Signs of Perimenopause: Your Essential, Science-Based Guide to Navigating This Natural Transition

[At Lefiano, our content is meticulously researched and reviewed against reputable scientific sources to ensure accuracy.]

Wondering about the signs of perimenopause? If you’re in your 40s (or even late 30s) and noticing changes in your body, mood, or mental clarity that feel confusing or overwhelming, you’re not alone. Perimenopause is one of the most significant transitions many women experience, yet finding clear, calm, and trustworthy information can still feel like searching for a lighthouse in fog.

At Lefiano, we believe that every stage of life is a journey worth understanding, and wellness is about navigating those stages with intention, knowledge, and self-compassion. This comprehensive guide is designed to be your considered resource. We’ll explore the scientifically recognized signs of perimenopause, clarify the distinct stages of this transition, dive deep into what’s happening in your body and brain, and discuss evidence-based lifestyle and nutritional strategies to help you feel your best during this natural life phase.*

What is Perimenopause, Exactly?

Perimenopause, literally meaning “around menopause,” is the transitional period before menopause when your body begins the gradual shift away from reproductive years. During this time, which can last anywhere from two to ten years (with an average of five to seven years), your ovaries gradually begin to produce less estrogen.*

Here’s what makes perimenopause distinctly different from menopause itself: Menopause is technically a single point in time, defined as occurring 12 months after your final menstrual period.* Everything leading up to that milestone is perimenopause, and everything after is postmenopause.

The hallmark of perimenopause is hormonal fluctuation, not a steady decline.* Think of it less like a gentle slope and more like a hormonal roller coaster, with estrogen and progesterone levels rising and falling unpredictably.* This erratic pattern is what causes many of the changes women notice in their 40s, and sometimes even in their late 30s.*

Why Perimenopause Varies So Much

Research shows that perimenopause is highly variable in its onset, overall duration, severity of symptoms, and impact on daily functioning.* As many as 90% of women may seek medical care for symptoms during perimenopause, yet each woman’s experience is unique.* Some women transition with minimal disruption, while others find their symptoms significantly affect their quality of life, work performance, and relationships.*

Understanding that your experience is valid, whatever it looks like, is the first step toward finding the right support for your journey.*

The Scientifically Recognized Stages of Perimenopause

To bring clarity to what can feel like a confusing timeline, reproductive health researchers developed a framework called the STRAW+10 staging system (Stages of Reproductive Aging Workshop).* This internationally recognized system helps clinicians and researchers communicate precisely about where a woman is in her reproductive life span.*

The menopausal transition (perimenopause) is divided into two distinct stages:*

Early Perimenopause (Stage -2)

The early stage is defined by a persistent difference of 7 days or more in the length of consecutive menstrual cycles.* For example, if your cycle was consistently 28 days and now you’re experiencing cycles that vary between 21 and 35 days, this marks the beginning of early perimenopause.*

During this stage:*

• Cycles remain mostly regular with relatively few interruptions*
• You may start noticing subtle changes in bleeding patterns (heavier or lighter flow)*
• Some women begin experiencing early symptoms like mood changes, sleep disruptions, or breast tenderness*
• Follicles (the structures containing eggs) grow more quickly but may ovulate at a smaller size*
• Hormone patterns start to deviate from mid-reproductive-aged patterns*

Late Perimenopause (Stage -1)

As the transition progresses, you move into late perimenopause, characterized by greater menstrual irregularity with periods of amenorrhea (absence of menstruation) lasting 60 days or more, up to 12 months.* In the beginning, it may be an occasional skipped period, but as you approach menopause, these gaps lengthen considerably.*

During this stage:*

• Menstrual cycles become highly unpredictable*
• You may skip multiple periods in a row*
• Vasomotor symptoms (hot flashes and night sweats) typically become more pronounced*
• Estrogen levels are experiencing their most dramatic fluctuations and eventual decline*
• The hormonal changes in this stage are often more pronounced*

Menopause Itself

Twelve or more months of amenorrhea defines your final menstrual period (FMP), after which you are officially postmenopausal.* In the United States, the average age for the final period is 51 to 52 years, though it can occur naturally anywhere from the mid-40s to late 50s.*

