Perimenopause is one of the most significant physiological transitions in a woman’s life, yet it remains one of the least consistently recognised in clinical practice. In 2025, new evidence is prompting a re-evaluation of how clinicians identify perimenopause, how early symptoms should be interpreted, and why global awareness still lags behind the science.

Large-scale studies from Australia and international cohorts show that many women experiencing clear biological indicators of perimenopause are not being identified as such. This under-recognition contributes to delays in care, misclassification, undertreatment and unnecessary reductions in quality of life. Emerging evidence suggests that the diagnostic frameworks most commonly used today may require updating – shifting from a cycle-first approach to one that places greater emphasis on symptom patterns.

New 2025 evidence: classic symptoms often precede menstrual cycle changes

A landmark Monash University–led study published in The Lancet Diabetes & Endocrinology in 2025 analysed symptom severity in more than 5,500 women aged 40-69.¹

Key findings include:

• Moderate to severe vasomotor symptoms (VMS) – such as hot flushes and night sweats – were nearly five times more prevalent in perimenopause than in premenopause.¹
• Vaginal dryness emerged as a highly specific indicator, occurring 2.5 times more often in perimenopause compared with premenopause.¹
• Symptoms such as low mood or memory concerns were far less discriminative, making them unreliable as standalone markers.
• Many women with regular cycles but changes in flow combined with VMS showed physiological patterns consistent with early perimenopause, despite being classified as premenopausal under the STRAW+10 criteria.¹

This suggests that symptom-first diagnostic cues – particularly VMS and vaginal dryness – may provide earlier and more accurate insight into menopausal transition.

Why the current diagnostic model is under strain

The STRAW+10 framework primarily defines perimenopause through menstrual cycle variability. However, the 2025 evidence clearly demonstrates that hallmark symptoms can emerge well before irregular cycles.¹

This mismatch contributes to:

• Delayed recognition
• Misclassification of perimenopausal women as premenopausal
• Undertreatment of moderate to severe symptoms
• Reduced quality of life during a critical midlife period

As a result, many experts are now advocating for a hybrid diagnostic model that incorporates strong symptom-based indicators alongside menstrual criteria.

The silent burden: nearly 40 per cent of women with VMS remain untreated

The Monash study revealed one of the most concerning statistics:
Almost 40 per cent of perimenopausal women experience untreated VMS.¹

Reasons for this treatment gap include:

1. Under-recognition in primary care: Hot flushes, sleep issues or vaginal dryness may be normalised or attributed to stress, ageing or lifestyle.
2. Diagnostic ambiguity: Women with regular cycles often assume they are “too young” for perimenopause, delaying care-seeking.
3. Limited consultation time: Time constraints in primary care reduce opportunities for comprehensive midlife health assessment.
4. Global knowledge gaps: A 2026 international study involving over 17,000 women across 158 countries found significant disconnects between the symptoms women recognise as perimenopausal and the symptoms they actually experience.³

This mismatch makes the global treatment gap measurable – and substantial.

Perimenopause is experienced differently worldwide

The same 2026 dataset identified significant cultural and regional differences in both symptom awareness and symptom interpretation.³

Key contrasts include:

• Hot flushes and sleep disturbances are widely recognised
• Early symptoms such as cycle flow changes or mood variability are often misunderstood or overlooked
• Many women do not realise symptoms can begin in their 30s, leading to delayed recognition across regions³

These insights highlight the need for culturally sensitive public health messaging and improved patient education globally.

Why 2025 marks a turning point in perimenopause research

The growing body of evidence from 2025-2026 reveals several important insights reshaping clinical understanding:

1. Symptom-specific markers are stronger than expected
   VMS and vaginal dryness clearly differentiate perimenopause from premenopause.¹
2. Cycle irregularity is not the earliest or most reliable indicator
   Symptoms often emerge before menstrual cycle changes.¹
3. Perimenopause may begin earlier in more women than previously recognised
   Stable cycles do not rule out biological transition.¹
4. The treatment gap is finally quantifiable
   Nearly 4 in 10 women experience untreated VMS.¹
5. Awareness is not keeping pace with science
   Knowledge gaps persist in nearly every global region.³

What this means for clinicians and health communicators

To support women more effectively through this transition, emerging evidence underscores the need for:

• Proactive screening for VMS and vaginal dryness in women aged 40-55
• Symptom-based diagnostic approaches to complement menstrual criteria
• Updated clinical education on early perimenopause recognition
• Clear communication about the wide and variable age range of symptom onset
• Support for women with symptoms despite regular cycles

Perimenopause is not simply a reproductive milestone – it is a critical phase that influences midlife wellbeing and long-term health trajectories.

This content is for educational purposes only and is not a substitute for health professional advice.

References

1. Monash University. First of its kind study explores symptom prevalence across the menopause transition. The Lancet Diabetes & Endocrinology. 2025.
   https://www.monash.edu/medicine/news/latest/2025-articles/first-of-its-kind-study-explores-symptom-prevalence-across-the-menopause-transition
2. Islam RM, Bond M, Ghalebeigi A, et al. Prevalence and severity of symptoms across the menopause transition. The Lancet Diabetes & Endocrinology. 2025.
   https://www.thelancet.com/journals/landia/article/PIIS2213-8587%2825%2900138-X/abstract
3. The Menopause Society. International differences exist in knowledge gaps and most common perimenopause symptoms. Menopause. 2026.
   https://menopause.org/press-releases/international-differences-exist-in-knowledge-gaps-and-most-common-perimenopause-symptoms