What exactly happens during perimenopause, and what helps against it?

Perimenopause begins as soon as your cycle becomes irregular and lasts until one year after your final period. During that time, your hormones fluctuate considerably, particularly oestrogen, before they decline for good. The best-known symptoms are hot flushes and night sweats. These are most intense during the first four to seven years, but in some women they persist for more than ten years. Vaginal dryness and pain during sex do not resolve on their own without treatment; they actually worsen over time.

Mood swings, low mood and anxiety are also part of the picture, and the risk of these rises considerably in the later stages of the transition. Sleep problems and low mood also reinforce each other through hot flushes, which can set a negative spiral in motion. Many women also experience difficulties with memory, attention and the speed of thinking. Whether this is directly caused by hormonal fluctuations or rather by sleep deprivation and mood, has not yet been established.

Less well-known but equally real changes include irregular bleeding, loss of bone density, increased abdominal fat and a slowing metabolism. Nearly 90% of women visit their GP for these issues, yet a well-personalised approach is still too rarely offered^1,2.

For hot flushes, night sweats and vaginal symptoms, hormone therapy with oestrogen is the best-supported treatment. For women under 60 who are within ten years of the start of menopause and have no contraindications, the balance of benefits and risks is generally favourable^3,4. A personal discussion with your doctor is always necessary. Hormonal contraceptives are an alternative during this phase: they address irregular bleeding, hot flushes, bone loss and mood problems all at once, and also prevent unwanted pregnancy, which is still possible during perimenopause⁵.

For cognitive symptoms there is as yet no proven treatment. The North American Menopause Society does not currently support hormone therapy for this purpose, at any age⁶. Animal studies show promising mechanisms, but human studies are too small to support any recommendation. Creatine supplements are showing early positive signals in broader female populations for muscle strength and possibly mood and cognition, but data on perimenopausal women are very scarce^7,8. Two researchers involved in those studies have financial ties to creatine manufacturers, which colours the interpretation of the findings.