When does menopause start: average age, first symptoms and signs

When menopause starts, the body rarely announces it clearly. Your cycle may begin to act up, sleep may become lighter, a few pounds may appear around the abdomen without an obvious reason. Irritability may arrive out of nowhere, or a sudden sensation of heat may wake you at night. Your mind may sometimes feel foggy.

These first signs of menopause are often dismissed as stress or tiredness. Instead, they have a precise name and a clear biological explanation: it is called perimenopause, the transition phase that comes before menopause itself. The problem is that very few women truly know about it, and not knowing what is happening in your body creates confusion, isolation and years of symptoms managed without the right tools.

In this guide we look at when menopause starts, at what age to expect the first changes, which signs to recognize and what you can do concretely.

The start of menopause and perimenopause: why they are not the same thing

Before looking more closely at when menopause begins, it is important to clarify a distinction that often creates confusion: menopause and perimenopause are not the same thing.

Menopause indicates a precise moment in a woman’s life, while perimenopause is the transition phase that comes before it, during which the body gradually begins to change.

This means that menopause is a single moment: the date on which twelve consecutive months have passed without a menstrual period. Only at that point, retrospectively, can you say that you have reached it.

Perimenopause, on the other hand, is the transition that leads to that moment, and it lasts much longer than many women expect. According to the EMAS care pathway (European Menopause and Andropause Society) published in Maturitas in 2022, this period can extend from four to ten years before the last menstrual period. Put simply, if menopause arrives at 51, your body may already be changing at 41. This is the data most women do not know.

Premenopause or perimenopause: what is the difference?

Besides not knowing the difference between menopause and perimenopause, many people also confuse perimenopause with premenopause. The two terms are often used as synonyms, but in medical literature they indicate different phases.

Premenopause is simply the fertile period before any hormonal change linked to the transition: in practice, a woman’s entire reproductive life. Perimenopause is, as we have said, the actual transition phase, the one in which the first symptoms appear.

For clarity, here is a summary table of all the phases of the menopausal transition:

How to know if you are moving toward menopause: the biology of the menopausal transition

To understand the first symptoms of menopause, you need to understand what is happening in a woman’s body during this phase.

During perimenopause, the ovaries progressively begin to reduce the production of estrogen and progesterone. But this reduction does not happen in a linear way. Hormone levels fluctuate irregularly, sometimes rising above normal, sometimes dropping sharply, before stabilizing at definitively low levels.

These fluctuations, more than the low levels themselves, generate most of the symptoms in the early phases. The body is trying to adapt to a new balance, and it does so through signals that affect practically every system: from the central nervous system to blood vessels, from the gut axis to the joints.

Estrogens, especially estradiol, have receptors in almost every tissue of the body, including the brain, heart, bones, skin, mucous membranes and muscles. When their levels change erratically, the systemic response is inevitably broad and varied. This explains why what we call the first symptoms of menopause can be so different from woman to woman, and why many do not immediately connect what they feel to a hormonal change.

Still, there are signs that many women observe in this phase. In the next sections, we will help you understand what they may be and what to pay attention to.

First menopause symptoms: what they are and how to recognize them

We have already said that the symptoms of approaching menopause can be very different from woman to woman, and this is one reason why they are often ignored or attributed to other causes.

Some women go through the transition with few symptoms, while for others the impact on daily life is significant. What research clearly tells us is that the initial symptoms tend to appear much earlier than women expect. Here are the main signs to learn to recognize:

1. Irregular periods: the first signs of menopause

The most classic sign of perimenopause is a change in the menstrual cycle. According to international clinical guidelines, an irregular cycle is the first recognizable indicator of the transition. But “irregular” can mean different things: shorter cycles (going from 28 to 21-24 days) or suddenly longer cycles, heavier flows alternating with almost absent periods, unexplained delays. Faced with these changes, many women think of pregnancy, thyroid dysfunction or stress. They rarely think of perimenopause, precisely because they expect the transition to begin later, or to be characterized mainly by the absence of periods. The irregular-cycle phase can last for years, and it is often the moment when hormonal symptoms appear most intensely.

