You’re in perimenopause!” my girlfriend Cristal proclaimed when I complained about my trouble sleeping and chronic exhaustion. We were the same age, and she had just started Hormone Replacement Therapy (HRT). Because she works at a urogynecology clinic in Perth, Australia, she encounters patients dealing with perimenopausal symptoms daily. And unlike Singapore, where this subject is discussed only in whispered tones if at all, conversations around the latest medical research on perimenopause is more widely talked about.
“But I don’t have hot flashes, and my periods are still regular! Plus, we’re not that old. I’m only 47,” I protested, suddenly feeling a phantom tick of my biological clock.
Which was ironic. I didnβt feel it ticking when I underwent multiple surgeries to remove fibroids and polyps in my late 30s and early 40s. Not when I got married at 43, or when I naively thought I could easily get pregnant at that age. I didn’t even feel it when I conceived naturally at 45, only to discover no heartbeat at our week-eight scan. I was devastated though.
Maybe I felt a slight tick when we tried IVF. Only five eggs were extracted and none of them made it to the blastocyst stage. But even then, there was no burning urgency to accomplish all the things I suddenly feel I am running out of time for now.
Our Hormones Affect More Than Our Fertility
Perimenopause. Why is this transition always associated with declining fertility, and not with our ongoing health, wellbeing, and longevity β which are far more important? Why do women respond so aghast at the mere implication of it, as if it only happens to “old” women? What does “old” even mean, anyway? Aging is a gift.
Looking back, why did no doctor tell me throughout all of those gynecological surgeries that I was in the thick of this transition? I was obviously aware my fertility window was closing, but I had never connected my weird, systemic symptoms to perimenopause. What even was it?
What Perimenopause Actually Is (And Why the First Sign is NOT Hot Flashes)
Perimenopause is the transition leading up to menopause β and it can last anywhere from four to ten years on average. Menopause itself is actually just one single day, defined as the milestone of going twelve consecutive months without a period.
Known as the “zone of chaos” because estrogen and progesterone donβt just decline. They fluctuate wildly causing a variety of symptomsβas many as 100 when you include the full range of physical, cognitive, emotional, and systemic changes. Progesterone is usually the first to dip, immediately leading to insomnia and anxiety. Meanwhile, testosterone decreases at a completely different rate (hello sudden rage, cystic acne, and random chin hairs!). And yes, you can still have regular periods and be in the thick of perimenopause.
Despite what we are constantly told, hot flashes are not the first symptom of perimenopause. They aren’t even in the top ten. Research shows that the five most prevalent symptoms are actually:
- feeling tired or lacking energy (96%)
- memory problems (93%)
- difficulty concentrating (91%)
- irritability (90%)
- feeling tense or nervous (90%)
Hot flashes ranked way down at 18th and are more common towards the end of perimenopause.
The Asian Blindspot
Furthermore, many Asian women donβt experience hot flashes (or hot flushes, if you follow the British terminology). Hot flashes are most common in women of African descent (about 80.7%) and Caucasian women (65.4%). Alarmingly, Caucasian women serve as the median clinical baseline for most global medical studies, skewing our perception compared to Asian women, whose prevalence sits at just 36.6%.
This statistical gap matters enormously. Because of this Eurocentric data, many Asian women conclude they cannot possibly be menopausal since they arenβt experiencing a single hot flash. They are wrong. And nobody is telling them otherwise.
Age of Menopause in Singapore
Did you know the average age of menopause in Singapore is 49? This means that perimenopause symptoms can begin as early as your late thirties. Most commonly between the ages of 41 and 45.
Singaporean women reach menopause two years younger than the global average of 51. Experts note this is primarily driven by genetics, but chronic stress and lifestyle play a massive role. A sign that we need to protect our sleep and our peace even more, ladies!
This timeline means we really shouldn’t be blindsided when symptoms start creeping up in our early to mid-forties. And yet, most of us are. Partly because a lack of knowledge on the subject means many Asian women choose to suffer in silence. Then there is the cultural expectation that women should endure without complaint, so many women don’t openly discuss their struggles.
