Symptoms, psychological aspects, proteins, core strengthening, natural and medication-based treatments, the role of osteopathy

Perimenopause is the transitional period leading up to menopause (defined as 12 consecutive months without a period). It begins, on average, around age 47, but can start as early as ages 40–45, and often lasts 4 years, though it can range from a few months to nearly 10 years.

This is not simply a “drop in estrogen.” Estrogen and progesterone levels fluctuate significantly. Several phases are typically described: shorter cycles with possible hyperestrogenism (breast tenderness, weight gain, bloating), followed by irregular cycles, and then longer cycles before menstruation stops. This instability explains why symptoms may appear, disappear, and then return more intensely.

The diagnosis is clinical. Routine hormone tests (FSH, estradiol) are of little use at this age, as hormone levels vary from day to day. Perimenopause is considered in cases of persistent cycle irregularities and/or menopausal symptoms, even in relatively young women.

The “classic” symptoms remain hot flashes, night sweats, genitourinary problems, and joint pain. But an international study published in 2025 in the journal *Menopause* (involving nearly 17,500 women) revealed a striking discrepancy: the most commonly recognized symptoms are hot flashes, sleep disturbances, and weight gain; the most commonly reported symptoms are fatigue, physical and mental exhaustion, irritability, low mood, sleep disturbances, digestive problems, and anxiety.

Common symptoms:

These symptoms are not “all in your head.” They reflect hormonal changes that affect the brain, the autonomic nervous system, metabolism, the digestive tract, and adipose tissue.

Perimenopause is a documented period of psychological vulnerability. A meta-analysis of 102 studies (involving more than one million women) estimates the point prevalence of depressive symptoms at approximately 32% during perimenopause and 30% after menopause; anxiety affects approximately 29% of women during perimenopause; insomnia is also very common.

The risk of major depressive disorder is 2 to 4 times higher than during the premenopausal period. A large proportion of women report experiencing “brain fog”; recent studies show that it is more closely linked to psychological symptoms (anxiety, mood, sleep) than to a significant, measurable decline in objective cognitive performance.

Mechanisms implicated include: fluctuations in estrogen levels affecting neurotransmitters (serotonin, GABA), sleep disturbances, low-grade inflammation, chronic stress, and, in some cases, a mental workload that is already high at this age (children, parents, career).

Practical implications: New-onset irritability, morning anxiety, or persistent sadness should not be dismissed as trivial. Specific treatment (psychotherapy, sometimes SSRIs/SNRIs, sleep hygiene, physical activity) is recommended. The effect of hormone therapy on mood is not as clear-cut as its effect on hot flashes; it may help some women, but it is not an antidepressant on its own.

Two phenomena are often conflated, and it is helpful to distinguish between them.

The gradual decline in estrogen promotes the storage of visceral fat (around the organs) rather than on the hips and thighs. This change in body composition can occur even without significant weight gain on the scale. It is accompanied by a loss of muscle mass (early-stage sarcopenia), a decrease in fat oxidation, and reduced metabolic flexibility. This represents a window of cardiometabolic vulnerability.

The Seattle Midlife Women’s Health Study (to be published in 2026) shows that the severity of bloating increases during the early and late stages of the menopausal transition. Anxiety and stress are associated with increased bloating; age and testosterone levels, on the other hand, are associated with decreased bloating. Possible mechanisms include fluid retention, changes in the gut microbiome, increased digestive sensitivity, estrogen-related changes in bowel motility, and stress-related abdominal hypertonicity.

The “perimenopausal belly” is therefore not just a cosmetic issue. It is a combination of visceral fat, loss of abdominal muscle tone, impaired digestion, and sometimes muscle tension.

Doing "crunches" every night isn't enough, and may even worsen poorly managed intra-abdominal pressure if the pelvic floor or diaphragm is already compromised.

What research on body composition in one's 40s and 50s shows:

Useful exercises: adapted planks, dead bug, bird-dog, anti-rotation (Pallof press), low abdominal breathing, core stabilization in functional positions, and strengthening of the glutes and posterior chain. The goal isn’t a “six-pack”; it’s a stable core, improved breathing mechanics, and a healthy muscle metabolism.

The official recommended intake of 0.8 g/kg/day is based on young adults. After age 45–50, and even more so due to anabolic resistance associated with declining estrogen levels, actual needs are higher.

Key points from the PROT-AGE and ESPEN groups and recent literature on women in transition:

Example: a woman weighing 65 kg → approximately 78 to 104 g of protein per day, depending on her activity level.

Sources: eggs, Greek yogurt, cottage cheese, fish, poultry, legumes, tofu, tempeh, dairy products, and, if needed, a powder (whey or a high-quality plant-based option). Supplementation isn’t required, but it’s a practical option when your morning appetite is low, meals are irregular, or you don’t consume at least 25 g at breakfast.