2. Hot flashes and night sweats

Hot flashes are among the best-known symptoms of menopause, but they frequently begin already in perimenopause. They are a sudden sensation of intense heat, often localized in the chest, neck and face, accompanied by skin redness and sometimes by heavy sweating. They usually last from one to five minutes and can happen several times a day. At night, hot flashes become night sweats that interrupt sleep. It is not unusual for a woman to wake up several times with wet clothes and sheets, then struggle to fall asleep again. This mechanism is linked to dysfunction of the thermoregulatory center in the hypothalamus, influenced by estrogen fluctuations. Clinical research has identified vasomotor symptoms, meaning hot flashes and sweating, as among the symptoms most directly associated with the menopausal transition.

3. Sleep disturbances

Many women in perimenopause describe a change in sleep quality well before night sweats appear. Sleep becomes less deep, you wake up in the middle of the night for no apparent reason, and early-morning waking becomes harder to recover from. This difficulty has a biological cause. The reduction in progesterone levels, which has a natural sedative effect, and estrogen fluctuations directly alter sleep architecture. The concerning point is that fragmented sleep has consequences that go well beyond daily tiredness. Recent research has documented a link between sleep quality in perimenopause and long-term cognitive health. Taking care of sleep in this phase is not a matter of comfort.

To learn more, read:

Guide - Sleep and Menopause

4. Mood, anxiety and brain fog

This is perhaps the most underestimated cluster of symptoms and the one most often misunderstood. Estrogen fluctuations act directly on neurotransmission: serotonin, dopamine and GABA are influenced by estrogen levels. When these fluctuate, mood does too.

The result is a set of symptoms that many women struggle to attribute to hormones, such as unexplained irritability, episodes of anxiety appearing for the first time in adult life, a sense of sadness or emotional flatness, and moments of feeling overwhelmed without a precise cause. Added to this is often the so-called brain fog, meaning difficulty concentrating, short-term memory issues and trouble finding words, which can be disorienting.

5. Joint and muscle pain in menopause

Another one of the first symptoms of menopause that many women do not connect to hormones at all is joint pain, often described as morning stiffness, pain in the hands, knees or hips that seems to appear “suddenly” around age 40. Estrogens have an anti-inflammatory role and help maintain 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 it rarely leads to an investigation of the hormonal picture. Recognizing it for what it is opens the possibility of targeted interventions, from anti-inflammatory nutrition to appropriate physical activity and hormonal support when indicated.

To learn more, read:

Frozen shoulder and joint pain in menopause

6. First signs of menopause involving weight, skin and hair

Weight gain and changes in where weight is distributed are among the most common and frustrating signs of perimenopause.

This is not about eating more or moving less. It is a true redistribution of adipose tissue toward the abdominal area, even in women whose lifestyle has not changed, producing what is often called “menopause belly”.

The reduction in estrogen and progesterone, combined with changes in insulin sensitivity and thyroid function, makes metabolism biologically different from before.

Often, this comes together with signs such as hair becoming thinner or falling out more diffusely, or skin losing elasticity more quickly, along with more fragile nails. These are early signs of menopause that contribute to the overall sense of “not recognizing yourself anymore” that many women describe in 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 for the start of the most evident 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 age 38-40.

Several factors can influence the age at which menopause begins, including family history (the age of the mother’s menopause is a significant predictor), smoking (which brings menopause forward by one or two years on average), certain autoimmune conditions, previous surgery and, to a lesser extent, lifestyle factors such as body weight and physical activity.

Average age of menopause in Italy

According to data from the Italian National Institute of Health (ISS), in Italy menopause generally occurs between ages 45 and 55.

The average age is around 51, in line with the European average. This means that many women between 40 and 47 who recognize the symptoms described in this article may be in a phase of perimenopause, without being aware of it yet.

First symptoms of menopause: why they are ignored and recognized late

There are historical, cultural and systemic reasons why perimenopause is recognized 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 weight that has made it difficult to talk about openly, creating decades of silence around a phase that affects every woman.

