Perimenopause: When Does It Start, Early Signs and How to Manage

In western countries, apart from changes in menstrual periods, the classical symptom of perimenopause is hot flushes and night sweats.

The top perimenopause symptoms cited by women locally are:

• New-onset muscle and joint aches (such as frozen shoulder)
• Disturbed sleep
• Sexual health and urinary symptoms (urgency or frequency)
• Physical and mental exhaustion

(Hot flushes and night sweats came in fifth)

“Every woman’s experience is unique so there is no ‘correct’ number of symptoms (for perimenopause),” Prof Puvanendran said.

According to a 2025 study by KKH, which involved 1,461 women aged 45 years to 65 years, several surprising findings were revealed:

Almost all women experienced at least one of 29 common menopausal symptoms (shown in the table below) which can affect a woman’s quality of life.  Menopause symptoms cut across multiple aspects of health: musculoskeletal, pelvic floor, sexual, mental, and even skin.

70 per cent of women (1,022) experienced moderate to severe menopausal symptoms, yet 70 per cent of these women have not sought medical attention.

The top five moderate to severe symptoms were weight gain, difficulty sleeping, head and/or neckaches, vaginal dryness, joint and muscle aches.

The results from this KKH study, together with a second study involving healthcare professionals, shaped the development of Singapore’s first set of Guidelines on Management of the Menopause Transition.

Prof Puvanendran added, “Lesser-known symptoms (for perimenopause) we have seen in our clinic include:

• Heart palpitations,
• Dry eyes and skin,
• Dental issues like gingivitis (gum inflammation)
• Mouth dryness (xerostomia) and
• Urinary infections

“These symptoms occur because of the role of oestrogen in the body. Most organs have oestrogen receptors. . During perimenopause, the oestrogen levels fluctuate and gradually decline, leading to a myriad of symptoms,” Prof Puvanendran explained.

“It’s difficult for a woman who is taking the pill (on birth control pill) to know if she is experiencing in perimenopause because it (taking the pill) mimics a regular period and masks signs like hot flushes,” she added.

However, Prof Puvanendran cautions against stopping contraception if a woman is sexually active as having a pregnancy during a later stage of life poses risks not just for the baby, but for the mother as well.

Optimising your lifestyle can help to reduce the severity of menopausal symptoms, as well as the long-term risks of heart disease and bone loss.

1. Eat a balanced diet

Use the ‘My Healthy Plate’ as a general guide for your diet:

• Fill ½ of your plate with fruits and leafy greens / non-starchy vegetables
• Fill ¼ of your plate with whole grains carbohydrate or starchy vegetables
• Fill ¼ of your plate with meat and other alternatives (i.e. tofu, egg, beans)

"This helps to prevent weight gain, especially visceral fat gain during menopause. Increasing intake of vegetables and fruits and healthy protein is important for healthy ageing," Prof Puvanendran said.

To promote healthier eating habits, you should:

• Use healthier fats and oils, limit fried foods to twice a week or less.
• Replace saturated fats (palm oil, animal fats) and trans fats (e.g. those found in frozen foods, commercial baked goods and fast foods) with healthier fats like olive oil, nuts (e.g. almonds, walnuts) and cold-water fatty fish (e.g. salmon, tuna).
• Reduce intake of processed foods and eat wholefoods instead.
• Substitute animal sources of protein (e.g. meat, chicken) with plant sources of protein (e.g. tofu, lentils, beans) twice a week.
  "There is some evidence that plant-based proteins are better for healthier ageing. This has been shown in studies of blue zones - regions where people routinely are known to live to 100 and beyond," shared Prof Puvanendran.
  
• Make water your drink of choice, limit sugar-sweetened beverages.
• Reduce alcohol intake.

Also, by avoiding spicy foods, red meats, caffeine and alcohol, this can help to reduce hot flushing.

