As you move through your forties, "something's shifted but I can't quite name it" is a very familiar feeling. The good news: you don't have to surrender to this stage. In the first note we talked about what's happening in your body; here we tackle the question I'm asked most — how do we actually manage these symptoms?
If you missed the first note on what's happening in perimenopause, start here.
First, a quick clarification, because the terms get muddled. Premenopause is when you're still having periods but hormones have begun to fluctuate. Perimenopause is the transition, when cycles become noticeably irregular. Menopause is defined officially once a full year has passed since your last period, and postmenopause is everything after. In this stage oestrogen can fall to a small fraction of its earlier levels — the body isn't left entirely without oestrogen, but it has to work with far less. That decline touches more than the reproductive system: it can affect heart rhythm, bone density, muscle strength, mood and urinary health. No two women travel this exactly the same way — but there are powerful areas you can influence.
Nutrition: start with your plate
Food is one of the places you can make the biggest difference. Fibre comes first: it feeds the gut microbiota, which matters a great deal here, because research suggests microbiome diversity can decline across this transition — and that shift has been linked to fat gain around the middle. Make pulses, fruit, vegetables, nuts and avocado regulars on your plate. And while we're on variety, don't forget fermented foods: yoghurt, kefir and pickles may support digestion and microbial diversity.
Second, protein. Spreading enough protein across the day (pulses, eggs, dairy, fish, meat) helps slow the muscle loss of midlife. Oily fish, flaxseed and chia are rich in omega-3, which may gently support joints and mood. Balancing meals with fibre, protein and healthy fat also helps keep blood sugar steadier. On supplements — vitamin D deficiency in particular is common — the sensible route is to check your levels with your doctor and decide together, rather than starting high doses on your own.
Exercise: strong, not just slim
If "I'm walking more but the weight won't budge" sounds familiar, it may be time to add resistance to your routine. The goal here isn't to be smaller, it's to be stronger. Protecting muscle mass is crucial for both metabolism and bone health, because muscle and bone loss become a real risk in the postmenopausal years. Two to three days a week of strength work — weights, Pilates, resistance bands — is valuable for bone density, joints and mood. Since the energy you burn at rest can also drop after menopause, holding on to muscle is one of the most sustainable ways to support your metabolism.
Sleep and stress
Sleep quality often suffers in perimenopause. Progesterone, which helps you drift off, is among the first hormones to fall; hot flushes and night sweats fragment sleep; and alcohol tolerance drops — even a single glass can shorten deep sleep. The things that help sound simple but work: less screen time before bed, a cooler bedroom, and going to bed at the same time each day. They're drug-free, easy to apply and sustainable — and these small changes add up.
Hormone therapy (HRT): a conversation with your doctor
HRT comes up a lot. Health authorities note that it can be effective at easing symptoms such as hot flushes, night sweats and disturbed sleep, and can help protect against bone loss; it also carries benefits and risks that vary with the type, dose and how it's taken. This is an entirely individual decision: the balance of benefit and risk depends on your age, symptoms and medical history, and is one to weigh up with your doctor. The point of this note isn't to recommend for or against HRT — only to say the option exists, and your doctor is the right person to explore it with.
There's no single prescription for hormone management between 35 and 55; it's a whole picture — nutrition, movement, sleep, stress management and, if needed, hormone support with professional guidance. When you get that balance right, it's often not just the symptoms that change but your quality of life. This stage isn't one you're meant to suffer through — the right information is the most powerful way to clear that foggy, alone feeling.
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I've also covered this topic on my YouTube channel — press play if you'd rather watch than read.
This article is for general information and isn't a substitute for individualised advice from your own doctor or dietitian.
Merve Tığlı, Dietitian
Sources: NHS — Menopause and perimenopause treatment, and Benefits and risks of HRT; British Menopause Society — lifestyle and HRT guidance; "Diet, the Gut Microbiome, and Estrogen Physiology" (Nutrients, 2026); systematic review of resistance training and bone mineral density in postmenopausal women (PMC, 2025).