Menopause is having a cultural moment. In the past two years alone, celebrities from Halle Berry and Drew Barrymore to Oprah and Michelle Obama have spoken openly about it. Companies including Pepsi, Bank of America, and Unilever have introduced menopause policies. Apps like Flo and Elektra Health promise to track every symptom. After decades of silence, it would seem that midlife women’s health has finally entered the mainstream conversation.
Yet despite the surge in conversation around menopause in general, more awareness around perimenopause hasn’t quite translated into understanding. A new study from Flo Health and the Mayo Clinic found that American women rank only sixth globally in perimenopause literacy — behind the UK, Ireland, Canada, Australia, and the Netherlands — revealing not just a knowledge gap but a diagnostic gap with consequences that extend far beyond individual health.
The research, published in Menopause, surveyed more than 17,000 women across 158 countries and found that among women over 35 who reported being in perimenopause, 95% experienced physical and mental exhaustion, 93% reported fatigue, and 91% dealt with irritability. Sleep problems and depressive mood rounded out the top five symptoms. Meanwhile, “classic” symptoms like hot flashes and night sweats ranked much lower in actual experience.
For context, perimenopause is the transition period leading up to menopause — a woman’s last menstrual cycle — and includes the 12 months afterward. During this time, hormone levels fluctuate, and menstrual cycles often become irregular, triggering a wide range of physical and cognitive symptoms. The transition typically begins in a woman’s mid-40s and lasts an average of six years, though symptoms can start as early as the 30s and continue for a decade. Despite affecting most women over 40, perimenopause remains surprisingly underrecognized and far less studied than menopause itself.
As a result, many women in their 30s and 40s dismiss their symptoms as stress, burnout, or personal failure — attributing exhaustion to not managing their workload well enough, mood changes to not being patient enough, and brain fog to not being strong enough.
“The expectations are based upon the most common symptoms that have been talked about in the past and how women have been historically treated when they sought help,” Dr. Sameena Rahman, board-certified OB-GYN and medical advisor for Flo Health, told BuzzFeed in an interview. “As a culture, women have been expected to — and sometimes embrace — suffering through symptoms and do not realize that it is not only because of the higher mental load, work stress, stress with raising kids/helping parents, or a number of other issues; the hormonal fluctuations prevent the normal mechanisms you may have used in the past to maintain homeostasis and lead to distress.”
By the time some women realize it may be perimenopause, they may have been experiencing it for years. And when they do seek help, their doctors sometimes miss it too, attributing exhaustion to thyroid issues or mood changes to depression without considering hormonal shifts.
“There is a mismatch in knowledge and expectations of perimenopause and actual symptoms experienced during perimenopause,” explains Dr. Mary Hedges, the study’s principal investigator at Mayo Clinic. “Many women in perimenopause may not yet be experiencing hot flashes and are more likely to be experiencing the cognitive and physical symptoms of fatigue, exhaustion, mood, sleep, or even digestive changes.”
The consequences go beyond discomfort. Delayed diagnosis means delayed treatment — as well as missed opportunities for preventive care. “Given the gap between expectations and reality, this could delay diagnosis and treatment of perimenopause, and we also could lose the possibility of treating to prevent disease, such as osteoporosis,” Dr. Rahman warns. “It reinforces the harmful norm that women should just ‘push through’ until menopause.”
The hormonal shifts driving perimenopause symptoms are more complex than a simple decline. Estrogen, for example, rises, then falls, and then rises again. “It is erratic,” Dr. Rahman explains. “This leads to changes in neurotransmitter signaling associated with mood and cognition. This eventually contributes to anxiety, cognitive distress, and sleep disorders, and daily stressors compound all of this.”
Given how early and varied these symptoms can be, Dr. Rahman emphasizes that women don’t need to wait until they become unbearable to seek help. “Any time a patient is in distress, not feeling like herself, or would like to improve her quality of life, she should see her doctor,” she says. In other words, women don’t need to rule out every other explanation before raising perimenopause with their doctor.
In many cases, perimenopause can also intensify conditions women are already managing. “She may be experiencing all of the above, and the perimenopausal transition can exacerbate the symptoms,” Dr. Rahman explains. “Patients may not be able to utilize the same tools they have used in the past to maintain their mental and physical health.”
Dr. Rahman points to several commonly overlooked early warning signs women in their 30s should watch for:
1.
Worsening mental health: Anxiety, depression, and ADHD symptoms that seem to intensify or appear for the first time. “There may be slight variations in cycle length, from 28 days to 26 or 24,” Dr. Rahman notes.
