What Every Woman Needs to Know About Perimenopause

Sometime in my early-ish to mid-forties things started to get weird. I developed severe anxiety, a full night’s sleep became elusive, I felt achy and old, was so fatigued, I gained weight (especially in my belly), I began having spells of vertigo, and overall, just generally didn’t feel at home in my body. None of this had happened before and it all happened without changing any lifestyle or dietary habits. I felt like I was falling apart. Was this the fabled midlife crisis I’d heard about my whole life? Turns out it was perimenopause.

When it comes to perimenopause, the biggest hormonal change that anyone with ovaries will go through, we’re left in the dark, or worse, brushed off, symptoms dismissed (this is especially true for African American and Latina women, who, on average, go through menopause earlier than white women, and also experience worse symptoms).1 2 When I asked my gynecologist about my cluster of symptoms, she seemed to only hear my complaint of weight gain, told me to eat less, and welcomed me to middle age. I left the appointment so disheartened, but I can’t blame her: A 2023 survey published in the journal Menopause found that nearly 70 percent of OB/GYN residency programs in the U.S. lacked curriculums dedicated to menopause, and a 2019 Mayo Clinic survey of medical residents (specializing in family medicine and obstetrics and gynecology) found that only 6.8 percent reported feeling “adequately prepared to manage women experiencing menopause.”3 4

Rather than being taken seriously, “the Change,” as it’s been coined, became a joke, a trope of women gone mad with rage and hot flashes, that no one really seemed to want to talk about. But the tide is changing. Women are talking about their symptoms, we’re connecting the dots, and we are seeking out ways to manage those symptoms.


Illustration portraits of women


What is perimenopause?

Illustration of female reproductive organsI’d never given much thought to perimenopause, and only vaguely thought of menopause as something that was very far in my future. Little did I know that perimenopause would knock me off my feet, at a time when I still felt so young. So what is it exactly? Perimenopause is the transition period leading up to menopause (menopause is when the ovaries completely stop producing estrogen and you haven’t had a period for a full year; fun fact: menopause is exactly one day—the day you haven’t had a period for 12 months, after that, you are considered post-menopausal). Perimenopause starts in your early to mid-40s on average, but it can start as early as your 30s and it can last between four and 10 years.5 It is a time of wild hormonal fluctuations, with extreme ups and downs, but with a general pattern of declining estrogen (and progesterone) production. It’s a time in which your monthly period can become unpredictable, sometimes not happening at all, and other times coming like a 100-year flood. Every woman’s perimenopausal experience is as unique as she is, and symptoms are far-ranging and some are even surprising. Here is a (non-exhaustive) list, in no particular order: heart palpitations, itchy, crawling skin, insomnia, anxiety, depression, joint pain, vaginal dryness, urinary incontinence, weight gain, especially in the belly, mood swings, loss of libido, brain fog, hair loss/hair thinning, memory loss, vertigo, night sweats, hot flashes, dry mouth, and bleeding gums. As you can see, it’s not just hot flashes; in fact, a survey of perimenopausal women found that the top three symptom complaints were mood swings, brain fog, and fatigue.6

It turns out that estrogen affects nearly every part of our bodies, and with its decline, we start experiencing (sometimes weird) symptoms. In addition to the more acute symptoms, long-term effects of estrogen loss—especially if there is no management of symptoms—include muscle loss, bone loss, and a higher risk for insulin resistance and other metabolic dysfunction, dementia, and cardiovascular disease. But there are ways to counteract this, and the perimenopausal years are the perfect window of opportunity for healthy interventions.

Shifting how you eat must become a priority

Illustration of asparagus, eggplant, olives, and beansWhen it comes to diet, one thing becomes crystal clear during perimenopause: what may have worked for years just doesn’t anymore. Sixty to 70 percent of women report gaining weight during the menopausal transition, particularly in the belly, and this weight gain can be a risk factor for cardiovascular disease.7 Perimenopause leads to reduced metabolic flexibility, or the ability to switch between burning carbs and fat for fuel, changes our body composition, with a significant increase in fat mass and a reduction in lean muscle mass, and changes where fat is distributed in our bodies (looking at you, belly fat), making it imperative to adjust how we eat.8 9

Lean into a low-inflammatory diet.