Comprehensive Signs and Experiences of Perimenopause

The experience of perimenopause is deeply individual, but certain patterns emerge consistently in research. The symptoms can affect virtually every system in your body because estrogen receptors are present in virtually every organ, making us highly sensitive to hormone fluctuations.* Let’s explore the most well-documented signs.*

1. Vasomotor Symptoms: Hot Flashes and Night Sweats

These are by far the most well-known and most common signs of perimenopause.* Research indicates that vasomotor symptoms affect approximately 75% to 80% of women during their menopausal transition.*

What They Feel Like:

• Hot flashes: A sudden sensation of intense heat, often starting in the chest and face, that can be mild to overwhelming*
• Flushing: Visible redness of the skin, particularly on the face and neck*
• Sweating: Perspiration that can range from mild dampness to soaking through clothes*
• Night sweats: Hot flashes that occur during sleep, often disrupting rest and leaving you drenched*

The Science Behind Them: Hormonal fluctuations, particularly declining estrogen, affect the hypothalamus, the part of your brain that acts as your body’s internal thermostat.* This causes your brain to mistakenly perceive that you’re overheating and trigger cooling mechanisms (flushing and sweating) even when your core body temperature is normal.*

Important Timeline Note: While many women experience vasomotor symptoms for just a year or two, more than half of women live with these symptoms for almost 12 years, according to research published in JAMA Internal Medicine.* Hot flashes typically begin in perimenopause (or even earlier for some women) and can persist for several years postmenopause.* They tend to worsen during late perimenopause when estrogen levels are at their lowest.*

2. Cognitive Changes and Brain Fog

This may be one of the most concerning yet under-discussed symptoms of perimenopause. If you’re experiencing what feels like “brain fog,” you’re far from alone.*

Common Cognitive Experiences:

• Forgetfulness: Difficulty remembering where you put things, appointments, or names*
• Word-finding difficulties: That frustrating experience of the word being “on the tip of your tongue”*
• Difficulty concentrating: Trouble focusing on tasks that previously felt effortless*
• Mental fatigue: Feeling mentally exhausted more quickly than before*
• Reduced processing speed: Taking longer to understand or respond to information*

What The Research Shows

Brain fog during perimenopause is real and validated by scientific research.* Longitudinal studies find small but reliable declines in objective memory performance as women transition into perimenopause, and these changes are not explained by advancing age alone.* The cognitive domains that change most reliably during the menopausal transition are verbal learning and memory, with more modest effects on working memory, attention, and processing speed.*

A 2023 comprehensive review published in Current Psychiatry Reports found that perimenopausal women experience difficulties particularly in:*

• Verbal memory (remembering spoken or written information)*
• Working memory (holding information temporarily while using it)*
• Executive function (planning, organizing, decision-making)*
• Processing speed (how quickly your brain processes information)*

Critical Reassurance: This is Temporary and Not Dementia

Here’s what you need to know: These cognitive changes typically begin in perimenopause and commonly normalize postmenopause.* When memory declines occur, performance levels remain within normal limits for all but a very small number of women (approximately 11-13% show clinically significant impairment).*

Research emphasizes that menopause-related cognitive problems should not be confused with dementia; dementia before age 64 years is rare.* Every woman will go through menopause in midlife, but only 20% ever develop Alzheimer’s disease.* The timing of these cognitive changes—beginning with menstrual irregularity—suggests an etiology linked to hormones and menopause symptoms rather than neurodegenerative disease.*

Recent neuroimaging studies have documented structural brain changes during perimenopause, including:*

• Temporary declines in cortex volume (the area involved with memory and information processing)*
• Reductions in white matter (the connections between neurons)*
• Decreased blood flow in the brain*
• Changes in hippocampus size (where memory formation occurs)*

Importantly, research also shows that over time, menopause increases the density of estrogen receptors in the brain, suggesting adaptation and resilience.* For most women, cognitive function stabilizes postmenopause.*

3. Mood Changes: Beyond Just “Being Emotional”

Hormonal fluctuations during perimenopause can significantly impact mood and emotional regulation.*

