Perimenopause and menopause are a natural stage in a woman’s life, you may sail through with no symptoms, or, this time, for you, will be a life changing experience affecting your quality of life, your work, your family and the way you feel and the way you think. Please don’t worry, no matter what symptoms you are experiencing, at Rowena Health Menopause Specialist Clinic, we can help.
What is Perimenopause?
This is the time running up to the menopause, lasting between 2 and 10 years, and is associated with wildly fluctuating hormone levels that can lead to changes in your periods. You period may become lighter or heavier, your cycle shorter or longer. You may have good days and bad days, good months or bad months, there is no predictable pattern during this phase. I describe it like a light bulb, in your pre-menopausal years the bulb shines brightly, you have a pattern of hormones released which gives you a regular cycle. In perimenopause the light bulb is dimming and flashing on and off in a hapazard fashion, sometimes releasing hormones but the levels of hormones are up and down and are erratic. After menopause the light bulb has gone out and the hormone levels are low, but settled. This can be a time of calm and, although menopausal symptoms can go on in some women, it can be much easier to manage that the time in the storm of perimenopause.
What is Menopause?
Menopause is when you have had no period for 12 months. In the UK, the average age of menopause is 51. This is the time that the ovaries settle down, stop ovulating and your hormonal fluctuations settle, and things may seem to calm. You may still have on going symptoms, but we can help with these.
- If you go through the menopause between the ages of 40 and 45, this is called an Early Menopause.
- If you go through the menopause before the age of 40, as can happen to 1-3/100 women this is called Premature Ovarian Insufficiency. This happens to 1/1000 women under the age of 30.
- If you have chemotherapy this may affect your ovaries, and you may develop symptoms, which may improve if your ovaries start to release hormones again after your chemotherapy has finished.
- If your ovaries are removed in an operation, this is called Surgical Menopause, this is sudden and needs discussion before the operation so treatment can be started as soon as it is safe to do so.
What are the symptoms?
The symptoms you may experience will be individual to you. Estrogen receptors are all over the body, so as estrogen declines your symptoms can be widespread and sometimes unusual. Please don’t feel worried reading this list, it is helpful to be aware of the symptoms you may experience, but that doesn’t mean you will, or that you will have everything on the list. Some women sail through perimenopause with no symptoms, for others symptoms come and go and for some they get symptoms which significantly affect the way they are able to live their lives, affect their work and their relationships.
Period changes in perimenopause can lead to a lighter bleed, more or less often, or a heavier bleed which could be prolonged. If you use a progestogen contraceptive you may not notice period changes but you may experience the other symptoms which might come and go. If you are bleeding heavily with prolonged bleeding please click this link and see a Dr.
Mood, emotions, memory and thinking
Low mood, anxiety, irritability, tearfulness, anger and outbursts of rage; difficulty concentrating, memory difficulties, hard to recall words, reduced ability to think clearly, worsening Premenstrual syndrome, headaches, migraine attacks, fatigue and tiredness and difficulty sleeping or insomnia.
Anxiety, estrogen and progesterone affect the neurotransmitters, the chemical messengers in your brain which affect mood and ability to focus and concentrate. Anxiety and low mood can become a problem for many women, even if you have never been anxious or low before. It can lead to reduced ability to perform at work, to see friends and to take part in your family life.
Poor memory, loss of verbal recall / brain fog describes a set of symptoms including poor concentration and recall, difficulty with word finding, forgetting names and problems with retaining information. Some women worry that they have early onset dementia, but this is very unlikely unless you have a family history of early dementia. This article and this information may be helpful. This can affect 10% of women significantly in perimenopause, and in most women this does recover in menopause. Does HRT improve this in perimenopause? No studies have been done to confirm this in perimenopause but it is thought that for 90% of women this will get better in menopause. Tiredness or fatigue, this can affect your quality of life, ability to think clearly, to control your emotions and to function well at work and at home. Risk factors for dementia that we cannot control include age, female gender and family history, but a healthy lifestyle with a good diet, exercise, maintenance of a healthy weight and avoiding smoking and excessive alcohol consumption can all help reduce the risk.
Headaches can worse, as can migraine attacks. Some women even start to suffer migraine attacks for the first time in perimenopause. This link and this podcast is excellent for information. Migraine and HRT fact sheet.
