The Perimenopause Transition

by Christiane Northrup, M.D.


Around age 40, women’s bodies begin perimenopause, the transition leading to menopause (the point in time when you stop menstruating permanently). The hallmark of this transition is a change in the levels of the hormones estrogen, progesterone, and the androgens. Yet this is not solely a physical event—it is also the biggest opportunity for personal growth and empowerment since adolescence. Approximately 40 million American women are going through the menopause process today, so if you are one of them, you are in very good company. Here’s a summary of what you need to know about this transition to help make it as smooth as possible.

There are three types of menopause. About 25 percent of women experience artificial menopause (menopause resulting from surgical removal of the ovaries, surgical disruption of the blood supply to the ovaries, radiation, chemotherapy, or taking certain drugs). For these women, menopausal symptoms can be severe and debilitating because there is no opportunity for gradual adjustment to the hormonal drop-off. Hormone treatments are often prescribed to help lessen these severe symptoms. The second type of menopause is premature menopause, which is diagnosed when a woman goes through menopause in her 30s or early 40s. It’s usually secondary to autoimmune disease, nutritional deficiency, or some form of chronic stress (including excessive athletic conditioning) that has adversely affected hormone-related reproductive functions. Premature menopause occurs not only earlier but also faster than normal menopause, often necessitating supplemental hormones to maintain physical comfort during the transition.

Buy Godesses Never Age, the newest book by Dr. Christiane Northrup

Most women go through the third type of menopause—natural menopause, which occurs gradually, usually between ages 45 and 55, in a woman who has at least one of her ovaries. Many women begin noticing changes in their menstrual cycle and/or mood years before they actually have their final period. This transitional perimenopause period usually lasts five to ten years, though the entire process can sometimes take up to 13 years. There’s normally a gradual crescendo in the beginning, a peak as one approaches mid-transition, and a gradual decrescendo towards the end, as the body learns to live in harmony with its new hormonal and emotional milieu. During perimenopause, periods may stop for several months and then return, and they may also increase or decrease in duration, intensity, and flow. Whether you need hormone replacement or alternatives for symptom relief during this time depends on what else is going on in your body and your life.

It is virtually impossible to tell when you’re finished with the menopausal transition until it has been a year since your last menstrual period. In other words, menopause itself can only be diagnosed a full 12 months after the transition is finished. Nevertheless, because hormone levels both in the brain and the body undergo progressive changes during perimenopause, salivary hormone levels, urine levels, or blood levels can be measured to give you an idea of where you stand. Hormone levels can also help you monitor your need for hormone replacement or your dose.

In order to have the best transition possible, it is important to be optimally healthy going in. That means understanding what is happening in your body, and supporting it so that you continue to produce adequate amounts of hormones for the rest of your life.

Typical Perimenopausal Symptoms:

Many women sail through “the change” without any symptoms at all. Others experience a wide range of symptoms, all of which have physical, emotional, and psychological aspects. During the years before menopause levels of progesterone typically decline, while estrogen levels remain stable or even increase. This is the most significant issue for the majority of women; many of the early symptoms that women feel are due to progesterone levels that are too low, in relation to their levels of estrogen. This state of a low progesterone-to-estrogen ratio is also referred to as “estrogen dominance.” Some of the symptoms that women suffer when progesterone declines include:

  • Breast swelling and tenderness
  • Mood swings
  • “Fuzzy thinking”
  • Irritability
  • Trouble sleeping
  • Water retention
  • PMS
  • Weight gain

Testosterone levels may also start to decline well before the last menstrual cycle. While the symptoms of low testosterone are often more subtle that those of low progesterone, for some women they can be significant. Symptoms of low testosterone include:

  • Loss of sex drive
  • Decreased sexual response
  • Decreased sensitivity in your erogenous zones
  • Decreased sense of well-being, energy, and ambition
  • Depression
  • Loss of or thinning pubic hair

Estrogen is often the last hormone to decline, but is the hormone that is traditionally associated with menopausal symptoms. As you approach menopause your ovaries slow their production of estrogen. While your ovaries continue to make some estrogen for the rest of your life and your body is still producing it from other sources, the overall effect is a dramatic drop in the level of estrogen circulating in your body—about 30–60 percent for most women. Symptoms of estrogen decline include:

  • Hot flashes
  • Night sweats
  • Vaginal dryness
  • Decreased energy and ambition
  • Depression or mood swings
  • Dizziness
  • Headaches
  • Mental confusion
  • Urinary incontinence
  • Recurrent urinary tract infections
  • Increased susceptibility to vaginal infections

The Wisdom of Menopause

Although women have been taught to dread menopause, this life stage ushers in the springtime of the second half of life and is often accompanied by surges in creativity, vitality, newfound ambition, and the need to be of meaningful service to the community in a larger way. During perimenopause and beyond, our goals and behavior become more motivated by the demands of our souls, not just those of society. We quite naturally seek answers from deep within instead of looking for approval from the outside.

