There is something that happens after the age of 40, sometimes even earlier, that many women find hard to recognise. The cycle that starts to behave strangely. The body that changes, the weight that increases without any change in diet or physical activity. Sleep that becomes lighter. An irritability that seems to come from nowhere, or that sudden sensation of heat that crosses through you at night and wakes you up in a sweat. The mind that occasionally clouds over, as if there were a thin fog between you and the things you need to remember.
These signals, often dismissed as stress, tiredness or simply "the passage of time", actually have a precise name and a clear biological explanation: it is called perimenopause, and it is the transitional phase that precedes menopause itself. The problem is that very few women truly know it. Not knowing what is happening in your own body generates confusion, isolation and, often, years of symptoms managed without adequate tools.
This article is designed to change things. Awareness is the first step towards wellbeing: when you understand what is happening in your body, you stop feeling alone with those signals and you can begin to make informed choices. Understanding the symptoms, grasping why they occur and knowing what to do concretely transforms perimenopause from a destabilising moment into an opportunity to build a health journey that can improve quality of life in the long term.
Menopause and perimenopause: understand the difference
Let's start with a distinction that changes everything. Menopause is technically a single moment: the date on which twelve consecutive months have passed without a menstrual cycle. Only at that point, retrospectively, can one say that menopause has been reached. The average age in Italy, as in the rest of Western Europe, is around 50-51 years.
Perimenopause, sometimes confused with premenopause, is instead the transition that leads to that moment. And it lasts much longer than women expect. According to the EMAS care pathway published in Maturitas in 2022 [Lambrinoudaki et al., Maturitas 2022], this period can extend from four to ten years before the last menstrual cycle. In clinical practice it is commonly observed that the first hormonal changes begin to manifest around the age of 40-45, and in some cases even earlier.
Put simply: if menopause arrives at 51, your body may already be changing at 41. This is the data that most women do not know.
A study published in npj Women's Health in 2025, conducted on over 4,400 women in the United States, documented a significant burden of perimenopausal symptoms already in the 30-45 age group, with many participants seeking medical support without receiving a clear diagnosis. The reason is simple: perimenopause is still far too little known, both among women and among doctors not specialised in this field.
What happens in your body: the biology of the transition
To understand the symptoms, one must understand the mechanism. During perimenopause, the ovaries progressively begin to reduce production of oestrogen and progesterone. But this reduction does not happen in a linear way. Hormone levels fluctuate irregularly, sometimes rising above the norm, sometimes dropping sharply, before stabilising at definitively low values.
It is these fluctuations, more than the low levels themselves, that generate the majority of symptoms in the early phases. The body is trying to adapt to a new balance, and it does so through signals that touch practically every system: from the central nervous system to the blood vessels, from the intestinal axis to the joints.
Oestrogens, in particular oestradiol, have receptors in almost all the body's tissues: brain, heart, bones, skin, mucous membranes, muscles. When their levels change erratically, the systemic response is inevitably broad and varied. This explains why perimenopausal symptoms are so different from woman to woman, and why many do not immediately connect what they feel to a hormonal change. To explore the role of oestrogens in female health, you can read this article [The role of the oestrogen hormone in female health].
The first signs to recognise: what your body is telling you
The menstrual cycle that changes
The most classic and earliest sign of perimenopause is a change in the menstrual cycle. According to international clinical guidelines, the irregular cycle is the first recognisable indicator of the transition. But 'irregular' means different things: shorter cycles (going from 28 to 21-24 days), suddenly longer cycles, heavier flows alternating with near-absent periods, unexplained delays.
Faced with these changes, many women think of pregnancy, thyroid dysfunction, stress. They rarely think of perimenopause, precisely because they expect the transition to begin later, or to be characterised mainly by the absence of their cycle. The phase of irregular cycles can last for years, and it is often the moment when hormonal symptoms manifest with the greatest intensity.
Hot flashes and night sweats
Hot flashes are among the best-known symptoms of menopause, but they frequently begin during perimenopause. They are a sudden sensation of intense heat, often localised in the chest, neck and face, accompanied by skin reddening and sometimes profuse sweating. They generally last from one to five minutes and can occur multiple times a day.
At night, hot flashes translate into night sweats that interrupt sleep. It is not uncommon for a woman to wake multiple times, with damp clothing and sheets, struggling to go back to sleep. This mechanism is linked to the dysfunction of the thermoregulatory centre in the hypothalamus, influenced by oestrogen fluctuations.
Clinical research has identified vasomotor symptoms, that is hot flashes and sweating, as the most directly associated with a perimenopause diagnosis, alongside cycle changes and urinary symptoms.
Sleep disturbances
Many women in perimenopause describe a change in sleep quality well before night sweats appear. Sleep becomes less deep, one wakes in the middle of the night for no apparent reason, the morning wake-up is early and difficult to recover from. This difficulty is not in the mind: it is biological. The reduction in progesterone levels, which has a natural sedative effect, and oestrogen fluctuations directly alter sleep architecture. We have explored this topic in a dedicated article [Sleep and perimenopause: how to rediscover rest].
