There is a moment women reach when something begins to feel different. They may find themselves wondering, “What is happening to me?”
Written by Laura Wade
Perimenopause, the hormonal transition leading up to menopause, typically begins in a woman’s 40s, though for some women it starts earlier. During this phase, estrogen and progesterone fluctuate unpredictably, affecting nearly every system in the body. As women move through this transition, there can also be metabolic shifts, including increased insulin resistance, changes in body composition, bone density loss, and elevated cardiovascular risk.
Although a completely natural phase of life, many women feel blindsided by it. Symptoms can include hot flashes, night sweats, anxiety, insomnia, brain fog, joint pain, painful intercourse, vaginal dryness, mood swings, weight changes, and shifts in libido.
While some experience some similar symptoms—hot flashes, forgetfulness, and mood swings—each woman’s experience is unique. Some women move through this transition with minimal disruption, while others feel deeply affected physically, emotionally, and cognitively. Changes in libido are not uncommon and impacts vary widely. Some women experience extreme dips in desire; others notice little change at all.
One of the most disruptive symptoms is the hot flash itself. Women often describe it as feeling like they are “baking from the inside.” The heat can rise suddenly through the chest, neck, and face, leaving them flushed, drenched in sweat, and desperate for relief. Women often begin dressing in layers or carrying handheld fans everywhere they go simply to cope with the unpredictability.
Morgan Blankenship, 44, shared that she began suffering from severe hot flashes at 42. She would wake 15 to 20 times per night, sweating and feeling flushed as waves of heat spread throughout her body.
“My husband told me he thought my thermostat was broken,” she said, “because my temperature would suddenly heat up so much, he could feel it when his hand was resting on me. Then 10 minutes later, I would be cold.”
Cognitive and emotional shifts can be unsettling. Forgetting words mid-sentence or feeling less focused are not uncommon. Neither is being emotionally reactive or sensitive to stress. It is partly this unpredictability that can leave women exhausted and emotionally depleted, especially when sleep becomes fragmented night after night.
Women sometimes dismiss these symptoms as signs of being overwhelmed or busy.
Dr. Manjusha Sahni, FACOG and physician specializing in menopause care at Carilion Clinic explained, “These symptoms are real, they are not imagined, and they deserve treatment.”
One of the biggest misconceptions surrounding perimenopause is that extensive hormone testing is required for diagnosis. There is no single lab test that definitively diagnoses perimenopause. Hormone levels fluctuate dramatically during this transition, often changing day to day. Diagnosis is largely clinical based on age, menstrual changes, symptoms, and overall health history.
“We all get so caught up in hormone testing and ordering labs that sometimes we lose sight of the patient and their life. These women are not simply a set of labs,” said Dr. Ariel Brooks, DABOM, MSCP and CEO and Founder of Asklia Concierge and Metabolic Medicine.
That perspective feels incredibly important because women deserve to feel heard, not dismissed or reduced to numbers on a chart.
While hormone testing may not diagnose perimenopause itself, healthcare providers may still recommend blood work to rule out other conditions that can mimic similar symptoms. Thyroid disorders, anemia, vitamin deficiencies, insulin resistance, or blood sugar imbalances can all contribute to fatigue, mood changes, brain fog, and weight fluctuations. Looking at the whole picture matters. That is where the conversation around perimenopause is beginning to shift in a healthier direction—not simply toward symptom management, but toward a more holistic understanding of women’s health during midlife.
Before discussing medications or supplements, there are additional considerations that matter deeply: sleep, stress management, nutrition, movement, and nervous system support. They are the backbone of good health during this transition.
Patrice Freeland, Holistic Wellness Practitioner, Wonderful Land of Oils shared that one of the greatest shifts in her own journey came from reducing “the things that were making my body work harder—stress, sugar, and toxins—in that order.”
