Perimenopause: the first signs, and when they usually start

Perimenopause: the first signs, and when they usually start

Two consecutive menstrual cycles that differ by more than seven days is, in clinical terms, an event. It is the opening criterion for early perimenopause in the staging system gynaecologists use. Most women who cross that line never notice, because a cycle of 26 days followed by one of 34 does not feel like a milestone.

In Sweden the last period arrives at a median age of 51 to 52, according to 1177, with a normal range of roughly 45 to 57. The years before that are the subject here. We have written separately about the biology of menopause itself and when to see a doctor. This is the part that comes first, lasts longer than most expect, and rarely announces itself with a hot flush.

The short version

• For most women perimenopause begins in the early to mid forties and runs for a median of about four years. The first sign is rarely a hot flush. It is two consecutive cycles differing by seven days or more, and sleep that fragments, often long before anything else is noticed.

• The objection that matters most: a hormone panel cannot date you. FSH is elevated but variable in the early transition, and NICE advises against laboratory testing in otherwise healthy women over 45. A record of cycle lengths kept for three to six months says more about where you are than a sample drawn on a Tuesday.

• Beauty Complete is a supplement for skin, not for menopause. It provides 500 mg of Cartidyss marine type II collagen from fish cartilage per daily dose, with vitamin C as PureWay-C. Vitamin C contributes to normal collagen formation for the normal function of skin. About menopause there is no authorised claim at all, and we make none.

Health Royals Beauty Complete, supplement with Cartidyss marine collagen, Hyabest hyaluronic acid, Ceramosides and vitamin C as PureWay-C

Skin at Health Royals

Beauty Complete is our supplement for skin. It contains Cartidyss, a hydrolysed marine type II collagen complex from fish cartilage, at 500 mg per daily dose, alongside hyaluronic acid as Hyabest, phytoceramides as Ceramosides and vitamin C as PureWay-C. Vitamin C contributes to normal collagen formation for the normal function of skin. It is background nutrition. No food supplement may be presented as treating or relieving menopausal symptoms, and this one does not.

See Beauty Complete

When does perimenopause begin, and how long does it last?

For most women it begins in the early to mid forties and runs for about four years, but the spread around that average is wide enough that it says little about any one person.

The framework is the Stages of Reproductive Aging Workshop + 10, published in 2012 and known as STRAW+10. It anchors everything to the final menstrual period, stage 0, and counts outward. The early transition, stage -2, is a persistent difference of seven days or more between consecutive cycles, persistent meaning it recurs within ten cycles. The late transition, stage -1, begins at the first interval of 60 days or more without a period and lasts one to three years on average.

A 2021 review in The Journal of Clinical Endocrinology and Metabolism puts the median duration of the whole transition at approximately four years, notes that it can begin as early as a woman's thirties, and adds that some women have bothersome symptoms for more than a decade.

What are the first symptoms of perimenopause?

Cycle length variability and fragmented sleep, in most cases well before any hot flush.

The JCEM review identifies irregular bleeding patterns, changes in how often periods come and how long bleeding lasts, as among the earliest signs. Easy to see, easy to dismiss, because one odd cycle means nothing and only the pattern carries information.

Sleep is the second. In the Study of Women's Health Across the Nation, a 2008 analysis of 3,045 women found the adjusted odds of difficulty falling asleep and staying asleep rose across the transition, and the JCEM review reports that close to 40 percent describe difficulty sleeping that tracks its timing. Not all of that is night sweats. Some of it is sleep that fragments on its own.

Hot flushes do arrive, but later and for longer than the popular version suggests. In SWAN, frequent vasomotor symptoms lasted a median of 7.4 years among 1,449 women, and for those whose symptoms began while they were still premenopausal or in early transition the median exceeded 11.8 years. Starting early predicted the longest course.

Why does a blood test say so little in perimenopause?

Because this phase is not a steady decline in oestrogen. It is a rise in variability, and one draw samples a single point in a system that is moving.

STRAW+10 describes follicle stimulating hormone in the early transition as elevated but variable, and the JCEM review makes the same point from the other side: FSH may be normal or only intermittently elevated while cycles are still close to normal. It is not walking down a slope. It oscillates around a rising trend, so a sample drawn on a Tuesday can look unremarkable in a woman who is unambiguously in transition. STRAW+10 does set a marker for the late transition, an FSH above 25 IU/L in a random draw, but calls biomarker criteria supportive rather than required, partly because assays are not standardised.