Common Mood Experiences:

• Increased irritability or shorter temper*
• Heightened anxiety or feelings of worry*
• Episodes of sadness or low mood*
• Emotional sensitivity (crying more easily)*
• Feeling overwhelmed by daily stressors*

What Research Reveals: Depression and increased anxiety also increase during the transition, with an abrupt rise in prevalence as women approach the later stages of the menopausal transition and have longer bouts of amenorrhea.* Women with a history of premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), or clinical depression may be more vulnerable to mood changes during perimenopause.*

A 2024 study published in npj Women’s Health, which surveyed 4,432 U.S. women, found that psychological symptoms were notably common, even in individuals aged 30-45 years, suggesting that mood changes can begin earlier than many expect.*

The Interaction Effect: These symptoms often interact with one another. Depressed women tend to experience worse hot flashes along with worse sleep, creating a compounding effect on overall wellbeing.* Similarly, severe menopause symptoms, especially depression and sexual problems, correlate with brain fog severity.*

4. Sleep Disturbances

Difficulty falling asleep or staying asleep becomes increasingly common during perimenopause.*

Sleep Challenges Include:

• Insomnia (affecting 35% to 65% of women in the menopausal transition)*
• Difficulty falling asleep*
• Waking frequently during the night*
• Early morning awakening*
• Non-restorative sleep (waking unrefreshed)*

Why Sleep Suffers: While night sweats are an obvious culprit, sleep disturbances in perimenopause aren’t always directly caused by vasomotor symptoms.* Sleep problems increase in relation to both the menopausal transition itself and aging.* Research shows that insomnia risk increases across all stages of perimenopause, but sleeplessness worsens in the later stages.*

Sleep is critical because it’s when your body repairs itself, consolidates memories, and regulates hormones.* Poor sleep can worsen cognitive symptoms, mood changes, and overall quality of life.*

5. Genitourinary Syndrome of Menopause (GSM)

This is the medical term for a collection of symptoms related to declining estrogen’s effect on vaginal and urinary health.*

Symptoms Can Include:

• Vaginal dryness and discomfort*
• Decreased lubrication during sexual activity*
• Pain or discomfort with penetration (dyspareunia)*
• Burning, itching, or irritation of the vulva*
• Changes in urinary patterns*
• Increased urinary frequency or urgency*
• Greater susceptibility to urinary tract infections*

Important Timeline Distinction: Many women will not notice symptoms of GSM during early perimenopause.* For some, symptoms may not become problematic until several years after menopause.* Unlike hot flashes and mood issues, vaginal symptoms will not resolve on their own without treatment and often persist or worsen without intervention.*

As estrogen decreases, the surface of the vulva and vagina become thin, dry, and less elastic.* Vaginal secretions diminish, resulting in less natural lubrication.*

6. Changes in Menstrual Patterns

For most women, this is the very first noticeable sign of perimenopause.*

What Changes Look Like:

• Cycles becoming shorter or longer than your historical pattern*
• Variation of 7 days or more between consecutive cycles*
• Heavier menstrual flow (menorrhagia)*
• Lighter menstrual flow*
• Fewer or more days of bleeding*
• Skipped periods (becoming more frequent as you approach menopause)*

Why It Matters: While cycle changes are normal during perimenopause, very heavy bleeding or bleeding between periods should be evaluated by your healthcare provider to rule out other conditions.*

7. Other Common Physical Signs

Research has documented many additional symptoms associated with perimenopause:*

• Breast tenderness: Often occurs in early perimenopause, typically improves in late perimenopause*
• Headaches or migraines: May increase in frequency, particularly during late perimenopause*
• Joint pain or stiffness: Commonly reported, particularly in knees*
• Skin changes: Loss of collagen (30% in the five years after menopause), increased dryness*
• Hair changes: Thinning hair on the scalp, sometimes increased facial hair*
• Weight changes: Tendency toward increased abdominal fat*
• Heart palpitations: Sensation of rapid or irregular heartbeat*

Supporting Your Body Through the Perimenopause Transition

While perimenopause is a natural process that cannot be prevented, there are many proactive, evidence-based strategies to support your body and potentially ease symptoms.*

