Mood swings. Unpredictable periods. Weight fluctuations. Trouble sleeping. But it’s not puberty. It’s not pregnancy. This time, it’s perimenopause. And doctors’ advice for how to manage perimenopause and menopause is changing.
“Everyone is talking about perimenopause these days,” says JoAnn V. Pinkerton, MD, UVA Health’s Director of Midlife Health and the emeritus executive director of the North American Menopause Society. That’s because, at the end of 2025, the federal Food and Drug Administration (FDA) made some long-awaited changes that will have a significant impact on managing perimenopause and menopause for a new generation.
At a Glance
- Perimenopause generally begins in the late 30s or early 40s.
- Symptoms of perimenopause include changes menstrual cycle, trouble sleeping, weight gain, hot flashes, mood swings, and brain fog.
- Cutting back on alcohol, getting enough sleep, exercising regularly, and eating enough protein can help manage symptoms and energy levels during perimenopause.
- FDA guidelines around hormone replacement therapy (HRT) changed in 2025.
- Taking hormonal birth control during perimenopause or estrogen after menopause can help manage symptoms with no increased risk of breast cancer, uterine cancer, or mortality.
- Talk with your doctor about medical and non-medical interventions for managing perimenopause and menopause.
What Is Perimenopause?
Menopause is the stage of life when a woman’s menstrual periods have permanently stopped and she can no longer become pregnant. The average age of menopause in the United States is 51, though it can happen earlier or later. Perimenopause, also known as the menopausal transition, is the time leading up to this point when a woman’s hormones and periods are changing in preparation for periods ending. This phase of life is natural, yet often misunderstood, and can feel disruptive, confusing, and even isolating for many women.
If it has been 12 months since your last period, perimenopause is over, and you’re officially in menopause. But it’s much harder to pinpoint when perimenopause begins.
Many women begin noticing changes in their late 30s or early 40s. Common symptoms of perimenopause include:
- Changes in menstrual cycle
- Trouble sleeping
- Night sweats and hot flashes
- Weight gain, especially around the abdomen
Other symptoms can include mood swings, brain fog, fatigue, pain or stiffness around the shoulder joint, sore breasts, low sex drive, headaches, and nausea.
Managing Perimenopause
If you are in your late 30s or 40s and experiencing symptoms related to perimenopause, Dr. Pinkerton recommends starting with lifestyle changes, such as limiting alcohol and stress management. Small, consistent habits often produce more sustainable improvements than drastic overhauls. As a starting point, she recommends:
- Regular exercise: 150 minutes per week of vigorous activity, plus weight work to improve muscle mass
- Sleep: At least 7 hours of sleep per night
- Protein: Getting enough at each meal to keep blood sugar regulated
These lifestyle changes can be difficult to implement, Dr. Pinkerton acknowledges, particularly during midlife when work and family responsibilities are so demanding. But keeping yourself healthy is what helps you keep all those plates in the air.
“Have plan A, get to the gym,” Pinkerton suggests. “But also have plan B, [which could be] jogging to work, having walking meetings during the day, or keeping exercise bands at home. Figure out how to work around injuries or joint pain. Find a way to continue even when things are tough or irregular.”
Once lifestyle factors are addressed, Pinkerton works with patients to tackle more specific issues they’re experiencing, such as heavy breathing or loss of libido.
Hormones, often in the form of birth control, can play a part in managing these symptoms. “Contraception can serve as cycle control during perimenopause,” Pinkerton explains. “For many women, issues are [happening] just before their period, so we might use just progesterone in the second half of their cycle.”
She also points out that women in perimenopause may benefit from taking hormonal birth control for a more basic reason: contraception. “Many women in their 40s think they don’t need to worry about pregnancy anymore,” says Pinkerton. “But it can still happen, even with the hormone fluctuations.”
Hormone Replacement Therapy & the New Menopause Treatment
For years, taking hormones during perimenopause or menopause was considered risky for patients.
“Back in 2002, a very large women’s health study was published, and it raised questions about risks [associated with hormone replacement therapy],” says Pinkerton. Those risks especially centered around hormone replacement therapy (HRT) being linked to heart disease and certain cancers. “Fear began driving the conversation about hormone replacement therapy for both patients and providers.”
In the 2002 study, the majority of women were age 63 and taking oral hormone therapy, primarily progesterone. But the warning was applied to all types of HRT for all patients.
However, in November of 2025, the FDA removed the warning on all estrogen products. Providers are now talking with their patients about the nuances and benefits that can come with HRT. These changes have helped shift the conversation from fear and avoidance to education and informed choice.
Important: Women who have a history of postpartum depression or PMS are at greater risk for mood disorders during perimenopause and menopause. If you have a history of depression or anxiety, talk to your provider to learn about warning signs and come up with a management plan.
Taking local vaginal estrogen, for example, can help women manage symptoms of painful sex, low sex drive, or bladder infections. And patients who take it show no increased risk of breast cancer, uterine cancer, or mortality.
“If you’re under age 60 or within 10 years of menopause, it’s much safer than people initially thought,” Pinkerton explains. “For women 50-59, the health outcomes are more favorable with HRT… Estrogen in this study was better for younger women. In the long-term followup, if you used estrogen, you were actually at less risk for breast cancer.”
“The message that I want to get out is that the risk is very low using systemic treatment if you’re young and healthy,” Pinkerton adds. “The risks are greater if you start treatment when you’re older… Women and their providers need to get into a detailed family history and have an individualized discussion of benefits and risks.”
When To Talk to Your Provider
When it comes to managing perimenopause and menopause, there’s never a wrong time to speak with your doctor. Dr. Pinkerton often sees patients in their 40s who don’t feel like they used to, even if they don’t have a specific complaint.
“Women in their 40s have so many demands on them. You have busy kids, aging parents, and work. Your plate is overflowing, and your body is changing,” says Pinkerton. “When you are overworked and stressed, your ovaries don’t work as well. It’s often hard to tease out what is perimenopause versus lifestyle.”
No matter what you are experiencing, if you are struggling, Dr. Pinkerton recommends talking to your doctor to create a management plan. Hormone-testing to confirm perimenopause, HRT, and supplemental treatments such as magnesium can all be part of helping women thrive during this transitional time in their lives. Whether you’re noticing hot flashes or changes in your mood, libido, or stress levels, Pinkerton urges, “Don’t push through. Ask for help.”
With better research, clearer guidance, and more open conversations about how to manage perimenopause, women today have more options and more support than ever before. Dr. Pinkerton wants women to know that, once you get through the transition into menopause, things settle back down.
“Perimenopause is really the difficult time. [But] the decision about [using] hormones for hot flashes isn’t the hard part. The hard part is prioritizing yourself during a busy time of life.”
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KATHARINE PALJUG is a freelance writer and novelist who lives in Charlottesville with two busy kids. She is a big fan of public libraries, homemade muffins, and inclusive spaces for queer families.