Perimenopause, the transitional phase leading to menopause, brings a range of symptoms and challenges that can significantly impact a woman’s quality of life. Many women experience irregular periods, hot flashes, night sweats, mood swings, fatigue, weight gain, and difficulty sleeping. Others face changes in libido, brain fog, and shifts in skin and hair health. Along with these physical symptoms, women often grapple with emotional and psychological concerns: Why am I feeling so irritable? Why is it suddenly harder to lose weight? Is this normal, or could it be something else? These questions highlight the uncertainty and frustration that can accompany this stage of life. Women in perimenopause are often searching for clarity, support, and effective strategies to navigate this complex and often misunderstood period of their lives.
WHAT’S HAPPENING TO ME PHYSICALLY?
Physiologically during perimenopause there is the gradual loss of eggs, wide hormonal fluctuations, and irregular menstrual patterns. This can last for more than 10 years. Menopause is defined as 12 consecutive months since the last menstrual cycle. Until then, women are categorised as being in perimenopause. The definition is not as important as understanding the symptoms women experience during this transitional phase.
Our current guidelines do not clearly identify when women are likely to experience the onset of symptoms related to perimenopause. This can delay or even miss the appropriate time to initialise treatments. During this transitional phase—or ideally before—emphasis on hormonal health, lifestyle, and overall wellness needs to be assessed. This can help alleviate any symptomology and support both metabolic and cardiovascular health.
Currently, there are no sex hormone markers in a blood test that can definitively predict perimenopause. Ideally, symptomology is the key assessment tool. Additional testing to screen and prevent negative long-term outcomes, however, is important:
- Anemia assessment (CBC, ferritin, iron levels)
- Thyroid metabolic assessment (TSH, free T3, free T4)
- Cardiovascular risk assessment (cholesterol, HDL, LDL, TG, inflammatory markers)
- Diabetes and blood sugar assessment (HbA1c, fasting glucose, fasting insulin)
- Vitamin D
- Liver function assessment (ALT, AST, GGT, bilirubin)
- And other individualised testing needs
Perimenopausal women experience many symptoms and are more likely to report:
- Fatigue
- Overwhelm
- Coping issues
- Low feelings
- Anxiety and nervousness
- Irritability
- Difficulty concentrating
- Difficulty making decisions
- Sadness
These feelings and sensations are like the crash and burn of adrenal fatigue due to changes in nutritional requirements and the hormonal fluctuations that occur. The hormonal fluctuations, alongside lowered daily energy expenditure, lead to metabolic changes that elevate the risk of developing metabolic disorders and cardiovascular diseases. Weight gain in perimenopausal women is associated with higher total and abdominal connective tissue and lower lean body mass.2 The decrease in estrogen affects the central nervous system leading to mental, emotional, and physical changes that can affect women’s well-being overall. The body requires better nutritional support to offset muscle breakdown and mineral deficiencies, and emotional connection support to prevent anxiety and depression.
The main areas of focus in clinical care for the treatment of perimenopausal symptoms are nutritional recommendations, lifestyle modifications, and nutraceutical support.
NUTRITIONAL RECOMMENDATIONS
Our nutritional requirements are based on what our body needs. In the period of perimenopause, many nutritional factors can reduce the risk of developing cardiovascular disease, insulin resistance, Type 2 diabetes, mellitus, osteoporosis, and tumours along with the symptoms characteristic of this period. As noted earlier, the decrease in estrogen during perimenopause affects the central nervous system causing increased food intake and decreased basal energy consumption (energy required for basic metabolic functions). It increases the liver breakdown of sugars which has the opposite effect to insulin—this all leads to higher caloric intake.3 These changes can create a domino effect of lowering the metabolic rate leading to more visceral fat, inflammation, and cardiometabolic risks.
The quality of the diet is a determining factor of an individual's health at every stage of life. A healthy diet can help counter the symptoms of perimenopause. Diets providing less than 1200 kcal/day may cause micro and macronutrient deficiencies, which could negatively affect, not only the nutritional status, but also the ability to manage weight.
The Mediterranean diet is characterised by foods that contain anti-inflammatories and antioxidants which show evidence of weight and blood sugar control, and lowering cardiovascular risks. It emphasises vegetables, healthy fats, and protein, which in turn support healthy outcome goals. The intake of polyunsaturated fats and increased dietary fibre (30–45 g/day) are also ideal for controlling blood sugar levels and cholesterol.3 Protein intake should be 0.8 g/kg/day following a balanced diet, and 1–1.2 g/kg/day for those who exercise regularly. Water intake needs to be assessed and monitored with a recommendation of a minimum of 2 L per day.
There is research in supplementation that can assist and support a woman during perimenopause. It’s important to note that this is in conjunction with a nutrient-dense nutritional plan.
Creatine has shown cognitive and mood benefits; a 2022 meta-analysis showed that creatine in doses greater than 5 g per day was associated with improved cognition. Supplementation with vitamins D, C, and B is important in providing foundational support.
The addition of soy isoflavones and soy products (tofu, tempeh, or fermented soy products), whether through food or supplementation, has been shown to reduce the symptoms of hot flashes. Soymilk isoflavones for 3 months of treatment may be a safe and effective alternative therapy for menopausal symptoms and may offer a benefit to enhance antioxidant status to improve women's health and quality of life.
A diet rich in plant-based and lean protein (0.8–1.2 g/kg/day), essential vitamins (D, C, and B vitamins), and omega-3 fatty acids supports hormonal and metabolic health. Consuming at least five portions of fruits and vegetables daily (approximately 500 g) ensures adequate intake of antioxidants, vitamins, and fibre, while incorporating legumes weekly and whole grains daily promotes gut and heart health. Fibre intake should be 30–45 g per day, with an emphasis on whole grains and fibre-rich foods.
LIFESTYLE MODIFICATIONS
Lifestyle modifications such as exercise are important for improving cognitive health and weight balance. Exercising more than 150 minutes per week, maintaining weight (BMI 18.5–25), maintaining social connections, and engaging in brain exercises can all support both mental and physical changes in perimenopause.
Sleep is an integral part of lifestyle modifications. There is a new onset of sleep disorders that are common in the menopause transition affecting 40–69 percent of women—the hallmark symptom being frequent waking. Creating calm environments, and engaging in pre-sleep activities such as meditation, stretching, or journaling can help support better sleep; the recommended sleep duration is a minimum of 8 hours. Both eating and sleep habits drive the circadian rhythm, which balances energy and wellness. Sleep deprivation itself affects energy intake, glucose uptake, and leptin resistance leading to a worsening of perimenopausal symptoms.
Therapies that can be utilised for ongoing mental and physical support include cognitive behavioural therapy, acupuncture, massage, and art therapy depending on the individual’s interest.
Managing perimenopausal burnout requires a comprehensive approach to diet, lifestyle, and overall well-being. Prioritising a healthy balanced eating schedule and avoiding simple sugars, sugary drinks, and alcohol, can help stabilise energy levels and reduce strain on the body.
A smoke-free lifestyle, paired with regular physical activity, is also crucial for maintaining energy and overall well-being during this transitional phase.