Understanding Why Lifestyle Matters: Bone and Heart Health

The “why” behind lifestyle recommendations is crucial for motivation. Declining estrogen can impact bone density, increasing the long-term risk of osteoporosis, and can also affect cholesterol levels and cardiovascular health.* Therefore, the nutritional and exercise guidance that follows isn’t just for feeling better today, but for protecting your long-term health.*

Estrogen plays a key role in protecting the heart, and when the hormone declines, cardiovascular disease risk increases.* An increase in abdominal fat, higher lipid levels, and changes in blood vessels during the menopausal transition can make you vulnerable to cardiovascular disease.*

Nourishing Your Body with Food

As we explored comprehensively in our guide Hormone Balancing Foods: 5 Essential Food Groups for Wellness [Link to your other blog], a diet rich in whole, plant-based foods is foundational for hormonal wellness.*

For Bone Health:

• Calcium-rich plant foods: Leafy greens (kale, collard greens, bok choy), fortified plant milks, tofu made with calcium sulfate, almonds, tahini*
• Vitamin D: Sunlight exposure, fortified foods, consider supplementation if deficient*
• Magnesium-rich foods: Pumpkin seeds, almonds, spinach, black beans, avocado*

For Heart Health:

• Healthy fats: Avocados, extra virgin olive oil, walnuts, flaxseeds, chia seeds*
• Omega-3 fatty acids: Ground flaxseeds, chia seeds, hemp seeds, walnuts, edamame (for plant-based ALA omega-3s)*
• Fiber: Whole grains, legumes, vegetables, fruits*

For Brain Function:

• Omega-3 fatty acids: Research suggests these may benefit memory and cognitive wellbeing*
• Antioxidant-rich foods: Berries, dark leafy greens, colorful vegetables*
• Mediterranean-style eating pattern: Associated with reduced incidence of cognitive impairment when paired with regular exercise*

The Critical Role of Movement

Weight-Bearing Exercise for Bone Health: Weight-bearing exercises like walking, jogging, dancing, and stair climbing are essential for maintaining strong bones and preventing osteoporosis.* Aim for 30 minutes most days of the week.*

Strength Training for Muscle and Metabolism: Resistance training becomes increasingly important during midlife to maintain muscle mass, which naturally declines with age and hormonal changes.* Strong muscles support metabolism, bone health, and functional independence.* Include 2-3 days per week of strength training.*

Movement for Mood and Cognition: Physical activity strongly influences hormonal health by improving blood flow and increasing hormone receptor sensitivity.* Exercise has also been shown to improve mood, reduce anxiety, and support cognitive function during the menopausal transition.* Adults should aim for 150 minutes of moderate exercise per week.*

Managing Hot Flashes and Sleep Naturally

Environmental Adjustments:

• Keep bedroom temperature cool (around 65-68°F)*
• Use a fan beside your bed*
• Choose moisture-wicking, breathable pajamas*
• Use layered bedding that’s easy to adjust*
• Keep cold water by your bedside*

Sleep Hygiene Practices:

• Maintain a consistent sleep schedule (same bedtime and wake time)*
• Create a relaxing bedtime routine*
• Limit screen time 1-2 hours before bed*
• Avoid caffeine after noon*
• Limit alcohol, which can worsen night sweats and disrupt sleep*
• Create a dark, quiet sleeping environment*

Stress Management: Chronic stress elevates cortisol, which can suppress reproductive hormones and worsen menopausal symptoms.* Incorporate practices like:*

• Meditation or mindfulness*
• Yoga (which has been shown to help with hot flashes and mood)*
• Deep breathing exercises*
• Time in nature*
• Activities that bring you joy and relaxation*

Targeted Nutritional Support: The Role of Cruciferous Vegetables and DIM

For many women, lifestyle adjustments can be complemented by targeted nutritional support.* One area of ongoing research focuses on cruciferous vegetables and their unique ability to support healthy estrogen metabolism.*

