Perimenopause refers to the transitional phase that occurs before menopause. It typically begins several years before menopause, although the exact duration can vary from woman to woman. During perimenopause, a woman's body undergoes hormonal changes as the ovaries start producing less oestrogen. Symptoms include hot flushes, night sweating, mood changes, vaginal dryness, and changes in libido.
What is the perimenopause?
Perimenopause means 'around the time of menopause' and refers to the time during which the body makes the natural transition to menopause.
The menopause is the time when the ovaries stop releasing an egg each month - it is said to have occurred when you are 12 months after your last period. Many women think of the menopause as the time of life leading up to, and after, their last period, though this is actually the perimenopause.
If you are experiencing menopausal symptoms but still having periods, then you are perimenopausal. You can expect to go through this menopausal transition stage for around four years - however, some women can experience anything from a few months to 10 years of symptoms.
Perimenopause ends when a woman has had 12 consecutive months without having a period, when you have reached the menopause.
When does the perimenopause start?
Most women begin to experience the symptoms of perimenopause naturally in their mid 40s, with an average age of 47 years.
The average age of the menopause is 51 years. However, perimenopause or menopausal transition occurs in the years before periods stop so is usually from the 40s into the early 50s.
Most women will experience some form of perimenopausal symptoms prior to the menopause.
Symptoms of the perimenopause can also be caused by some medical procedures that will affect how the ovaries work. These include some medications (such as tamoxifen, which is used for breast cancer), chemotherapy or radiotherapy to the pelvic area, also to treat cancer. And of course, having your ovaries removed surgically, possibly as part of a hysterectomy operation, will also cause these symptoms.
What are the symptoms and signs of the perimenopause?
Many of the symptoms experienced during perimenopause are a result of decreasing hormone levels. A lower level of oestrogen is the main change, but progesterone and testosterone also play a part.
When you have a normal period, the levels of oestrogen and progesterone hormones rise and fall in a regular pattern throughout the menstrual cycle. But during perimenopause, hormone levels are all over the place. The hormones don’t just stop, so neither do your periods. As a result, there may be irregular bleeding or spotting.
Some months, your period may be longer and heavier. Other months, it may be shorter and lighter. The number of days between periods may increase or decrease, and you may begin to skip periods. This irregular bleeding is normal. However, if your bleeding is very heavy, occurs more often than every three weeks, or lasts much longer than usual, you should contact your doctor.
Hot flushes (also called hot ‘flashes’) are the most common perimenopausal symptom. These are characterised as a sudden onset of heat and warmth beginning in the chest and face. They are often accompanied by sweating and last around two to four minutes. Hot flushes can occur daily or even hourly.
Many women find they wake up several times each night drenched with sweat and need to change their bed clothes and bed linen. This is known as night sweats.
Mood swings, irritability or increased risk of depression may happen during perimenopause.
Problems with sleep during perimenopause can be worsened by hot flushes, night sweats, and other uncomfortable symptoms.
Fluctuating oestrogen levels may be partly to blame for the weight gain that often happens, particularly around the tummy and bottom areas.
Headaches and migraines can get worse as hormones fluctuate.
A fuzzy head
Many women also notice they have trouble concentrating during the perimenopause. This is often called 'brain fog' by those that experience it.
Low levels of oestrogen can lead to many joints feeling stiff and aching.
Vaginal dryness and changes in sexual function
Problems with vaginal dryness and intercourse are another common complaint in perimenopausal women. A drop in hormone levels (predominantly testosterone) is responsible for a reduced or absent sex drive - also called libido.
Changes in skin and hair
The hormone oestrogen also keeps hair shiny and skin ‘plump’, so when oestrogen levels fall you might notice changes in your skin and hair. Hair may become dry and brittle, and skin may look dull and feel a little ‘saggy’.
Is there a test for perimenopause?
Hormone blood tests
A healthcare professional can usually diagnose the menopause by the typical symptoms. Hormone blood tests are not usually needed to confirm that you are going through the perimenopause. However, they may be helpful in some cases - for example, in younger women - where perimenopausal symptoms might not be expected.
The blood test often used measures the levels of follicle stimulating hormone (FSH). It is advisable to do 2 tests at least 4-6 weeks apart. This test is unreliable if a woman is using combined hormonal contraception at that time. If the level is over 30 IU/L, it is in the menopausal range.