NICE guideline NG23 therefore tells clinicians to diagnose perimenopause without laboratory tests in otherwise healthy women over 45, on vasomotor symptoms and irregular periods, reserving FSH testing for ages 40 to 45 with symptoms or suspected menopause under 40. Läkemedelsboken says the same for Swedish practice: a typical history is enough, and hormone tests such as S-FSH are not necessary at normal menopausal age.

What happens to the skin during the transition?

It gets thinner, drier and slower to heal. The direction of that change is well established. The number most often quoted for it is not.

A 2022 review in Climacteric treats skin as an endocrine organ and a target of oestrogens, androgens and cortisol. It lists the skin symptoms of menopause as dryness and itch, thinning and atrophy, wrinkles and sagging, poor wound healing and reduced vascularity, and the hair symptoms as reduced scalp density, altered hair quality and more unwanted facial hair. It also says what most articles leave out: the visible signs of skin ageing are almost exclusively caused by environmental factors, above all solar radiation. Hormones change the substrate. The sun does most of the visible damage.

Then the number. You will read almost everywhere that roughly 30 percent of dermal collagen is lost in the first five years after menopause. It traces to work by Brincat and colleagues in London in the 1980s, so we read those papers. In Obstetrics and Gynecology in 1987 the group reported that skin collagen content, skin thickness, the metacarpal index and forearm bone mineral content all declined at a similar rate, between 1 and 2 percent per year after menopause. In the British Journal of Obstetrics and Gynaecology the same year they measured thigh skin collagen in 69 untreated postmenopausal women and 37 women on hormone implants, and found it fell with years since menopause in the untreated group but not the treated one.

Neither paper reports 30 percent in five years. What was measured was 1 to 2 percent per postmenopausal year. Both were cross-sectional rather than follow-ups, each had around a hundred participants, both sampled thigh skin with the methods of the early 1980s, and the treated group was a self-selected clinic population. We report the measured figure and leave the dramatic one alone. On skin ageing more generally, see the biology of radiant skin.

What actually helps with menopausal symptoms?

For hot flushes and night sweats the strongest evidence by a wide margin is menopausal hormone therapy, prescribed and followed up by a doctor.

NG23 tells clinicians to offer hormone therapy for vasomotor symptoms after discussing the short-term and longer-term benefits and risks. Läkemedelsboken states that oestrogen, with or without a gestagen, has good effect against sweats and flushes. The JCEM review calls it the most effective treatment for bothersome vasomotor symptoms, and notes that the only approved non-hormonal drug for hot flushes is low-dose paroxetine.

Two caveats. NICE warns that the efficacy and safety of unregulated compounded bioidentical hormones are unknown, as are the quality and purity of many complementary products. And the Climacteric review states that hormone therapy is not indicated for skin and hair symptoms alone, because the balance of risk and benefit does not support it. This is a decision made with a doctor who knows the history, not something a supplement substitutes for.

Does exercise help during the menopause transition?

Not for hot flushes, on the available evidence, but for almost everything else that shifts in this decade it is the intervention with the widest reach.

The Cochrane review of exercise for vasomotor menopausal symptoms, updated in 2014, pooled five randomised trials and 762 women and found the evidence insufficient to show whether exercise is an effective treatment. Across three studies and 454 women there was no difference from no intervention in symptom frequency or intensity, and in one trial of 14 women the hormone therapy group reported fewer flushes than the exercise group. The evidence was rated low quality.

That is a narrow question with a clear answer, not a verdict on training. Bone and muscle are the reason to train: in those same 1987 measurements, forearm bone mineral content fell alongside skin collagen at the same 1 to 2 percent per year. Folkhälsomyndigheten recommends at least 150 to 300 minutes of moderate activity a week and, separately, muscle-strengthening work on at least two days a week covering all the major muscle groups. The second half is the half most people skip, and it is the half that loads bone.

What can supplements do here, and what can they not?

They can contribute nutrients. Under EU law they may not be presented as treating or relieving menopausal symptoms, and for the most popular candidate the science does not support it either.

Soy isoflavones are the test case. EFSA concluded that the evidence was insufficient to establish a cause and effect relationship between soy isoflavone intake and either reduction of vasomotor symptoms associated with menopause or maintenance of bone mineral density. A separate 2015 EFSA safety assessment of isolated isoflavones found no increased breast cancer risk in the observational data and no effect on endometrial thickness up to 30 months at 150 mg a day, but could not derive a health-based guidance value. Not shown to work, not shown to be harmful at the doses studied, and no agreed upper level.

