A few weeks ago, I had a patient on the table who had just had a baby. She mentioned—almost casually—that she felt like she had stepped straight out of the postpartum period and directly into perimenopause.

She wasn’t distressed by it, exactly. More thoughtful than anything. She said she knew it wasn’t about getting her body “back to before,” but about moving into a new phase altogether.

That conversation stuck with me.

Because I see versions of this story all the time. Women in their 30s and 40s who are navigating enormous transitions—new babies, growing families, demanding careers, aging parents—and quietly realizing that their bodies feel different in ways they didn’t expect yet.

And while I don’t think it’s necessary to label yourself as being in any particular phase, I do think it’s incredibly important to understand what perimenopause actually is, how it can show up, and what your options are.

Because knowledge really is power.

The more you understand what’s happening in your body, the better equipped you are to advocate for yourself, ask the right questions, and make choices that support your long-term health—rather than just trying to push through symptoms that are often dismissed or misunderstood.

What Is Perimenopause, Really?

Perimenopause is defined as the 10–15 years leading up to menopause, which is officially marked by the cessation of menstrual cycles for 12 consecutive months.

Many of us grew up thinking menopause was something that happened to women in their 60s. In reality, the average age of menopause is 51.

Do the math, and that means perimenopausal changes can begin in the mid-to-late 30s for many women.

This surprises people. A lot.

Perimenopause isn’t a single moment or diagnosis—it’s a gradual, fluctuating transition. And it often starts quietly, with symptoms that come and go, making it easy to dismiss them as stress, poor sleep, or “just getting older.”

What’s Actually Changing in the Body?

One of the earliest drivers of perimenopause is a decline in egg quality and ovulatory consistency.

As we move through our late 30s and into our 40s, ovulation may not happen every single month. And this matters more than most women realize.

Ovulation is what triggers progesterone production.

So when ovulation doesn’t occur, progesterone drops—and low progesterone can create a cascade of symptoms that feel both physical and emotional.

Common Low Progesterone Symptoms

Difficulty staying asleep (especially waking between 2–4am)
Increased anxiety or feeling “wired but tired”
Heightened inflammation
Joint or muscle pain
Increased PMS
Shorter cycles or spotting

One month you may feel completely fine. The next month, you feel like a stranger in your own body.

That inconsistency is one of the hallmarks of perimenopause—and one of the reasons it’s so confusing.

When Estrogen Starts to Shift Too

As women move further into their 40s (and sometimes early 50s), estrogen levels may also begin to decline or fluctuate more dramatically.

Importantly, this can happen while you are still cycling. You do not need to be in menopause to experience low estrogen symptoms.

So on top of sleep disruption and anxiety, women may begin to notice:

Common Low Estrogen Symptoms

Brain fog (which can also happen with low progesterone)
Increased joint and body aches
Genitourinary symptoms such as:
- Increased urinary frequency
- More frequent UTIs
- Vaginal dryness
- Pain with sex
Decreased libido

And then there are the symptoms that feel completely random if you don’t know what’s driving them:

Itchy skin
Frozen shoulder
Itchy ears
Constipation

Not exactly what anyone signed up for.

What’s Happening Beneath the Surface

Behind the scenes, declining estrogen contributes to:

Increased systemic inflammation
Gradual loss of bone density and bone quality
Changes in connective tissue and joint resilience

This doesn’t happen overnight, and it won’t look the same for every woman. But for many, these changes are already underway long before menopause arrives.

Understanding this matters because early intervention is often far more effective than waiting.

Hormone Support Before Menopause: A Reframe We Need

One of the most important shifts we need to make—both culturally and medically—is understanding that hormone support does not need to wait until menopause.

For many women, supporting progesterone and/or estrogen during perimenopause is not only safe, but advisable.

Women in their 30s and 40s already carry an enormous mental and emotional load:

Raising children
Supporting aging parents
Managing careers
Maintaining relationships
Trying to care for their own health

Suffering through hormone-driven symptoms on top of all of that should not be considered normal or inevitable.

And yet, it often is.

A Quick (But Important) Clarification

Birth control pills are not hormone replacement therapy.

They suppress your natural hormone production rather than replacing hormones in a physiologic way.

IUDs can be helpful for local uterine support, but they do not provide systemic hormone replacement and will not address many of the symptoms discussed here.

If you’re exploring hormone support, it’s essential to work with a practitioner who understands these distinctions and can guide you appropriately.

Lifestyle Still Matters — A Lot

Hormones don’t exist in a vacuum. Lifestyle plays a powerful role in how we experience perimenopause.

Foundational practices that matter now more than ever:

Building and maintaining muscle
Supporting bone density
Eating enough protein and calories
Managing stress (as realistically as possible)
Prioritizing sleep
Staying curious and adventurous in how we move and live

I often say: Let’s be strong, stable, adventurous old ladies—not the opposite.

And that work doesn’t start later.
It starts now.

The First Step Is Awareness

Understanding where you are in the perimenopausal journey is the first step toward feeling better.

You don’t need to label yourself.
You don’t need to panic.
You just need information—and support.

If you want to talk through your individual symptoms, history, and options, you’re always welcome to schedule a Functional Medicine new or return patient appointment.

Onward.

Frequently Asked Questions About Perimenopause

What exactly is perimenopause?

Perimenopause is the transitional period—often 10–15 years—before menopause. During this time, hormone levels fluctuate and gradually decline, leading to a wide range of symptoms that can occur even while you are still having regular periods.

At what age can perimenopause start?

Perimenopause can begin as early as the mid-to-late 30s for some women, though it more commonly becomes noticeable in the 40s. Every woman’s timeline is different.

Can I be in perimenopause if I’m still having periods?

Yes. Many perimenopausal symptoms occur while cycles are still present. Hormonal fluctuations, missed ovulation, and declining progesterone or estrogen can all happen before periods stop.

What are the earliest signs of perimenopause?

Early signs often include sleep disruption, increased anxiety, worsened PMS, cycle changes, and feeling more inflamed or achy than usual. These symptoms may come and go from month to month.

Is hormone replacement only for menopause?

No. Many women benefit from hormone support during perimenopause. Supporting hormones earlier can reduce symptoms and help protect bone, brain, and overall health.

Is birth control the same as hormone replacement?

No. Birth control suppresses natural hormone production and is not the same as physiologic hormone replacement. IUDs may provide local support but are not systemic hormone therapy.

Do I have to treat perimenopause?

Treatment is always optional. The goal is not to “fix” your body, but to support it. Some women choose lifestyle strategies alone, while others benefit from hormone support. The right approach is individualized.

Why is bone health a concern during perimenopause?

Estrogen plays a key role in maintaining bone density. As estrogen fluctuates and declines, bone loss can begin earlier than many women realize, making early awareness and support important.

What’s the most important takeaway?

Perimenopause is not something to fear—but it is something to understand. The more informed you are, the better you can advocate for your health and choose support that aligns with your life and goals.