Perimenopause and menopause: Understanding the hormonal journey

Menopause is not a singular event. It is part of a broader continuum of change that begins years before the final menstrual period and continues long after. Understanding this passage, beginning with perimenopause, can turn confusion into clarity, and fear into empowerment.

Across Bangladesh and much of the world, women often enter the perimenopausal stage of life with little awareness and even less preparation. Conversations around it are scarce, cloaked in discomfort and cultural silence. Yet this transition — a complex hormonal and emotional shift — touches nearly every aspect of a woman's life, from her physical wellbeing to her psychological stability and sense of identity.

"My sleep was a mess, I kept forgetting things, and my heart would race for no reason. For months, I thought I had an anxiety disorder or early dementia. It never crossed my mind that it could be perimenopause"

Menopause doesn't arrive all at once. Dr Syeda Husna Akhter, Senior Consultant Gynaecology and Obstetrics at Super Specialized Hospital, Dhaka, explains, "There's a transitional stage called the climacteric. It includes perimenopause, the early shift, and post-menopause, which follows after periods have permanently stopped."

Perimenopause typically begins in a woman's early to mid-40s, though some experience symptoms earlier. It can last anywhere from a few months to over a decade. During this time, oestrogen, the hormone responsible for regulating the menstrual cycle, mood, and reproductive health, fluctuates unpredictably. This hormonal imbalance affects the brain, heart, bones, and even digestion.

"You might have irregular periods, or go two or three months without one, and then suddenly get two in a single month," says Dr Akhter. "The ovaries begin to reduce their hormone response, but not all at once. That's why the symptoms can be so erratic."

"I was snapping at my children for no reason, crying during meetings, and waking up at 3 AM every night. I thought I was just burned out."

Many women initially misattribute their experiences, describing it as a period of "emotional short-circuiting." In truth, they are going through a biological transformation that affects every woman, yet is rarely explained well.

The range of symptoms can be broad and deeply personal. From sudden heat in the face and chest — hot flashes — to insomnia, depression, vaginal dryness, brain fog, digestive trouble, and loss of libido, the body starts to send signals that many find hard to interpret.

"Hot flashes are a hallmark symptom," says Dr Akhter. "They usually last two to three minutes and cause the face and upper body to flush. For some women, they're barely noticeable; for others, they disrupt sleep and work. Stress and lifestyle factors can worsen them."

Psychological symptoms are just as common. Mood swings, irritability, or even unexplained grief can descend without warning. Hormones regulate the reproductive system and the brain. As oestrogen drops, women can feel mentally unbalanced, like they're not themselves anymore.

"I thought pregnancies cannot happen if periods are months apart"

One common misconception is that once periods become irregular, fertility ends, but that's not necessarily true. A largely unspoken aspect of this life stage is its impact on intimacy and sexual health. Vaginal dryness, discomfort during intercourse, and reduced desire are all common but rarely addressed.

"After oestrogen declines, the vaginal lining thins and loses elasticity," explains Dr Akhter. "This can cause painful sex, urinary discomfort, or even cystitis. Many women suffer in silence because they don't know this is connected to menopause."

Dr Akhter encourages women to speak up and seek help. "These are natural changes, and they can be managed – either through lifestyle, topical treatments, or in certain cases, hormone therapy."

In Bangladesh, hormone replacement therapy (HRT) is prescribed conservatively due to potential side effects.

"We try to start with non-medical solutions," says Dr Akhter. "Good sleep, regular exercise, a calcium-rich diet, and emotional support go a long way."

She adds, "If symptoms become unmanageable — severe insomnia, mood crashes, unbearable hot flashes — we do consider HRT but only in minimal doses and with close monitoring. Side effects like breast tenderness, irregular bleeding, or reduced breast firmness can occur."

"I would cry in the shower and then walk into the office like nothing happened. I didn't even know it was hormonal"

For those without access to specialists, the first line of treatment is often understanding and reassurance. "The role of psychological support is huge," says Dr Akhter. "Sometimes, women just need to hear that what they're experiencing is normal and that it will pass."

Despite its inevitability, menopause remains a topic shrouded in discomfort. In South Asian households, where women's identities are still tied closely to reproductive roles, this transition is viewed as a loss rather than an evolution.

"Menopause doesn't mean a woman's value has ended," says Dr Akhter firmly. "It's a time for reflection, for shifting priorities, and embracing maturity with strength."

Hossain puts it best: "I thought menopause would mean life slowing down. But instead, it gave me clarity. I stopped worrying about monthly cycles and started focusing on myself. I only wish I had known more about what to expect."

Perimenopause and menopause are not medical tragedies; rather, they are deeply human transitions. With education, support, and agency, women can reclaim this stage not as a decline, but as a redefining of their lives.

"Menopause is not a disease," Dr Akhter emphasises. "It's a phase. With the right tools — physical, emotional, and social — women can move through it with dignity."

In a country like Bangladesh, where health conversations are still layered with stigma, breaking the silence around menopause is not just necessary — it's liberating.

Because every woman deserves to understand her body, and every woman deserves to feel whole, even as she changes.