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Are you “very peri”? ….and did you know that it’s linked to your heart, bone and mental health?

A recently published research paper (called a narrative review) has summarised the body composition and cardio-metabolic changes related to the menopause transition.

A narrative review presents robust scientific findings in a nice and easy to understand format. The authors came to their conclusions systematically sorting, evaluating, and presenting strong and reliable studies from the scientific literature.

What is the “perimenopause”?

Perimenopause is the transitional time around menopause. Menopause is when a woman, trans or non-binary person's periods stop. It's marked by changes in the menstrual cycle, along with other physical and emotional symptoms.

Hang on, I think I’m too young!

This time can last 2 to 10 years before someone reached their menopause (at around 51 years of age). So for everyone, it’s really time to start thinking about this in your 40s!

What might I experience?

Many people who are entering the perimenopausal phase (also known as ‘menopausal transition’) are quite shocked to find out that the symptoms are more than just hot flushes and low libido! Most of our body systems are affected by oestrogen in some way.

The perimenopause (ie menopausal transition) can be more symptomatic than the menopause, and the management depends on understanding the menstrual cycle patterns and the symptoms present.

The changes in oestrogen is the greatest influencer on the menopause transition and beyond.

We often just think of oestrogen as being involved in fertility and reproduction. However, oestrogen is a great multi-tasker! It influences our heart and blood vessels, our brain, as well as adipose tissues (the way our body stores fat). Oestrogen has an anti-inflammatory effect, as well as cardio-protective one which keeps our HDL (high density lipoprotein or “good” cholesterol”) high and blood vessels elastic.

Twenty percent of (2 in every 10) people will experience very few symptoms in the perimenopause. However, the remaining eighty percent (8 in every 10) will experience moderate to significant symptom. Even if you are not feeling any changes, there are silent symptoms that we explain below.

What is going on in my body in perimenopause and why?

Early on in perimenopause, your body will be making more and more ovarian hormones (oestrogen and follicular stimulating hormone, FSH) to try and ‘make the most’ of your remaining ovarian reserve (the follicles/eggs you have left). As this progresses your oestrogen gets to critically low levels (but follows an up and down path like a rollercoaster on the way there!).

Collectively, the studies suggest that loss of oestrogen promotes abdominal fat accumulation and a drop in energy expenditure. It is well known that body fat distribution rather than weight status alone is a good indicator of cardiometabolic risk during the menopausal transition.

Body composition changes, including bone, muscle and fat

On average, people gain between 2 to 3 kilograms during this time, but this is highly variable. It doesn’t have to happen but is driven strongly by oestrogen deficiency.

People with higher abdominal fat stores have been observed to be more likely to experience ‘vasomotor symptoms’ (hot flushes, night sweats), insomnia, and decreased quality of life.

Some people don’t experience a change in weight, but their fat free mass (muscle) and bone mineral density decreases while their fat mass (adipose tissues) increase. Body composition (muscle and fat stores) changes accelerate during the perimenopausal phase and stabilises during the post-menopausal phase.

Bone mineral density decreases most rapidly in the year (to three years) before the final menstrual period and declines but does not cease to three to four years following this.

Energy intake and energy expenditure

An increased energy (kilojoule) intake can contribute to weight gain. However, studies that have followed people over longer periods (rather than just a one-off measurement) have shown that in the three to four years in the lead up to menopause onset energy intake has been shown to decrease. This validates so many people’s experiences of “I’m not eating more but the weight is going on to my middle!”.

Studies have also shown that decreases in oestrogen results in decreased energy expenditure (including physical activity) and fat oxidation (the body burning fat).


People in the perimenopause experience disrupted sleep (shorter and not as restorative). This may be because of ‘vasomotor’ symptoms (hot flushes, night sweats), but even people without these symptoms report not sleeping as well and experienced decreased quality of life. The knock-on effect is to disrupted appetite hormones, decreased appetite regulation, changed sensitivity to food rewards and dysregulated eating (read: more comfort eating, food ‘hugs’) leading to increased energy intake.


Women experience cardiovascular disease ten to 15 years later than men due to the cardioprotective effect of oestrogen. With the oestrogen drop, abdominal fat gain leads to an increase in unhealthy blood fats and less ‘elastic’ blood vessels. The anti-inflammatory effects of oestrogen also disappear. This is accentuated by the relatively more ‘inflammatory’ estrone (a ‘bad’ version of oestrogen released by adipose tissues to try to maintain estrogen levels).


While this review covered the effects of decreased oestrogen on the heart and metabolism, the brain and mental health is also affected. This resource provides a great summary of impacts and supports for people experiencing mental health issues in the perimenopausal phase.

All of these changes listed occur if/when someone is not receiving MHT (menopause hormonal therapy, the new name for HRT, hormone replacement therapy). There is a popular hypothesis called the “timing hypothesis” that suggests that starting MHT within ten years of the final menstrual period (FMP) is cardioprotective as not too much vascular dysfunction has had a chance to occur.

Is there anything I can do? And when should I start??

Current clinical guidelines do not recommend the use of menopausal hormone therapy (MHT, the new name for HRT) for preventive indications; it is indicated only for the treatment of menopausal symptoms present.

However, it is an IDEAL time to

1. Assess your cardio-metabolic risk with your doctor,

2. Start (or change up) lifestyle behaviours, and

3. Increase careful monitoring of risk factors, including hypertension, cholesterol and diabetes markers.

There have been many good studies that have shown starting lifestyle modification programs that incorporate diet and exercise (aerobic and resistance training) during perimenopause may be timelier and have a higher yield in terms of reducing future risk of cardiometabolic than waiting until the postmenopausal years, after substantial weight gain and fat mass accrual have already occurred.

Rather than follow generic advice in the popular media, why don’t you ask for individual assessment and management by one of the experienced expert health professionals at Lifestyle Metabolic.

At Lifestyle Metabolic we pride ourselves on keeping up-to-date with the latest research from a number of different disciplines, and integrated for the assessment and management for individual patients, with a focus on their goals, needs and quality of life.

Photo 91993179 / Menopause © James Vallee |

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