Regulation 1924/2006 permits only health claims on the EU authorised list, in the authorised wording, and Regulation 432/2012 holds that list. There are claims for nutrients: vitamin C contributes to normal collagen formation for the normal function of skin, zinc to the maintenance of normal hair, skin and nails. There is no authorised claim about menopause at all. Claims for collagen peptides and most botanicals are on hold or were rejected, and Regulation 1169/2011 prohibits presenting any food as preventing, treating or curing a disease.

So the honest position is narrow. A supplement is background nutrition. It is not a hormone, it is not a treatment, and it does not move anyone in the staging. Barrier function is reasonable to look after, and we have written about how ceramides work in the skin barrier, but that is a different claim from relieving a symptom of the transition.

What does the evidence not show?

Several widely held assumptions do not survive the primary literature.

  • That a hormone panel can tell you where you are. STRAW+10 makes biomarkers supportive rather than required, and NICE advises against testing in otherwise healthy women over 45.
  • That 30 percent of dermal collagen disappears in five years. That is not what the primary papers measured.
  • That exercise reduces hot flushes. Cochrane found the evidence insufficient.
  • That isoflavones reduce vasomotor symptoms or maintain bone mineral density. EFSA found the evidence insufficient for both.
  • That any supplement alters the timing or the course of the transition. Nothing shows that.

The staging system and most of the long-term cohort data also come from largely North American research populations. The shape of the transition is well described. The precision with which one person can be placed inside it is not.

What is reasonable to do now?

Record the length of each cycle for three to six months, and look at the difference between consecutive cycles rather than any single one. Note how you sleep, separately from whether heat wakes you. Take that record to a doctor rather than asking for a hormone panel: in an otherwise healthy woman over 45 it is the better instrument.

For skin, the leverage here is unglamorous: sun protection, since solar radiation still drives most of the visible change, and a barrier-supporting routine kept up over years. Our skin page collects that. Meet the activity floor, and treat the two strength sessions as the part that is not optional.

If you want a supplement in the background of that, our skin formula is Beauty Complete, with every ingredient and dose listed on its page.

Further reading

Frequently asked questions

How do I know if I am in perimenopause?
The clearest sign is cycle length. STRAW+10 counts a persistent difference of seven days or more between consecutive cycles as the start of the early transition, persistent meaning it recurs within ten cycles. Record the length of every cycle for three to six months and look at the difference between consecutive cycles rather than at one odd month.

How long does perimenopause last?
The median for the whole transition is about four years according to the 2021 JCEM review, but the spread around that is wide. The late transition, counted from the first interval of 60 days or more, lasts one to three years on average. Some women have bothersome symptoms for more than a decade, and in SWAN frequent vasomotor symptoms lasted a median of 7.4 years.

Can a blood test show where I am?
Rarely. FSH is elevated but variable in the early transition and can look normal one day and raised the next. NICE advises against laboratory testing in otherwise healthy women over 45, and Swedish practice guidance says the same. Testing is reasonable with symptoms between 40 and 45, or where menopause under 40 is suspected.

Is there a supplement for menopausal symptoms?
No, and it may not be claimed either. There is no authorised health claim about menopause in the EU, and for soy isoflavones EFSA found the evidence insufficient both for vasomotor symptoms and for bone mineral density. What we sell is nutrition carrying authorised wordings about other things: Beauty Complete for skin with vitamin C, Peak Performance with 25 µg vitamin D3 and 90 µg K2, where vitamin D and vitamin K contribute to the maintenance of normal bones, and Hair Beautification, where biotin and zinc contribute to the maintenance of normal hair.

Is it true that you lose 30 per cent of skin collagen in five years?
That figure is not in the original papers. Brincat and colleagues measured 1 to 2 per cent per postmenopausal year in two 1987 studies, both cross-sectional, each with around a hundred participants and the methods of the early 1980s. The direction of the change is well established. The number people quote is not.

Does exercise help with hot flushes?
According to the 2014 Cochrane review of five randomised trials and 762 women, the evidence is insufficient to show that it does, and it was rated low quality. That answers a narrow question rather than passing a verdict on training. The reason to train through these years is bone and muscle, and the muscle-strengthening half of the public health recommendation, at least two days a week, is the half most people skip.

Sources