Perimenopause and Menopause Demystified: What Every Woman Needs to Know

Perimenopause and menopause are topics that more women are talking about openly than ever before—and for good reason. Yet myths, misconceptions and outdated information still leave many feeling confused or alone in their experience. In this article, Dr. John Alton, OB/GYN with Southwest General Medical Group – Women’s Health, cuts through the noise with straightforward answers on everything from symptoms to treatment options.

What Is Perimenopause, Really?

Perimenopause typically begins in the mid-40s and refers to the years-long transition leading up to menopause. Dr. Alton describes it as a kind of reverse puberty. This means a gradual winding down of ovarian function that can be unpredictable from month to month. “Sometimes, the ovaries are acting like they're twenty," he explains. “The next time, they dim. And then the next time, they're not even on.” That inconsistency is what makes perimenopause so difficult to pin down.

Importantly, not every woman experiences significant symptoms. Dr. Alton estimates that about 85 percent of women move through this transition without major complaints. For those who do struggle, symptoms have evolved beyond the classic hot flashes and night sweats. “A lot of women come in just not feeling like themselves,” he notes. Low libido, unexplained weight gain, mood changes and fatigue are now among the most common concerns he hears.

The Weight Gain Question, Answered

Weight gain during perimenopause and menopause is real, and it involves both hormonal changes and the natural effects of aging. As estrogen levels shift, the body compensates by producing a weaker form of estrogen called “estrone” through fat cells. “The body is trying to compensate to make estrone in fat cells to help get through menopause,” Dr. Alton explains. “That's the body's way of doing it, although that hormone is not a very good one.”

His approach to weight management centers on resistance training and, what he calls, mindful eating. Three components he often recommends to patients include tracking caloric intake, prioritizing protein and incorporating intermittent fasting. “You can't really exercise yourself to weight loss,” he advises. “Food has to be the key component.” On fasting timelines, he keeps his guidance practical: Start with a 12-hour overnight fast and work up gradually, finding what fits your lifestyle.

Irregular Bleeding: When to Pay Attention

Cycle changes are common in perimenopause, but irregular bleeding always should be discussed with a provider. “If a woman thinks it's abnormal, I think it's abnormal,” Dr. Alton cautions. Irregular bleeding can have multiple causes. Some are benign, some require evaluation for precancerous changes. His philosophy is simple: trust the patient, investigate thoroughly and offer solutions.

Treatment Options: Perimenopause and Beyond

For women still having cycles but experiencing significant symptoms, Dr. Alton frequently turns to low-dose hormonal options, including progesterone-based contraceptives that can help level out hormonal fluctuations and manage related concerns like weight, acne and hair changes.

For women who have reached menopause, which is defined as one full year without a period, hormone replacement therapy (HRT) remains the cornerstone of treatment. Dr. Alton's strong preference is for transdermal delivery, such as patches or creams, over oral hormones.

The reason is twofold. Oral estrogen is processed by the liver, which can increase levels of the less beneficial estrone and increase clotting risk, which transdermal formulations largely avoid. “If you're putting a patch on that's a steady release, you're going to have a lot more steady hormone,” he explains. “And, that's what we're trying to do. Keep things steady."

Beyond symptom relief, hormone therapy is associated with maintained bone density, improved skin hydration, better cholesterol profiles and an overall sense of well-being. “The number one thing about women on hormone replacement is just the sense of well-being,” Dr. Alton shares. “They feel more like themselves.”

Who Should Not Take Hormones?

Hormone therapy is not appropriate for everyone. Women with active breast cancer, active clotting disorders such as DVTs or pulmonary embolism or unexplained abnormal bleeding should not begin hormone therapy until those conditions are fully evaluated and addressed. Women with past histories of these conditions should have individualized conversations with their provider about risk and benefit.

For those who cannot or choose not to use hormones, Dr. Alton emphasizes that options still exist, from non-hormonal prescriptions to nutritional supplements. His guidance on supplements is clear. Give any new supplement a fair trial of about 90 days. If there is no meaningful improvement, it is unlikely to help in the long term.

Clearing Up the Biggest Myth

Perhaps the most important thing Dr. Alton wants women to understand is this: menopause is not a decline. “It's a transition from one part of your life to another,” he emphasizes. “It's not your personality changing. You're being inundated with some hormonal changes that are affecting your attitude and your mood, but those can be adjusted.”

Above all, no woman has to simply endure it. “Even if hormones aren't your gig, there are lots of other options. Finding a provider that works with you is the key,” urges Dr. Alton.

To schedule an appointment with Dr. Alton, visit swgeneral.com.