The Six Pillars of Perimenopause
Looking beyond hormones and taking a whole person approach to mid- life health
There is no shortage of information about perimenopause.
Open a newspaper, scroll through social media or listen to a podcast and you will find endless discussions about hormones, HRT and symptom checklists.
Yet after more than 25 years as a GP, I have come to believe that whilst hormones matter, they are only part of the story.
The women who seem to navigate this transition most successfully are not necessarily those taking the most medication. More often, they are the women who understand that perimenopause is asking them to pay attention to their health in a different way.
This is where the six pillars of lifestyle medicine come in.
They form the foundation of how I approach perimenopause in clinic and, in my experience, can be just as important as any prescription.
Perimenopause can begin anywhere from the mid-forties, although for some women it starts earlier. Symptoms vary enormously and can include almost anything, which is one reason why it can be so difficult to recognise.
The transition itself can last anywhere from a few years to almost a decade. Menopause is defined as twelve months after a woman’s last menstrual period and occurs at an average age of around 51 years in the UK, although there is considerable variation.
There are also significant cultural differences in how menopause is perceived. In some societies, women are respected and valued for reaching this stage of life. It is seen as a time of wisdom and experience, bringing greater status and seniority amongst younger women. In other cultures, including some ethnic minority communities, menopause remains a taboo subject and is rarely discussed.
Whatever our cultural background, perimenopause is a very real part of life and can bring with it a multitude of physical and emotional symptoms that many women find extremely challenging.
During perimenopause, oestrogen, progesterone and testosterone levels begin to fluctuate. In the early stages, oestrogen levels may remain relatively normal whilst progesterone levels often decline first. This is one reason why treatment needs to be tailored to the individual and why symptoms cannot always be explained by hormone levels alone.
For some women, hormone replacement therapy can be life-changing. For others, non-hormonal approaches, lifestyle measures or a combination of strategies may be more appropriate.
Equally important is recognising that not every symptom occurring during midlife should automatically be attributed to “the change”. Other medical conditions can develop at the same time and symptoms should never simply be ignored.
In fact, only recently I saw a former patient who perfectly illustrated why menopause can be so difficult to navigate.
She was 46 years old and had been struggling for around nine months with poor sleep and a feeling of anxiety or dread first thing in the morning. Once she was up and moving, the feeling largely settled. She had no hot flushes, no night sweats and none of the symptoms most people traditionally associate with menopause.
She had sought help but found it difficult to access a GP appointment. Blood tests had been arranged and she had subsequently been started on oestrogen gel. Yet she felt she had never really had the opportunity to sit down with someone and explore what might be contributing to her symptoms.
What struck me was not whether the treatment was right or wrong. Medicine is rarely that simple. What struck me was how quickly the conversation had become focused on hormones and how little time had been spent exploring everything else that might have been influencing how she felt.”
We talked about sleep, work pressures, stress, exercise, relationships and overall wellbeing. We also reviewed her contraception and discussed whether her Mirena coil was still appropriate if it was being relied upon for endometrial protection alongside oestrogen therapy.
This highlighted another challenge within menopause care. The guidance around contraception and HRT can be complex, and what is appropriate for contraceptive purposes is not necessarily the same as what is appropriate for endometrial protection when oestrogen therapy is being used.
It served as a reminder that menopause care is rarely straightforward and that individual circumstances matter.
By the end of the consultation we had agreed to pause, step back and start again.
This is not an argument against HRT. For many women it can be incredibly effective. Rather, it is a reminder that good medicine starts with listening.
One of my concerns is that menopause has become increasingly medicalised. Of course, there is absolutely a place for HRT and other treatments and for some women they can be transformative. However, I sometimes feel we have become so focused on finding the perfect prescription that we risk overlooking the foundations of health that were there all along.
The challenge for clinicians is to remain curious.
When a woman presents with symptoms such as anxiety, poor sleep, fatigue or low mood, it can be tempting to immediately view them through a menopausal lens. Sometimes that assessment is entirely correct. At other times, the picture may be more complex.
Our role is to look beyond hormones alone. To explore lifestyle, stress, relationships, physical health and emotional wellbeing alongside hormonal factors. To ask what else might be contributing and to resist the temptation to reduce every symptom to a hormone deficiency and every solution to a prescription.
Good menopause care should not be about choosing between HRT and lifestyle medicine. It should be about understanding the whole person and using the right tools for the right individual at the right time.
No hormone can compensate for chronic sleep deprivation, a diet high in ultra-processed foods, unmanaged stress, loneliness or complete physical inactivity.
This is why I am such a strong advocate for lifestyle medicine.
Lifestyle medicine is based on six pillars: nutrition, physical activity, sleep, stress management, healthy relationships and avoiding risky behaviours. These pillars can be applied to almost every chronic condition we encounter in healthcare, but they are particularly relevant during perimenopause.