In fact, even if they know about perimenopause, the uptake on Hormone Replacement Therapy or HRT is surprisingly low. Only 8.8% of perimenopausal women in Singapore are on HRT compared to 12-50% in western countries.
Perimenopause is the longest hormonal stage of any humanβs life. It is officially classified as a critical neurological transition state. And it is far more intense, volatile, and dangerous to systemic health than our teenage puberty ever was. It impacts a womanβs health, wellbeing, and sanity far more than full menopause. And it lasts longer than our reproductive years.
So, why are these conversations not happening more openly in Singapore? Or perhaps it’s only happening behind closed doors.
How Most Women Discover Perimenopause
Iβm not the only woman to have been βofficiallyβ diagnosed by a bestie. According to global stats, 42% of women identify this stage of their life through sharing their struggles with family or friends. Another 42% of women get their “diagnosis” from Dr. Google when they try to piece together what their strange and sudden symptoms mean.
In fact, data shows only 8% of women in perimenopause receive a formal, confirmed diagnosis from a clinician. And because doctors rarely initiate the conversation, most of us are left to figure things out ourselves. Additionally, many women are misdiagnosed. Clinicians frequently treat symptoms like exhaustion, insomnia, and palpitations as standalone conditions. I was referred to a specialist for anxiety when I told my asthma doctor how I had difficulty sleeping and wondered if it had to do with my breathing issues.
Itβs quite frustrating but also a wake-up call. For too long we have relied on doctors to tell us about our health. Perimenopause is when we have to tell them.
How To Advocate for Yourself
To be clear, none of what I have shared here is a direct criticism of individual doctors. It is a systemic failure of a medical framework that is still struggling to evolve as new research emerges. And this gap is exactly why so many women spend years suffering unnecessarily. They end up blaming themselves, or feeling completely unheard when they finally build up the courage to speak up.
Like when my agonizing frozen shoulder was dismissed as a routine result of aging, rather than the textbook symptom of perimenopausal estrogen drop that it actually was. But that is a story for another day.
This article aims to empower you to take your health into your own hands and have a confident, informed conversation with your doctor about the modern, body-identical hormones (like transdermal gels and micronized progesterone) available today.
And if your doctor wonβt listen to you? Go find another one. Here is what to do:
1. Gather Your Evidence
Do your research and build a paper trail. Track your symptoms (fatigue, brain fog, joint pain, insomnia, anxiety), your menstrual cycles, and even your lifestyle habits like food, activity, and sleep. Doctors respond to objective, organized data. Show them exactly how these symptoms are disrupting your daily quality of life.
2. Find a Certified Specialist
Be aware that there are still many practitioners in Singapore who rigidly follow the old-school, post-2002 guidelines of prescribing the “lowest dose for the shortest amount of time.” However, the latest global research proves that starting HRT within ten years of menopause provides the most profound long-term benefits, and explicitly supports extended, lifelong use to protect your bones, brain, and heart.
To help you skip the guesswork, you can visit the KK Menopause Centre. You can also find a list of registered local providers through the Obstetrical & Gynaecological Society of Singapore Menopause Section or book an integrated, modern consultation with a specialized team like Hey Taylor.
3. Create Your Personal Healthcare Squad
Work with a perimenopause-informed coach like myself to help you cut through the confusion, track your data, and decode your bodyβs signals. Just book a complimentary call with me to get started.
For a long time, I naively believed I just needed one single doctor to handle my “lady bits.” But our bodies are far more complex than that, particularly when perimenopause is a multi-system, full-body neurological overhaul that affects the whole woman β not just our βlady bitsβ. And so expecting one single practitioner to handle everything β especially when it falls outside their specific training β is seriously shortchanging ourselves.
Instead, view yourself as the CEO of your health and build a personal healthcare squad. You might need a skilled surgeon for structural issues like fibroids, a modern primary care provider to manage your hormones, and an allied health team to support your lifestyle changes. My personal squad includes an osteopath and even regular fascial massage treatments.
The Route to HRT
Be aware that blood tests (like FSH or estrogen) may not reliably capture the roller coaster ride a woman’s hormones go through in perimenopause. Ultimately it is your symptoms, menstrual changes and age that determine it.
