Menopause is, unfortunately, a stigmatized topic in women’s health. Stereotypes, like menopause being a marker of old age or an illness, only lead to more confusion and misunderstanding. Due to the lack of open discussion, many don’t realize that women actually transition into menopause and experience symptoms for an average of four years, and sometimes as many as ten.

This transition into menopause is known as perimenopause, which means “around menopause.” Though perimenopause is overshadowed by and less talked about than menopause, it can actually be more uncomfortable. “Some women breeze through perimenopause while others have a terrible time with it,” says Kristy Vermeulen, a San Francisco-based naturopathic doctor who specializes in functional endocrinology and female sex hormone treatment. “It can be a tough time — even more so than menopause.”

We talked with Vermeulen to get a better understanding of perimenopause and how it differs from menopause.

What is perimenopause?
According to Vermeulen, perimenopause is the period in which your ovaries gradually begin producing fewer hormones, especially estrogen and testosterone. During this time, less progesterone is produced. But Vermeulen notes that this decline is slow and sporadic — imagine a chart with many spikes that downtrend over time. “You’re going through constant hormone fluctuations,” she says. “For example, your estrogen levels will come back, drop, then come back again.”

These fluctuations may lead to menstrual cycle changes like frequent, heavy periods or even constant bleeding. “Women in perimenopause are going in and out of experiencing menopause symptoms like menstrual cycle changes, PMS symptoms, trouble sleeping, vaginal dryness, mood swings, hot flashes, and more,” she explains.

Perimenopause typically starts in a woman’s early to mid-forties. But for some, it can start as early as the mid-30s or as late as the early-50s. Vermeulen emphasizes that perimenopause is an extremely individual experience.

How does perimenopause differ from menopause?
During perimenopause, sex hormone levels are slowly decreasing and the body has to push harder for ovulation to happen. These changes signal the end of a woman’s reproductive years. Once you haven’t had a period for 12 consecutive months, you’ve officially reached menopause.

“Hormone fluctuations during perimenopause make the progression to menopause unpredictable and confusing,” says Vermeulen. “A woman may not have a period for eight months and assume she’s four months away from menopause. But then, her period suddenly comes back.”

The erratic nature of perimenopause is one of the things that can make it more difficult than menopause. “It’s common to feel like you have little to no control over your body,” adds Vermeulen. “During perimenopause, women don’t know what’s going to happen next. When you’re in menopause, your hormones, though low, are flatlined and stable — not shooting up and down. You’ll either feel fine or awful.”

In other words, at least there’s predictability — even if it’s predictably feeling low or experiencing symptoms — during menopause.

Strategies to manage and ease perimenopause symptoms
“The number one thing you can do to feel better during perimenopause is regulate and balance your hormones in order to establish a more regular cycle with less hormonal ups and downs,” says Vermeulen. She explains that this can help you regain some control and predictability.

There are many ways you can work to balance your hormones, like taking supplements, adjusting your diet, or treating with bioidentical hormones. Vermeulen is a proponent of acupuncture, which is said to clear blockages in the body to promote flow. She also suggests trying seed cycling. “Seeds, like pumpkin, flax, and sesame, contain natural compounds called lignans and essential fatty acids,” she explains. “Lignans help our body bind up excess hormones, whereas essential fatty acids work to promote optimal hormone production. Together, their actions contribute to optimal hormone levels and a balanced menstrual cycle.”

If you choose to seek support from a professional, Vermeulen says they can walk you through additional solutions like herbal extracts or progesterone cream that work to balance hormones. “Perimenopause can be an incredibly difficult time,” says Vermeulen. “Many women don’t know what’s going on in their bodies or why. But they don’t have to experience it alone. You can feel your ‘normal’ again by seeking support.”

English Taylor is a health and wellness writer living in San Francisco. Her work has been featured in Nylon, Refinery29, and The Atlantic. English enjoys spending time with her friends, family, and 150-pound dog named Bubbles. Her favorite foods are peanut butter and pickles (sometimes together).