Understanding of perimenopause has grown significantly in recent years. Across the medical community, clinicians, researchers, and educators are helping to reshape how the menopause transition is recognized and managed. And yet, a considerable knowledge gap remains — even among health care professionals.1
“Having received very limited training in menopause topics, even as a woman, I had to seek out my own training, knowledge, and eventual NAMS [North American Menopause Society] certification,” says Dr. Angela Jones, obstetrician, gynecologist, and attending physician at the Jersey Shore University Medical Center, New Jersey, US. And her experience is far from unique. Only 20% of obstetrics and gynecology residents report that their programs include a formal menopause curriculum, while 83% of program directors identify a need for additional menopause education and resources.2
The reality is, “Perimenopausal symptoms are vast and varied in timing, severity, and type or constellation of symptoms,” says Dr. Sara Twogood, obstetrician and gynecologist at Cedars-Sinai Medical Group, California, US. “If a health care professional does not have perimenopause at the forefront of their mind, it’s common to give each symptom a separate diagnosis instead of a global diagnosis that encompasses it all.” And that can mean patients aren’t getting the support they need when they need it.
With the help of Dr. Jones and Dr. Twogood — who both sit on Flo’s medical advisory board — here we discuss why oversimplified symptom maps and generalized approaches are holding us back when it comes to perimenopause treatment — and how deeper insights and a more nuanced understanding of patients’ midlife changes can transform care.
With limited research to work with, we’re still learning about the complexities of perimenopause.
We know that during perimenopause, estrogen levels (specifically estradiol) fluctuate significantly — and that these fluctuations are linked to a range of symptoms. But due to said fluctuations, women might present with varying symptoms of relative estrogen excess, estrogen insufficiency, or a random mix of both.3
What’s more, newer research suggests that symptoms are not driven by hormone fluctuations alone, but how sensitive an individual is to those fluctuations. Two patients might have similar estrogen fluctuations, but their bodies can respond very differently based on their genetics — further explaining why symptoms can feel unpredictable, disproportionate, or highly individual.4
The Study of Women’s Health Across the Nation has found that menopause symptoms can present differently among different cultures and ethnicities, too. For example, Southeast Asian women may report more forgetfulness, joint and muscle pain, and sexual issues, while Hispanic women are more likely to undergo early or premature menopause.5
The implication for care is clear: We can’t make assumptions, rely on simplified models, or take a one-size-fits-all approach.
"Women's health issues are often minimized, or women are made to feel their symptoms are 'all in their heads," says Dr. Jones, an experience that may be even more likely if their perimenopause trajectory doesn't fit the typical patter. “As clinicians, it is important to listen to what women are saying,” she emphasizes, and to pursue a considered, individualized care plan in response.
Of course, “We also don’t want to run the risk of overdiagnosing perimenopause and missing other important diagnoses,” adds Dr. Twogood. It’s a balance. So, thoughtful evaluation is key, she notes, to distinguishing perimenopause from other, similarly presenting medical conditions.
We know that perimenopause symptoms can vary widely. So let’s take a closer look at some less familiar examples.
“Estrogen receptors are found all over the body; hence, symptoms of perimenopause and menopause can present in a number of ways,” says Dr. Jones. Of course, among the most commonly discussed are unpredictable periods, hot flashes, night sweats, insomnia, brain fog, and vaginal dryness. But Dr. Jones has observed burning mouth syndrome, changes in bowel habits, dry skin, joint pain, and vertigo, too.
Dr. Twogood, meanwhile, highlights anxiety, depression, and disproportionate psychological responses to everyday stressors — as well as a general sense of patients “not feeling like themselves.” Muscle and joint pain, changes in weight and body composition (particularly more weight distribution in the midsection), and sexual concerns (like low sex drive, pain with intercourse, or differences in sexual stimulation) also come up in her practice.
For a fuller picture of perimenopause symptoms, read our breakdown of The emotional and physical impact of perimenopause, insights for OB/GYNs.
Many studies suggest that most women have begun perimenopause by age 45 to 47.6 It can be broadly split into early and late stages, where the early stage is defined by occasional missed cycles or cycle irregularity, and the later stage by greater menstrual irregularity, with longer periods of amenorrhea, ranging from two months to one year, until menopause is confirmed.7
Both Dr. Jones and Dr. Twogood agree that cycle changes are usually the earliest clues they see of perimenopause: shorter or longer cycles, heavier or lighter bleeds, maybe skipped periods on occasion. This is where longitudinal cycle tracking, such as with Flo, can be particularly useful, allowing patients to share logged data rather than relying on memory, providing a more detailed history for clinical review.