Worsening PMS symptoms, these may have been manageable for years but suddenly become worse when hormones change. Migraine attacks and worsening PMS need a gentle approach in perimenopause, both conditions become more difficult with fluctuating hormones, so understanding them and stabilising the hormones can be really effective. For PMS please look at these three links: NAPS, IAPMD and Guidelines. Please ensure good lifestyle and nutrition as these can be so beneficial, particularly essential vitamins and exercise, when you look at your lifestyle.
Sleep can be more difficult in perimenopause for many reasons, it can be hard to get to sleep, you may wake up for a number or reasons, it could be that you start snoring and have gaps in your breathing, called sleep apnoea or that you suffer restless legs. Please see my article on sleep and menopause.
Hot flushes and night sweats are called vasomotor symptoms. Estrogen affects thermoregulation (temperature control) and when these flushes occur at night they are called night sweats, and can affect your ability to sleep well and lead to you feeling tired. If flushes occur in the day they can affect your ability to work and concentrate.
Muscles, joints and bones
Joint pain and stiffness; frozen shoulder, tennis elbow, plantar fasciitis, muscle pain and muscle loss (sarcopenia). Oestrogen is an anti-inflammatory, so as levels fall, you may ache after exercise or take longer to recover. Please see my article on joint pain and menopause.
Cardiovascular (heart and blood vessels)
Palpitations and or dizziness can occur, and can be associated with a hot flush or with feeling anxious, for example. Please see my article on palpitations and if you are concerned about these please see your Dr.
Bowel and digestive symptoms
Constipation, diarrhoea, heartburn, gastric reflux, wind, bloating, irritable bowel like symptoms. If these are new for you please speak with your GP, as there are some serious causes for these symptoms and anyone with changing bowel habit, unexplained weight loss, persisting abdominal or pelvic pain or bleeding from the bottom needs to discuss this with the Dr.
Genital and sexual
Vaginal dryness, vaginal discharge, vulval itch, feelings of thrush or bacterial vaginosis. These symptoms affect 80% of women who do not take HRT and 25% of women who do take HRT. Please see my article on Genitourinary Syndrome of the Menopause for more information. The walls of the vagina are thick, supple and healthy pre-menopause, when we are aroused we may have a increase in wetness ( but lubricants can help this too) and if there is a small cut in the vaginal wall it heals very quickly, often within hours and it is a lovely acidic environment with plenty of lactobacillus healthy bacteria. Once oestrogen falls the tissues thin by 2/3 and become dry and can be sore, itchy and bleed after sex and can hurt. There can be a wetness, not a dryness, a constant discharge and the lactobacillus reduces. Do not wash inside the vagina, only water on the lips and use a good quality vaginal moisturiser and lube like YES VM and YES OB and WB (take care wit condoms). Protect against STI’s as you need to. Vaginal oestrogen can help and is a long term, very safe treatment for almost every women, chat with your Dr about this.
A change in sexual desire, either higher or lower, this could be spontaneous sexual desire, or responsive sexual desire, a difficulty becoming aroused or achieving orgasm. Many women report a lack of interest in sex around this time. This can affect their feelings about intimacy, pleasure and sex. Falling levels of estrogen and testosterone can impact on sexual arousal, receptiveness and pleasure. This could cause distress for you and your partner. See my article on sexual desire for more information. It gives two books which are fascinating about female sexual desire, which I recommend to al my patients.
Increased frequency of passing urine, having to get up at night to pass urine, leaking on the way to the loo (urge incontinence), leaking on coughing or sneezing (stress incontinence), urine infections could start or become more frequent. The bladder is rich in oestrogen receptors and these symptoms can occur. Remember your pelvic floor exercises and again, as above see the article on Genitourinary Syndrome of the Menopause and consider vaginal oestrogen.
Ear, nose and throat (ENT), eyes and oral health
Eyes can become dry or watery and you may need moisturising eye drops if you wear contact lenses. Some women experience tinnitus, a ringing in the ears, please look a this article on tinnitus. Some experience globus, a feeling of something in the throat, which could be associated with a panic attack. Some experience voice changes. Burning mouth syndrome, a soreness in the mouth with no other cause is also more common around the time of menopause, please look at this article on Burning Mouth Syndrome. Gum disease, a change in oral health, a change in teeth and a dry mouth can occur.
