A guide to perimenopause
Much like the rest of our body, as ovaries age, they don’t function as well as they used to. This can lead to fluctuations of hormones and overall, less oestrogen being produced.
This change in hormone levels eventually leads to menopause, where your period stops completely, and you reach the end of your fertile years. However, before you reach menopause, you go through a stage known as perimenopause.
What is perimenopause?
Perimenopause is defined as the transitional period in the lead-up to menopause, where the ovaries gradually stop working, your levels of oestrogen and progesterone fluctuate, and your body begins to prepare for the end of its reproductive years.
Perimenopause can last two to eight years, with the average being about four years and, during this time, you might experience highly fluctuating hormones and the symptoms that occur as a result. However, your periods may still be regular initially.
This can be confusing for women, as you might not understand why this is happening. This means that perimenopause is sometimes misdiagnosed as depression, amongst other things.
The difference between perimenopause and menopause
Perimenopause is when you have symptoms associated with fluctuating hormone levels and your periods may be irregular, but they have not stopped. Menopause, on the other hand, is defined as the point in a woman’s life where she has gone 12 consecutive months without a menstrual period, vaginal bleeding or spotting.
Perimenopause normally commences in a woman’s 40s and lasts several years. Menopause usually occurs between the ages of 45 and 55 but the average age in the UK is 51.
Can perimenopause be diagnosed?
Perimenopause can be diagnosed by a healthcare provider, usually by symptoms alone. However, it can sometimes be difficult to tell if you have signs of perimenopause as many of its symptoms can also be caused by other conditions, medications and lifestyle factors. For example, an underactive thyroid and menopause often have overlapping symptoms.
It’s also possible to be in perimenopause and have few or no symptoms. Typically, perimenopause is only diagnosed if its symptoms are impacting your day-to-day life, and treatments or management of symptoms need to be explored.
What causes perimenopause?
Oestrogen is an important hormone within a woman’s menstrual cycle. It plays a role in ovulation and helps to thicken the lining of the womb in preparation for pregnancy.
As menopause draws closer, oestrogen levels start to drop off greatly. It’s the decline in oestrogen that causes menstrual period irregularities, and the raft of symptoms women often experience during perimenopause.
When does perimenopause usually happen?
Women enter perimenopause at different ages. You’ll usually notice some signs, such as changes to your period, sometime in your 40s. However, some women experience symptoms as early as their mid-30s. Perimenopause can last for several years before you reach menopause.
How do I know if I’m in perimenopause?
Perimenopause is the gradual stage leading up to menopause. You are classed as having reached menopause when you have gone 12 consecutive months without a menstrual period, vaginal bleeding or spotting.
If you have a persistent change of a week or more in the length of your menstrual cycle, this could indicate that you are in early perimenopause. If you are still having periods but have a space of 60 days or more between them, you’re likely in late perimenopause.
It is not just irregular periods that act as a tell-tale sign of perimenopause. There are other physical, emotional and mental symptoms you may experience.
Symptoms of perimenopause
Oestrogen receptors are located throughout the whole body. As a result, lowering oestrogen levels can cause symptoms in practically every organ system. The most common symptoms of perimenopause are:
- Anxiety
- Brain fog
- Hair loss
- Headaches
- Hot flushes
- Irregular periods
- Low libido
- Mood swings
- Night sweats
- Palpitations
- Rage
- Sleep issues
- Sore muscles and joints
- Vaginal dryness
- Weight gain
Many symptoms of perimenopause are also symptoms of menopause. For example, hot flushes and night sweats in menopause are experienced by about 80% of women and menopause headaches are not unusual throughout perimenopause and menopause, but do usually improve post menopause.
Symptoms of perimenopause can be similar to those caused by other conditions. PCOS doesn’t cause perimenopause, for instance, but the mirroring of symptoms can make it more difficult to diagnose PCOS once perimenopause begins.
You may find it useful to keep a symptom diary, keeping note of changes to your menstrual cycle, mood and other symptoms. This can be particularly beneficial should you reach out for support from a doctor.
Treatment for perimenopause
There is no way to stop perimenopause – it’s a natural part of ageing. However, there are treatments that can alleviate its symptoms.
The best treatment is an oestrogen replacement, a form of HRT. Modern research suggests that when it comes to perimenopause and HRT, using modern body identical hormones is safe and even has numerous health benefits. This includes heart and vessel protection and osteoporosis prevention.
The hormones we prescribe at Menopause Care are identical to the hormones your body produces naturally. But in contrast to ‘bio-identical hormones’, they are produced and regulated under strict conditions and national guidelines and are available on UK formulary.
Body identical HRT (Hormone Replacement Therapy)
We offer Body-identical HRT, normally in the form of Estradiol (patch, spray or gel) and Utrogestan micronised progesterone.
It is safer to prescribe oestrogen through the skin (transdermal route) so we would not normally initiate oral HRT unless you have a very strong view on it or a particular medical reason.
How early can menopause start?
For most women, menopause occurs between the ages of 45 and 55. However, menopause can happen in your 20s, 30s or 40s. Menopause before the age of 45 is called early menopause and menopause before 40 is called premature menopause.
Natural early menopause affects around 5% of women under 45. Premature menopause occurs in approximately 1% of women under 40 and 0.1% of women under 30.