Estrogen plays an important role in modulating inflammation in our bodies, so as estrogen decreases, inflammation increases. Inflammation can increase the severity of menopausal symptoms and the risk of a number of degenerative diseases.10 11 12 Now is the time to lean into a low-inflammatory diet. What does that look like? The main things to avoid (or at least strictly limit) include sugars, refined carbohydrates and processed grains, fried foods, high omega-6 vegetable oils, and alcohol, as they are all drivers of inflammation. Instead, fill your plate with quality protein, healthy fats, and loads of fiber-rich vegetables. Take inspiration from the Mediterranean diet, which comes out on top in research for promoting health through perimenopause and beyond, including reducing cardiovascular risk, maintaining bone mineral density and a healthy weight, preventing cognitive decline, improving mood, decreasing hot flashes, and reducing the risk of all-cause mortality.13 14 15 This way of eating is based on a foundation of anti-inflammatory and antioxidant-rich foods: seafood, olive oil, pastured dairy and meat, nuts and legumes, vegetables, and an array of spices. 

Learn to prioritize protein.

Illustration of a fishDuring the menopausal transition, protein breakdown increases and protein synthesis declines.16 To counteract the loss of lean muscle mass, it is imperative to eat enough protein. Experts recommend 1.2 grams of protein per kilogram of body weight for perimenopausal women; converted to pounds, that would be 81.6 grams of protein per day for a 150-pound person. If you are very physically active, especially if you are strength training (a must for peri- and post-menopausal women!), those requirements can increase to 2 grams per kilogram of body weight daily.17 One study found that post-menopausal women who consumed at least 1.1 g/kg body weight daily had lower fat mass and better upper and lower body strength compared to those in the low protein group (less than .8g/kg/body weight/day).18 Good protein sources include grassfed or regeneratively raised beef, bison, pork, chicken, and eggs; seafood; pasture-based Greek yogurt, cottage cheese, whey protein; and tofu.

It's also important to fill in nutritional gaps with key supplements, including a multivitamin (a multi will cover your bases, including the B-complex vitamins; however, if you opt out of a multi, take a B-complex supplement); vitamin D to keep your bones, immunity, and cardiovascular system in tip-top shape; and magnesium and vitamin K2 to provide cardiovascular support and protect from osteoporosis. A quality omega-3 fish oil is also a must for managing inflammation.

Supplements for your symptoms

Illustration of broccoliIndole-3-carbinol (I3C). While estrogen levels decline throughout perimenopause, they do so in an irregular manner, which can lead to estrogen imbalances. I3C is a compound found in cruciferous vegetables like broccoli and kale and research has shown that it maintains a healthy balance of estrogen by metabolizing more potent, cancer-causing estrogens into non-toxic forms.

Try: 150-300 mg daily.19


Progesterone cream. While we often think of estrogen as the only hormone that decreases during menopause, progesterone levels decline more quickly than estrogen during the perimenopausal years. There are progesterone receptors throughout the body and symptoms of low progesterone can include anxiety, irritability, brain fog, elevated cortisol, headaches, heavy and/or prolonged periods, and breast tenderness. Using a natural progesterone cream can improve these symptoms. Progesterone is also important for a woman who has low estrogen levels, because the body can convert progesterone into estrogen when levels get too low.20 21 22 Because progesterone directly affects hormone levels, and is a precursor to other hormones, it is important to follow the directions on the label and start at the lower dose to find the amount that works well for you.  


Black cohosh. The herb black cohosh is one of the most studied—and most widely used—natural treatments for menopausal symptoms. It has been shown to be especially effective for reducing the severity and frequency of hot flashes, in addition to reducing other symptoms such as mild anxiety and depression, vaginal dryness, decreased libido, and sleep disturbances. Most research has found that women begin to see relief of symptoms between four and eight weeks of supplementing.

Try: 40-80 mg, twice daily.23 24 25 26


Illustration of Rhodiola plantRhodiola. Recent research has found that black cohosh is even more effective when paired with the adaptogenic herb rhodiola. Rhodiola supports the body during mental and physical stress and has been studied for its ability to reduce anxiety, mental fatigue, stress, and depression. A study published in 2020 showed that a combination of black cohosh and rhodiola was “significantly superior” to black cohosh alone in reducing a number of menopausal symptoms, including hot flashes and sweating, sleep problems, depressed mood, irritability, anxiety, and both physical and mental exhaustion.