The concerning finding is that fragmented sleep has consequences that go far beyond daily tiredness. Recent research, including some cited in the IMS World Congress on Menopause 2024 review published in Climacteric [Simon et al., Climacteric 2025], has documented a link between sleep quality in perimenopause and long-term cognitive health. Taking care of sleep at this stage is not a matter of comfort: it is prevention.
Mood, anxiety and brain fog
This is perhaps the most underestimated and most frequently misdiagnosed cluster of symptoms. Oestrogen fluctuations act directly on neurotransmission: serotonin, dopamine and GABA are influenced by oestrogen levels. When these fluctuate, so does mood.
The result is a set of experiences that many women find hard to attribute to hormones: inexplicable irritability, episodes of anxiety manifesting for the first time in adult life, a sense of melancholy or emotional flatness, moments of feeling overwhelmed without a clear cause. Added to all this is often what is called in the literature 'brain fog': difficulty concentrating, short-term memory problems, struggling to find words, which can be disorienting and worrying. We have discussed this in detail in this article [Brain fog in menopause: causes and remedies].
One of the most documented risks in this area is the over-diagnosis of depression in perimenopausal women who would actually benefit from hormonal support. According to EMAS experts, it is not uncommon for women in perimenopause to be directed towards antidepressants when the central issue is hormonal. This does not mean that mental health in perimenopause does not deserve clinical attention, but that a multidisciplinary approach evaluating both dimensions is needed.
Joint and muscle pain
A symptom many women do not connect to hormones at all: joint pains, often described as morning stiffness, pain in the hands, knees, hips, that seem to appear 'suddenly' around age 40. Oestrogens have an anti-inflammatory role and contribute to maintaining joint cartilage. When their levels fall, joint pain can become one of the first signs of the transition.
This symptom tends to be interpreted as early osteoarthritis or as a consequence of lifestyle, and rarely leads to investigating the hormonal profile. Recognising it for what it is opens up the possibility of targeted interventions, in terms of anti-inflammatory nutrition, appropriate physical activity, and hormonal support when indicated.
Physical changes: weight, skin, hair
Weight gain and changes in its distribution are among the most common and most frustrating signs of perimenopause. This is not about eating more or moving less: it is a hormonally-driven redistribution of adipose tissue towards the abdominal area, even in women with an unchanged lifestyle. The reduction of oestrogen and progesterone, combined with changes in insulin sensitivity and thyroid function, makes metabolism biologically different from before. We have dedicated a specific article to this topic [Menopause belly: the hormonal causes no one explains to you].
Added to this are often: hair that thins or falls out more diffusely, skin that loses elasticity more rapidly, more fragile nails. These are signals that contribute to that overall sense of 'no longer recognising oneself' that many women describe during this phase.
At what age does perimenopause begin: what research says
The average age of perimenopause, according to the most recent international evidence, is around 45-47 years for the onset of the most evident cycle changes. But the underlying hormonal transition, with the first changes in FSH levels and ovarian quality, can begin in the late reproductive phase, even around ages 38-40.
In Italy, the average age of menopause is aligned with the European average, around 50-51 years. This means that many women between 40 and 47 who recognise the symptoms described in this article may be in an early perimenopause phase, without being aware of it.
There are factors that influence the age of onset of the transition: family history (the age of maternal menopause is a significant predictor), smoking (which advances menopause by an average of one to two years), certain autoimmune conditions, previous surgical procedures and, to a lesser extent, lifestyle factors such as body weight and physical activity.
Early menopause, which occurs before the age of 40, and premature ovarian insufficiency (POI), which manifests before the age of 40, deserve separate discussion: they require specific and timely clinical attention, both for symptom management and for the prevention of long-term risks to cardiovascular and bone health.
Why so many women receive a late diagnosis
There are historical, cultural and systemic reasons that explain why perimenopause is recognised late. The first is that menopause has long been associated with the idea of 'old age' or 'the end of femininity', with a negative cultural charge that has made it difficult to discuss openly. This has created decades of silence around a phase that concerns every woman. We have discussed this in this article [Menopause as a cultural phenomenon: beyond medicine, beyond symptoms].
The second reason is that perimenopausal symptoms are non-specific: fatigue, concentration difficulties, insomnia, mood variations overlap with many other conditions. Without an anamnesis specifically oriented to the woman's phase of life, it is easy for the picture not to be recognised.
The third is that medical training on menopause is still insufficient in many contexts. Few gynaecologists and even fewer general practitioners have up-to-date training on the menopausal transition, and many women are bounced between specialists without receiving an integrated assessment.
The result is that many women reach full menopause after years of poorly managed symptoms, or symptoms not managed at all. And this has consequences that go far beyond daily discomfort, as documented in this in-depth piece on menopause and public health [Menopause and public health: a topic that concerns everyone].
