Perimenopause Clarifications and Definitions

Perimenopause is an increasingly “hot” topic these days, and for good reason.  Perimenopause suffers from an unhelpful definition.  The standard definition relies on defining perimenopause and menopause by menstrual cycle frequency, irrespective of symptoms.  The definition of perimenopause according to the Stages of Reproductive Aging Workshop (STRAW+10) – criteria, perimenopause, or the menopausal transition, begins with variations in menstrual cycle length and ends 12 months after the final menstrual period (FMP), also known as menopause. It encompasses the early (Stage -2) and late (Stage -1) phases of the menopausal transition.  This definition is problematic in several ways, starting with those women who historically have irregular cycles, but also including women who have had an endometrial ablation or hysterectomy, or are using hormonal contraception.   Blood, urine or saliva tests are not reliable for the diagnosis of the immensely variable hormonal fluctuations that are normal in perimenopause.   Other problems with this diagnosis of perimenopause based on cycle frequency, is that many perimenopausal women begin to have other perimenopause/menopause symptoms prior to cycle variation.  Most common are vasomotor symptoms (hot flashes/nightsweats), vulvovaginal dryness, brain fog, mood changes, and sleep disturbances.

Women tend to seek menopause related health care only when they have bothersome symptoms.  The STRAW definition, and thus the standard definition, does not include vasomotor symptom as part of the diagnostic criteria, and the only symptoms mentioned in the STRAW + 10 staging are vasomotor symptoms.  In addition, the STRAW mentions vasomotor symptoms as likely in the late menopause transition and most likely in the first year after the menstrual period.  We know from other research, vasomotor symptoms can precede the FMP by several years and on average, last 7-10 years.  Standard of care guidelines do include low mood, sleep disturbance, memory issues, and reduce sexual desire, in addition to vasomotor symptoms, as distinct perimenopause symptoms.

The purpose of the current study was to investigate the prevalence and severity of symptoms from the late reproductive state to late postmenopause, and identify which symptoms might best differentiate menopause onset, rather than just the menstrual cycle.

In this Australian Women’s Midlife Years (AMY) Study, 8096 women were recruited: 5509 women were classified using STRAW +10 definitions with 1250 as premenopausal, 344 as early perimenopausal, 271 as late perimenopausal and 3644 postmenopausal.  Among moderately to severely bothersome symptoms, hot flushes showed the greatest change in prevalence from premenopause to late perimenopause.  There was less variation for other symptoms including poor memory and low mood.  Vaginal dryness was the most distinct sexual function symptom noted from premenopause to late perimenopause.  Women with vasomotor symptoms and a change in their menstrual flow, had more frequent moderately to severely bothersome symptoms compared with women without vasomotor symptoms.  Early perimenopausal women with vasomotor symptoms reported more frequent poor memory compared with premenopausal women with vasomotor symptoms and a change in the menstrual cycle.

What’s the take home?????  This study suggests that moderately to severely bothersome vasomotor symptoms are a reliable indicator of the onset of perimenopause in women with infrequent or no menses.  These bothersome symptoms can have an onset earlier than what many providers are aware of.  Why is this important? Nearly 40% of perimenopausal women have untreated moderately to severely bothersome vasomotor symptoms.  Women need to seek guidance from a qualified and well informed menopause practitioner to get the help they need and not be dismissed.  Treatment options from a more integrative or naturopathic practitioner would include botanicals, nutraceuticals, and safe and effective hormone therapy prescriptions.

Reference:  Islam R, Bond M, Ghalebeigi A, et al.  Prevalence and severity of symptoms across the menopause transition: cross-sectional findings from the Australian Women’s Midlife Years (AMY) Study.  Lancet Diabetes Endocrinol 2025 Jul 25:S2213-8587(25)00138-X.