Takeaway
Make perimenopause a routine part of midlife care: normalize symptoms, screen for sleep disturbance, mood changes, and offer evidence-based hormonal and non-hormonal treatment options. If needed, refer to a certified menopause specialist.
Lifelong Learning in Clinical Excellence | November 20, 2025 | 3 min read
By Ashley Gordon-Phillips, MD, MPH. Johns Hopkins Medicine
“I feel like I’m going crazy.”
“I just don’t feel like myself.”
“I feel like my body is against me.”
As a women’s health physician, I hear these phrases frequently from women in their 40s. While a lot of work has been done to encourage parents to discuss changing bodies with their pre-teens (Remember “The Care and Keeping of You” from “American Girl”?), the same push hasn’t been made to encourage older parents to discuss changing bodies with their adult children.
For a long time, menopause has been brushed under the rug and is something women are told to just “get through.” But the changes that come with the menopause transition can range from irritating to life-altering, and we’re just not prepared. The Women Living Better Survey asked participants to think back to when they were 30 years old and when they expected they would start having symptoms of menopause: 59% expected symptoms of menopause to start at age 50 or later. However, most people start experiencing menopausal symptoms in their mid-40s, so it often comes as a surprise. It is our responsibility as physicians to have “The Talk” with our patients and prepare them for this next stage of life.
What is perimenopause?
While we have all heard of “menopause,” “perimenopause” might be a less familiar term. Basically, perimenopause is the period before women have their final menstrual cycle. Perimenopause starts when estradiol levels (the type of estrogen made by the ovaries) start to decrease. In early perimenopause, menstrual cycles start to vary in length, often with longer periods of bleeding. Eventually, women will reach late perimenopause where we start to see skipped cycles, usually going more than 60 days between periods until they stop completely. Twelve months after this final menstrual period, we consider women to be “post-menopausal.” The amount of time women spend in perimenopause, leading up to their final period, varies but on average is about four to six years.
What are the symptoms of perimenopause?
A better question would be—what aren’t the symptoms of perimenopause? There are estrogen receptors all over the body, and when estradiol levels start to drop, the changes can be felt almost everywhere. However, the most common symptoms are:
1. Hot flashes and night sweats
2. Changes in sleep
3. Changes in mood
4. Brain fog and forgetfulness
5. Weight gain
6. Vaginal dryness, pain with sex
7. Decreased libido
How can we support our patients?
Talk to your patients about perimenopause! Comprehensive primary care teaches us to counsel our patients on fertility goals, contraception, and taking a sexual health history—we can include menopause as part of these conversations. Consider these four talking points when discussing perimenopause with your patients:
1. Symptoms can start early—even before the mid-40s.
While most people start having symptoms in their mid-40s, some can have symptoms even earlier. This is a natural, gradual change that happens over time. Ask patients if they’ve noticed changes to their body so you can keep track together.
2. Encourage patients to keep track of their menstrual cycles.
Using a period-tracking app, or even just recording cycle start and stop dates on a calendar, can make it clear when cycles start to change length and become irregular. Knowledge is power!
3. Symptoms are different for everyone.
Symptoms are different for everyone, but review the most common ones mentioned above with your patients, so they know what to look out for.
4. Remind patients that they don’t have to grin and bear it.
We can treat perimenopausal symptoms using both hormonal and non-hormonal therapies. If you’re stumped, find a women’s health physician to consult with. We ‘re always happy to see your patient for a women’s health consult at the Women’s Wellness and Healthy Aging Program!
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This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.