Understanding Perimenopause and Menopause
October was Menopause Month, with International Menopause Awareness Day reminding us of the importance of literacy around this profound life stage. Menopause is finally having its moment — a long-overdue focus on women’s health, hormone literacy, and the value of integrative care. Yet, alongside awareness, confusion still lingers. For clinicians and women alike, understanding both the medical and functional perspectives of menopause is essential.
Why Oestrogen Matters Far Beyond Fertility
Oestrogen is a systemic hormone, influencing nearly every body system. Its decline during menopause underpins many of the physical, mental, and metabolic changes women experience.
Neuroprotective – Supports dopamine and serotonin balance, mood regulation, memory, and thermoregulation (reducing hot flushes).
Cardiovascular & metabolic – Enhances endothelial function, reduces cholesterol synthesis, raises HDL, and supports triglyceride metabolism.
Skin & connective tissue – Promotes collagen and elastin; lower oestrogen accelerates visible ageing.
Bone – Essential for bone mineral density (BMD) development and maintenance; bone loss accelerates at menopause.
Symptoms such as vasomotor changes (hot flushes) or poor sleep are more than nuisances — they can indicate increased cardiovascular, bone, and cognitive risks later in life.
Recognising the Transition
Menopause is defined as the final menstrual period, confirmed after 12 months of amenorrhoea, typically between 45–55 years of age (average 50–52). The perimenopausal transition usually begins in the early- to mid-40s and lasts four to six years. Hormone fluctuations cause cycle irregularity, mood shifts, sleep changes, and metabolic adaptations such as central weight redistribution.
In the late reproductive years, subtle changes begin — slightly shorter cycles, heavier bleeding, and gradual shifts in follicle-stimulating hormone (FSH) and oestradiol levels. These are early signs that the hormonal landscape is beginning to change.
When Menopause Comes Early
Premature ovarian insufficiency (POI) occurs before age 40, affecting up to 2% of women, while early menopause refers to onset between 40–45. Both carry heightened risks for cardiovascular, metabolic, bone, and neurological decline.
Timely menopausal hormone therapy (MHT) is life-saving in these cases — delaying or avoiding it can shorten lifespan more than smoking. Women with POI or early menopause should always be co-managed with a menopause-literate GP or specialist.
The Hormone Therapy Story
The 2002 Women’s Health Initiative (WHI) trial led to widespread fear of hormone therapy, after early data linked “HRT” with increased cancer and cardiovascular risk. Later analyses clarified that the findings applied mainly to older women (60+), years post-menopause, using oral conjugated equine oestrogen with synthetic progestins.
Modern evidence paints a different picture:
Body-identical 17β-oestradiol, delivered transdermally (patch or gel), avoids clotting risk and supports brain, bone, and cardiovascular health.
Micronised progesterone (or dydrogesterone) is used for endometrial protection, with far safer breast and cardiovascular profiles than older synthetic forms.
Starting MHT within 10 years of menopause provides the best protection; many women can continue safely long-term under supervision.
The Functional Approach: Beyond Hormones
Functional medicine complements MHT beautifully — addressing metabolism, inflammation, mood, and the whole-body adaptation to changing hormones.
1. Soy Isoflavones (SIF)
Naturally occurring phytoestrogens, SIFs act as selective oestrogen receptor modulators (SERMs), binding primarily to ER-β receptors in brain, bone, and vasculature. They behave oestrogenically when levels are low, and anti-oestrogenically when high — helping to smooth hormonal fluctuations.
Clinical studies show benefits for:
Hot flushes and vasomotor symptoms
Mood and cognitive support
Lipid metabolism and NAFLD risk reduction
Bone and joint health
Protective associations in hormone-related cancers
Typical dosage: 40–160 mg/day isoflavones (equivalent to ~15–40 g soy protein).
2. Protein, Collagen & Resistance Training
Muscle and bone loss accelerate with declining oestrogen. Adequate protein intake, progressive resistance and impact training, and collagen supplementation preserve strength, stability, and BMD.
3. Metabolic & Mood Support
Key nutrients such as omega-3, CoQ10, vitamin E, curcumin, saffron, and creatine provide additional support for cardiovascular, cognitive, and emotional wellbeing. Adaptogens such as rhodiola or rehmannia may be selected based on cortisol patterns. Work with your naturopath or herbalist, as not all herbs are suitable for everyone.
Managing the Transition — Phase by Phase
Late reproductive (mid-30s to early 40s) – Optimise adrenal, thyroid, and metabolic health; ensure protein sufficiency and begin structured resistance training.
Early perimenopause – Address mood changes, joint pain, and cycle irregularity with SIF, Vitex, sleep hygiene, and metabolic support.
Peak perimenopause – For severe hot flushes or insomnia, transdermal oestradiol offers the most effective relief, with herbal or nutritional adjuncts for additional symptom control.
Post-menopause – Prioritise bone density, cardiovascular health, and cognitive support through ongoing oestradiol therapy (where suitable), nutrition, and movement.
Red Flags and Referral Points
Seek prompt medical review if:
Menopause occurs before age 45
There is new-onset depression, suicidality, or psychosis
Bleeding is heavy or unexplained
There are new headaches, significant lipid changes, or recurrent urinary infections
The Takeaway
Menopause is not a decline but a recalibration — a time to reinforce the body’s resilience and protect long-term health. Integrating evidence-based MHT with functional strategies such as nutrition, exercise, and phytoestrogens provides a comprehensive approach to symptom relief and disease prevention.
Understanding this transition empowers women to move through midlife with clarity, confidence, and vitality redefining menopause not as an end, but as a new beginning for hormonal balance and whole-body wellbeing.