Marla Shapiro, CM‎, MDCM, on Recognizing Early Perimenopause: Sleep, Mood, and Other Missed Clues

For many women, the transition into menopause begins years before their final menstrual period—yet the early, often nonspecific symptoms of perimenopause are easily overlooked in primary care. As Marla Shapiro, CM‎, MDCM, CCFP, MHSC, notes, changes in menstrual frequency and flow are expected, but the earliest manifestations are frequently less obvious and more diffuse. Sleep disturbance, for example, is one of the most common but underrecognized symptoms. Fragmented or nonrestorative sleep may precede overt vasomotor symptoms by several years and is reported by up to 40% of women in early perimenopause.¹˒²

Mood changes are another subtle sign. Transient anxiety, irritability, or mood lability may be attributed to life stress or depression rather than to fluctuating ovarian hormones.³ Similarly, worsening premenstrual symptoms or new-onset joint discomfort can reflect hormonal variability during this stage.⁴ Vasomotor symptoms, when present, may be mild or intermittent and thus dismissed or misattributed to thyroid dysfunction or anxiety.⁵

Recognizing this constellation of symptoms as possible indicators of perimenopause can change the clinical conversation. Early identification allows for patient education, reassurance, and management strategies tailored to individual symptom burden and risk profile—including discussion of sleep hygiene, mental health support, and, when appropriate, hormonal or nonhormonal options for symptom control.⁶

Shapiro, professor in the department of family and community medicine at the University of Toronto, emphasizes that clinicians who "open the door" to considering perimenopause create opportunities for meaningful dialogue and proactive care during a life stage that is often misunderstood or minimized.

References

1. Kravitz HM, Janssen I, Santoro N, et al. Sleep difficulty in women at midlife: a community survey. Menopause. 2003;10(1):19–28.

2. Baker FC, Lampio L, Saaresranta T, Polo-Kantola P. Sleep and sleep disorders in the menopausal transition. Sleep Med Clin. 2018;13(3):443–456.

3. Freeman EW, Sammel MD, Lin H, et al. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Arch Gen Psychiatry. 2006;63(4):375–382.

4. Lu CB, Liu PF, Zhou YS, et al. Musculoskeletal pain during the menopausal transition: a systematic review and meta-analysis. Neural Plast. 2020;2020:8842110.

5. DePree B, Shiozawa A, King D, et al. Association of menopausal vasomotor symptom severity with sleep and work impairments: a US survey. Menopause. 2023;30(9):887–897.

6. The North American Menopause Society. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017;24(7):728–753.