Menopause — it’s a word that might stir up feelings of uncertainty, curiosity, or even a touch of dread. But here’s the thing: menopause is not a sudden shift or an end to anything, really. It’s more of a slow evolution, and it deserves to be talked about openly, honestly, and, maybe even with a bit of humor. After all, we’ve been through enough life changes to know that knowledge (and a sense of humor) is power.

This post is designed as a basic roadmap of what to expect when you’re “expecting” peri/menopause [I’m looking at you, too, children + spouses, coworkers and friends!]. Let’s break it down:

What is Perimenopause and Menopause, exactly?

Let’s start with some quick definitions. Menopause has traditionally been defined as the moment 12 consecutive months have passed without a menstrual cycle. (Average age in the US is somewhere between 51-52 years old). However, menses may be absent for any number of reasons like an IUD, ablation, PCOS, or surgical absence of a uterus (no kidding!) — In these cases, family history, and personal history (menarche, birth control, pregnancies and medications) can clue us in to a best-guess window of when menopause did/may be occurring.

Perimenopause, on the other hand, is the transitional period leading up to menopause. Think of it like a rollercoaster inching its way up to the peak — except instead of a thrill ride, you’re experiencing hormone fluctuations. This phase can begin as early as your mid-late 30s or early 40s (everyone’s ride is different).

Takeaway: Many people talk about menopause as this entire window, but perimenopause, menopause (really only a day-in-time) and post-menopause are distinct phases that may have overlapping symptoms.

The Symptoms: Perimenopause vs. Menopause

If you’re perimenopausal, you might feel like you’re walking through life with a blindfold on, wondering which symptom will show up next.

Below are some of the more common symptoms associated with perimenopause, though not exhaustive:

Irregular periods: This is often a first clue. Your periods may become shorter, longer, lighter, or heavier — essentially, the menstrual roulette wheel.
Sleep disturbances: If you’re wide awake at 3 a.m. wondering why sleep is avoiding you like a bad ex, this is a common perimenopausal issue.
Mood swings: Anxiety, irritability, rage, and depression can pop up, often with no clear reason. Hormones are doing a dance, and your emotions are, unfortunately, the unwitting partner.
Brain fog: Forgetting your keys or why you walked into a room? It’s not just getting older — your hormones are affecting your cognitive function.
Weight gain and body composition changes: Suddenly, your favorite jeans don’t fit quite the same, even though you haven’t changed your exercise, supplement and dietary habits.
Hot flashes and night sweats: You’re sitting at work or relaxing at home, and suddenly, you feel like you’ve been transported to the sun’s surface. It’s not just in your head — it’s hormones at play.

Once you’re in post-menopause, some of those perimenopausal symptoms stick around, but they might change in intensity. Here’s what you can expect:

Hot flashes: These can last for years after menopause, but for many women, they become less frequent over time. They tend to be worse in the years right before and after menopause.
Vaginal dryness and discomfort: Lower estrogen levels mean that your vaginal tissue becomes thinner and drier, leading to discomfort during sex or even daily activities.
Bone health: Lower estrogen can affect bone density, making osteoporosis a concern. Osteoporosis can make the bones more susceptible to fractures after a fall, and fractures (particularly hip fractures) are a major source of morbidity + mortality.
Changes in metabolism: That stubborn weight gain around your midsection? Could be to blame on declining estrogen that started in perimenopause.
Sleep and mood: Sleep problems may continue, and anxiety or mood changes can still be a common part of life post-menopause.

Takeaway: Symptoms can vary greatly person-to-person and even intra-personally depending on the phase. Symptoms of peri/menopause are MUCH broader than the old-school “Oh it’s just hot flashes and night sweats.”

What’s Causing All This? The Hormonal Tango

The root of all these changes? Hormones, of course. As we age, our ovaries produce less estrogen and progesterone and testosterone. Estrogen and progesterone are the primary drivers of menstruation, but they also impact a whole host of other systems in your body.

Estrogen: Plays a role in everything from bone health to heart health to maintaining healthy skin. As estrogen levels drop, you may notice changes in your energy levels, mood, and physical appearance. There are estrogen receptors in every organ system in the body, so this explains why the myriad symptoms people experience can be so wide-ranging.

Progesterone: Its decline often happens earlier than estrogen (remember the sleep disturbance in perimenopause?) and can cause those irregular periods during perimenopause.

Testosterone: Yes, women have testosterone too. It helps maintain muscle mass, bone health, energy, and libido, and as levels decline, you might notice changes in your muscle strength, desire for sex, motivation and get-up-and-go.

During perimenopause, estrogen and progesterone hormones fluctuate wildly, leading to the rollercoaster of symptoms, while testosterone goes on a steady decline. By the time you reach post-menopause, your hormone levels have mostly stabilized at lower levels, which is why some of the more dramatic symptoms (like heavy periods or mood swings) tend to taper off, while others (like hot flashes) may persist.

Takeaway: During reproductive years, hormones (for most people) are on a rhythmic, monthly up/down cycle. In perimenopause, they’re on a wild unpredictable cycle, and in post-menopause, they’re pretty much flatlined.

How Do We Manage This in Integrative Primary Care?

Management during this decade or so of life doesn’t have to mean just gritting your teeth and pushing through. The good news is there are many approaches that can make this transition smoother, especially when viewed through an integrative lens. We’re not just treating symptoms; we’re supporting your whole body.