Skin, hair and nails
Loss of oestrogen causes a reduction in production of ceramides and sebum which can cause drying of the skin and associated itching. Reduced collagen production and loss of elasticity also leads to thinning and sagging of the skin and wrinkles can become more pronounced. Hormonal fluctuations can also exacerbate rosacea and acne, especially in women who suffered with spots in their teenage years. In addition, oestrogen deficiency can cause thinning and loss of hair.
Oestrogen replacement can help improve skin and hair quality and reduce itching by reversing some of these changes and promoting water retention and plumpness in the skin. Increasing the level of oestrogen in relation to testosterone could also help prevent spots.
Click for further information about acne (spots) and rosacea. It is important to care for your skin, and avoid any products such as soaps that could cause further drying. An emollient cream can be used as a soap substitute, and you should moisturise your face and body regularly. Protect yourself from sun damage by using a high factor SPF in the summer and avoid excessive exposure. Triggers such as caffeine, alcohol and spicy foods can set off rosacea as well as hot flushes and sweats.
Some women experience a feeling of things crawling under the skin or electric shock like symptoms. They may also notice a change in body odour.
Thinning hair can occur with age, and hair loss on the head can occur around perimenopause as the balance of hormones change with oestrogen and testosterone. Menopausal hair loss fact sheet. Other things to consider are ferritin levels for good hair growth and thyroid disease. Unwanted hair growth can occur, for example thicker hairs growing from the chin.
Metabolic health, weight change and bone health
It is common to gain body weight as we age and around perimenopause, for a number of reasons. Despite there often being no change in diet or exercise regime, there is often a change in body shape once oestrogen falls with weight being more easily gained around the middle. Blood cholesterol rises and so does insulin resistance, insulin is our fat storage hormone, and this can contribute to central weight gain. Other things to contributing to weight gain include genetic reasons affecting our appetite, the type of food we choose, sensation of fullness, for example; the food we eat; stress; poor sleep and medication. Starting with a food diary has been shown to be helpful, writing down what you eat, when you eat, why you eat (are you hungry, thirsty, eating for comfort, for example). Unfortunately no one diet has been shown to be better than another for weight loss, but the Mediterranean Diet appears to have the most supportive evidence for weight management and health protection.
Muscle loss, sarcopenia, it is important to move every day and the advice is to do a moderate intensity exercise for 2.5 hours a week, with two strength sessions to keep muscle mass steady.
Although we cannot see our heart, as oestrogen falls we are at increased risk of cardiovascular disease like heart attack and stroke. An NHS health check with blood fats (lipids), blood sugar (to rule out Type 2 Diabetes) and blood pressure is important. Metabolic Syndrome is a term used to describe an increase in certain blood fats, blood sugar and blood pressure and waist circumference and having metabolic syndrome can increase our risk of cardiovascular disease and Type 2 Diabetes. The tests are easily arranged on the NHS and lifestyle changes can reverse this condition and the use of medication and HRT can be beneficial, too.
Reduced tolerance to alcohol, increasing allergies are more common and this article on histamine intolerance is fantastic.
Breasts can change in size and can become painful. Please ensure you have a well supporting bra and this article on breast pain may help.
I have these symptoms, what can I do to help myself?
The list of symptoms above can seem overwhelming, don’t worry, the first thing to do it to keep a symptom tracker, as your symptoms may come and go in perimenopause. In menopause the symptoms may settle, but for some women this is not the case and symptoms can be ongoing.
Please make an appointment with a health professional if your symptoms are affecting the quality of your life. After talking with you we can decide if you need any further investigations and support you to decide on the best way to manage your symptoms. The advice will depend upon your age, symptoms, your past medical history, family history, any medication or supplements you take. Understanding the role of oestrogen, the symptoms that you might experience, talking through each one in turn, and discussing all of the choices is so important.
Blood tests are not necessary above the age of 45, as we diagnose perimenopause and menopause by listening to your symptoms and taking a thorough history. If we are concerned there is a different diagnosis we will consider blood tests.
Between 40 and 45 years we may consider blood tests confirm menopause, and to rule out other causes for your symptoms. Blood tests are not helpful in this age group to diagnose perimenopause.
Below the age of 40 we will take blood tests, if we are considering a diagnosis of Premature Ovarian Insufficiency, POI, menopause below the age of 40. Two tests are needed 4-6 weeks apart, measuring FSH, follicle stimulating hormone. This is normally done in women who stop having periods or who’s periods become irregular and both tests would be high, confirming the diagnosis.
