SMITHFIELD, Va. — Perimenopause can begin as early as age 35, and the symptoms go far beyond hot flashes, but many women never connect what they're feeling to their hormones.
That's according to Riversdie Smithfield Hospital board-certified OB-GYN Dr. Diane Maddela, who says the lack of awareness around perimenopause is leaving women without answers at a critical time in their health.
"Women don't have to struggle," Maddela said. "Women don't have to just relegate to the fact that this is their life now. We have so many effective, science-backed, and safe treatment options for women in this time."
What is perimenopause?
Perimenopause is the phase before menopause when the ovaries begin producing less estradiol, progesterone, and testosterone. It can begin after age 35, though most women experience symptoms after 40.
Menopause itself, Maddela explained, is technically just one day the point after a woman has gone 12 consecutive months without a menstrual cycle. Everything after that is considered post-menopause.
"Menopause is really a day," she said, "but we do use that term a lot to kind of describe post-menopause and perimenopause."
Symptoms extend far beyond hot flashes
While night sweats, hot flashes, and irregular periods are the most commonly recognized symptoms, Maddela said the full picture is much broader.
Because estradiol and progesterone receptors exist in every organ and system in the body, women can experience muscle aches, joint pain, gastrointestinal disturbances, constipation, acid reflux, dry eye, and dry mouth often without realizing those symptoms are hormone-related.
Maddela said new-onset anxiety and difficulty focusing are also common during this transition, and are frequently misattributed to stress or other causes.
"A lot of women don't even realize they're going through perimenopause because they may not be having hot flashes and night sweats," she said.
Mental health and the brain connection
Maddela said perimenopause can significantly worsen pre-existing anxiety, depression, and undiagnosed ADHD.
That's because estradiol plays a direct role in regulating dopamine, serotonin, and norepinephrine, neurotransmitters in the brain that affect mood, focus, and emotional stability.
"It's not unusual to see significant mood disturbances during this period," she said.
Women with a history of anxiety or depression may find those conditions become more severe, while women with undiagnosed ADHD may notice their focus and attention deteriorate more sharply during this time.
Health risks increase during the transition
As estradiol levels decline, Maddela said women face a higher risk for heart disease, diabetes, and high blood pressure making lifestyle choices during this period especially important.
She said strength training and resistance exercise are particularly beneficial because building muscle mass improves insulin sensitivity, which helps the body process glucose more efficiently rather than storing it as fat.
Cardiovascular exercise is also critical, she said, for protecting heart and respiratory health as those risks increase.
Sleep disturbance is often an early warning sign
Sleep disruption is frequently one of the first symptoms women notice in perimenopause, according to Maddela.
She said progesterone, the first hormone to decline, plays a calming role in the brain through GABA receptors, and its loss can trigger insomnia. As estradiol later begins to fluctuate, night sweats can cause women to wake repeatedly throughout the night.
Maddela said the consequences of chronic sleep loss during this phase are serious, linking it to increased risk for obesity, cardiovascular disease, and dementia.
"We don't have that resilience that we used to have in our 20s and 30s to bounce back from two to three hours of sleep," she said. "It just isn't there anymore when we're in our 40s and 50s."
Empowerment through awareness
Maddela said the most important message she wants women to take away is that suffering through perimenopause is not inevitable.
She encouraged women to view this transition as a turning point, a signal from their bodies to reassess lifestyle habits and take their long-term health seriously.
"Who you are right now, whether you be in your 30s, your 40s, your 50s, what is your goal 30 years from now?" she said. "This is the time where women really need to take charge and focus on their health because it is gonna determine where they're gonna be 20 and 30 years from now."
To learn more about perimenopause and menopause, click here.