Try: 400 mg daily.27 28


Shatavari. Traditionally used in Ayurveda as the main tonic for the female reproductive system, shatavari supports hormonal balance, healthy libido, and vaginal moisture. Animal research has also found that shatavari has an anti-anxiety effect, similar to a common prescription anti-anxiety medication.29

Try: Doses start at 500 mg daily.30


Perimenopause is inevitable, but suffering through it is not.

Illustration of WomenAnd the more you learn about this transition, the less frightening it becomes. Let’s continue to talk about perimenopause and educate ourselves and each other. We deserve to thrive through our middle years, and we can!


  1. Harlow Sioban, Prof Emeritus Epidemiology. “25 years of research shows insidious effect of racism on Black women’s menopausal transition, health,” University of Michigan School of Public Health, Feb 23, 2022. https://sph.umich.edu/news/2022posts/insidious-effect-of-racism-on-blac…
  2. Gupta AH. “How Menopause Affects Women of Color,” The New York Times, Aug. 23, 2023 https://www.nytimes.com/2023/08/23/well/live/menopause-symptoms-women-o…
  3. Welsh Erin T, MA. “Most OB/GYN residency programs in US lack dedicated menopause curriculum.” Healio, August 10, 2023. https://www.healio.com/news/womens-health-ob-gyn/20230810/most-obgyn-re…
  4. Kling JM, MacLaughlin KL, Schnatz PF, Crandall CJ, Skinner LJ, Stuenkel CA, Kaunitz AM, Bitner DL, Mara K, Fohmader Hilsaca KS, Faubion SS. Menopause Management Knowledge in Postgraduate Family Medicine, Internal Medicine, and Obstetrics and Gynecology Residents: A Cross-Sectional Survey. Mayo Clin Proc. 2019 Feb;94(2):242-253. doi: 10.1016/j.mayocp.2018.08.033.
  5. Haver, Mary Claire, MD. “What Is Perimenopause?” The ‘Pause Life, https://thepauselife.com/blogs/the-pause-blog/what-is-perimenopause
  6. Harper JC, Phillips S, Biswakarma R, Yasmin E, Saridogan E, Radhakrishnan S, C Davies M, Talaulikar V. An online survey of perimenopausal women to determine their attitudes and knowledge of the menopause. Womens Health (Lond). 2022 Jan-Dec;18:17455057221106890. doi: 10.1177/17455057221106890. 
  7. Kodoth V, Scaccia S, Aggarwal B. Adverse Changes in Body Composition During the Menopausal Transition and Relation to Cardiovascular Risk: A Contemporary Review. Womens Health Rep (New Rochelle). 2022 Jun 13;3(1):573-581. doi: 10.1089/whr.2021.0119.
  8. Eaton SA, Sethi JK. Immunometabolic Links between Estrogen, Adipose Tissue and Female Reproductive Metabolism. Biology (Basel). 2019 Feb 7;8(1):8. doi: 10.3390/biology8010008.
  9. Simpson SJ, Raubenheimer D, Black KI, Conigrave AD. Weight gain during the menopause transition: Evidence for a mechanism dependent on protein leverage. BJOG. 2023; 130(1): 4–10. https://doi.org/10.1111/1471-0528.17290
  10. McCarthy, M., Raval, A.P. The peri-menopause in a woman’s life: a systemic inflammatory phase that enables later neurodegenerative disease. J Neuroinflammation 17, 317 (2020). https://doi.org/10.1186/s12974-020-01998-9
  11. Vegeto E, Benedusi V, Maggi A. Estrogen anti-inflammatory activity in brain: a therapeutic opportunity for menopause and neurodegenerative diseases. Front Neuroendocrinol. 2008 Oct;29(4):507-19. doi: 10.1016/j.yfrne.2008.04.001.
  12. Harding AT, Heaton NS. The Impact of Estrogens and Their Receptors on Immunity and Inflammation during Infection. Cancers (Basel). 2022 Feb 12;14(4):909. doi: 10.3390/cancers14040909.
  13. Vetrani C, Barrea L, Rispoli R, Verde L, De Alteriis G, Docimo A, Auriemma RS, Colao A, Savastano S, Muscogiuri G. Mediterranean Diet: What Are the Consequences for Menopause? Front Endocrinol (Lausanne). 2022 Apr 25;13:886824. doi: 10.3389/fendo.2022.886824. 