The second reason is that some perimenopause symptoms are nonspecific, such as fatigue, difficulty concentrating, insomnia and mood changes, and they overlap with many other conditions. Without a clinical history specifically oriented around a woman’s life stage, it is easy for the picture not to be recognized. One of the most documented risks in this sense is the overdiagnosis of depression in perimenopausal women. According to EMAS experts, it is not uncommon for women to be directed toward antidepressants when the central issue is hormonal.

The third reason is that medical training on menopause is still insufficient in many contexts. The result is that many women reach established menopause after years of poorly managed symptoms, or symptoms that were not managed at all.

Pausetiv was created from exactly this awareness. In Italy, specialists with focused training in menopause are few, appointments are hard to obtain and too often women find themselves managing alone a phase that deserves serious and personalized support.

This is why Pausetiv has built a multidisciplinary team dedicated exclusively to menopause and perimenopause: gynecologists, endocrinologists, nutritionists and other specialists who can work together to help every woman understand what she is experiencing and restore her balance, at every stage of change.

How can you tell if you are moving toward menopause?

This is certainly one of the questions women facing the first symptoms ask most often. The most important answer is to develop awareness, because learning what is happening in your body is a concrete act of self-care.

Some useful questions to ask yourself may be:

• Has your cycle changed in the past few months or in the past year?
• Have you had sudden episodes of heat, even mild ones, at night or during the day?
• Has your sleep changed, even without obvious stress factors?
• Does your mood or ability to concentrate feel different compared with a few years ago?
• Have you noticed a change in weight distribution, especially around the abdomen?

Observing hormonal changes is also important, but as the European Society of Endocrinology clarifies in its 2024 clinical guidelines published in the European Journal of Endocrinology, hormone values such as FSH and AMH vary significantly during perimenopause and are not reliable as a sole criterion. A correct clinical assessment integrates symptoms, menstrual history and, when appropriate, laboratory tests into an overall picture.

So, after observing these first signs of menopause, it is advisable to seek the opinion of a specialist with specific training in menopause and perimenopause, who can assess the whole picture.

How to find your way through the signs of menopause: a tool designed for you

Asking the right questions is already an act of awareness, and to help you begin doing that, we have created a tool that can support you.

The Pausetiv PauseTest is an online assessment built with scientific criteria that helps you understand the state of your wellbeing during the menopausal transition, perimenopause and menopause and orient yourself toward the next steps with awareness.

It does not replace a medical evaluation, but it helps you gather and read the signs your body is sending you, understand which phase you may be in and orient yourself toward the specialists most suited to your situation. It is a concrete tool for transforming confusion into a clear starting point.

Take the PauseTest

Disclaimer: the information contained in this article is for informational and educational purposes only. It does not in any way replace the advice, diagnosis or indications of a doctor or health professional. If you have doubts or symptoms that worry you, always contact a qualified specialist.

Frequently asked questions about the start of menopause

When does menopause start?

Menopause itself is defined as the absence of menstrual periods for at least 12 consecutive months, and in Italy it occurs on average around age 51. But the hormonal changes that precede it, meaning perimenopause, can begin already around age 40-45, and in some cases even earlier. Many women who notice the first signs are already in this transition phase without knowing it.

What are the first symptoms of menopause?

The most common initial symptoms are irregular periods, hot flashes, sleep disturbances, mood changes and brain fog. Joint pain, changes in weight and fat distribution, and changes in skin and hair often appear too. The intensity and combination of symptoms vary greatly from woman to woman.

How does menopause manifest?

Not abruptly, but progressively. The first signs appear during perimenopause, with hormonal fluctuations that influence the cycle, sleep, mood and many other functions. Only after 12 consecutive months without menstruation can we speak of established menopause. Before that moment, the body may already have been changing for years.

What should you do when menopause starts?

The first step is not to ignore the signs. The second is to contact a specialist with specific training in menopause, who can assess the full picture and, if needed, build a personalized pathway that may include nutritional, hormonal, psychological or physical-activity support, depending on your needs.