Perimenopause Starts Earlier Than You Think

You are 34. Your periods have become unpredictable. You are waking at 3am for no reason. Your anxiety has climbed to a level you cannot explain. You go to the doctor and are told it is stress. You are told you are too young for it to be hormonal. 

You might not be.

It Starts Earlier Than Anyone Tells You

Perimenopause is the transitional phase before menopause, when oestrogen and progesterone begin to fluctuate unpredictably. Most people associate it with women in their late 40s. The research tells a different story. A 2025 study published in NPJ Women's Health, analysing data from more than 4,400 women through the Flo health tracking application, found that more than half of women aged 30 to 35 reported symptoms meeting the criteria for moderate to severe on the Menopause Rating Scale. Among women aged 36 to 40, that figure rose to 64.3 percent.(1) Despite this, most women do not seek treatment until they are 56 or older.(1)

That is a gap of over two decades.

Why the Symptoms Are So Easy to Miss

Perimenopause does not always announce itself with hot flushes. Mental health symptoms, including anxiety and depression, frequently emerge before the more recognisable physical signs.(1) This is because oestrogen receptors are present throughout the brain, and fluctuating oestradiol destabilises serotonin pathways, creating mood changes that can meet the threshold for a clinical mental health diagnosis.(2) Around 4 in 10 women experience mood symptoms during perimenopause that mirror premenstrual syndrome, but without the predictability of the menstrual cycle.(3) Sleep disruption, brain fog, joint pain, and changes in libido are also common, and frequently attributed to stress, ageing, or other causes.

The symptoms most commonly missed or misattributed include irregular periods, new or worsening anxiety, early morning waking, brain fog, disproportionate fatigue, mood volatility, and joint pain. A combination of several of these in a woman over 30 warrants hormonal investigation.

The Long-Term Stakes

Perimenopause is not only a symptomatic phase. It is a period of meaningful change in cardiovascular, metabolic, and bone health. Research confirms that perimenopausal women already show early indicators of hypertension, oxidative stress, and endothelial dysfunction, elevating long-term cardiovascular risk.(4) Younger age at menopause is consistently associated with higher risk of cardiovascular disease, osteoporosis, and fracture.(5) This makes the perimenopausal window a critical time for preventive health, not just symptom management.

What It Looks Like in Malaysia

The mean age of menopause in Malaysian women is approximately 50.7 years,(6) placing the onset of perimenopause for many women in their early to mid-40s, and for some considerably earlier. A population-based study of 1,825 Malaysian working women found the most commonly reported symptoms were joint pain, sleep disturbances, brain fog, mood swings, and digestive issues(7) — symptoms most women are likely attributing to something else entirely. Research on Malaysian women consistently shows low rates of treatment seeking and limited awareness of perimenopause as a hormonal phase. A study of East Coast Malaysian women found that none of the participants sought treatment for menopausal symptoms, partly due to a lack of knowledge and cultural reluctance to discuss the topic openly.(8)

What to Do If You Suspect It

Request a hormonal blood panel that includes FSH, LH, oestradiol, and AMH. Understand that hormone levels fluctuate significantly in perimenopause and a single result may not capture the full picture. Symptoms must be interpreted alongside test results, not replaced by them. If your doctor dismisses your symptoms on the basis of age, ask specifically whether perimenopause has been considered. Current evidence does not support age 45 as a floor for assessment. If needed, seek a second opinion from a clinician with experience in hormonal health.

And alongside symptom management, ask about your cardiovascular and bone health baseline. These conversations should not wait until your 50s.

Think your symptoms might be hormonal? Start with a free AI-powered symptom check to identify which hormones to investigate and how to advocate for yourself at your next appointment.

References

1. University of Virginia Health System. Young women suffering menopause symptoms in silence, study reveals [Internet]. Charlottesville: UVA; 2025 Feb [cited 2025 May]. Available from: https://news.virginia.edu/content/uva-study-reveals-women-suffer-menopause-symptoms-decades-early

2. Solly EL, Kleidon A, Wittert GA, Heilbronn LK, Hocking SL, Le Fevre L, et al. Severe mental illness and the perimenopause. BJPsych Open [Internet]. 2024 Dec [cited 2025 May];10(6). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11669460/

3. American College of Obstetricians and Gynecologists. Mood changes during perimenopause are real. Here's what to know [Internet]. Washington DC: ACOG; 2023 [cited 2025 May]. Available from: https://www.acog.org/womens-health/experts-and-stories/the-latest/mood-changes-during-perimenopause-are-real-heres-what-to-know

4. Parikh M, Nair M, Aggarwal P, Bhatt P, Bhatt DL. Cardiovascular health during menopause transition: The role of traditional and nontraditional risk factors. PMC [Internet]. 2025 [cited 2025 May]. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12352403/

5. Anagnostis P, Christou K, Artzouchaltzi AM, Gkekas NK, Kosmidou N, Siolos P, et al. Bone and heart health in menopause. Maturitas [Internet]. 2022 [cited 2025 May]. Available from: https://pubmed.ncbi.nlm.nih.gov/35400590/

6. Ismail R, Aziz AA, Yahya Z. A study on the menopause in Malaysia. Asia Pac J Public Health [Internet]. 1994 [cited 2025 May];7(3):153-156. Available from: https://pubmed.ncbi.nlm.nih.gov/7799827/

7. Ahmad Termizi NA, Ahmad NS, Zolkepali NA, Ahmad Termizi MA, Mohamad Zainuddin SI. Menopausal symptoms among multi-ethnic working women in Malaysia. Menopause [Internet]. 2025 [cited 2025 May]. Available from: https://pubmed.ncbi.nlm.nih.gov/40503911/

8. Zainal A, Chinna K, Farizah MH, Hamid AM, Mahdy ZA. Exploring women's perceptions and experiences of menopause among East Coast Malaysian women. BMC Womens Health [Internet]. 2021 [cited 2025 May]. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8088743/