Cruciferous vegetables like broccoli, kale, cauliflower, and Brussels sprouts contain compounds called glucosinolates, which your body converts to indole-3-carbinol (I3C) and then to Diindolylmethane (DIM).* As we explained in detail in our previous article What is DIM? A Clear Guide to This Key Nutrient for Hormonal Balance [Link to your DIM blog], DIM plays a supportive role in the body’s natural process of metabolizing estrogen.*

Research suggests that DIM may help promote a favorable balance of estrogen metabolites, potentially supporting hormonal equilibrium during the menopausal transition.* While eating cruciferous vegetables regularly is excellent for overall health, obtaining a consistent, concentrated amount through diet alone can be challenging.*

Lefiano DIM Ultra: Thoughtful Support for Your Transition

At Lefiano, our DIM Ultra formula was created with women navigating hormonal transitions in mind. It provides:*

• 350mg of DIM – A potent dose aligned with research on hormone balance support*
• 100mg Broccoli Extract – A natural source of glucosinolates from cruciferous vegetables*
• BioPerine® – Clinical research demonstrating enhanced nutrient absorption*

This formula is designed to complement a healthy lifestyle, providing targeted support for the body’s natural process of balancing hormones during perimenopause and beyond.*

BioPerine® is a registered trademark of Sabinsa Corporation, USA.

Learn More About Lefiano’s DIM Ultra

When to Seek Medical Care

While perimenopause is natural, certain situations warrant professional guidance:*

Consult Your Healthcare Provider If:

• You’re experiencing extremely heavy bleeding or bleeding between periods*
• Your symptoms are significantly impacting your quality of life or ability to function*
• You’re struggling with persistent depression or anxiety*
• You’re having thoughts of self-harm*
• You’re interested in exploring hormone therapy or other medical treatments*
• You’re under 40 and experiencing symptoms (premature menopause)*
• You’re concerned about your bone health or cardiovascular risk*
• Your cognitive symptoms are worsening or accompanied by other concerning signs*

Remember, as many as 90% of women seek medical care for symptoms during perimenopause.* There’s no need to suffer in silence, and seeking help is a sign of self-care, not weakness.*

The Bigger Picture: Perimenopause in Context

Despite the significance and prevalence of perimenopause, there remains a substantial gap in both medical research and societal understanding.* For most of our lives, discussions about female hormones focus on childbearing, but women are far more than reproductive function, and hormones affect far more than monthly cycles.*

A 2025 survey published in Healthcare examining perimenopause awareness found that general knowledge about perimenopause remains limited, with misconceptions about its onset, duration, and symptoms common even among those experiencing it.* Many studies suggest that most women have begun perimenopause by age 45-47, yet awareness often lags behind biological reality.*

The good news? This is changing. The current generation of women in midlife is ready to break the silence, demand better research, and access the support they deserve. By educating yourself, talking openly with friends and healthcare providers, and advocating for your wellbeing, you’re part of this positive shift.*

The Takeaway: Knowledge, Compassion, and Empowerment

Perimenopause is a natural and significant chapter of life, not a medical condition to be “fixed” or a weakness to be hidden.* It’s a neurological and hormonal transition that every woman with ovaries will experience.* While the symptoms can be challenging, they are also temporary for most women, and there are numerous evidence-based strategies to support your body and mind during this time.*

By understanding the signs and stages of perimenopause, recognizing that your experiences are valid and common, and embracing a holistic approach to wellness through nourishing food, regular movement, quality sleep, stress management, and targeted nutritional support when appropriate, you can navigate this transition with confidence, grace, and clarity.*

You are not alone in this journey. Millions of women are going through or have been through exactly what you’re experiencing. With knowledge, self-compassion, and the right support, you can not only survive perimenopause but truly thrive during this transformative life stage.*

For More Information:

• What is DIM? Complete Guide to Hormone Balance – Deep dive into the science of estrogen metabolism support
• Hormone Balancing Foods: 5 Essential Groups – Comprehensive nutrition guide for hormonal wellness
• Our Brand Story – Learn about Lefiano’s commitment to transparency and education

---

Medical Disclaimer

Disclaimer: The information provided on this site is for educational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. The statements on this page have not been evaluated by the Food and Drug Administration (FDA). Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. Our product, DIM Ultra, is a dietary supplement and is not intended to diagnose, treat, cure, or prevent any disease.

