underlying health metrics.

Empowering women with lifestyle, exercise, and stress management guidance — Integrating lifestyle interventions such as physical activity, stress management, and heart rate variability monitoring can empower women to understand their own health patterns and transitions.

Practical Recommendations

Seek care from providers experienced in menopause and perimenopause, ideally those using North American Menopause Society guidelines.
Track symptoms and menstrual cycles; educate oneself on the four stages.
Consider evidence-based supplements, lifestyle protocols, and, where appropriate, hormone therapy.
Address mental health proactively; resilience practices improve outcomes.
Look for community support or education programs dedicated to menopause and midlife transitions.

Next Steps

The four stages of perimenopause offer a roadmap to understanding, anticipation, and evidence-based care. Recognizing perimenopause is a foundation for protecting vitality and long-term health, breaking the silence and stigma, and empowering women everywhere with science-backed solutions.

Every woman deserves knowledgeable, empathetic care at this transformative stage.

Register to watch our free webinar — In this FREE training, I share my 3-step system helping women navigate perimenopause.

References

[1] Y. Pyne, J. Burgin, and M. Hickey, “Towards a more accurate global picture of perimenopause,” Bulletin of the World Health Organization, vol. 102, no. 12, p. 922, Dec. 2024, https://doi.org/10.2471/BLT.24.292659.

[2] L. Verrilli and S. L. Berga, “What Every Gynecologist Should Know About Perimenopause,” Clinical Obstetrics & Gynecology, vol. 63, no. 4, p. 720, Oct. 2020, https://doi.org/10.1097/grf.0000000000000578.

[3] A. Cunningham, Y. Martin, A. Wickham, C. Prentice, J. L. Payne, and L. Zhaunova, “Perimenopause symptoms, severity, and healthcare seeking in women in the US,” npj Women s Health, vol. 3, no. 1, Feb. 2025, https://www.nature.com/articles/s44294-025-00061-3.

[4] C. Ciano, T. S. King, R. R. Wright, M. L. Perlis, and A. M. Sawyer, “Longitudinal Study of Insomnia Symptoms Among Women During Perimenopause,” JOGN Nursing, vol. 46, no. 6, p. 804, Sep. 2017, https://doi.org/10.1016/j.jogn.2017.07.011.

[5] M. Rostami-Moez, S. Z. Masoumi, M. Otogara, F. Farahani, S. Alimohammadi, and K. Oshvandi, “Examining the Health-Related Needs of Females during Menopause: A Systematic Review Study,” Journal of Menopausal Medicine, vol. 29, no. 1. p. 1, Jan. 01, 2023. https://doi.org/10.6118/jmm.22033.

Science-Backed Guide to the Four Stages of Perimenopause