Women Living Better research collaborator, Dr. Marcie Richardson presented the findings from our 2020 research at The Menopause Society’s 2025 annual meeting. Her talk was titled When Does Perimenopause Actually Begin?
Here we share the key messages of ten of her slides.
Slide 1: At What Age Do Women Expect Perimenopause Will Actually Begin?
In the 2020 Women Living Better survey we asked a question: Think back to when you were 30. In which of the follow age ranges did you assume the changes associated with the lead up to menopause would begin?
The answer choices were: 35-44, 45-49, or 50+.
→ 59% of women didn’t expect changes to start until age 50 or later as shown in the slide below.
Slide 2: Not Feeling Like Myself in Perimenopause — What Does it Mean?
Also in our 2020 Women Living Better survey, we wanted to learn more about the often-used phrase “Not Feeling Like Myself” and specifically what it means during perimenopause.
We asked: Many women report “just not feeling like themselves” during this phase of life. How often was this true for you over the past three months?
The answer choices were:
1 – None of the time
3 – Half of the time
5 – All of the time
We looked at which symptoms were reported by those participants reported who said they did not feel like themselves more of the time.
→59% of women in the Late Reproductive Stage (before noticeable menstrual cycle changes) felt not like themselves 50% of the time or more.
→63% of all participants (those before and after noticeable menstrual cycle changes) felt not like themselves 50% of the time or more.
The spider graph in the slide below illustrates the correlation between symptoms and reports of “not feeling like myself”. Overwhelmed, less able to cope, fatigue, low feelings and anxiety were most correlated with reports of “not feeling like myself”. And hot flashes and vaginal dryness were least correlated.
Slide 3: What Dr. Richardson Hears from Her Patients
Dr. Richardson shared three comments that she hears regularly from her patients. She asked the audience of health care professionals whether they thought the comments were consistent with a perimenopausal woman or not.
The comments were:
- “I’m not sleeping like I used to. I’m waking up at 2 or 3 am and can’t back to sleep.”
- “I’ve become so irritable and I’m snapping at my family. This isn’t me!”
- “I have new anxiety. I feel like I can’t cope like I used to, and nothing has changed in my life.”
And then she asked the audience whether their thinking would change if they knew the patient was younger: 40, 42 or 38?
And further she asked, “does your thinking change if the woman is still getting a period every month?”
Note the definition of the Late Reproductive Stage is that there begin to be subtle changes to cycle length, amount of flow (heavier/lighter) or number of days of flow (more or fewer). Women who are not paying close attention may not notice these “subtle” changes.
Slide 4: Seeking Healthcare During Perimenopause — What Do Women Experience?
Next Dr. Richardson shared data (quotes) from women that were part of a quantitative analysis from the 2020 Women Living Survey. Participants were asked whether they sought healthcare for their most bothersome perimenopause symptom. If they had sought healthcare, they were asked: How did that go?
950 responses were analyzed for keywords and then responses were grouped into themes associated with either satisfied or dissatisfied visits.
Dr. Richardson shared these 2 quotes from dissatisfied visits:
- “Initially, I was completely dismissed when discussing all of my perimenopause symptoms. Two doctors dismissed me, one quite rudely. I now work with a private hormone specialist and am getting the help I need.”
- “Consulted my OB/GYN about perimenopause and mood swings, sexual interest. She blew me off and said I was too young for menopause.”
And she shared this quote from Susan Dominus’s article in the New York Times magazine from 2023 that brought perimenopause into the mainstream.
- “When one friend mentioned that she was waking once nightly because of hot flashes, her gynecologist waved it off as hardly worth discussing.”
→Her concluding point was that patients are feeling dismissed in when they seek healthcare in perimenopause.
Slide 5: New Research About Anger During the Late Reproductive Stage
Next Dr. Richardson shared findings come from a recently published paper looking at measures of anger. These data are from the Seattle Midlife Women’s Study, a study that included women starting at age 35. It suggests that women experience the most anger during the Late Reproductive Stage (LRS) when they are having monthly periods but with subtle changes to their cycle lengths and menstrual flow. This is the stage before the Menopausal Transition (MT) — the time when menstrual cycle changes become more obvious.
→The graph shows that in both measures of State Anger and Trait Anger, the late reproductive stage has the highest mean STAXI score.
Slide 6: What Symptoms Can Women Experience Before Noticeable Menstrual Cycle Changes?
Next Dr. Richardson shows a bar graph with findings from the 2020 Women Living Better survey that depicts the top symptoms reported by 945 late reproductive stage women. Late reproductive stage was defined by women who had 3 or 4 periods n the past 3 months and noticed subtle changes to their cycle length or menstrual flow.
Dr. Richardson pointed out that forgetfulness (reported by 60%), irritability (reported by 57%) and low libido (reported by 52%) are not the typical symptoms women expect. Of the twelve symptoms listed, hot flashes an an expected symptom is last on the list.
→ In summary, there is a much broader range of symptoms reported before very noticeable menstrual cycle changes than is normally expected.
Slide 7: The Australian Midlife Years Study New Findings About Hot Flashes Being Associated with Other Symptoms
The next slide illustrates findings from the very recent Australian Midlife Years Study that document symptoms when women have only noticed a change to their menstrual flow (such as more or fewer days of flow or heavier or lighter flow) but not yet had a 7-day difference in cycle lengths.
→This research also suggests that when a woman has hot flashes or night sweats, she has a more other symptoms.
Slide 8: Is There A New/Emerging Way to View When Perimenopause Starts?
Dr. Richardson concluded by asking the audience to consider whether there might be an “old” versus “emerging” view about the start of perimenopause.
In the old view, the 1st menstrual sign of perimenopause was irregular periods, the expected age of onset was late 40s and the expected symptoms were hot flashes and vaginal dryness.
In the emerging view, the 1st menstrual sign of perimenopause is subtle changes to periods and cycles, the expected age of onset is earlier, late 30s and early 40s and the expected symptoms are much broader.
Slide 9: Dr. Richardson Offers 6 Things That Would Benefit Women by Age 35!
Dr. Richardson suggested that the healthcare providers in the audience consider doing these 6 things with their midlife patients:
Slide 10: Women Would be Better Served if All Healthcare Providers Shared This (Dr. Richardson’s) View
Dr. Richardson concluded with her take on When Does Perimenopause Actually Begin.
Dr. Richardson believes that perimenopause begins when our patients notice something has changed, and for some, it’s before noticeable changes to menstrual cycles.
She acknowledged that the research needs to catch up but that as clinicians and researchers, we need to listen to, study and learn how to support perimenopausal women.