---

References

1. Harlow, S. D., Gass, M., Hall, J. E., Lobo, R., Maki, P., Rebar, R. W., Sherman, S., Sluss, P. M., de Villiers, T. J., & STRAW+10 Collaborative Group. (2012). Executive summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging. The Journal of Clinical Endocrinology and Metabolism, 97(4), 1159-1168. https://doi.org/10.1210/jc.2011-3362
2. Delamater, L., & Santoro, N. (2018). Management of the Perimenopause. Clinical Obstetrics and Gynecology, 61(3), 419-432. https://doi.org/10.1097/GRF.0000000000000389
3. Santoro, N. (2016). Perimenopause: From Research to Practice. Journal of Women’s Health, 25(4), 332-339. https://doi.org/10.1089/jwh.2015.5556
4. Gava, G., Orsili, I., Alvisi, S., Mancini, I., Seracchioli, R., & Meriggiola, M. C. (2019). Cognition, Mood and Sleep in Menopausal Transition: The Role of Menopause Hormone Therapy. Medicina, 55(10), 668. https://doi.org/10.3390/medicina55100668
5. Reed, R. G., Weihs, K. L., Sbarra, D. A., Breen, E. C., Olmstead, R., & Irwin, M. R. (2022). Perimenopause symptoms, severity, and healthcare seeking in women in the US. npj Women’s Health, 3(1), Article 61. https://doi.org/10.1038/s44294-025-00061-3
6. The Menopause Society. (2025). Perimenopause. Professional Patient Education. https://menopause.org/patient-education/menopause-topics/perimenopause
7. Mayo Clinic. (2025, August 14). Perimenopause – Symptoms and causes. Mayo Clinic Health Information. https://www.mayoclinic.org/diseases-conditions/perimenopause/symptoms-causes/syc-20354666
8. National Institute on Aging. (2024, October 16). What is menopause? National Institute on Aging, National Institutes of Health. https://www.nia.nih.gov/health/menopause/what-menopause
9. Freeman, E. W., Sammel, M. D., Lin, H., & Nelson, D. B. (2006). Associations of hormones and menopausal status with depressed mood in women with no history of depression. Archives of General Psychiatry, 63(4), 375-382. https://doi.org/10.1001/archpsyc.63.4.375
10. Avis, N. E., Crawford, S. L., Greendale, G., Bromberger, J. T., Everson-Rose, S. A., Gold, E. B., Hess, R., Joffe, H., Kravitz, H. M., Tepper, P. G., Thurston, R. C., & Study of Women’s Health Across the Nation. (2015). Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Internal Medicine, 175(4), 531-539. https://doi.org/10.1001/jamainternmed.2014.8063
11. Maki, P. M., & Jaff, N. G. (2024). Menopause and brain fog: how to counsel and treat midlife women. Menopause, 31(7), 647-649. https://doi.org/10.1097/GME.0000000000002382
12. Metcalf, C. A., & Duffy, K. A. (2023). Cognitive Problems in Perimenopause: A Review of Recent Evidence. Current Psychiatry Reports, 25(10), 501-511. https://doi.org/10.1007/s11920-023-01447-3
13. Maki, P. M., & Thurston, R. C. (2020). Menopause and Brain Health: Hormonal Changes Are Only Part of the Story. Frontiers in Neurology, 11, 562275. https://doi.org/10.3389/fneur.2020.562275
14. Weber, M. T., Maki, P. M., & McDermott, M. P. (2014). Cognition and mood in perimenopause: a systematic review and meta-analysis. The Journal of Steroid Biochemistry and Molecular Biology, 142, 90-98. https://doi.org/10.1016/j.jsbmb.2013.06.001
15. Bromberger, J. T., Kravitz, H. M., Chang, Y., Cyranowski, J. M., Brown, C., & Matthews, K. A. (2011). Major depression during and after the menopausal transition: Study of Women’s Health Across the Nation (SWAN). Psychological Medicine, 41(9), 1879-1888. https://doi.org/10.1017/S003329171100016X
