The Silent Symptoms Of Perimenopause Every Woman Needs To Know
When Gail, a fifty-one-year-old accountant, was at her annual checkup, she could not recall the date of her last period when the medical assistant asked. Gail had been so busy with tax season that she completely forgot. After doing some quick thinking to jar her memory, Gail was shocked to realize that her last period was nine months ago. It left without a trace and seemingly never came back. She counted herself lucky to have not had noticeable symptoms like so many of her girlfriends had, but when her lab results come back, Gail was surprised to learn that her cholesterol was up by more than thirty points, even though her diet hadn’t changed at all.
Some women, like Gail, are lucky to not experience perimenopausal symptoms until they are either well into their transition or they have blown past the one-year anniversary of their last period. If you are one of them, you’re fortunate—but that doesn’t mean your hormonal changes aren’t impacting your current and future health.
What's happening in the body
Even if you don’t experience a single noticeable symptom—the underpinnings of the health of every woman who goes through perimenopause are changing, and not for the better. The slow fade of estrogen has a direct impact on a laundry list of important health markers:
- Your cholesterol, glucose, and insulin levels tend to rise, which can then negatively impact your weight, heart health, metabolic health, and brain health and pave the way for type 2 diabetes, metabolic syndrome, fatty liver disease, and even dementia.
- Your bones are becoming less dense; your joints also feel the impact from the decline in estrogen, which could show up as a loss of range of motion, creakiness, or chronic pain. The loss in bone density, if left unchecked, often leads to osteoporosis and a high risk of fracture, which, for those who are in their seventies and beyond, can very often be fatal.
- You’re losing muscle mass, which plays a role in your declining bone density (since what strengthens muscles also strengthens bones) and your slowing metabolism (as muscle tissue requires more calories to maintain than fat or bone). Not counteracting this natural loss of muscle paves the way for growing frail as you get older. We’re also learning more and more about muscle’s role in producing hormones and neurochemicals that have widespread effects throughout the body—even in the brain! If you have less muscle, you also have less of these helpful chemical messengers on hand, which has far-reaching ripple effects.
- Your vaginal and urinary tissues are becoming less resilient. While you may not necessarily notice this change in your daily life, you’ll become more prone to urinary tract infections, sexually transmitted diseases, urinary incontinence, and even organ prolapse (where an abdominal organ can drop from its position and create a bulge in the vaginal canal).
Taking action before it starts
I don’t want to scare you—these risks don’t accumulate all at once. But I do want to alarm you just enough that you will be inspired to either start or continue doing the things that reduce these risks.
If you are reading this chapter because you want to get ahead of the curve and learn about perimenopause even though you aren’t currently experiencing any symptoms, I want to give you a special shout-out—points for being proactive! (Your reading this excerpt is also wise because, remember, perimenopause can last up to ten years; thus, while your symptoms may be silent now, they may get louder next year.)
I hope that even if you have identified a symptom set that is vexing you, you will read this chapter so that you understand the bigger health picture. By learning about the long-term health risks that perimenopause and menopause bring, you’ll be better informed, which means you’ll have the opportunity to make better choices. And you won’t have to be blindsided in your sixties, like my patient Susan was.
Susan, whose story I shared in my previous book, Unlock Your Menopause Type, considered herself one of the lucky ones—she never had hot flashes, or mood changes, or experienced painful sex. She thought menopause had taken it easy on her and was grateful for that fact, up until Thanksgiving Day when she was sixty-four. That’s when Susan reached into the oven to pull out the turkey, heard a loud pop, and felt a sharp stab of pain in her lower back. Her trip to the ER revealed that she’d experienced a compression fracture and had osteoporosis—something she hadn’t even realized she was at risk of.
On top of her discomfort and shock, Susan felt betrayed by the medical system, as no doctor had ever warned her of the risk of osteoporosis, much less told her about the many preventive steps she could have taken to keep it at bay. That’s why I call these symptoms silent—because you won’t necessarily feel them happening. But just because they aren’t making their presence known in this moment doesn’t mean they aren’t real.
Sometimes not having any symptoms can lull you into thinking you don’t need to prioritize your self-care and health care. You may blow off scheduling your annual checkup or forget to book your screening tests because you feel fine. To prevent this from happening, I need to give you some tough love: Relying on youthful resilience and lucky genetics to keep your health in a good place is not a great long-term health strategy. At some point these changes mean you’ll start going to the doctor more, perhaps needing more medications and experiencing more negative health events. Sorry to be a bummer, but this is not a drill.
The days of thinking you can “get away” with things—whether it’s drinking too much, skimping on sleep, blowing off exercise, or opting for only highly processed foods—without paying any consequences are dwindling fast. It’s time to admit that you soon will become the age where the music you listened to in middle school is playing on the oldies station. It’s just part of the circle of life, and a sign that it’s time to step it up.
No regrets
I can’t tell you how many postmenopausal women, like Susan, have come to me saying that they wish they had been given the facts about how their body would change during the menopause transition, wishing they could go back in time and make different decisions. It was only a few years ago that women simply didn’t know about these risks. This is how we change that narrative.
The good news is that by learning about the health risks you face and the many things you can do to counteract them, you have an amazing opportunity to lay down a foundation now that will boost your health today and for decades to come. You have a huge opening for building what I call generational health for both yourself and the members of your family who come after you. Generational health is how you will be able to get down on the floor and play with your grandkids and how you can reduce the amount of time (and money) your children will need to devote to taking care of you. When you start adopting habits that support your long-term health—which I will cover in this chapter—in ten, twenty, or thirty years, you will be so grateful that you did.
Excerpted from The Perimenopause Survival Guide by Heather Hirsch, MD, MS, MSCP. Copyright © 2025 by Heather Hirsch, MD, MS, MSCP. Reprinted with permission of Balance Publishing, an imprint of Hachette Book Group. All rights reserved.