Lifestyle Changes: Your First Line of Defense

Adequate sleep: Easier said than done, right? But prioritizing your sleep can make a world of difference in managing menopause symptoms. Sleep hygiene practices like avoiding screens before bed, keeping your room cool, and sticking to a routine can be helpful. If night sweats are waking you up, look into moisture-wicking bedding or even cooling devices designed for this.

Nutrition: Protein becomes especially important during this time to maintain muscle mass, which naturally declines as estrogen decreases. Aim for protein and fiber-rich meals, and don’t forget about calcium and vitamin D for bone health. Some women find that reducing alcohol and caffeine can help with hot flashes and heart palpitations.

Supplements and Nutrition Support

Some women find meaningful symptom relief with targeted supplements during perimenopause and menopause—but it’s essential to remember that “natural” doesn’t always mean safe or effective for everyone. It’s wise to consult a healthcare provider before starting anything new, especially if you’re on medications or have underlying health conditions.

Phytoestrogens, naturally occurring plant compounds found in foods like soy, flaxseeds, lentils, and chickpeas, may have mild estrogen-like effects in the body. Some women notice a reduction in hot flashes and night sweats when they regularly consume soy products like tofu, edamame, or tempeh. The research is mixed, but these foods are nutritious regardless—and including more plant-based meals can be a win for overall health.

Omega-3 fatty acids, found in fatty fish (like salmon, sardines, and mackerel) or in fish oil supplements, support cardiovascular health—a big deal as heart disease risk rises after menopause. Omega-3s may also play a role in mood regulation and reducing inflammation, which can contribute to joint pain or brain fog.

Magnesium is a quiet hero during this transition. It supports sleep, muscle relaxation, and may ease symptoms like anxiety or irritability. Magnesium glycinate or citrate tend to be gentler on the stomach than other forms. Plus, many women don’t get enough magnesium through diet alone—leafy greens, nuts, seeds, and dark chocolate are good food sources.

Other supplements worth discussing with a provider include:

- Vitamin D and calcium, to support bone health as estrogen levels decline
- B vitamins, which help with energy, mood, and cognitive function
- Adaptogens like ashwagandha or rhodiola, which some women use for stress and hormonal balance (though more human studies are needed)

While supplements can help fill in the gaps or ease certain symptoms, they work best when paired with a nutrient-dense, balanced diet. Eating regularly, staying hydrated, and focusing on fiber, healthy fats, and lean protein can make a big impact in how you feel day to day.

Hormone Therapy (HT)

We can’t talk about this life change without at least mentioning hormone therapy (HT). It’s a powerful tool for managing symptoms and supporting long-term health, especially for women at high risk of osteoporosis. However, it’s not a one-size-fits-all solution, and deciding whether it’s right for you requires a discussion with your healthcare provider, weighing the risks and benefits.

Systemic HT: Includes estrogen (sometimes combined with progesterone) and can help with hot flashes, night sweats, and bone health.
Local Estrogen Therapy: Helps with vaginal dryness and urinary symptoms with minimal systemic absorption.
Bioidentical vs. Synthetic Hormones: Bioidentical hormones are structurally identical to those naturally produced in the body, while synthetic hormones have slight chemical differences. Both have pros and cons, and the best choice depends on individual health history.

Current research emphasizes that for many women, HRT can be a safe and effective treatment, especially when started early in menopause.

Stress Management and Mental Health

The menopausal transition can be stressful. Between the physical changes and the emotional shifts, it’s easy to feel overwhelmed. That’s why stress management is key. Whether it’s through yoga, mindfulness, therapy, or even a simple walk in nature, finding ways to reduce stress can help alleviate some of the mood-related symptoms of menopause.

Pelvic Floor Health

With the decline in estrogen comes changes in your pelvic floor: Pelvic floor physical therapy (this is a specialized area of physical therapy), along with topical creams/ointments (hormonal OR nonhormonal) can make a big difference in maintaining sexual health, urinary + bowel habits, and overall quality of life.

Takeaway: A lot of the same things we do to manage the rest of our lives apply now, too, with altered ratios and regimens.

Finding your Best Fit

With so many options, how do you determine what’s right for you? The key is a personalized approach.

Identify Your Goals: Are you looking for symptom relief, long-term health protection, or both?
Work with a Knowledgeable Provider: Trained practitioners can help assess hormone levels, lifestyle factors, and medical history to create a customized plan.
Track Your Symptoms: Keeping a journal of symptoms, diet, sleep, and stress levels can help identify patterns and effective interventions.
Be Open to Adjustments: Menopause is an evolving transition. What works now may need tweaking later.

Embracing the change

Peri/Post-menopause isn’t something to be feared. It’s a natural part of life, and with the right tools, it can be managed effectively. Think of it as your body evolving, and you’re just getting a little more experienced along the way. This is a great time to re-evaluate your health, focus on self-care, and prioritize what makes you feel good — physically, mentally, and emotionally.

After all, you’ve survived everything else life has thrown your way, haven’t you? Menopause is the next adventure.

This blog post was written by Liz Frost, PA-C, MSCP and Vice President at Integrative Family Medicine of Asheville. You can read more about Liz in her bio.

Navigating Menopause: A Journey, Not a Destination