But new research from Flo also suggests that symptom patterns may vary by age in ways that hadn’t previously been demonstrated.7 Mood symptoms such as anxiety, irritability, and depressed mood were found to be most prominent in earlier perimenopause (approximately ages 41 to 45), while vasomotor symptoms and other physical complaints, including sleep disruption, musculoskeletal pain, bladder issues, sexual concerns, and vaginal dryness, appear to become more prominent later, closer to and right after menopause (ages 51 to 55).
The research also found that a substantial proportion of women in their 30s reported symptoms aligning with moderate-to-severe menopausal symptom burden, as measured by the Menopause Rating Scale.
If a patient is experiencing perimenopausal symptoms from around their mid-40s, Dr. Twogood describes a stepwise action plan. It starts with getting curious about the symptom presentation and history, ruling out non-perimenopausal causes, and then tailoring management based on how disruptive the symptoms are, ranging from “active monitoring” to hormonal intervention.
“If perimenopause symptoms are occurring prior to the age of 45, a formal workup should be done to distinguish between early menopause and premature ovarian insufficiency,” adds Dr. Jones. “Diagnosis of these are important due to long-term health risks associated with estrogen deficiency such as cardiovascular impact, bone health, and more.”
Staying abreast of the evolving science of perimenopause is vital, but translating that knowledge into meaningful, collaborative consultations with patients is critical, too. Here, Dr. Jones and Dr. Twogood share their top tips.
In a 2022 survey of 947 perimenopausal women, more than 60% said they did not feel informed about menopause at all — a gap that can fuel anxiety, confusion, and delayed care.
“Female physiology needs to be addressed in the 30s as it relates to changes that a woman’s body will experience after the childbearing years,” says Dr. Jones. “Imparting this knowledge early on will make the transitions much smoother, and anticipated. There are lots of conversations around preparing for our first period. There are lots of conversations around preparing for pregnancy. Why not have these same conversations around menopause?”
Patients coming to you about symptoms? Tell them what info you need in advance
In order to rule out other diagnoses and get patients the perimenopause support they need as soon as possible, you need information. But it’s not uncommon for patients to come in with vague or muddled accounts of symptoms.
That’s why Dr. Twogood likes to advise patients to bring in “a written list of concerns and general descriptions of symptoms — including timing, severity, frequency, and where they show up within the menstrual cycle, for example.” Again, a cycle-tracking app can be a really helpful tool here: With Flo, patients can easily download a health report summary of their self-reported symptoms, detailing their last six months’ of logged data and then share it with you to help inform your clinical assessment and care plan for them.
Research shows that women can be reluctant to consult health care professionals about perimenopause.9 Proactive inquiry can help bridge that gap.
“For me, that includes a survey that I give to most of my patients inquiring about their periods and if their cycles are still ‘regular,’ says Dr. Jones. “I inquire about PMS symptoms, mood lability, and if anyone in their circle is impacted by their moods. I ask about sex and how their libido is, how their vaginas are. Specifically, are they as lubricated as usual, or are they drier than usual? I ask about sleep, if women are waking up in the night, and if so, how often.”
Perimenopause conversations can suffer when they’re squeezed into the final minutes of a general wellness visit. As Dr. Twogood points out, offering dedicated appointments for perimenopause concerns can allow for more thorough assessment, education, and shared decision-making.
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Ultimately, perimenopause doesn’t always follow a predictable script. It’s a highly individual transition shaped by various factors. For many health care professionals, the best care involves listening closely, questioning assumptions, and embracing a more nuanced view of midlife reproductive health.
By recognizing atypical presentations, rethinking timelines, and fostering open, informed conversations, clinicians can help patients feel seen, supported, and empowered.
Flo for Perimenopause includes a personalized symptom tracker that allows users to log and monitor symptoms such as hot flashes, mood changes, fatigue, and sleep disturbance over time. In addition, users can monitor cycle irregularity longitudinally. Based on user-reported data, the tool provides a summary view of symptom burden intended to help users recognize patterns and changes during the perimenopausal transition.
Flo for Perimenopause is informed by clinical guidance and developed with input from scientists and medical experts. It is not intended for diagnosis or clinical decision-making, but to support symptom awareness and preparation for clinical discussions.
Flo also provides free, evidence-based patient education resources that health care professionals can share with patients to support engagement between visits. These resources are designed to help patients better understand perimenopause and prepare for clinical conversations about their symptoms.
It’s easy to sign up for your OB-GYN Co-Care Pack from Flo — complete with educational reproductive health leaflets for your practice, Flo Premium discount cards for your patients, and complimentary Flo Premium and branded items for you.
Disclaimer: Flo is an educational tracking tool and is not a licensed medical device, clinical diagnostic tool, or method of birth control. The Flo Health Report and Perimenopause Score are summaries of self-reported user data and should be used to support, not replace, professional clinical judgment. Decisions regarding diagnosis and treatment remain the sole responsibility of the healthcare provider.