2. Stay physically active

Aim for:

• 150 minutes of moderate exercise weekly or
• Strength training at least twice a week

Exercises you can consider include:

• Brisk walking (to know how to do it right, see this article)
• Yoga, which also helps to reduce anxiety and promotes relaxation
• Swimming
• Pilates, which enhances core strength and promotes flexibility

3. Improve sleep habits

• Keep a consistent bedtime. Establish a 30 to 60-minute wind-down routine — such as reading, warm baths, or meditation — while avoiding blue light from phones/screens.
• Keep the bedroom cool (to cope with hot flushes)
• Limit caffeine intake

4. Manage stress

Keep stress in check with coping strategies such as:

• Practice meditation (you can try this simple exercise!)
• Deep breathing exercises (here are several you can try!)

5. Strategies to manage hot flushes

• Dress in layers so you can remove clothing when hot flushes strike
• Carry a fan
• Use a facial water spray
• Drink cold water

6. Start tracking symptoms proactively

Keep track of new physical, mental or emotional changes by starting a diary or use a reliable menopause app.

“This will help you to recognise patterns. Take note of symptoms that often cluster. Night sweats, for instance, can lead to sleep disruption, which results in brain fog and irritability the next day. Addressing one symptom can break the chain,” Prof Puvanendran said.

“When consulting a healthcare provider, be prepared with data on your symptoms. You can say something like: I have tracked waking up at 3am for 15 of the last 30 nights, and it is affecting my work. Or: I am concerned these changes are related to perimenopause. Can we explore that?” She added.

7. Go for annual health screenings

This is important as blood pressure, cholesterol and blood sugar levels start increasing as a woman transits into menopause.

Screening for chronic diseases as well as regular mammograms and cervical cancer screenings are important for all women in their 40s and 50s. For more information, visit www.kkh.com.sg/wise

8. Menopause Hormone Therapy (MHT)

Menopause Hormone Therapy (MHT), previously known as Hormone Replacement Therapy (HRT), is safe and effective in reducing menopausal symptoms and for preventing and treating postmenopausal osteoporosis, when prescribed appropriately. This was reaffirmed in the Guidelines on Management of the Menopause Transition.

Examples of MHT include oestrogen (pills or patches) and/or progesterone (pills or intrauterine device).

“For each individual woman, its (MHT’s) benefits must be weighed against the increased risk of serious side effects such as thromboembolism (blood clots) and breast cancer. Any woman taking MHT should be reviewed regularly by her doctor,” advised Prof Puvanendran.

Can supplements help with symptoms?

Prof Puvanendran answered, “Supplements marketed for menopause, such as black cohosh and soy isoflavones, have insufficient evidence on their efficacy. They are not regulated in Singapore.  

“Not every symptom may be due to perimenopause, since conditions like iron deficiency anaemia, vitamin deficiencies and thyroid dysfunction can have similar symptoms. If in doubt, see a doctor.

Do seek medical help immediately if you experience new and severe headache patterns, chest pain (not just palpitations), significant unexplained weight loss or neurological changes like numbness or weakness,” she warned.

9. Seek help to address intimacy issues

Menopause symptoms such as vaginal dryness, painful intercourse, decreased libido and urinary issues can affect a couple’s intimacy and overall relationship. Don’t hesitate to raise such concerns to your family doctor or GP.

With the new guidelines, healthcare professionals are also encouraged to proactively screen for these symptoms and provide clear treatment pathways, sexual health must be managed holistically. However, if vaginal dryness and painful intercourse are affecting intimacy, consider use of vaginal moisturisers and vaginal oestrogen therapy as appropriate.

Lifestyle optimisation is the essential cornerstone for every woman navigating menopause.

By adopting proactive habits such as maintaining a healthy diet, regular exercise, weight management, not smoking, minimising alcohol intake, stress management, and improving sleep – they serve as a first-line defence in reducing symptom severity and mitigating long-term risks of cardiovascular disease and osteoporosis.

Ref: F26

Related articles:
Menopause: How to Manage

Can Diet Affect Menopause Symptoms?

Menopause and Heart Disease: What's the Link?

Menopause Q&A with Associate Professor Rukshini Puvanendran