While perimenopause can start earlier, if you are 45 or over, a doctor is not likely to argue with that. Before your doctor puts you on an HRT plan, they will also want to rule out other medical issues such as thyroid disorders or anaemia. So be prepared for the process to take 1 to 3 months in total, especially if it is through the subsidised public route β starting at a polyclinic and moving toΒ KK Womenβs and Childrenβs Hospital (KKH).
Also be prepared to get your mammogram and ultrasounds done. Women between the ages of 40 and 49 should be getting them done annually and those aged 50-59, every two years.
It is important to note that HRT is not a “cure” for your symptoms. I still sleep terribly but most times it has to do with cortisol levels and other undesirable pre-bedtime habits (yes, doomscrolling, guilty as charged). HRT can help reduce the intensity of most of your discomforts. But to truly find your mojo again and reclaim your energy, you will have to make several lifestyle changes.
Why modern HRT Combined with a Healthy Lifestyle is a Game-Changer
We cannot afford to wait for a broken system to catch up to the science. We must educate ourselves, understand our bodies, and actively advocate for our own wellbeing and longevity. Because once you truly understand how our wildly fluctuating hormones impact our bone, brain, and heart health, your entire perspective shifts. You won’t just be demanding HRTβyouβll be lifting weights at the gym to build muscle, prioritizing protein, and cutting down on wine without a single complaint.
Of course, it is important to note that there are specific medical scenarios where systemic HRT is not compatible. These include a history of breast cancer or other estrogen-dependent cancers, active or recent blood clots, a recent heart attack, stroke, or severe angina, active liver disease, undiagnosed vaginal bleeding, untreated endometrial hyperplasia, pregnancy, uncontrolled high blood pressure, active gallbladder disease, or high baseline cardiovascular risk.
But even if you fall into one of these categories, that doesnβt mean you are helpless.
In fact, localized vaginal estrogen cream is almost never contraindicated. Even women who have survived breast cancer and cannot use systemic HRT can often safely use localized vaginal estrogen. This is because it stays entirely within the pelvic tissue and does not alter circulating bloodstream levels. (And yet, I still had to practically insist on being prescribed Vagifem. Again, a story for another day.)
This is A Season Of Becoming
Now, I donβt want you to think perimenopause is all doom and gloom. In fact, this is a profoundly powerful season of becoming more of who you are than ever before. You see, perimenopause is the ultimate bullshit detector. When estrogen starts to decline, so does your tolerance for things that no longer align with your values. You suddenly stop making excuses for yourself, and you definitely stop making them for others.
This newfound clarityβand the bold audacity that midlife gives youβis exactly why I walked away from a highly successful 16-year radio career just four days before my 48th birthday in 2023. And it wasnβt because I suddenly felt incapable, or because I lacked the same zest and energy I had in my 30s. No, it wasnβt even because of the random hand cramps, the brain fog, or the insomnia from hell.
It was because of a very strong, unshakeable realization that the woman I was becoming no longer fit inside a windowless radio studio hosting a show I had literally named The Afternoon Tune Up. Inspired by the universal 3 PM slump, my goal back then was to tune up your day with fun stories and great music from the 80s. But who I was becoming wanted more meaningful work and a much deeper connection with my audience than a radio mic could offer.
Welcome to Your Next Chapter
That is exactly why I became a Midlife Performance Coach. After 30+ years navigating three high-pressure, high-profile industries β fitness, showbiz, and media β I now help busy professionals perform at their absolute best in both their personal and professional lives by tuning up their Vision, Vitality, Voice, and Visibility.
So, I hope you too will realize that your symptoms are not a crisis. They are a signal β an explicit invitation to build new habits, prioritize your health, and step into the most intentional chapter of your life yet. Your body is not failing. It is recalibrating.
And if you resonate with anything I wrote here, and no doctor has said it to you yet, let me be the very first to tell youβ¦ βYouβre in Perimenopause!β
Welcome to the zone of chaos, and welcome to the other side. You are going to be just fine. In fact, the best is yet to come.
Cheryl Miles is a certified nutrition coach, media trainer, and creator of The Encore Performance Method: Backstage to Spotlight.