  14. Cano A, Marshall S, Zolfaroli I, et al. “The Mediterranean diet and menopausal health: An EMAS position statement.” Maturitas, Vol 139, September 2020. https://doi.org/10.1016/j.maturitas.2020.07.001
  15. Carla Gonçalves, Helena Moreira, Ricardo Santos. Systematic review of mediterranean diet interventions in menopausal women[J]. AIMS Public Health, 2024, 11(1): 110-129. doi: 10.3934/publichealth.2024005
  16. Simpson SJ, Raubenheimer D, Black KI, Conigrave AD. Weight gain during the menopause transition: Evidence for a mechanism dependent on protein leverage. BJOG. 2023; 130(1): 4–10. https://doi.org/10.1111/1471-0528.17290
  17. Simpson SJ, Raubenheimer D, Black KI, Conigrave AD. Weight gain during the menopause transition: Evidence for a mechanism dependent on protein leverage. BJOG. 2023; 130(1): 4–10. https://doi.org/10.1111/1471-0528.17290
  18. Gregorio L, Brindisi J, Kleppinger A, Sullivan R, Mangano KM, Bihuniak JD, Kenny AM, Kerstetter JE, Insogna KL. Adequate dietary protein is associated with better physical performance among post-menopausal women 60-90 years. J Nutr Health Aging. 2014;18(2):155-60. doi: 10.1007/s12603-013-0391-2. 
  19. Vanderhaeghe L, MS and Pettle A, MD. Sexy Hormones: Unlocking the Secrets to Vibrant Sexual Health; Chapter 5. Basic Health Publications, Inc., 2010
  20. Catenaccio E, Mu W, and Lipton M. “Estrogen- and progesterone-mediated structural neuroplasticity in women: evidence from neuroimaging.” Brain Struct Funct. 2016 Nov; 221(8): 3845-3867 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5679703/
  21. Vanderhaeghe L, MS and Pettle A, MD. Sexy Hormones: Unlocking the Secrets to Vibrant Sexual Health; Chapters 2 and 3. Basic Health Publications, Inc., 2010
  22. Prior, JC. “Progesterone for Symptomatic Perimenopause Treatment—Progesterone politics, physiology and potential for perimenopause.” Facts Views Vis Obgyn. 2011;3(2): 109-120. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987489/#!po=75.0000
  23. Mehrpooya M, Rabiee S, Larki-Harchegani A, et al. “A comparative study on the effect of “black cohosh” and “evening primrose oil” on menopausal hot flashes.” J Edu and Health Promot 2018; 7:36. http://www.jehp.net/temp/JEduHealthPromot7136-5643627_154036.pdf
  24. Mohammad-Alizadeh-Charandabi S, Shahnazi M, Bayatipayan S. “Efficacy of black cohosh (Cimicifuga racemose L.) in treating early symptoms of menopause: a randomized clinical trial.” Chin Med. 2013;8:20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4029542/
  25. Jiang K, Jin Y, Huang L, et al. “Black Cohosh Improves Objective Sleep in Postmenopausal Women with Sleep Disturbance.” Climacteric. 2015;18:4 https://www.tandfonline.com/doi/full/10.3109/13697137.2015.1042450
  26. Northrup C, MD. Women’s Bodies, Women’s Wisdom; Chapter 14: Menopause. Bantam Dell, 2006.
  27. Pkhaladze L, Davidova N, Khomasuridze A, et al. “Actaea racemose L. Is More Effective in Combination with Rhodiola rosea L. for Relief of Menopausal Symptoms: A Randomized, Double-Blind, Placebo-Controlled Study.” Pharmaceuticals. May 2020; 13(5): 102 doi: 10.3390/ph13050102
  28. Edwards D, Heufelder A, Zimmerman A. “Therapeutic effects and safety of Rhodiola rosea extract WS 1375 in subjects with life-stress symptoms—results of an open-label study.” Phytother Res. Aug 2012; 26(8): 1220-5 doi: 10.1002/ptr.3712
  29. Garabadu D and Krishnamurthy S. “Asparagus racemosus Attenuates Anxiety-Like Behavior in Experimental Animal Models.” Cellular and Molecular Neurobiology. Feb 2014;34, 511-521. https://link.springer.com/article/10.1007/s10571-014-0035-z
  30. Lall A. “This Ayurvedic Supplement Reduces Anxiety and Fights Menopause Symptoms.” First for Women, Nov 2, 2019. https://www.firstforwomen.com/posts/health/shatavari-for-menopause-anxi…