Perimenopause Affects Every Major Organ In Your Body. Doctors Reveal What's Really Happening And How To Stay Healthy.
The hormonal changes we experience starting in perimenopause affect every major organ system in our body. Understanding these biological changes isn't just important for managing symptoms—it's critical for your long-term health. We enlisted Rajita Patil, MD, MSCP, and director of the UCLA Comprehensive Menopause Program, to share how these changes impact our health, plus tips to extend your healthspan in this next phase of life.
Bone Health
Estrogen plays a protective role in bone health. A loss of estrogen is associated with a decline in bone mineral density, which can increase the risk of osteoporosis (when bones become weak and brittle) and fractures. The most rapid bone loss typically begins in late perimenopause, about two years before the final menstrual period, and persists for four to five years after.
Tip: Strength train and engage in weight-bearing exercises at least three days per week; eat foods rich in calcium (at least 1200 mg/day) and Vitamin D (at least 800 IU per day), and supplement when necessary; avoid smoking and limit alcohol intake. Consider hormone therapy, which has been shown to decrease the risk of osteoporosis and fractures.
Muscle Mass
Declining levels of estrogen, testosterone, and progesterone in menopause are associated with sarcopenia—a loss of muscle mass and strength.
Tip: Some studies show that prolonged use of hormone therapy (estrogen and progesterone) is associated with higher muscle mass and lower prevalence of sarcopenia, but these effects aren't consistently observed across all populations or study designs. See the tips under 'Bone Health' to preserve muscle mass, plus make sure to eat a gram of protein per ideal weight daily.
Heart Health
Low estrogen levels are linked to an increase in cardiovascular risk in women, particularly after menopause. This accelerates cardiovascular disease (CVD) by promoting negative effects on cholesterol, body fat distribution (central deposition which is linked to insulin resistance), and blood pressure. Interestingly, low testosterone is associated with a more favorable cardiovascular risk profile.
Tip: Hormone therapy is NOT recommended for CVD prevention in postmenopausal women. It can, however, be beneficial for perimenopausal women who are younger and farther from this timeframe. Additionally, eliminate smoking; prioritize regular physical activity (at least 150 minutes per week of moderate-intensity aerobic exercise); eat a heart-healthy diet, like the Mediterranean diet; do regular screenings to monitor blood pressure, cholesterol, and glucose; minimize stress; address mood changes; and aim for good quality and duration of sleep.
Mental Health
During the menopause transition, there's a well-documented increase in the risk of new onset depressive, anxiety symptoms, and exacerbation of pre-existing mood disorders due to fluctuations in estrogen and, to a lesser extent, progesterone.
Tip: Studies show that transdermal estradiol (with or without intermittent micronized progesterone) is effective in preventing and treating depressive symptoms in perimenopausal women. Consider hormone therapy, cognitive behavioral therapy (CBT), or SSRI/SNRI for new onset mood changes. It's just as important to focus on physical activity and exercise; optimize sleep; reduce stress; adhere to lifestyle behaviors (proper diet, regular social engagement; avoid smoking and substance use).
Brain Health
Fluctuations or declines in estrogen cause altered neural connectivity and decreased activation of the hippocampus and prefrontal cortex—regions that are critical for memory and attention. While most of the time the brain fog is transient and people will not develop Alzheimer's Disease, for some there is progressive long-term neurodegenerative changes that put them at higher risk for development of cognitive impairment and, eventually, Alzheimer's Disease.
Earlier menopause with a longer duration of estrogen deficiency and a strong family history of Alzheimer's disease are associated with higher Alzheimer's Disease risk. The role of testosterone and progesterone on cognitive function is less clear.
Tip: Current evidence doesn't recommend hormone therapy for use of treating brain fog or prevention of Alzheimer's Disease. However, there's some data to suggest that estrogen-only hormone therapy started in perimenopause may be associated with a reduced risk of Alzheimer's disease. The MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay), Mediterranean, and DASH (Dietary Approaches to Stop Hypertension) diets are associated with slower cognitive decline and lower risk of dementia. What's good for the heart is good for the brain (and vice versa). See lifestyle tips under 'Heart Health,' plus stay connected and socialize!