Other blood tests or scans may be undertaken in some women, especially if they do not have symptoms which are typical of the menopause and other causes of their symptoms need to be considered.
How do I manage perimenopausal symptoms?
At some point, most women will experience symptoms related to perimenopause. While you cannot control whether or not your body goes through these changes, you can find ways to manage the symptoms.
Keep a record of the symptoms related to menopause. Document the changes to your periods and any other bothersome symptoms you are experiencing. This will help your doctor develop a treatment plan that works for you.
Move your body
Staying active and eating healthy foods are beneficial for every phase of perimenopause. Aim for 30-60 minutes each day - five days a week - of both aerobic and strength training exercise. This will also help reduce the raised risk of osteoporosis that comes with the menopause.
Eat healthy foods
Nutrition in the form of whole foods - quality protein, vegetables, fruits, complex carbohydrates, and good fats - will help keep blood sugars level. Eliminating or reducing alcohol, caffeine, and sugar may also help reduce symptoms. These changes can help stabilise moods and fight fatigue, a bloated tummy, and weight gain. If you can match symptoms to foods you have eaten (perhaps by keeping a diary), you can tailor your diet to relieve your symptoms.
Manage hot flushes
Hot flushes are generally managed conservatively by dressing in loose-fitting layers, personal fans and avoiding irritants such as spicy foods. However, moderate or severe symptoms may require medication such as HRT.
Develop a good sleep routine
Treating hot flushes can help alleviate some of the sleep disturbances. Having a slightly cooler room to sleep in often helps. Turn the radiator setting lower, or let in some cooler air through the window before bedtime. Otherwise following good sleep hygiene advice is sensible.
Use a lubricant
Lubricants (lube) will make sex less uncomfortable if you feel dry in the vaginal area. However, this area often requires oestrogen therapy, which is given as vaginal oestrogen treatment - cream or pessaries. Oestrogen cream (as GINA®) can now also be bought from the pharmacy.
Consider medication if needed
When should I see a doctor about the perimenopause?
Women who experience milder symptoms may be able to manage any discomfort on their own by adapting lifestyle and surroundings. But if you are unable to find relief, it may be time to visit your doctor to talk about other options.
Can you get pregnant in the perimenopause?
Although women are less likely to conceive as they age, it is still possible to become pregnant around the time of the menopause. So, if you are sexually active but don't want to be pregnant, you will need to consider contraception, such as coils, barrier methods or birth control pills.
You will need contraception:
- Until a year after your last period if you are 50 or over.
- Until two years after your last period if you are under 50.
Deciding when to stop contraception is more difficult if your periods have stopped due to your current contraception. For example, the implant, the hormone coil and some pills can cause your periods to stop. Another scenario is when your contraception creates a withdrawal bleed (such as a combined hormonal contraception) as this makes it difficult to tell whether you are still having periods.
If you are not sure whether you are menopausal, because your contraceptive method has affected your periods, then you can ask your doctor for a blood test called FSH, to be done at any point over the age of 50. If the result is in the menopausal range then you can stop contraception one year after the blood test is done.
Alternatively, you can continue contraception until the age of 55 (at which time all women can stop), though you may need to change the type of contraception at age 50. An option favoured by many is to have a long-acting method fitted, such as the Intrauterine system (Mirena) which can remain in place for at least 5 years and in addition to contraception, can also provide part of the hormone treatment found in HRT (the progestogen part). See our dedicated leaflet on Contraception for women over 40.
Further reading and references
Menopause; NICE CKS, September 2022 (UK access only)
Delamater L, Santoro N; Management of the Perimenopause. Clin Obstet Gynecol. 2018 Sep61(3):419-432. doi: 10.1097/GRF.0000000000000389.
Marjoribanks J, Farquhar C, Roberts H, et al; Long-term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev. 2017 Jan 171(1):CD004143. doi: 10.1002/14651858.CD004143.pub5.
Marlatt KL, Pitynski-Miller DR, Gavin KM, et al; Body composition and cardiometabolic health across the menopause transition. Obesity (Silver Spring). 2022 Jan30(1):14-27. doi: 10.1002/oby.23289.
Menopause and later life; RCOG