The The Only Predictable Thing About Perimenopause Is Unpredictability, Says Dr Marla Shapiro

Perimenopause can be a challenging life transition for primary care physicians to manage and not because of its complexity, but because of its wide variability. In a video interview with Patient Care,© during The Menopause Society's 2025 Annual Meeting, Marla Shapiro, CM, MDCM, CCFP, professor in the department of family and community medicine at the University of Toronto, and a well-recognized medical expert on Canadian network TV, shares practical insights on identifying and understanding this transitional phase.

Shapiro emphasizes a critical point that sets the tone for clinical management: "The only thing that's predictable about perimenopause is the unpredictability of perimenopause." In the short video above, she defines perimenopause, discusses typical age ranges and duration, and explains why recognizing this variability is essential for supporting patients through this transition.

The following transcript has been lightly edited for style.

Patient Care: Could you define perimenopause, including the typical age range and duration that you see in practice?

Marla Shapiro: I often tell women in my practice that the only thing that's predictable about perimenopause is the unpredictability of perimenopause, because each woman's journey is going to be very different, as opposed to the similarity of menopause, marked by a year without menstrual cycles.

So it's a transitional period, and it's that period of time that leads up to menopause, and because it's marked by fluctuating ovarian hormone levels, particularly estrogen and progesterone, it's going to vary from woman to woman. There's no journey, and we often use a staging criteria to try and define whether it's early, mid or late.

It can typically begin in the mid to late 40s. It can last anywhere from four to eight years, but it can start as early as the mid 30s. It can continue into the early 50s. That variability is very common, but we confirm menopause once a woman has gone 12 consecutive months without a menstrual period.

So it is that unpredictable duration of time with unpredictable symptoms that leads up to menopause, which can be very difficult to help a woman navigate, which is why it's important for her to understand that these changes may herald perimenopause, and it's a good time to come in and talk about your symptoms, if you're having any symptoms or are worried about a change in your cycles, the frequency, the duration, or any other adjunctive symptoms that happen as well.

Shapiro offered these key points to remember:

• Wide Age range: While perimenopause typically begins in the mid to late 40s, clinicians should maintain awareness that it can start as early as the mid 30s and continue into the early 50s.
• Variable duration: The perimenopausal transition typically lasts 4-8 years, though this timeline varies significantly among individuals.
• Hormonal fluctuation: Unlike the more predictable hormonal state of menopause, perimenopause is characterized by fluctuating estrogen and progesterone levels, creating variable symptoms.
• Clinical confirmation: Menopause is confirmed retrospectively after 12 consecutive months without a menstrual period—making the perimenopausal phase a diagnosis based on clinical presentation rather than a specific endpoint.
• Patient communication: Normalizing the unpredictability of this transition helps set appropriate expectations and encourages patients to report changes early.

Coming Next: In Segment 2, Dr. Shapiro discusses the subtle early symptoms that primary care clinicians often miss or misattribute to other conditions, including sleep disturbances, mood changes, and joint pain.