Things Doctors Don't Tell You About Perimenopause

The Gap Between What's Known and What Gets Shared

Most doctors received very little training in perimenopause. A 2019 survey found that fewer than 7% of medical residents felt adequately prepared to manage menopause. That's not a criticism of individual providers. It's a gap in how medicine has historically treated this transition.

The result is that many people go years without understanding what's happening to them. Symptoms get attributed to depression, anxiety disorders, thyroid issues, or just aging. Sometimes those diagnoses are right. Often, the hormonal picture is missing.

The information below reflects current evidence. It's the kind of context that can help you ask better questions and advocate more clearly in your appointments.

Symptoms Can Start Years Before Your Periods Change

Most people think perimenopause begins when periods become irregular. But hormonal fluctuations can start years earlier, sometimes in the early 40s or even late 30s, while cycles still look completely normal on paper.

In the early phase, called late reproductive stage or very early perimenopause, estrogen begins to fluctuate in subtle ways. Sleep can become lighter. Mood can shift. PMS may intensify. Brain fog can creep in.

Because periods haven't changed yet, many providers don't flag this as perimenopause. But it often is, and understanding that can be a significant relief.

Anxiety Can Be the First Sign, Not Depression

Depression gets more attention in the context of hormonal transitions. But for many people, anxiety is the first symptom of perimenopause, and it often comes without an obvious life trigger.

Estrogen affects the amygdala (the brain's threat-detection center) and GABA levels, a neurotransmitter that helps regulate calm. As estrogen fluctuates, the nervous system can become more reactive. Heart palpitations, racing thoughts, a sense of dread, and waking at 3am with a jittery feeling are all common reports.

If you've developed anxiety that feels out of character, a hormonal connection is worth exploring before assuming it's purely psychological.

Testosterone Matters for Women Too

Testosterone is not just a male hormone. Women produce it throughout their lives, and it plays a real role in libido, energy, mood, and cognitive sharpness.

Testosterone levels in women peak in the late 20s and decline gradually through perimenopause and beyond. This decline contributes to reduced sex drive, fatigue, and low motivation in ways that often go unaddressed because providers don't routinely test or discuss it.

While testosterone therapy for women is currently off-label in many countries, there's a growing body of research supporting its use, particularly for low libido. A menopause specialist can walk you through the evidence and whether it might be relevant for you.

Vaginal Estrogen Is Safe for Almost Everyone

Vaginal dryness, discomfort during sex, and urinary changes are among the most under-treated symptoms of perimenopause. They tend to get worse over time without treatment, and they rarely come up spontaneously in appointments.

Vaginal estrogen, applied locally to the vaginal tissue, is absorbed minimally into the bloodstream. It does not carry the same systemic risks sometimes associated with oral or patch-based estrogen. Most major menopause societies, including those in the UK, US, and Europe, agree it is safe even for breast cancer survivors in most cases.

You don't have to accept discomfort as inevitable. Asking about vaginal estrogen directly is often the only way it gets offered.

CBT-I Outperforms Sleeping Pills for Perimenopausal Insomnia

Sleep problems in perimenopause are extremely common. They're driven by a combination of factors: night sweats that interrupt sleep, hormonal changes that lighten sleep architecture, and anxiety that makes it hard to fall or stay asleep.

Sleeping pills are often the first thing offered. But Cognitive Behavioral Therapy for Insomnia, known as CBT-I, has better long-term outcomes in clinical trials. It works by restructuring sleep-disrupting thought patterns and behaviors. Effects last after treatment ends, unlike medication.

CBT-I is available through therapists trained in sleep, through several digital apps, and through some telehealth providers. It's worth knowing this exists before defaulting to medication.

The HRT and Breast Cancer Story Is More Complicated Than You've Heard

The 2002 Women's Health Initiative study created lasting fear about hormone therapy. Many providers, and many patients, still operate from that fear. But the science has moved significantly since then.

Research now shows that for most women who are under 60 and within 10 years of their final period, the benefits of hormone therapy typically outweigh the risks. Body-identical progesterone, which is derived from plants and mirrors the body's own progesterone, carries a more favorable risk profile than the synthetic progestins used in the 2002 study. Transdermal estrogen (patch, gel, or spray) does not raise clotting risk the way oral estrogen does.

This doesn't mean hormone therapy is right for everyone. But the blanket fear is not supported by current evidence, and you deserve a conversation that reflects the full picture.

Perimenopause Affects Your Teeth and Gums

Estrogen has receptors throughout the body, including in gum tissue and the jawbone. As estrogen declines, gum tissue can become more inflamed and sensitive, and bone density in the jaw can decrease. This can accelerate gum disease and increase tooth sensitivity.

Dry mouth, another estrogen-related change, reduces saliva's protective effect and raises decay risk. Many people notice their dental health shifting during perimenopause without connecting it to hormones.

Telling your dentist you're in perimenopause is relevant clinical information, not just personal context. It can change how they monitor and treat your oral health.

You're Allowed to Ask for a Specialist

If your primary care provider doesn't have training in perimenopause, a referral to a menopause specialist is a reasonable request. The Menopause Society (formerly NAMS) and the British Menopause Society maintain directories of certified practitioners.

You don't have to accept being told your symptoms are normal if they're disrupting your quality of life. You don't have to accept a single option if you want to understand the full range. And you don't have to wait until things are severe before seeking thorough care.

PeriPlan's symptom tracking tools can help you build a record of patterns to bring to those conversations. Concrete data tends to move appointments forward faster than trying to describe symptoms from memory.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.