What causes early menopause?
Premature menopause is an indication that the ovaries aren’t working as they should and stop producing eggs earlier than they would naturally from ageing. The cause of premature menopause, which happens before the age of 40, is unknown in 90% of cases. However, known causes of early and premature menopause include:
- Medical treatments: Chemotherapy or radiation therapy for cancer may damage the ovaries and cause early menopause
- Surgery: Removal of the ovaries (oophorectomy) or a hysterectomy can trigger early menopause
- Lifestyle factors: Smoking has been linked to earlier onset of menopause, as it can reduce oestrogen levels
- Chromosomal abnormalities: Conditions like Turner syndrome can lead to ovarian dysfunction and early menopause
- Starting your period earlier: Early menopause is more likely if you had your first menstrual period before the age of eight
- Birth history: If you have never given birth, or have only given birth once or twice, menopause can occur earlier
- Medication: Certain hormone medications can bring on early menopause
- Weight: Women who are underweight at the age of 35 are nearly 60% more likely to enter early menopause
Is premature menopause hereditary?
You do have a higher chance of premature menopause if other women on your mother’s side of the family experienced menopause earlier than usual. One study found that 37.5% of early menopause cases reported a family history of menopause before the age of 46 compared to only 9% of women who did not go through menopause early.
What are early menopause symptoms?
The main symptom of early menopause is your periods becoming irregular (short or longer, lighter or heavier, or not occurring every month) or stopping completely. Other symptoms include those typical of perimenopause and menopause such as hot flushes, night sweats, mood swings and vaginal dryness.
Are there any benefits of early menopause?
Early menopause can reduce your risk of breast cancer and ovarian cancer. This is because these types of cancer are oestrogen-sensitive and linked to higher levels of the hormone. In women who go through early menopause, oestrogen levels are significantly lower.
However, there are also health risks associated with early menopause including a higher risk of heart disease and cancer for women who enter menopause before 40.
It can also increase the risk of osteoporosis and depression. Women who experience menopause at age 40 or later are about half as likely to experience depression as women who experience premature menopause.
Early or premature menopause can also impact a woman's mental and emotional health due to its impact on fertility. Women experiencing early menopause or premature ovarian infertility have just a 1-5% lifetime chance of conceiving spontaneously.
Is there any way to avoid early menopause?
In most instances, when menopause begins is beyond your control. However, some steps may help reduce the risk or delay its onset, especially if lifestyle factors are involved:
- Quit smoking: Smoking is one of the most significant risk factors for early menopause. Quitting can help preserve oestrogen levels.
- Maintain a healthy weight: Being underweight or overweight can affect hormone balance. A healthy diet during menopause and regular exercise can support overall reproductive health.
- Manage stress: Chronic stress can affect hormone levels, and research indicates that it may contribute to a reduced age at natural menopause.
- Monitor family history: If early menopause runs in the family, working with a healthcare provider to monitor hormone levels may allow for early intervention.
When should I see a doctor about perimenopause?
You should see a doctor about perimenopause if you're experiencing bothersome symptoms, such as irregular periods, night sweats, mood changes, or sleep problems, especially if these affect your quality of life.
When it comes to diagnosing menopause, your doctor will evaluate your symptoms, menstrual history, and overall health. No single test can definitively confirm you’ve entered perimenopause. Instead, diagnosing perimenopause involves considering your:
- Symptoms
- Medical history
- Age
- Lifestyle
Sometimes, a physical exam can help with a diagnosis and in some instances, blood tests to measure your hormone levels will provide further insight.
Blood tests for perimenopause and menopause aren’t usually necessary for women over the age of 45 but they are recommended for younger women as they can help exclude other underlying conditions that may be causing symptoms.
If you can, it's best to consult a specialist who understands women’s hormonal health and reproductive issues. They can offer personalised care, guide you through managing symptoms and offer treatments if needed.
At Menopause Care, we have a team of experienced menopause doctors and nurses here to help you navigate perimenopause, menopause and beyond. If you would like to discuss your symptoms, want to know more about HRT so you can make an informed choice about treatment, or would like specific nutritional or mental health support, book a consultation today.
¹What is the menopause?. Mr Haitham Hamoda in collaboration with the medical advisory council of the British Menopause Society (October 2024)
²Cigarette Smoking and Risk of Early Natural Menopause - PMC. Brian W Whitcomb et al. (August 2017)
³Menopausal Hot Flashes: A Concise Review - PMC. Ramandeep Bansal, Neelam Aggarwal (March 2019)
⁴Early and premature menopause | NHS inform. NHS Inform (March 2023)
⁵Early menopause is more likely if you’ve ever been underweight | New Scientist New Scientist (October 2017)
⁶Family history as a predictor of early menopause Kramer et al. (October 1995)
⁷Early menopause - NHS NHS (February 2021)
⁸Premature menopause may increase risk of death from heart disease, cancer Medical News Today (Ginger Vieira, May 2024)
⁹Earlier Age at Menopause Increases Risk of Depression - MGH Center for Women's Mental Health MGH Center for Women's Health (January 2016)
¹⁰Emotional impact of early menopause and fertility loss - Healthtalk Australia Healthtalk Australia