2.
Sleep changes: Difficulty falling asleep, staying asleep, or feeling rested — even when maintaining the same sleep schedule.
3.
Sexual function changes: Pain during sex, urinary frequency and urgency, and diminished desire.
4.
Digestive issues: Bloating, nausea, diarrhea, constipation, and food sensitivities ranked among the top three symptoms across multiple countries in Africa, Latin America, Europe, and Asia. In the overall study, 76% of respondents reported digestive issues — yet these symptoms are almost never discussed in connection with perimenopause. Instead, they’re dismissed. “Digestive issues are usually siloed as ‘IBS,’ stress, or poor diet and have not been culturally linked to perimenopause,” Dr. Rahman explains. The global data reveal these aren’t isolated complaints but a widespread pattern that’s been systematically overlooked.
5.
“Generalized feelings of ‘not feeling like myself'”: This is how Dr. Rahman describes one of the most common ways women describe early perimenopause — a vague but persistent sense that something is off.
Often, the clearest sign that something hormonal is happening is a pattern — symptoms that worsen over time, appear in clusters, or affect multiple systems in the body, sometimes alongside subtle menstrual changes. Because they may develop gradually, Dr. Rahman recommends that women track menstrual changes along with shifts in mood, cognition, sleep quality, temperature regulation — including hot flashes and night sweats — and digestive symptoms.
Though the symptoms of perimenopause are biological, the confusion surrounding them is cultural, shaped by decades of medical assumptions, social stigma, and systemic gaps in women’s healthcare. At the same time, there are signs the conversation around perimenopause may be shifting. Millennial women, in particular, are approaching the transition differently than previous generations — and far earlier.
According to a 2024 survey, four in five millennial women are already researching menopause before symptoms even begin. Thirty-seven percent are familiar with hormone replacement therapy, and 32% say they would seriously consider it, compared with only 18% of Gen X women at the same age. Menopause apps now allow women to track symptoms and generate health reports to share with clinicians, helping address what researchers describe as “epistemic injustice” — the dismissal of patients’ knowledge of their own bodies.
At the same time, this generation is navigating a convergence of pressures that can make the transition both more visible and more disruptive. Women are having their first children later than ever. The average age is now 27–28, up from 24–25 in 2000. Among women with advanced degrees, it rises to 33. Because perimenopause can begin in the late 30s, many women are now managing fertility decisions and early hormonal shifts simultaneously. More than 54% of people in their 40s also have both a living parent over 65 and a dependent child — the so-called “sandwich generation” — facing peak caregiving demands at the same time that perimenopause symptoms often begin.
But increased awareness doesn’t necessarily translate into better understanding. Despite the recent surge in menopause advocacy — from celebrities speaking out to new workplace policies — the study reveals that US women still lag behind their peers in countries with more robust healthcare systems and less cultural silence around women’s midlife health. The study found that perimenopause knowledge scores were highest in high-income countries (mean score: 13.41 out of 26), but even within that category, the US ranked sixth, with the UK scoring highest at 15.17.
The US knowledge gap isn’t simply about access to information. It reflects deeper cultural and medical frameworks that have shaped how menopause is understood — and misunderstood — for decades.
Medical anthropologist Margaret Lock’s landmark research found that in Japan, menopause falls under konenki, roughly meaning “renewal energy season” — a gradual transition rather than a medical crisis. In traditional Chinese medicine, menopause is referred to as “second spring.” Among Cree, Māori, and Iroquois nations, post-menopausal women often take on leadership roles in their communities, with menopause understood as conferring wisdom and healing power. The pattern across cultures is striking, as women in societies that associate menopause with status and transformation rather than decline report fewer and less severe symptoms.
The Western framework, by contrast, traces partly to Freudian psychology, which rooted women’s worth in reproductive capacity, and to Robert A. Wilson’s 1966 bestseller Feminine Forever — funded by an estrogen manufacturer — which described menopause as “living decay.” The book sold 100,000 copies in seven months and helped propel estrogen to become the most prescribed drug in America by 1975. “We have a culture of silence around midlife women and aging in the US,” Dr. Rahman explains. “We support women in pregnancy and puberty, but in perimenopause, women are left feeling uneducated about what is happening to them.”
However, culture is only part of the story. Structural features of the US healthcare system also shape how perimenopause is recognized — or overlooked. The study found significant differences in knowledge scores based on country income groups, with high-income countries scoring highest, followed by upper-middle-income, lower-middle-income, and low-income countries. Yet even within high-income countries like the US, systemic barriers persist.