Blood tests in perimenopause are not helpful at diagnosing perimenopause, this is because the hormonal levels fluctuate wildly so can be normal, low or high. Many women find they are told their blood tests are normal, but they are experiencing symptoms, which commonly start in the mid to late 30’s and can come and go. This can be difficult so keeping a symptom diary is helpful looking at all the information above, then seeing a Dr. to talk about the symptoms and how to best manage them.
Rest, and self care this seems a small thing, but during perimenopause it is necessary, if possible? Are some healthy changes you might be able to make to your lifestyle?
- Sleep: good quality sleep is what we aim for, there are lots of ways to help this. Try reading this sleep article. Consider if you are snoring or have restless legs. Menopause and insomnia fact sheet
- Diet: a diet rich in nutrients is important. As women our bodies thrive when we are nourished with essential vitamins and minerals, protein, complex carbohydrates, healthy fats, fibre and when we are well hydrated. Gut health, blood sugar balancing, time restricted eating are all topics for discussion. Calcium in the diet will help protect bones, the Royal Osteoporosis Society has a wonderful website full of information about nutrition and exercise for bone health. Nutrition in Menopause fact sheet
- Stress: mindfulness and mediation; effective breathing techniques can all be helpful in reducing stress and improving symptoms. Many of my patients recommend the HeadSpace app.
- Exercise: for physical health, mental heath and bone health: aerobic, strength, pelvic floor exercises, balance exercises are all important. Women who do take the recommended moderate intensity exercise for 2.5 hours a week with two strength sessions report better symptom control. Walking is an excellent way to start. There are many online instructors who are excellent to follow for guidance on improving strength, from whatever level you are at including chair based exercises. Sitting all day is bad for our health, try and have snacks of exercise regularly. Exercise in Menopause fact sheet
- Alcohol: keeping within sensible limits, under 14 units a week (one bottle of wine is 9 units), many women struggle to tolerate alcohol and report that their symptoms are much improved when they don’t drink alcohol.
- Smoking: it is best to get support to stop smoking, there are no health benefits.
- Caffeine: absolutely if you have the genetic profile to tolerate caffeine well then that’s great, but it can affect sleep so having it before midday might be best for you.
- Supplements: these may be necessary, certainly almost always a Vitamin D tablet 1000iu a day for women in the UK may be recommended for bone health. Be careful with supplements, they are not all the same. This book may be helpful in guiding good brands and good nutrition. The Natural Menopause Method.
- Weight and menopause fact sheet
- Pelvic floor exercises: these are so important to keep the muscles strong and avoid prolapse, please look at the Squeezy app
Hormone Replacement Therapy
There is a great deal that can be done to help relieve your symptoms and get you feeling like you again. Some women choose to take HRT, and this has benefits and risks which are individual for each woman. For some that is not possible, or simply not something they want to take. They might choose vaginal oestrogen even if they cannot take HRT.
- Oestrogen as part of HRT
- Progesterone or progestogen as part of HRT
- Testosterone as part of HRT
- Vaginal oestrogen (is not HRT – see below)
Please see my article on Hormone Replacement Therapy for more details.
Vaginal and bladder treatments
These are not HRT and can be used with or without HRT to help improve the bladder and genital tract symptoms, called Genitourinary Syndrome of the Menopause. They are inserted into the vagina as a pessary, tiny tablet with an applicator, a cream or a small plastic ring, most commonly and are used for 2-3 weeks every night and then ongoing, long term twice a week, usually. They can cause irritation for a couple of weeks and then take 2-4 months to work. They are not to be stopped or the tissues will revert to how they were prior to treatment. This treatment can be safely used in almost every woman, even those who have had an oestrogen dependent tumour like a breast cancer. Non hormonal moisturisers and lubricants on having sex are really important.
Symptoms such as urge to pass urine, frequency of passing urine, leaking, either on the way to the loo, or on coughing, sneezing, jumping or running or urine infections can occur. These can be helped by doing regular pelvic floor exercises and taking vaginal oestrogen, making sure you are well hydrated and avoiding bladder irritants. Some women have an overactive bladder and have recurrent cystitis and please talk with your GP if that is the case.
STI use is increasing in people above the age of 40 so please ensure you use protection if you need it.
There are some non-hormonal prescribed medications which can be helpful to relieve hot flushes, like antidepressants in low doses. For some women antidepressants in doses to relieve anxiety and depression are also beneficial. There is a new medication called Fexolinetant which is very effective as relieving hot flushes and night sweats. This is available privately in the UK at the moment while NICE guidance is approved and it is not recommended yet for women after breast cancer as studies for safety are still ongoing in this group of women.