She began incorporating mindfulness, Reiki, movement, sunlight, strength training, and essential oils to support her emotional and physical well-being. “Getting 15 minutes of sunlight and some type of exercise every day is critical to my mental health,” she explained. “Doing strength training several times a week also helps reduce the weight gain and will ensure that I keep my bones strong.”
Dr. Brooks echoes the importance of good lifestyle practices, particularly sleep and exercise. Prioritizing sleep becomes essential, especially for women experiencing hot flashes or the dreaded 2–3 a.m. wake-up that so many women describe. Resistance training also plays a key role—not only for weight management, but for preserving muscle mass, supporting metabolism, protecting bone density, and supporting mental health.
Good nutrition is key. Blood sugar balance becomes increasingly important during this phase of life. Protein, fiber, healthy fats, and nutrient-dense foods support both hormones and brain health.
Freeland describes intentionally planning meals around her schedule, reducing processed foods and sugar, and increasing fresh foods and healthy fats to support her energy and overall well-being. She suggests that women explore ways to reduce their toxic load by switching to cleaner home, skincare, and personal care products and reducing plastics and environmental chemicals where possible.
When it comes to treatment options, women today have far more choices than they did even a decade ago. Hormone therapy with estrogen and/or progesterone remains an effective evidence-based treatment for many perimenopause and menopause symptoms. It can significantly reduce hot flashes, night sweats, sleep disruption, vaginal dryness, mood symptoms, and may also help preserve bone density.
At the same time, treatment must be individualized. Hormone therapy is not right for every woman, particularly those with certain medical histories such as breast cancer, blood clots, stroke, or significant cardiovascular disease.
Dr. Sahni explains that fear surrounding hormone therapy still lingers because of the 2002 Women’s Health Initiative study, which linked some hormone therapies to increased risks of breast cancer, stroke, and blood clots. She adds that later research added critical context: Several women in that study were already in their 60s and 70s and were given only a specific oral formulation of hormones.
Dr. Sahni said evidence suggests that for healthy women under 60 or within 10 years of menopause appropriately prescribed hormone therapy can be both safe and highly effective. Newer non-oral delivery methods such as patches, gels, sprays, and rings often offer a more favorable risk profile than older oral formulations.
For women who either cannot or prefer not to use hormones, there are increasingly effective non-hormonal options available as well. It is best to ask your doctor about recently approved medications that can target hot flashes through non-hormonal pathways as well as other medications that have shown benefits for symptom management.
Beyond medication, therapies such as cognitive behavioral therapy and clinical hypnosis have demonstrated meaningful improvements in sleep and women’s ability to cope with hot flashes and anxiety. While evidence surrounding some alternative therapies remains mixed, many women find practices like acupuncture, Reiki, massage, breathwork, meditation, and essential oils supportive.
Freeland uses oils such as Clary Sage, Copaiba, Frankincense, Neroli, Jasmine, and Grapefruit to support mood, anxiety, and hormone balance during symptom flares.
Another important concern is vaginal and pelvic health. Dr. Brooks emphasizes that vaginal estrogen deserves far more attention and should be considered proactively rather than after symptoms become severe. Supporting vaginal tissue health early can help prevent dryness, painful intercourse, and recurrent urinary tract infections that often emerge during this transition.
What matters most in all of this is remembering that there is no single right way to move through perimenopause. Some women feel best with hormone therapy. Others prefer non-hormonal support. Many find the greatest benefit through a thoughtful combination of medical care, lifestyle shifts, emotional support, and holistic practices.
As Freeland beautifully reminded us, “Each woman is different, and your perimenopause journey will be, too. You are your best advocate.”
And perhaps that is the deeper invitation hidden within this transition.
Not simply to survive changing hormones, but to reconnect with yourself in a new way. To listen more closely to your body. To care for yourself with greater compassion. To ask what truly supports your wellbeing physically, emotionally, mentally, and spiritually.
Your body is not betraying you.
It is asking you to listen.
The story above first appeared in our July/August 2026 issue.
