A large mixed-methods study has found that more than a third of women in midlife were unsure of whether they had entered perimenopause.

“Limited public awareness and inconsistent clinical recognition further compound this uncertainty,” the study’s lead investigator, Yihan Xu, PhD, and her colleagues wrote.

The median age of perimenopause onset is 45 years, with a median duration of somewhere between 4 and 8 years. Common symptoms are vasomotor, psychological, or urogenital in nature, and can have adverse impacts on daily functioning. At present, there are no laboratory tests or biomarkers for determining perimenopause. 

According to Xu and colleagues, midlife women “hold assumptions based on age, or have difficulty distinguishing perimenopause from stress or other health conditions.” They cited the 2002 Women’s Health Initiative findings, which they said, “resulted in a significant decline in hormone therapy prescribing and gaps in menopause training for clinicians, and thus also a decline in clinicians’ confidence and approach to perimenopause care.”

Based on these questions about perimenopause, Xu, who is lead research scientist for Flo Health, Ltd., based in London, England, and her colleagues conducted a cross-sectional survey of US women aged 35 years or older to learn how the cohort was experiencing their reproductive timeline. The investigators’ aim was to describe their findings both quantitatively and qualitatively.

The results of the study are published online in advance of publication in Menopause next year.  

Participants who consented to have their data anonymously collected for the study were recruited from users of the Flo app, a digital platform for women’s health. In all, 13,122 US-based participants visited the survey page. Those who used current hormonal birth control (n = 797) were excluded from the analysis. The final cohort of women studied numbered 7640.

When presented with standardized definitions of female reproductive stages (premenopause, perimenopause, and postmenopause), and asked to select the stage that best described them, 5072 survey takers self-reported a specific reproductive stage, whereas 2568 answered they were “unsure” which stage they were in.

Those who self-identified as unsure of their reproductive stage were prompted to elaborate on why they were unsure. There were 409 responses considered valid by the study’s criteria. Xu and colleagues then stratified 20% of this subcohort (n = 409) by age (35-39, 40-44, 45-49, 50+ years) and by menstrual rating scale severity levels (minimal, 0-4; mild, 5-8; moderate, 9-15; severe, 16+).

More than a third (95% CI, 33%-35%) of survey respondents reported being unsure of their reproductive stage. Uncertainty varied by age and symptom severity (P < .001), with 42% (95% CI, 41%-43%) of those aged 40-44 years reporting they were unsure, and 37% (95% CI, 36%-38%) of those with severe symptom burden reporting uncertainty.

Over half (56%; n = 230) of the subcohort studied attributed their uncertainty to symptom confusion and difficulty interpreting bodily changes in the context of their own expectations of perimenopause. 

Over a third (37%; n = 151) of participants linked their uncertainty to menstrual cycle changes, or lack of them. Menstrual cycle changes were often recognized by respondents as a core indicator of perimenopause but sometimes they reported their cycles remained regular despite the onset of other signs of perimenopause. “My periods are still regular, but I have symptoms like hot flushes, weight gain, mood changes,” one survey taker in the 40- to 44-year age group wrote, with an menstrual rating severity scale rating of “moderate.”

About 16% (n = 59) were unsure if they knew how to define perimenopause, how it manifested, or how to recognize it in themselves.

Only 66 (16%) women self-reported barriers to confirmation and care, including dismissive clinicians. Younger women (aged 35-39 years) were more likely to cite knowledge gaps, while healthcare barriers peaked in the 40- to 44-year age group (P = .05).

Although the study does not link perimenopausal uncertainty to specific adverse outcomes, Xu and her colleagues wrote that theirs is the first study to report metrics around perimenopause uncertainty, while also identifying qualitative factors that may contribute to difficulties recognizing its onset.

One implication of the study for clinical practice, according to Xu, is that uncertainty about perimenopause is common in women aged 35 years or older. “Recognizing this phenomenon will help shift the conversation from simply confirming or excluding a diagnosis toward helping women understand what they are experiencing,” Xu told Medscape Medical News. “Even when a definitive diagnosis is not yet possible, clinicians can provide evidence-based information, validate women’s experiences, and discuss appropriate symptom management and follow-up. Supporting women through uncertainty is itself an important part of good care.”

A professor of pharmacology at Georgetown University Medical Center in Washington, DC, suggested the study overlooks the possibility of illnesses common in older women. “Perimenopause is an artificial construct as demonstrated by the fact that it has no distinct symptoms, hormonal profile, or even timeframe,” Adriane Fugh-Berman, MD, told Medscape Medical News. “Sure, hormones bounce around sometimes years before menopause, and women may experience both premenstrual symptoms, like sore breasts, and menopausal symptoms, like hot flashes. That’s normal, but if symptoms are uncomfortable, they can be treated. But why medicalize midlife?”

Fugh-Berman has an appointment in the Department of Family Medicine at Georgetown University Medical Center. She also directs PharmedOut, a research and education project at Georgetown that examines how pharmaceutical industry marketing affects prescribing practices.

“What’s most interesting about this study is that the women surveyed seem much more realistic about this phase of their lives than the researchers. ‘Women are not sure they are in perimenopause.’ Why should they care? It’s an artificial construct.” If they attribute symptoms to aging, that’s perfectly reasonable, she said.

Fugh-Berman said there is real danger of attributing every symptom that midlife women have to perimenopause instead of actually determining whether a woman is anemic, has hypothyroidism, is depressed, or has some other medical condition. “No one needs to treat perimenopause, or menopause for that matter, unless they are experiencing troublesome symptoms,” she said.

Xu reported being a current employee of Flo Health Ltd and holding equity interests in Flo Health Ltd. Fugh-Berman reported being a paid expert witness at the request of plaintiffs in litigation regarding pharmaceutical marketing practices.