The transition has stages. So should your care.
A clinical guide to understanding where you are in the menopausal transition, what symptoms are expected, when they warrant evaluation, and how STRAW+10 staging helps your physician determine the right time for treatment.
Perimenopause is the transitional period preceding menopause, defined by the STRAW+10 staging system as Stages -2 (early transition) and -1 (late transition). It typically begins in the mid-40s but can start as early as the late 30s, and lasts an average of 4–8 years. Symptoms include menstrual irregularity, vasomotor symptoms (hot flashes, night sweats), sleep disruption, mood changes, vaginal dryness, and cognitive changes. Perimenopause is a clinical diagnosis based on menstrual pattern changes and symptoms — routine hormone testing is generally not recommended for women over 45 because hormone levels fluctuate too much to be diagnostically reliable NAMS 2022. When symptoms significantly affect quality of life, evaluation by a physician with menopause expertise is warranted to discuss treatment options including whether HRT is appropriate. At Broad Medical Group, Dr. Jennifer Broad uses STRAW+10 staging to precisely assess each patient’s position in the transition and determine optimal treatment timing. For a complete guide to HRT candidacy, risk-benefit, and treatment options, see our Menopause & HRT Evidence-Based Guide.
Most people think of menopause as an event — you stop having periods. In reality, the most symptomatic phase is the transition that precedes it. Perimenopause is when hormone levels fluctuate most dramatically, menstrual patterns change, and symptoms like hot flashes, sleep disruption, and mood changes typically begin. By the time you reach menopause itself (12 months without a period), the most turbulent hormonal phase may already be behind you.
The term “perimenopause” literally means “around menopause.” Under the STRAW+10 staging system, it encompasses two distinct phases:
Your menstrual cycles begin to vary in length by 7 or more days compared to your established pattern. You might have a 24-day cycle followed by a 35-day cycle. Periods may become heavier or lighter than usual. FSH levels begin to rise but fluctuate significantly. This is often the first clinically recognizable sign of the transition.
You begin to skip periods entirely, with intervals of 60 or more days of amenorrhea. FSH levels are more consistently elevated (>25 IU/L). Vasomotor symptoms (hot flashes, night sweats) are most common in this stage. This phase typically lasts 1–3 years before the final menstrual period.
You can still get pregnant during perimenopause. Until you have gone 12 consecutive months without a period, ovulation may still occur irregularly. If pregnancy is not desired, contraception should be continued until menopause is confirmed. Discuss contraceptive options with Dr. Broad at your evaluation.
Perimenopause affects virtually every system influenced by estrogen — which is most of them. The symptom experience varies enormously between individuals. Some women have minimal symptoms; others experience significant disruption to sleep, work, mood, and relationships. Recognizing these symptoms as part of the transition — rather than dismissing them — is the first step toward effective management.
Track your periods before your appointment. The most valuable diagnostic information you can bring to Dr. Broad is a record of your menstrual cycles — dates, duration, flow intensity, and any spotting. A pattern of increasing variability (≥7 days difference from your normal cycle) is the clinical hallmark of early perimenopause. A simple calendar or period-tracking app is sufficient.
Mild perimenopause symptoms that don’t significantly affect daily life may not require medical intervention. But when symptoms disrupt your sleep, work, relationships, or overall wellbeing, evaluation is warranted. And some symptoms — particularly abnormal bleeding patterns — require evaluation regardless of severity.
Abnormal uterine bleeding during perimenopause should not be assumed to be “just the transition.” While irregular cycles are expected, heavy bleeding, intermenstrual bleeding, and postcoital bleeding can indicate endometrial hyperplasia, polyps, fibroids, or other conditions that require evaluation. An endometrial biopsy or transvaginal ultrasound may be recommended depending on the bleeding pattern and risk factors.
If you are reading this and recognizing your own experience, the next question is: what are my options? The answer depends on your symptom severity, where you are in the STRAW+10 staging, your health profile, and your preferences. Our comprehensive guide to treatment options — including HRT candidacy, risk-benefit analysis, non-hormonal alternatives, and monitoring protocols — is here:
If perimenopause symptoms are affecting your quality of life, you deserve more than “it’s just your age.” Dr. Broad provides structured evaluation using STRAW+10 staging and evidence-based guidance — whether that means monitoring, treatment, or simply understanding where you are.
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