Warning: In cases of kidney failure, medical advice is essential. An unbalanced intake of protein—especially if fluid intake and fiber intake are insufficient—can increase bloating in some women. The goal is not an extreme high-protein diet, but rather an adequate, consistent intake combined with strength training and a Mediterranean-style diet (vegetables, fiber, healthy fats, and few ultra-processed foods).

Protein also helps promote satiety and, indirectly, bone health: an insufficient intake is associated with poorer bone remodeling.

Before considering any medication, French and European guidelines emphasize lifestyle changes:

For chronic insomnia during perimenopause and postmenopause, a 2026 meta-analysis suggests that non-pharmacological approaches (CBT for insomnia, techniques that reduce sympathetic hyperactivation—such as yoga, acupuncture, and massage) are more effective than sleeping pills alone.

Phytoestrogens (soy, red clover, etc.) have shown mixed results. The HAS does not recommend herbal preparations containing phytoestrogens as the primary treatment for hot flashes. They should not be taken without medical supervision, especially in cases of a history of hormone-dependent cancer.

During perimenopause, the pattern of full-blown menopause does not automatically apply. Conventional hormone replacement therapy (HRT) is not always the first choice if menstrual cycles are still occurring, due to the risk of an “excessive dose” of estrogen during phases of hyperestrogenism.

Common regimens based on symptoms (to be confirmed with a doctor):

Hormone therapy is not without risks: an individualized benefit-risk assessment is required (age, time since menopause, history of breast cancer, thrombosis, migraine with aura, and meningioma for certain progestins). In particular, the HAS 2025 guidelines excluded certain progestins associated with a risk of meningioma and tibolone from the standard treatment strategy. Reevaluation should occur at least once a year.

Contraception remains an issue: decreased fertility does not mean infertility. An IUD (copper or levonorgestrel) is often the preferred option at this age.

Osteopathy is not a substitute for hormones and does not directly affect estrogen levels. It’s important to make that clear. However, it addresses all the areas that perimenopause puts under strain: joints, back, pelvis, abdomen, autonomic nervous system, posture, and circulation.

Joint pain, lower back pain, neck stiffness, shoulder tension, and pelvic discomfort are among the most common reasons. Changes in body composition, decreased muscle tone, sleep disturbances, and anxiety often cause stiffness in the rib cage, diaphragm, and abdominal muscles—which contributes to a bloated feeling and fatigue.

Areas an osteopath can address on an individualized basis:

Specific studies are still few in number and small in scale. An older controlled study (using low-force osteopathic techniques) observed a reduction in hot flashes, night sweats, urinary frequency, and depressive symptoms. More recent, modest studies suggest an improvement in quality of life and symptom relief, though this varies from person to person rather than being uniform. In other words: osteopathy is not a “menopause treatment”; rather, it is a useful tool for addressing the musculoskeletal, visceral, and autonomic nervous system consequences of this transition.

That is precisely why follow-up care at the office makes sense. A woman going through perimenopause doesn’t just need a prescription or a diet plan. She needs someone to assess her lower back tension, support her diaphragm, check how her abdomen responds to physical exertion, and integrate these findings with muscle strengthening and, if necessary, gynecological care.

Each session is tailored to the patient’s specific needs on the day of the appointment: some patients come mainly for back pain, others for abdominal discomfort, sleep issues, or a feeling of being “on edge” in their bodies.

Osteopathy is part of a multidisciplinary care approach involving a physician, a gynecologist, and possibly a nutritionist or a coach trained in midlife issues. It does not preclude hormone therapy, nor does it replace it. It helps the body better cope with the changes it is undergoing. 

Our practice is equipped with Tecarthérapie using Winback technology. This medical radiofrequency therapy (capacitive and resistive high-frequency current) is used to complement manual techniques: it promotes local circulation, helps release muscle and fascial tension, reduces certain types of pain, and prepares the tissues for osteopathic treatment. During perimenopause, it is particularly helpful for joint stiffness, lower back pain, a sensation of abdominal tightness, pelvic floor tension, and recovery following muscle strengthening exercises. The session is non-invasive and generally comfortable; the energy level is adjusted to the specific area being treated and the patient’s sensitivity on that particular day. Winback does not affect hormone levels and is not a substitute for a gynecological evaluation or any potential menopausal hormone therapy: it supports tissue comfort and mobility, helping the body better navigate this transition. A preliminary assessment is conducted to verify indications and contraindications (pacemaker, pregnancy, local infection, history of cancer—to be discussed on a case-by-case basis).

Perimenopause is not a disease. It is a challenging biological transition that is better understood today than it was ten years ago. Recent studies agree: we can influence hormones if necessary, muscles and protein intake with certainty, stress and sleep in a decisive way, and the body’s mechanics through specific physical exercises. A bloated stomach, fatigue, and irritability are not inevitable conditions to be endured in silence.

If you recognize yourself in these lines, working with us at our practice can help you connect what you’re feeling with what your body is showing: tension, mobility, breathing, and pelvic alignment. This is often where daily life becomes easier—as a complement to, not a substitute for, appropriate medical care.