The Quiet Start of Perimenopause - Dr Lori Brotto

Poor sleep, anxiety, brain fog and changes in desire often show up years before women expect menopause. UBC researcher and psychologist Dr. Lori Brotto explains what's happening, why so many women stay quiet, and the everyday supports that help.

Ask most women what menopause looks like and they'll describe hot flashes in their late fifties. But for many, the changes start much earlier, and they don't always look the way we expect.

For World Menopause Day, we spoke with Dr. Lori Brotto, a psychologist and professor in the Department of Obstetrics & Gynaecology at the University of British Columbia, who has studied women's sexual health for more than 20 years. She shared what surprises women most, the changes no one talks about, and why being kind to yourself is part of the plan.

It starts earlier than most women expect

"What surprises women most is often when it starts," says Dr. Brotto. "Many expect menopause to be a single moment in their late fifties marked by hot flashes. Then in their early-to-mid forties they find themselves sleeping poorly, feeling anxious or foggy, perhaps noticing that sex has become more painful, and noticing that desire or arousal feels different."

Because these changes don't match the picture they had in mind, many women don't connect them to hormones or to the start of perimenopause.

The changes no one mentions

The second surprise, she says, is pelvic changes: dryness, burning, pain and more urinary urgency. Women are rarely told about these ahead of time, and unlike hot flashes, which tend to ease over time, these changes usually don't resolve on their own.

A cultural taboo around intimacy, especially for women later in life, keeps many women from raising it. "Most women suffer in silence and never speak to a healthcare provider about these issues," she says.

Her message is clear: this is common, it has a name (genitourinary syndrome of menopause), and it is very treatable. Options such as low-dose estrogen, moisturizers, lubricants and pelvic floor physiotherapy can make an enormous difference. "You don't have to wait until it's unbearable, and you don't have to accept pain as the price of getting older."

The everyday supports that matter most

Sleep comes first. "Almost everything else gets harder without it, including mood, patience, energy, and sexual desire." Dr. Brotto suggests a cooler bedroom, a consistent wind-down routine, and getting night sweats treated rather than tolerated.

Then movement, especially strength training. Muscle and bone density decline during this transition, and resistance exercise is one of the best investments a woman can make for the decades ahead. It also helps mood and sleep, and current menopause guidelines recommend exercise as a foundation of health.

Paying attention, without judgment. Mindfulness, even a few minutes a day, helps women notice what's happening in their bodies "with curiosity instead of criticism." That shift lowers stress, and Dr. Brotto's research shows it has measurable benefits for sexual desire and satisfaction.

And connection. "Talk to friends who are going through it, and talk to your partner. So much of the suffering in this stage comes from feeling alone with it."

Why so many women stay quiet

There's still a lot of shame around sexuality, especially in midlife. Many women assume declining interest or painful sex is simply part of aging, and many healthcare providers don't ask. "If no one opens the door, most women won't walk through it on their own," she says. "I'd love for every woman to know that this is a legitimate health concern, worth raising, and worth treating."

On supplements: stay curious, and ask

As a scientist, Dr. Brotto follows the broader research on supplements, and the one she's asked about most is creatine. She's honest that the evidence varies: creatine is getting attention for muscle, bone and possibly cognition, especially when paired with strength training, and that research is promising but still emerging.

Her advice is to choose supplements that support your overall health, and to check with your doctor or pharmacist if you're unsure about safety or how a supplement might interact with medications you take.

The routine you'll actually keep

This is where her training as a psychologist comes in. "The best routine is the one you'll actually do," she says. Start small and attach a new habit to something you already do every day, like taking a supplement with your morning coffee or doing a two-minute breathing practice before brushing your teeth. Track it loosely, and be kind to yourself when you miss a day.

"Self-compassion isn't indulgent. It's what keeps people going over the long term."

The takeaway

Perimenopause often starts sooner, and touches more of life, than women are told. The changes are common, many are treatable, and they're worth talking about. Protect your sleep, build strength, pay attention with kindness, and don't go through it alone.