What can be done
Recognising the signals is the starting point. But the next step is equally important: having a place where these signals are listened to, assessed and translated into a personalised plan.
The first step is awareness. Getting informed about what is happening in your own body is a concrete act of self-care. Knowing that that fatigue, irritability or brain fog have a precise biological explanation changes everything: you stop feeling 'wrong' and begin to understand what you need. A tool like Pausetiv's Smart Assessment allows you to map your hormonal, metabolic, nutritional and psychophysical health status in a structured way. This is not a generic questionnaire, but a clinically designed tool to identify priority areas for intervention and guide you towards the most appropriate pathway.
The second step is specialist support. Perimenopause requires a multidisciplinary approach: gynaecology, endocrinology, nutrition, physical activity and psychological support are not separate compartments, but integrated dimensions of a single care pathway. At this moment in life, women have very specific needs and deserve professionals with specific training in menopause and perimenopause. A consultation with a menopause-expert gynaecologist allows assessment of whether there is an indication for hormonal therapy, local or systemic, and the creation of a personalised treatment plan. You can read more about local hormonal therapies in this article [Local hormonal therapies in menopause: when science surpasses fear].
The third step is long-term prevention. Perimenopause is also an extraordinary time window for acting on future health. The reduction of oestrogens progressively increases cardiovascular risk, bone mass loss and, according to recent research, some forms of cognitive decline. Addressing these risk factors in perimenopause, before they consolidate into established conditions, is one of the most effective preventive acts a woman can carry out for her health at 60, 70 and 80 years. We have explored this topic here [Prevention in menopause: a window of opportunity for long-term health].
This completely changes the perspective. Perimenopause is not the end of something. It is the beginning of a phase in which, with the right information and adequate support, one can build a healthy longevity.
How to know if you are in perimenopause: what you can do now
If, reading this article, you have recognised some of the signals described, the first step is not to dismiss them, but to begin informing yourself. The second is to speak with a specialist who deeply knows this phase of life.
Some useful questions to ask yourself: has your cycle changed in the last few months or in the past year? Have you had episodes of sudden heat, even mild ones, at night or during the day? Has your sleep changed, even in the absence of evident stress factors? Does your mood or your concentration capacity seem different compared to a few years ago? Have you noticed a change in weight distribution, especially in the abdominal area?
There is no single test that definitively answers the question 'am I in perimenopause'. As the European Society of Endocrinology clarifies in its 2024 clinical guidelines published in the European Journal of Endocrinology [ESE Clinical Practice Guideline, European Journal of Endocrinology 2024], hormonal values such as FSH and AMH vary significantly during perimenopause and are not reliable as the sole diagnostic criterion. The correct clinical assessment integrates symptoms, menstrual history and, when appropriate, laboratory tests into a comprehensive picture.
What you can do right now is collect information about your cycle, monitor the symptoms you perceive and their frequency using the Symptom Diary on the Pausetiv platform, and arrive at your appointment with as documented a picture as possible.
A new way of looking at this phase
There is a cultural narrative about menopause that is worth stopping repeating: the one that describes it as decline, as loss, as a passage towards a phase in which the body is 'finished'. This narrative does not correspond to biology, and it does not correspond to the experience of millions of women who go through this transition with vitality, clarity and a self-awareness they did not have before.
Perimenopause, when faced with the right tools, can be the beginning of a deeper relationship with one's own body. A moment to stop ignoring the signals and begin, for the first time, to listen to them.
Knowing the symptoms is the first step. Understanding why they happen is the second. Having a pathway to address them is the third. On this, Pausetiv is here.
Book an appointment with a Pausetiv specialist: start here your path towards wellbeing
Sources:
Lambrinoudaki I. et al., "Menopause, wellbeing and health: A care pathway from the European Menopause and Andropause Society", Maturitas, 2022. https://www.maturitas.org/article/S0378-5122(22)00090-1/fulltext
Panay N. et al., "International Menopause Society (IMS) recommendations and key messages on women's midlife health and menopause", Climacteric, 2025. https://www.tandfonline.com/doi/full/10.1080/13697137.2025.2585487
Panay N. et al., "Menopause and MHT in 2024: addressing the key controversies, an International Menopause Society White Paper", Climacteric, 2024. https://www.tandfonline.com/doi/full/10.1080/13697137.2024.2394950
Simon J.A. et al., "State of the art in menopause: current best practice approaches from the IMS World Congress 2024, Melbourne", Climacteric, 2025. https://www.tandfonline.com/doi/full/10.1080/13697137.2025.2457993
European Society of Endocrinology, "Clinical practice guideline for evaluation and management of menopause and the perimenopause", European Journal of Endocrinology, 2024. https://academic.oup.com/ejendo/article/193/4/G49/8281862
Santoro N. et al., "Perimenopause symptoms, severity, and healthcare seeking in women in the US", npj Women's Health, 2025. https://www.nature.com/articles/s44294-025-00061-3
