Perimenopause: the underestimated early stage of the menopause

In our natural, regular cycle – before hormonal changes begin – one or more eggs mature in the follicles month after month. The process is predictable:

• During the first phase of the cycle, oestrogen levels rise
• After ovulation, progesterone production increases
• Both hormones prepare the body for a possible pregnancy.

These hormonal fluctuations can also affect performance, energy levels and recovery, which is why cycle-based training takes into account the different hormonal conditions of each phase of the cycle.

During perimenopause ovarian function gradually declines; fewer and fewer follicles containing fertile eggs mature and ovulation becomes less frequent. Progesterone levels often fall early on in perimenopause whilst oestrogen levels can fluctuate significantly before eventually declining permanently. As the hormonal changes progress, many cycles eventually become anovulatory — that is, they occur without ovulation at all.

The menstrual cycle can change progressively during perimenopause. During the early transitional phase, the cycle often remains regular for many people; however, as hormonal changes intensify, fluctuations become increasingly common as perimenopause progresses: bleeding may be heavier or lighter, shorter or longer, or may occasionally cease altogether.

Later transitional phase of perimenopause

In the later stages of perimenopause a marked oestrogen deficiency becomes apparent, which ovarian function can no longer fully compensate for. Symptoms become more pronounced and bone mineral loss also becomes measurable.

Oestrogen influences the nervous system, metabolism, temperature regulation, muscle and bone health as well as sleep and mood, whilst progesterone has a calming effect and supports stress regulation. Fluctuating hormone levels make the nervous system more sensitive, which affects sleep quality, energy levels, concentration and emotional resilience.

Periods without menstruation often lengthen to over 60 d in the later stages of the transition phase; FSH levels rise, progesterone levels fall and ovulation becomes less frequent – however, spontaneous ovulation and therefore theoretical fertility remain possible right up until the last menstrual period.

The duration and severity of symptoms depend on age, BMI, smoking and genetic predisposition.

Particularly during perimenopause, discomforts and symptoms often increase significantly and may occur more frequently or with greater intensity. The hormonal changes affect many areas of the body – from changes to the menstrual cycle and sleep problems, through mood, energy levels and metabolism, to the skin and hair. It's also typical for the symptoms not to occur constantly, but rather to fluctuate greatly in intensity and severity throughout the course of perimenopause.

Changes to your period

Disruptions and changes to your natural cycle can occur during the menopause, but they don't have to appear at the start of the perimenopause. Your cycle may change, yet you may already be experiencing a wide range of other symptoms and be well into the perimenopause before your periods actually become irregular.

Although changes to your cycle can, in principle, occur at any stage of life – for example, due to stress or lack of sleep – for some people they may also be part of perimenopause. Typical signs in this case include:

• First missed period
• Fluctuations in cycle length (shorter or longer than usual)
• Changes in the heaviness of bleeding (heavier or lighter)
• Irregular ovulation or even anovulatory cycles

Sleep disturbances

Sleep disturbances become more common from your 40s onwards and often intensify during perimenopause. When combined with hot flushes, they can make it hard to stay asleep and leave you feeling restless.

During sleep, important regenerative and processing processes take place in the brain: synaptic connections are reorganised and neural networks are regulated. Without restful sleep, new information is processed and saved less effectively – the brain feels downright ‘foggy’. Alongside this ‘brain fog’, typical symptoms include concentration problems, inner restlessness and reduced resilience to stress the following day.

To help rebalance your hormonally and neurologically overloaded system, focus above all on improving your sleep quality and stabilising your energy and stress levels (see the chapter ‘Coping with perimenopause: the most important strategies for women’). If you want to work specifically on your sleep, our online prevention course ‘Sleep better – at every stage of life’ will guide you with practical strategies and exercises.

Hot flushes

Hot flushes are among the most common vasomotor symptoms of the menopause. They can occur as early as the perimenopause, but for many people their frequency and intensity only increase later on during the hormonal transition phase.

Factors such as smoking, high body weight, stress, anxiety or depressive moods can exacerbate the symptoms. For some people they're only temporary, while for others they can persist for many years.

Mood swings and low energy

During perimenopause emotional strain, increased irritability and mood swings can become more pronounced. As the hormonal changes progress some people also experience depressive moods, anxiety, low energy and tiredness. Those with chronically high stress levels, sleep problems or little social support are particularly affected.

There's no definitive test for perimenopause, but you can recognise the first signs of hormonal change by spotting certain symptoms:

• Irregular periods and varying cycle lengths
• Heavier or lighter bleeding
• Sleep disturbances
• Hot flushes
• Mood swings

These symptoms don’t automatically indicate perimenopause. A medical assessment is necessary: hormones such as FSH, oestradiol and AMH (anti-Müllerian hormone, a marker of ovarian reserve) provide a more accurate picture.

