Menopause Mini-Series: Part 2 — Managing perimenopause | Rodolico Health

Menopause Mini-Series: Part 2 — Managing perimenopause | Rodolico Health

This article is the second in a short series on menopause and perimenopause, designed to provide clear, evidence-based information across what can often feel like a complex and confusing area. We began by looking at what menopause is and how it presents. In this article, we move on to practical approaches to managing symptoms. The final article will look in more detail at hormone replacement therapy (HRT) and when it may be appropriate.

Managing perimenopause: a practical, evidence-based approach

Perimenopause is often where symptoms are most noticeable and most disruptive. Hormonal fluctuation, rather than steady decline, means that many women experience unpredictable patterns of symptoms that can affect sleep, mood, cognition, and physical wellbeing.

For some women, particularly those who are neurodivergent, these changes can feel more pronounced, or harder to interpret at first.

Management is not one-size-fits-all. A thoughtful approach usually combines lifestyle foundations, selective use of supplements, and, where appropriate, medical treatment such as HRT. Just as importantly, it should be individualised, taking into account personal preferences, medical history, and how symptoms are actually affecting day-to-day life.

Lifestyle: the foundation

Lifestyle interventions are not a substitute for medical treatment when it’s needed. However,  they form the baseline that everything else builds on.

Sleep

Sleep disturbance is one of the most common and impactful symptoms (we explore this further in our article on sleep and overall health). Supporting sleep may include:

  • consistent sleep and wake times
  • reducing late caffeine and alcohol
  • keeping the bedroom cool (particularly for night sweats)

Even modest improvements in sleep can have a meaningful effect on mood, cognition, and resilience.

Exercise: with a focus on strength training

Regular movement supports both physical and mental health, but strength training becomes particularly important during perimenopause.

Declining oestrogen is associated with:

  • loss of muscle mass
  • reduced bone density
  • changes in metabolism and body composition

Resistance training helps counter these changes by:

  • preserving and building muscle mass
  • supporting bone strength and reducing long-term fracture risk
  • improving insulin sensitivity and metabolic health
  • contributing to confidence and physical resilience

Ideally, this includes 2–3 sessions per week focusing on major muscle groups, alongside aerobic exercise for cardiovascular health. The aim is consistency rather than intensity; building a routine that is sustainable over time.

Nutrition

A balanced diet supports overall health, with a few key principles:

  • adequate protein intake
  • sufficient calcium and vitamin D for bone health
  • minimising highly processed foods where possible

Consistency matters more than perfection.

Alcohol and caffeine

Both can worsen sleep, anxiety, and vasomotor symptoms in some women. Reducing intake, particularly in the evening, can be helpful.

Supplements: where they fit

Many women explore supplements during perimenopause. Some can be helpful, but it’s important to stay grounded in evidence, and to be cautious of the growing market of menopause-branded products that often promise more than they deliver.

A useful way to think about supplements is not in terms of “treating menopause”, but in supporting overall health, particularly:

  • bone health
  • cardiovascular health
  • brain and mood health

Menopausal symptoms themselves are primarily driven by hormonal change, not vitamin deficiency. This is why supplements rarely replace more effective treatments when symptoms are significant.

Vitamin D

Vitamin D is one of the most consistently recommended supplements, particularly in the UK and Europe where levels are often low. It plays an essential role in:

  • calcium absorption
  • bone strength
  • muscle function
  • and potentially mood regulation

Supplementation is often appropriate, particularly in the autumn and winter months.

Calcium

Calcium remains important for bone health, but most women can meet their needs through diet. Supplementation is usually only needed if dietary intake is insufficient.

Iron

Iron requirements depend on whether periods are ongoing. Women who are still menstruating may be at risk of deficiency, particularly with heavy periods. After menopause, requirements fall.

Symptoms such as fatigue or reduced exercise tolerance should prompt assessment rather than self supplementation, as iron therapy is best guided by blood testing.

Magnesium

Magnesium is involved in multiple physiological processes (we discuss magnesium and other supplements in more detail in the context of migraine) and may be helpful for:

  • sleep
  • muscle symptoms
  • stress and relaxation

While evidence is still emerging, some women find it beneficial, particularly where sleep disturbance is prominent.

Probiotics

There is increasing interest in the role of the gut microbiome in hormone health, immunity, and metabolism. Early evidence suggests some women may benefit from a good quality probiotic, although this remains an evolving area.

Herbal and “menopause” supplements

Products containing ingredients such as black cohosh, red clover (isoflavones), or St John’s wort are widely marketed.

There is some evidence they may reduce symptoms such as hot flushes in some women. However:

  • the quality of evidence is variable
  • results are inconsistent
  • safety and interactions are not always well established

Importantly, these are not equivalent to oestrogen and do not provide the same level of symptom control or long-term health benefits as HRT.

A practical perspective

In practice:

  • focus on diet first
  • use supplements to fill specific gaps
  • be cautious of expensive menopause branded combinations
  • avoid relying on supplements alone if symptoms are significant

HRT: what has changed—and why it matters

Menopause care has evolved significantly over the past 10–15 years. For many years, HRT was approached with broad caution, largely driven by early interpretations of studies in the early 2000s. That caution had real consequences: many women were left untreated or undertreated.

