The Hormones Behind the Symptoms
At some point, over 50% of the world’s population will experience perimenopause and menopause with most experiencing some type of symptom caused by the decreasing sex hormones estrogen, progesterone, and testosterone. Yes, women make testosterone too.
For me, it started with hot flashes, or what are starting to be called hot flushes (I find this term a lot more fitting). They started during the summer so I chalked it up to our Valley heat. But when they continued the following fall and winter, and, by spring, I was having 10-15 per day, it was time to do something.
Since that time, I’ve also experienced night sweats, extreme weight gain, hair loss, tendinopathy, joint pain, sleep disturbances, gut health issues leading to rosacea, mood swings, brain fog and short attention span, anxiety and irritability, fatigue, low libido, and more. Most of these kicked in after my periods stopped, but not all.
On average, perimenopause begins around age 45-47, but can start much earlier. I was 40 when my periods started getting heavier and it took over ten years for them to completely stop.
Menopause itself is just one day: traditionally, the one-year mark after your last period. For me, a blood test showed that I was in menopause before that point as my estrogen, progesterone, and testosterone levels were almost non-existent. Everything after that point is postmenopause which you are in for the rest of your life. The evolution of symptoms is bio-individual. Some women will say that their symptoms lessen or even go away over time. Some women experience symptoms for the rest of their lives.
Here's a high-level look at what symptoms tend to show up first, and which symptoms tend to continue on.
It usually starts with progesterone
Progesterone is often the first hormone to decline, sometimes years before a period is ever late. Progesterone is produced mainly after you ovulate. As you enter perimenopause, your ovaries begin to skip ovulation or release eggs less predictably. Without regular ovulation, your body produces less progesterone overall. While it falls, estrogen often continues to fluctuate or stay high relative to progesterone. This imbalance is sometimes called “estrogen dominance”.
Symptoms of low progesterone can include:
Trouble sleeping or waking up early
Increased anxiety, irritability, or mood swings
Heavier, longer, or more irregular periods
Shorter menstrual cycles
Worsening premenstrual syndrome (PMS)
This early phase is easy to misread. The cycle still looks "normal enough" on paper, so the sleep and mood changes could be dismissed as stress or life circumstances rather than hormones.
Then estrogen starts to drop
As perimenopause progresses, estrogen doesn't decline smoothly. It swings, sometimes surging higher than usual before it falls, which is part of why symptoms can feel erratic rather than steadily worsening. This is the hormone behind the most recognizable symptoms:
Hot flashes and night sweats
Vaginal dryness and discomfort with sex
Brain fog and word-finding trouble
Joint aches
Skin that's drier, less elastic
These symptoms typically intensify in the one to two years before the final period, but, as discussed above, they don't necessarily stop once menopause is reached. Hot flashes, for example, last a median of about seven years from when they start, and for some women that stretches well into postmenopause.
Testosterone declines more quietly, and later shows itself
Testosterone drops more gradually across this whole span, and its effects tend to surface a little later or get noticed last, because they're less dramatic than a hot flash:
Lower libido
Musculoskeletal issues
Energy that doesn't bounce back with rest
A flatter sense of motivation or drive
Harder time maintaining muscle and strength
I especially noticed loss of testosterone when lifting weights, which I have been doing my entire adult life. Weights that I could easily lift the year before now hurt my joints. I also had all the symptoms listed above.
Because this decline is gradual and its symptoms are easy to attribute to "just getting older" or being busy, it often goes unaddressed the longest.
Not experiencing symptoms?
Are you in perimenopause or menopause and not feeling symptoms? That is fabulous. However, I would still encourage you to speak with your health care provider about whether MHT might be a fit for you for the long term benefits which include bone density and fracture prevention, improved metabolic regulation, reduced colorectal cancer, cardiovascular, breast, and brain health.