Gut Health
The gut microbiome and estrogen have a cozy relationship. Gut microbes regulate estrogen metabolism, and estrogen influences microbial composition and function. A decline in estrogen is linked to a shift in the gut microbiome and increased gut barrier permeability. This can cause inflammation and contribute to metabolic dysfunction. The link between progesterone and testosterone to gut health are less well-studied, though testosterone levels are linked to specific microbiome changes.
Tip: For optimal gut health, eat the Mediterranean diet (it's strongly supported for its ability to increase gut microbial diversity, reduce intestinal permeability, and lower systemic inflammation), increase fiber intake from sources such as whole grains, legumes, fruits, and vegetables, engage in regular physical activity, potentially supplement with a pre- or probiotic, and, yes, consider hormone therapy.
Metabolism
Estrogen deficiency impairs energy homeostasis (the balance between food intake and food expenditure), leading to increased fat accumulation and reduced metabolic flexibility.
Tip: Hormone therapy isn't recommended solely for the purpose of improving metabolic health or for weight loss, but when initiated in perimenopause, it's associated with reduced central adiposity, improved insulin sensitivity, lower fasting glucose, and a decreased risk of developing Type 2 diabetes. See lifestyle modifications in the sections above to implement as well.
Sleep
Multiple studies demonstrate that declining estrogen and progesterone contribute to sleep disruption both directly—via effects on central nervous system sleep regulation—and indirectly by exacerbating vasomotor symptoms such as hot flashes, which can disrupt sleep.
Tip: Hormone therapy can help improve sleep (both estrogen and combined estrogen-progesterone regimens are effective, with the addition of progesterone showing greater benefit for sleep disturbance than estrogen alone). On the other hand, CBT is the most effective nonpharmacologic intervention for improving sleep in menopausal women. Additionally, focus on physical exercise, mindfulness and relaxation techniques; address vasomotor symptoms; maintain a regular sleep schedule; and see a sleep specialist to rule out a sleep disorder for persistent issues.
Genitourinary Health
Estrogen deficiency can result in vaginal dryness, burning, irritation, dyspareunia (recurrent or persistent pain during sex), urinary urgency, frequency, dysuria (pain, burning, or discomfort during urination), and recurrent urinary tract infections. The decline in testosterone as we age contributes to the severity and persistence of these symptoms.
Tip: Local estrogen therapy is the first-line treatment for Genitourinary Syndrome of Menopause (GSM). Clinical studies show that intravaginal DHEA (prasterone) improves GSM symptoms as well. Prasterone converts to both local estrogen and testosterone, which is an added benefit as there are androgens receptors in this area. Use oil-based or silicone-based lubricants and avoid irritants (e.g., perfumed soaps, douches) that exacerbate the vulvovaginal irritation and dryness; pelvic floor physical therapy can improve urinary, vulvovaginal, and pelvic floor dysfunction symptoms.
Sexual Health
Low estrogen levels are strongly associated with negative impacts on sexual health, particularly through the development of vulvovaginal atrophy (the thinning, drying, and inflammation of the vaginal walls), which leads to vaginal dryness, reduced lubrication, dyspareunia, and decreased arousal and orgasmic capacity. Estrogen deficiency also contributes to reduced vaginal blood flow and elasticity, further impairing sexual function. Low testosterone levels may contribute to reduced sexual desire and arousal.
Tip: See "Genitourinary Health" section above. Structured programs—including CBT and mindfulness techniques—have demonstrated significant improvements in overall sexual function, as well as in specific domains such as desire, arousal, lubrication, orgasm, satisfaction, and pain. Addressing communication, sexual myths, and partner dynamics is essential for optimizing outcomes; Testosterone therapy can also be considered in select cases of hypoactive sexual desire disorder.
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