We now have a much clearer understanding of risk.

For most women under 60, or within 10 years of menopause, the balance of benefit and risk is favourable when HRT is appropriately prescribed (as reflected in guidance from the National Institute for Health and Care Excellence).

Modern HRT is also different:

  • Transdermal oestrogen (patches, gels, sprays) avoids first-pass liver metabolism
  • This means no increased risk of blood clots compared to baseline
  • It avoids some of the risks associated with older oral preparations

Progesterone has also evolved, with body-identical formulations improving tolerability.

HRT remains the most effective treatment for vasomotor symptoms, but its benefits often extend further:

  • improved sleep
  • better mood stability
  • reduced cognitive symptoms
  • support for bone health
  • improvement in urogenital symptoms

In perimenopause, one of its most important roles is stabilising hormonal fluctuation.

From a migraine perspective, this is particularly relevant, as fluctuating oestrogen is a recognised trigger.

Genitourinary symptoms, vaginal dryness, and libido

Vaginal dryness, discomfort during sex, urinary symptoms, and changes in libido are extremely common, but often under-discussed.

These symptoms are driven by reduced oestrogen at a tissue level and can:

  • cause dryness and irritation
  • lead to pain during sex
  • contribute to urinary symptoms
  • affect confidence and intimacy

Importantly, these symptoms are treatable.

Topical (local) oestrogen (creams, pessaries, or rings) is highly effective:

  • low dose
  • minimal systemic absorption
  • safe for long-term use in most women

Changes in libido are often multifactorial, relating to sleep, mood, hormonal change, and physical comfort (we discuss hormonal imbalance and testosterone in more detail separately). Addressing underlying symptoms often leads to improvement.

Who is HRT right for?

HRT may be particularly helpful for women who:

  • have moderate to severe symptoms
  • feel symptoms are impacting daily life
  • are in perimenopause or early menopause
  • experience symptoms linked to hormonal fluctuation, including migraine

It may also support bone health and long-term wellbeing in selected individuals.

HRT is not suitable for everyone, and decisions should be individualised. In practice, it is about balancing benefit and risk in context, rather than applying blanket rules.

Neurodivergence and menopause

An area that is increasingly recognised—but still under-discussed—is the impact of menopause on neurodivergent women, including those with ADHD and autistic women (we explore ADHD more broadly in our article on navigating ADHD abroad).

Hormonal fluctuation can affect neurotransmitter systems involved in attention, mood, and executive function. Oestrogen in particular interacts with dopamine and serotonin pathways, which are central to focus, emotional regulation, and cognitive processing. As oestrogen levels fall and fluctuate during perimenopause, many women notice a significant shift in how their brain functions, with previously manageable traits becoming more difficult to regulate.

In practice, this can present as a period of decompensation. Women may experience:

  • increasing difficulty with planning and organisation
  • reduced executive function (often described as feeling “out of control”)
  • heightened sensory sensitivity
  • more pronounced mood variability
  • sleep disruption, which further compounds cognitive symptoms

For autistic women in particular, this period can bring a noticeable increase in sensory overload, including greater sensitivity to noise, light, touch, and temperature (for example hot flushes). Changes in routine, internal state, and physical comfort may become harder to manage, and the cumulative effect can be significant.

Many autistic women have developed effective ways of navigating the world over time, including masking or compensatory strategies. During perimenopause, these strategies may become harder to sustain. Women who have previously managed complex routines, work demands, and social expectations may find that these coping mechanisms no longer work in the same way, leading to increased fatigue, overwhelm, and withdrawal.

For women with ADHD, hormonal fluctuation can make symptoms such as inattention, reduced focus, and emotional variability more noticeable. This likely reflects the interaction between oestrogen and dopamine pathways, meaning that periods of instability may amplify difficulties that were previously manageable.

There is growing evidence that neurodivergent women may be more sensitive to hormonal change, rather than having fundamentally different hormone levels. This helps explain why relatively small hormonal fluctuations can have a disproportionately large impact.

In some cases, this is also the point at which previously unrecognised neurodivergence becomes more apparent, as long-standing coping strategies become harder to maintain.

Importantly, these symptoms are often under-recognised in clinical settings and may be attributed solely to anxiety, depression, or burnout. Recognising the hormonal contribution allows for a more accurate, validating explanation—and supports a more tailored approach to management.

In some cases, hormonal treatment such as HRT may help stabilise symptoms, particularly where fluctuation is a key driver.

A balanced, individualised approach

Not everyone will need HRT, and not everyone will choose it. Equally, some women benefit significantly and wish they had considered it earlier.

The aim is to ensure that all options are understood and accessible:

  • lifestyle measures
  • supplements where appropriate
  • and HRT when symptoms are impacting quality of life

Perimenopause is a transition, but it should not be something to simply endure. With the right support, most women can feel well, function clearly, and continue to engage fully with daily life. You can also read our introduction to menopause and how it presents in the first article in this series.

If you would like to discuss any symptoms you are experiencing, you are very welcome to get in touch or book an appointment.

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