16. Portman, D. J., & Gass, M. L. (2014). Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause, 21(10), 1063-1068. https://doi.org/10.1097/GME.0000000000000329
17. Kravitz, H. M., Ganz, P. A., Bromberger, J., Powell, L. H., Sutton-Tyrrell, K., & Meyer, P. M. (2003). Sleep difficulty in women at midlife: a community survey of sleep and the menopausal transition. Menopause, 10(1), 19-28. https://doi.org/10.1097/00042192-200310010-00005
18. Zhang, Y., Chen, X., & Yao, G. (2025). Sleep and Brain Function at Menopause. Cureus, 17(1), e77097. https://doi.org/10.7759/cureus.77097
19. Shifren, J. L., & Gass, M. L. (2014). The North American Menopause Society recommendations for clinical care of midlife women. Menopause, 21(10), 1038-1062. https://doi.org/10.1097/GME.0000000000000319
20. Thurston, R. C., & Joffe, H. (2011). Vasomotor symptoms and menopause: findings from the Study of Women’s Health across the Nation. Obstetrics and Gynecology Clinics of North America, 38(3), 489-501. https://doi.org/10.1016/j.ogc.2011.05.006
21. Rodríguez, A. L. (2024). Brain Changes During Menopause: A Review of Recent Evidence. Presented at The Menopause Society Annual Meeting, Orlando, FL.
22. Jacobs, E. G., Weiss, B. K., Makris, N., Whitfield-Gabrieli, S., Buka, S. L., Klibanski, A., & Goldstein, J. M. (2016). Impact of sex and menopausal status on episodic memory circuitry in early midlife. The Journal of Neuroscience, 36(39), 10163-10173. https://doi.org/10.1523/JNEUROSCI.0951-16.2016
23. Mosconi, L., Berti, V., Dyke, J., Schelbaum, E., Jett, S., Loughlin, L., Jang, G., Rahman, A., Hristov, H., Pahlajani, S., Andrews, R., Matthews, D., Etingin, O., Ganzer, C., de Leon, M., Isaacson, R., & Brinton, R. D. (2021). Menopause impacts human brain structure, connectivity, energy metabolism, and amyloid-beta deposition. Scientific Reports, 11, 10867. https://doi.org/10.1038/s41598-021-90084-y
24. North American Menopause Society. (2020). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause, 27(9), 976-992. https://doi.org/10.1097/GME.0000000000001609
25. Cleveland Clinic. (2023). Perimenopause. Cleveland Clinic Health Library. https://my.clevelandclinic.org/health/diseases/21608-perimenopause
26. Harvard Health Publishing. (2024). Perimenopause: Rocky road to menopause. Harvard Medical School. https://www.health.harvard.edu/womens-health/perimenopause-rocky-road-to-menopause
27. Office on Women’s Health, U.S. Department of Health and Human Services. (2021). Menopause basics. https://www.womenshealth.gov/menopause/menopause-basics
28. American College of Obstetricians and Gynecologists. (2021). The Menopause Years. ACOG Patient Education. https://www.acog.org/womens-health/faqs/the-menopause-years
29. Santoro, N., Epperson, C. N., & Mathews, S. B. (2015). Menopausal Symptoms and Their Management. Endocrinology and Metabolism Clinics of North America, 44(3), 497-515. https://doi.org/10.1016/j.ecl.2015.05.001
30. Delage, B., & Ho, E. (2025, March 7). Indole-3-Carbinol. Linus Pauling Institute, Oregon State University. https://lpi.oregonstate.edu/mic/dietary-factors/phytochemicals/indole-3-carbinol
31. Institute for Functional Medicine. (2024). Nutrition and Impacts on Hormone Signaling. https://www.ifm.org/articles/nutrition-impacts-hormone-signaling
32. Guan, X., Li, M., Li, T., Gao, F., Zhao, C., Zhang, W., Zhang, Y., Ma, C., & Zhao, Z. (2025). Current Status of the Impact of Perimenopause on Women’s Awareness, Healthcare Providers’ Training, Perceptions, and Beliefs. Healthcare, 13(1), 91. https://doi.org/10.3390/healthcare13010091