Cognitive Behavioural Therapy
CBT, cognitive behavioural therapy, can be very helpful for women who are struggling to sleep, feel anxious or low, or who are suffering from hot flushes and night sweats. This can be done using a self help book, like this one: Managing Hot Flushes or Night Sweats; or in a group session or a 1-1 session.
Some women find other psychological therapies helpful, especially if they want to discuss past events in more detail so different treatments like counselling can be helpful.
Yoga, acupuncture, reflexology, hypnotherapy are all other complementary treatments to consider. Complementary and alternative therapies fact sheet. British Complementary Medicine Association website gives details on all therapies which is helpful.
Herbal Medicine and Homeopathy
Herbal medicines plants or plant extracts, such as St John’s wort, black cohosh and isoflavones (soya products), can help reduce hot flushes and night sweats for some women. However, their safety is unknown and they can react with other medicines that you may be taking for conditions such as breast cancer, epilepsy, heart disease or asthma. You should check with your healthcare professional before taking any herbal medicine. Unlike conventional medicine, there is no legal obligation for herbal medicines to be licensed. Unlicensed products may vary greatly in their actual contents. If you buy herbal products, look for a product licence or Traditional Herbal Registration (THR) number on the label to ensure that what you are buying has been checked for purity. It is advisable to buy remedies from a reputable source. This article on Herbal Medicine may be helpful. This article on use of acupuncture may be helpful. This article about reflexology might be helpful. What is homeopathy? The Society of Homeopaths website might be helpful.
Women need to use contraception until the age of 55, but if you have a natural cycle and are not taking any hormones like HRT or contraceptives, you ca stop using contraception one year after your last natural period, if it was over the age of 50 and 2 years after your natural period if it was under the age of 50. HRT is not a contraceptive unless you are using a Mirena IUS, which is we use for a maximum of 5 years as part of HRT. The licensing for the Mirena has changed so it can be used for 8 years for contraception, if fitted under the age of 45; if fitted age 45 or over it can be used as contraception until age 55. It is licensed for 5 years for heavy menstrual bleeding, with a review at 5 years. Mirena guidance. The combined contraceptive pill must be stopped age 50 but other progestogen only methods of contraception, like the progestogen only pill or implant, can be used until the age of 55. Contraception in the older woman.
Do attend your cervical screening and mammograms when you are invited and remember regular body checks are important so you know what is normal for you.
It can be more difficult to work when you are struggling with symptoms of perimenopause and menopause. Here is some advice, should you need it.
Helping family and friends understand
Showing them this article may be helpful. ‘Menopause may be happening directly to your partner but it will no doubt have an effect on you, and potentially other family members, friends and work colleagues. Talking about it honestly and openly, at a time when you are both calm can be helpful. If she feels supported and nurtured, despite not feeling her normal self, she will find it easier to ask for help. It is important to find out what she is going through when her hormones are changing, and what options there are for supporting her at home and at work.’
Your future health
Hormonal changes at menopause result in an increase in risk of cardiovascular disease (heart and blood vessel like heart attack and stroke) and in osteoporosis for women. As we age blood pressure can also rise, blood lipid profiles can change and you may gain weight around your waist. Some women develop metabolic syndrome. This condition can be reversed by making healthy lifestyle changes and sometimes by using medication and HRT can help. Your GP can arrange an NHS health check for you looking at your waist measurement, blood lipids, blood sugar, weight and blood pressure.
- Bone health: Osteoporosis fact sheet
- Heart and blood vessel health: an NHS health check, an annual blood pressure check, healthy lifestyle can all help to protect the heart. Heart health UK
- Check your pulse: it should be regular and a rate of 60-100 beats a minute. Read about atrial fibrillation
- Joint health: read about arthritis: Versus arthritis website
Premature Ovarian Insufficiency (menopause under the age of 40 years)
Menopause after cancer
- This article on Menopause after breast cancer is fantastic
- This article on Family history of breast cancer
For an appointment with Dr Carys Sonnenberg BMS Menopause Specialist, please visit the Rowena Health booking page. We are delighted to see you online or in person at our Guildford Clinic.
Last updated January 2024 Dr Carys Sonnenberg
Rowena Health is not responsible for the content on external websites