I often describe perimenopause as one of life’s lightbulb moments because it creates an opportunity to pause and take stock.
Research has shown that lifestyle interventions can significantly reduce future disease risk. One large study demonstrated a 23% reduction in cardiovascular disease risk through lifestyle measures alone. We also know that healthy lifestyle choices can reduce the risk of osteoporosis, improve body composition and support long-term physical and emotional wellbeing.
Perhaps menopause is less about hormone deficiency and more about a message.
A message that the strategies that got us through our twenties, thirties and forties may no longer be enough. The body starts asking us to pay attention. To rest. To move differently. To nourish ourselves better. To put ourselves somewhere on a very long list of priorities.
Pillar One: Nutrition
Hormonal changes affect weight, energy levels, bone health, mood and blood sugar control.
Rather than focusing on restrictive diets, I encourage women to think about nourishment.
A Mediterranean-style diet rich in vegetables, legumes, whole grains, fish, nuts and olive oil provides an excellent foundation.
Prioritising protein with meals helps maintain muscle mass and promotes satiety. Choosing high-fibre carbohydrates rather than refined alternatives helps stabilise blood sugar and insulin levels, which can reduce weight gain and energy fluctuations.
Bone health becomes increasingly important during this stage of life. Calcium-rich foods such as dairy products, fortified plant milks, tofu and leafy green vegetables, alongside adequate Vitamin D, can help maintain bone strength.
Gut health matters too. Fermented foods such as live yoghurt and kefir may support a healthier microbiome and overall wellbeing.
Many women also find that reducing alcohol, excessive caffeine and highly processed foods improves symptoms such as hot flushes, palpitations and disrupted sleep.
Pillar Two: Physical Activity
Exercise is one of the most powerful tools we have during perimenopause.
Resistance training helps maintain muscle mass, strengthen bones and improve metabolic health. Weight-bearing exercise can increase bone mineral density and reduce the risk of osteoporosis, whilst cardiovascular exercise supports heart health, mood and energy levels.
The best exercise is ultimately the one you enjoy enough to continue doing consistently.
Pillar Three: Sleep
Poor sleep is one of the commonest complaints I hear from women during perimenopause.
Sleep disruption can worsen anxiety, brain fog, fatigue and irritability. Maintaining regular routines, reducing alcohol and caffeine intake and keeping the bedroom cool and dark can all help.
Improving sleep quality often creates a positive cycle in which many other symptoms begin to improve too. Better sleep supports hormonal regulation, reduces cortisol levels and improves overall resilience.
Pillar Four: Stress Management
Modern life places enormous demands on women.
Many are juggling careers, relationships, children, ageing parents and countless other responsibilities. Chronic stress elevates cortisol levels and can worsen many menopausal symptoms.
Walking, mindfulness, yoga, breathing exercises and spending time in nature can all help calm the nervous system.
Sometimes, however, the answer is even simpler.
In a previous post I wrote about the art of doing nothing. It sounds almost absurd in today’s world, but many women are exhausted. We readily recharge our phones when their batteries run low, yet often ignore the signs that our own batteries need recharging too.
Rest is not laziness. It is a biological necessity.
Pillar Five: Healthy Relationships
One thing I have learnt both as a doctor and through my own life experiences is that we are not meant to navigate difficult transitions alone.
Talking openly with partners, friends, family members or healthcare professionals can reduce feelings of isolation and help women realise they are not alone in what they are experiencing.
Sometimes simply feeling heard, understood and supported can be therapeutic in itself.
Pillar Six: Avoiding Risky Behaviours
Smoking increases the risk of cardiovascular disease, osteoporosis and earlier menopause. Excess alcohol can worsen anxiety, sleep disturbance and hot flushes.
Reducing or eliminating these behaviours can have significant benefits both for menopausal symptoms and long-term health.
We also know that smoking, obesity, diabetes and socioeconomic deprivation are associated with more severe menopausal symptoms. Women from more deprived backgrounds and some ethnic minority groups may experience menopause earlier and face additional barriers to support and treatment.
Perhaps the greatest lesson of perimenopause is not about hormones at all.
Many women reach this stage of life after years spent looking after everyone else. Careers have been built, children raised, ageing parents cared for and responsibilities carried. Often there has been very little time left over for themselves.
Maybe that is why this phase can feel so uncomfortable. It asks us to stop and pay attention.
Not because we are failing.
Not because we are broken.
But because our bodies are reminding us that we matter too.
Perimenopause is not a disease to be cured. It is a transition to be understood.
And whilst there is no single path through it, perhaps the women who navigate it best are those who stop fighting the journey and begin listening to what it is trying to teach them.
Thank you for reading.
This article was originally posted on Notes from a GP.
If you are interested in finding out how we can support you through the menopause please visit our Women’s Health page.