The menopausal transition is actually a profound developmental stage in which unfinished business from the past comes up once again for resolution and healing, so that we can free ourselves from the outmoded beliefs and behaviors of our past. All the issues that weren’t resolved during puberty and early adulthood—such as body image, relationships, vocation, fear of aging, and self-esteem issues—now arise once more to be healed and completed.

While menopause itself is a normal life stage that does not cause health problems, the menopausal transition is marked by a statistically increased risk for breast cancer, osteoporosis, heart disease, arthritis, depression, and memory loss—all of which can be prevented if a woman heeds the wisdom of menopause and opens to her increased intuitive capacities. There are also a wide variety of options available for addressing and relieving the most common symptoms that arise during the menopausal transition.

Learn More — Additional Resources

For a full discussion of the three different types of menopause and effective approaches for possible symptoms, see Chapters 4, 5, and 6 in The Wisdom of Menopause by Christiane Northrup, M.D.

Christiane Northrup, M.D.

Christiane Northrup, M.D.

Christiane Northrup, M.D., is a visionary pioneer and a leading authority in the field of women’s health and wellness. Recognizing the unity of body, mind, and spirit, she empowers women to trust their inner wisdom, their connection with Source, and their ability to truly flourish.


Add comment
  1. Maria
    1 month ago

    I think I just had my last period 6 weeks ago. I am 54 years old. For the last three weeks I feel these crumps, same once I would normally feel before getting my periods in the past. Is it normal to have these crumps for so long and I also feel quite bloated.
    Should I be worried or is this normal? Any advise/comment would be appreciated.

  2. Kim
    1 month ago

    Ladies, the uterus does not have an open door! The cervix is the entry point…not the vagina. Things do not flow in and out of the womb as one might imagine. The vagina yes, uterus no. As far as I know, as when in labor and during menstruation the cervix opens (painful/uncomfortable cramping) allowing its contents (baby/menstrual blood) to exit. Then it closes again.

  3. Jolanda Simone
    4 months ago

    Hi Christine, I am a big fan of you and your work, i bought that book: “womens heath, womens wisdom” a long time ago and i followed your work ever since. But i stay with a question i have never seen answered yet anywhere. It is never discussed openly i can recall. My question is the following:
    Once a woman does not have her monthly menstruation anymore: how does the womb/uterus still cleanse itself?
    I refer to having sex for instance, semen and other related flueds could still remain in the body, even if you cleanse
    it. Normally we would have our monthly period to cleanse and wipe the remaining smells and not wanted energies
    out, and make the womb PH neutral again. To my knowledge :) But when that stops? How does the womb get rid of
    the sperm and smells which are not of her own? I have noticed that i smell my “guy” still after a week, and i am really good for my body, eat healthy and am very much in balance. Can you tell us, what happens when we are not menstruating anymore? Thank you. :)

  4. 4 months ago

    I’ve also been meditating on the identical point myself recently. Glad to see a person on the same wavelength! Nice article.

  5. Kim
    5 months ago

    I love your article.
    I really need some advice. I am 56years old and have been having awful symptoms for I would say 4years. I recently went to my doctor and results show I am peri menopause. She has given me an option of hrt. I am scared. I have no breast cancer in family. I have all pretty much symptoms, put on a good 2 stone. I had a hysterectomy when I was 32years old, I kept my ovaries. I have tried herbal remedies but nothing works or maybe I needed to take longer. Look fwd to your reply. Thank you. Please help. kim

    1. Patti
      4 months ago

      I also had a hysterectomy and left my ovaries and I’m 52 yrs old I’m emotional one min then laughing the next,tired am also a breast cancer survivor so I can’t go on any hrt.i have learned that there is bio- identical hormone treatments.

  6. Lynn
    9 months ago

    In 2013 I had 2-3 periods (I was 43). In 2014 I had one period in January. I’m now approaching one year without a period. I’ve had hot flashes (warm moments) over the past two years but no other problems. My doctor told me today I should take provera to force my period because a thickening uterine wall could lead to uterine cancer. I feel hesitant to alter what my body is going through, natural menopause, by forcing a period. Blood work showed perimemopause. Any insight or feedback is appreciated.

    1. Pat
      6 months ago

      I’m going through the same thing. Perimenopause was about the same as yours with some “warm” moments and pretty much no other symptoms. Now a year and ten months after my last period I had post menopausal bleeding with all the old symptoms of pms ……breast tenderness, acne and cramps. I saw my Dr who did a transvaginal ultrasound and found irregular thickening of the endometrium so she did an endometrial biopsy which came back benign. Now she wants me to take Progesterone 100mg for ten days to bring on a heavy period to shed the lining. I’m having symptoms of tense muscles, irritability…laughing one minute and wanting to cry the next, and foggy thinking. I’m scared if I take it it will throw my whole system off! And why all of a sudden am I having these symptoms? Ugh! Help!!!

      1. Ms. O
        6 months ago

        So glad I came across this.
        I, too, am having the same exact symptoms. Dr. is recommending progesterone to force a cycle. My body is doing fine. I have been able to manage all my symptoms with food and diet. I do not feel the need for the prescription. Is it necessary? I am 49 years old.
        Any advise will be greatly appreciated!

Leave a Reply

Your email address will not be published. Required fields are marked *