The overall picture, comprising symptoms, menstrual cycle patterns and laboratory results, is always decisive.

Perimenopause is a phase characterised by symptoms that vary from person to person. Nevertheless, it needn’t be a phase to be ‘afraid’ of – with a few symptom-focused approaches, we can specifically improve quality of life and make the most of the period surrounding the menopause.

Focus on four key areas: exercise and strength training (including fascia training), diet, sleep and stress management and medication options.

Strength training for muscle and bone maintenance

Strength training is beneficial at every stage of life – but particularly during perimenopause and the years that follow, falling oestrogen levels lead to an accelerated loss of bone density and muscle mass.

Studies show that, due to falling oestrogen levels, people in this phase lose up to 10% of their bone mass whilst simultaneously experiencing a decline in strength and muscle mass. Perimenopause is therefore a critical window of opportunity to take preventive measures – and to counteract these structural losses through intensive strength training.

Current research indicates that progressive strength training is a highly effective non-pharmacological strategy for slowing muscle and bone loss during perimenopause. Follow these recommendations:

• 2–3 strength training sessions per week in the form of a full-body workout
• Leave at least 48 h for recovery between sessions.
• High mechanical loads of approximately 70–85% of maximum strength (a perceived exertion of around 7 or 8 on a scale of 1–10) are particularly effective.

Research shows that these intensities have a greater effect on muscle strength and bone structure than moderate training. Seek guidance from a qualified professional to learn correct technique and minimise the risk of injury.

Moderate strength training is also beneficial — particularly for beginners, older people or those returning after a break — so increase the workload gradually and train regularly, tailoring sessions to your needs.

Think long term: it takes the body around 6–12 months to show structural changes.

Exercise and fascia training

Regular physical activity is one of the most important non-pharmacological strategies for alleviating symptoms during the perimenopause. Both aerobic exercise (swimming, cycling, brisk walking) and strength training have positive effects.

Regular training (i.e. at least 3–4 sessions per week over a period of at least 3 months) can reduce symptoms such as sleep disturbances, low mood and fatigue. Various guidelines, such as those from the American College of Sports Medicine, recommend a combination of endurance and strength training, supplemented by mobility and balance exercises.

Include fascia and mobility work: myofascial techniques such as foam rolling, dynamic stretching and bouncing mobilisation exercises can improve mobility, reduce muscular stiffness and relieve pain. Compact tools such as the BLACKROLL Mini Ball and the BLACKROLL Standard Foam Roller are particularly helpful here. Use them to target muscular tension, improve mobility and support recovery.

During perimenopause, when joint and muscle discomfort becomes more common, this approach can complement your strength and endurance work.

Diet: Protein and an anti-inflammatory diet

A protein-rich, balanced diet plays a key role during the peri- and post-menopausal periods, as the age- and hormone-related loss of muscle mass (sarcopenia) can be accelerated. An adequate protein intake helps maintain muscle tissue, promotes recovery after exercise and counteracts the loss of strength in everyday life.

Spread your protein intake evenly throughout the day (e.g. 20–30 g of protein per meal). Aim to consume around 1.2 to 1.6 g of protein per kg of body weight per day, especially if you're physically active.

Focus on an anti-inflammatory diet: eat plenty of vegetables, fruit, whole grains, pulses, nuts and high-quality fats such as omega-3 fatty acids to help reduce systemic inflammation and ease symptoms like tiredness or metabolic changes.

Sleep and stress management

Sleep and effective stress management are important during the peri- and post-menopausal periods, as hormonal fluctuations can make you more sensitive. Increased stress levels — and chronic stress in particular — are very often accompanied by sleep problems, inner restlessness and low energy levels.

An important marker here is heart rate variability (HRV), which reflects the body’s ability to adapt to stress. Measures such as regular sleep patterns, exercise, breathing exercises or relaxation techniques can help to improve stress regulation and stabilise sleep quality.

Medication options: HRT and herbal remedies

According to studies, hormone replacement therapy (HRT) can be used effectively to treat typical symptoms such as hot flushes, sleep disturbances and menstrual problems. It primarily involves the use of oestrogens (as the main active ingredient) and — depending on the status of the uterus — additional progestogens or progesterone to stabilise hormone levels and protect the endometrium.

We'll tailor the dose to you, aiming to smooth out sharp hormonal fluctuations. You'll usually take it continuously and, if needed, we can combine it with contraception.

Alternative pharmacological options include antidepressants such as SSRIs (selective serotonin reuptake inhibitors), topical oestrogens, gabapentin or melatonin, which may help with hot flushes, low mood, vaginal dryness or sleep problems depending on your symptoms.