The Four Phases of Perimenopause

For most of us, it’s not until we hit our 40s that we begin to think about perimenopause or menopause or even consider understanding what that means for us.

When I see women in my clinic, there is often confusion about HOW this process of declining hormones, oestrogen, and progesterone unfolds. While the information in this article is meant to help clarify the natural phases of perimenopause, each woman’s journey will differ a little, or maybe a lot.

What is menopause?

You could be forgiven for thinking this is a simple question, but it’s not the most straightforward one to answer. There are so many different theories and perspectives that, even for a practitioner, it’s difficult to nail down a perfect definition.

From a conventional viewpoint, menopause is considered to be just one day in the calendar. This day can only be identified once you have reached twelve months without a period. That last day of your last period is said to be menopause, and everything after that is then called post-menopause.

But from a more holistic viewpoint, menopause is considered to be the 30+ years following your last period. Again, you won’t know you’re ‘in menopause’ until twelve months after your last bleed, but forever after, you are considered to be menopausal.

Sigh!

I don’t like either of these definitions and honestly think there should be a more empowering way to describe this inspirational and transformative time for women. I’m open to suggestions.

The importance of understanding the four phases of perimenopause

Imagine you are about to embark on a journey in a foreign land. You are not the first to embark on this journey, nor will you be the last. However, previous travellers have kept the details of their journeys undisclosed, perhaps not because they did not want to share their experiences but because of social expectations and taboos surrounding this journey, which is often considered a torturous journey in Western society.

But what if you could have a mud map, a rough journey outline, to help you get your bearings, understand where you are, and “see” where you are headed?

The Four Phases of Perimenopause

Phase One – Very Early Perimenopause

Duration: approximately two to five years

This first phase of perimenopause is characterised by increased levels of oestrogen and declining progesterone. Because of the tendency to have spikes of oestrogen during this phase, some women will experience the most amount and intensity of symptoms during this time.

In phase one, women will often experience heavier bleeds, increased period pain, migraines, sleep issues and difficulty with regulating moods.

As the brain adjusts to these fluctuations in oestrogen levels and the whole endocrine system adjusts to these shifts, women can often experience a decline in overall energy.

Increased oestrogen levels during this time can have a kick-on effect, stimulating mast cells and producing histamine. This can potentially cause issues with hives, itchiness, hayfever, or anxiety.

Phase Two – Early Menopause Transition

Duration: approximately three years

In this second stage, women will begin to notice irregularity in their menstrual cycle, with cycle length varying from seven or more days.

During this time, progesterone continues to decline, and oestrogen levels begin on their descent, often dropping below levels from previous fertile years.

These big drops of oestrogen from peak levels in phase one to comparatively lower levels in phase two can trigger hot flushes and night sweats. They can occur just before, just after, or during menstruation.

This further decline in progesterone triggers a remodelling of the immune system, increasing one’s susceptibility to autoimmune conditions.

Phase Three – Late Menopause Transition

Duration: approximately three years

Things start to progress during this third phase, with skipped periods lasting 60 days or more without flow. Progesterone levels no longer fluctuate, and oestrogen levels continue to decline.

Symptoms such as hot flushes and night sweats may start to intensify, and additional declines in oestrogen may cause irritability or depression.

Phase Four – Late Perimenopause

Duration: approximately one year

This fourth phase is identified by the first cycle lasting more than 60 days without a bleed. Although it lasts approximately one year, for some women, menopause could arrive four years later.

This phase is the beginning of the stage of lower oestrogen levels and corresponding fading of progesterone.

Unless another period arrives, uncomfortable symptoms start to subside.

Menopause – The Fifth Stage

Duration: approximately 30 + years

Beginning 12 months after the last menstrual bleed, this final phase is characterised by low oestrogen and low progesterone levels.

Oestrogen finally settles to its normal low level.

However, the risk for insulin resistance, osteoporosis and heart disease begin to feature heavily during this time of lower oestrogen.

Symptoms characteristic of low oestrogen levels during this time could include: vaginal dryness, low libido, urinary tract infections, stress incontinence, prolapse, insomnia, weight gain or memory loss.

The four stages of perimenopause, in conclusion

It is important to remember that this transition can be different for every woman, some will transition quickly or with intense symptoms, and for others, the journey may take longer, with fewer symptoms. As a natural process and a time of great wisdom and learning for women, understanding this journey and its phases can help empower women on this great transformative adventure.