At certain points in life, women’s bodies undergo drastic change – menarche, pregnancy, menopause. The first two get a lot of attention, but seldom are women prepared for the changes of menopause. Menopause isn’t simply a sudden cessation, but rather a gradual process that can begin as early as 40. Just as women’s bodies undergo changes to prepare for menstruation, they also undergo changes to prepare for menopause. Experts call this transitory phase before full menopause ‘perimenopause’ and it begins with an irregular period.

But there are other changes during this time that may not be as apparent, says Dr Kumaravel, Endocrinologist and Director of Alpha Hospital & Research Centre, Madurai.

Perimenopause is the time in a woman’s life shortly before she experiences menopause. It starts around age 45 lasts for four years, on average – though it can be a brief as a few months, or as long as 10 years — and ends when a woman has gone 12 months without a period. Most of the symptoms associated with menopause begin irregularly during this time, primarily stemming from decreasing levels of the reproductive hormones estrogen and progesterone as ovary activity wanes, Dr Kumaravel says.

Lower levels of these hormones cause a lot of fallout – some serious, some merely uncomfortable.

While science doesn’t have all the answers yet to why hot flashes – one of the primary symptoms of perimenopause — occur, research suggests lower hormone levels can set off a temporary glitch in the functioning of the hypothalamus, the area of the brain that regulates your body temperature. When the hypothalamus perceives core temperature as too hot, it triggers sweating throughout the body to cool it off, resulting in hot flashes and night sweating. Researchers have also found increased activity in the brainstem area immediately before a hot flash, but the link, if any, between the two are unclear.

Hot flashes are uncomfortable, but they aren’t harmful and seldom require treatment. Other annoying symptoms of perimenopause include severe vaginal dryness, which can make intercourse painful and increase risk to urinary tract infections, sleep disturbances, fatigue and insomnia. As the body gradually adjusts to declining hormones, these symptoms usually disappear on their own.

But your bones and muscles are more seriously affected.

“A major change that occurs during this time is the rapid reduction in bone mass, a direct result of declining estrogen,” Dr Kumaravel says. “This can put more women at risk for osteoporosis.”

Loss of muscle tone is also common during perimenopause and can put women at greater risk for osteoporosis, trigger weight gain and changes in body shape.

Emotions, too, can morph.

“The transition into menopause may be a turbulent time for some women,” says Dr Khushali Manikandan, a clinical psychologist and counsellor based in Chennai. “Rapid changes in hormone levels may influence neurotransmitters in the brain (which in turn influence behavior). Depression, sadness, feelings of anxiety can be heightened at this time.”

While these emotional changes aren’t life-threatening and often resolve over time, they can make life very difficult, especially in Indian culture, Dr Khushali says.

“In India, conversations about the menstrual cycle are still taboo in many households, a fact that can cause great isolation,” she says. “I see women very disconnected with themselves, not having a clue as to what’s wrong with them.”

With all of these dramatic changes in the body, it can be difficult for women to stay positive. But it’s a natural part of life that will soon right itself, Dr Kumaravel says, and has its own advantages.

“It’s the ideal time to put the spotlight on your health,” he says. “Review and update your prescriptions, get your blood sugar checked. Make lifestyle changes if you’ve been sedentary.”

To make sure your perimenopause changes don’t lead you down the path toward osteoporosis, Dr. Kumaravel advises incorporating light weight-bearing exercises into your daily routine.

“It’s imperative that you do moderate intensity exercise for at least 45 minutes at 75% of your heart rate,” he says. He also recommends taking a calcium supplement regularly.

Regulating emotions, however, has a less clear-cut prescription. Dr Khushali advises women to talk about what they are feeling with family and friends.

“Motivate yourself to try new things and divert your energy into other more important aspects of your life,” she says. If women struggle to do this on their own, there is no shame; instead, Dr Khushali adds, they should look into interpersonal therapy and cognitive behavioral therapy to hone mindsets and tools to cope.

Perimenopause can be uncomfortable, no doubt; but with an understanding of the physiological changes that occur and the right mindset, it can also be graceful.