“We also have a health care system that is set up to fail women, with fragmented care, short visits, insurance dictating care, and variability of training in health professionals,” Dr. Rahman says. “We are left with minimal knowledge and understanding of our bodies.”
That “variability of training” is an understatement. Only 31.3% of US OB-GYN residency programs include any menopause curriculum at all. Even programs that do offer training only report five or fewer lectures per year, and one in five OB-GYN residents receives no menopause education at all.
The result is a stark shortage of specialists. Roughly 1,300 certified menopause practitioners serve an estimated 54 million menopausal women in the United States — about one specialist for every 42,000 women. For comparison, there is roughly one cardiologist for every 1,200 Americans.
When primary care doctors, gynecologists, and mental health providers operate in separate systems — with appointments capped at 15 minutes and insurance determining access to specialists — comprehensive hormonal care becomes difficult. When clinicians themselves receive little training in menopause, it becomes even harder.
Whether it’s six weeks of maternity leave or being told perimenopause symptoms are “just part of getting older,” the message is the same. Women’s discomfort is expected, their pain normalized, and the burden of coping placed squarely on them.
The economic consequences of that dismissal are significant. A Mayo Clinic study estimates that menopause symptoms cost the US economy $26.6 billion each year through lost work time and medical expenses. Women experiencing the most severe symptoms were more than 15 times more likely to report problems at work — including missed days, reduced productivity, or leaving jobs altogether. Black women were nearly three times more likely than white women to experience those impacts.
In a 2025 study, Stanford economist Dr. Petra Persson described what she calls the “menopause penalty,” finding that women whose menopause symptoms are severe enough to require medical attention earn about 10% less four years later. “For decades, social scientists have analyzed the ‘motherhood penalty,'” Dr. Persson wrote, “but until now, we haven’t known what the financial consequences are for women at the other end of the reproductive spectrum.”
These systemic failures in perimenopause care don’t affect all women equally. The long-running Study of Women’s Health Across the Nation (SWAN) — which has tracked more than 3,000 women for 25 years — reveals stark disparities that compound across every health dimension.
Black women, for instance, experience the highest burden of vasomotor symptoms — including hot flashes and night sweats — of any group, with longer duration, greater frequency, and more severe symptoms overall. They also tend to spend more time in the menopausal transition. Yet despite having the most severe symptoms, Black women are significantly less likely to receive hormone therapy or other treatments.
Instead, the medical system creates a distinct trajectory through what researchers call the “fibroid-to-hysterectomy pipeline.” By age 50, roughly 80% of Black women develop uterine fibroids (compared to 70% of white women), and are two to three times more likely to undergo hysterectomy — often during peak childbearing years. Notably, surgical menopause is abrupt and typically more severe than natural menopause. Even after accounting for insurance status and fibroid size, Black women undergoing hysterectomy face 40% higher complication rates and are significantly less likely to receive minimally invasive procedures.
These disparities trace back to what University of Michigan researcher Dr. Arline Geronimus calls “weathering,” the cumulative physiological impact of structural racism that accelerates biological aging. Black women carry disproportionately high allostatic load scores — a measure of chronic stress on the body — at every socioeconomic level, creating a biological disadvantage that makes perimenopause symptoms more severe while simultaneously making access to care more difficult.
Taken together, these disparities highlight how poorly understood perimenopause remains — not just among patients, but within the systems meant to care for them. Dr. Anna Klepchukova, chief medical officer at Flo Health, believes that part of the solution begins with making the transition easier to talk about. “We need to normalize conversations around perimenopause and menopause,” she says, “so women feel empowered to have honest conversations with their doctors and other support systems.”
For women in their 30s or 40s experiencing any combination of these symptoms — fatigue, mood changes, sleep disruption, digestive issues, cognitive fog — perimenopause should be part of the conversation with a doctor. As the data from more than 17,000 women across 158 countries shows, these experiences are widespread, predictable, and real.
As Dr. Rahman puts it, “Perimenopause really is a whole-body transition, not limited to reproductive health and menses. You do not have to push through or ‘earn’ the right to be taken care of or taken seriously. By tracking symptoms and naming their impact on your life, we can procure an evidence-based plan to navigate this stage of life proactively — getting you back to yourself and improving your long-term health.”
Have you experienced unexpected perimenopause symptoms in your 30s or 40s — or had a doctor dismiss concerns you later realized were hormonal? Tell us about it in the comments below.
