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

Perimenopause is the transitional period that begins when the menstrual cycle becomes irregular and ends one year after the last menstrual period. During this phase, sex hormones -- especially oestrogen -- fluctuate and decline. This causes the well-known vasomotor symptoms: hot flushes and night sweats. These symptoms are most severe during the first four to seven years, but in some women they can persist for more than ten years. Urogenital symptoms such as vaginal dryness and pain during sex do not resolve on their own without treatment and become progressively worse.

In addition to the physical symptoms, perimenopause also increases the risk of mood swings, low mood and anxiety. This risk rises sharply in the later stages of the transition. Depressive symptoms and sleep problems further reinforce each other through hot flushes, which can create a negative spiral. Cognitive complaints, such as difficulty with verbal memory, attention and processing speed, are also common. The precise brain mechanisms have not yet been causally proven, however: it is difficult to separate what is caused by hormonal fluctuations from what is caused by sleep deprivation or mood.

Less well-known but nonetheless real changes include: irregular bleeding, loss of bone density, an increase in abdominal fat and a deterioration in metabolism. Women and healthcare providers do not always recognise these changes as a consequence of perimenopause, which stands in the way of adequate care. Research shows that almost 90% of women consult their doctor because of symptoms, yet a symptom-focused and personalised approach is still not applied often enough.

Hormone therapy based on oestrogen is the most effective treatment for hot flushes, night sweats and urogenital symptoms. For women under 60 and within ten years of the onset of menopause, without contraindications, the benefit-risk ratio is generally favourable. Hormone therapy is not without risks, however, and always requires an individual assessment together with a doctor. Hormonal contraceptives are an alternative during perimenopause that can simultaneously address irregular bleeding, hot flushes, bone loss and mood problems, while also preventing unwanted pregnancy (which remains possible at this stage). Here too, the choice depends on personal risk factors.

For cognitive symptoms the situation is different: the North American Menopause Society does not currently support hormone therapy specifically as a treatment for cognitive problems, at any age. Animal research is promising, but clinical studies in perimenopausal women are too small and too limited in design. Creatine supplementation shows promising signals in broader female populations for muscle strength, body composition and possibly mood and cognition, but specific data on perimenopausal women are very scarce. Moreover, two authors of the relevant research have financial ties to creatine manufacturers, which should be taken into account when interpreting the findings. Non-hormonal and behavioural treatments are mentioned in the literature as available alternatives, but concrete effect sizes cannot be given on the basis of the available sources.