Perimenopause and menopause

Perimenopause and menopause are a natural stage in a woman’s life. Some women do not experience symptoms, but about 75% of women do and for 25% of women, the symptoms can have a significant impact upon their quality of life. At Rowena Health we often see women in their late 30’s and early 40’s for whom hormones are changing and they need advice and support. We also see women in their 50’s and 60’s with symptoms and ongoing symptoms. Every woman, no matter what age can ask for support with their hormonal health.

What is Perimenopause?

This is the time running up to the menopause, lasting between 2 and 10 years. It is associated with wildly fluctuating hormone levels that can lead to changes in periods and symptoms of changing hormones.

What is Menopause?

Menopause is said to have occurred when a woman has had no period for 12 months, and is not taking hormonal contraception. In the UK, the average age of menopause is 51, but it can occur between the ages of 45 and 55.

Early Menopause

If you go through the menopause between the ages of 40 and 45, this is called an Early Menopause.

Premature ovarian insufficiency

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.

Medical Menopause

If you have treatment such as chemotherapy, radiotherapy or hormone blocking drugs this may affect the function of your ovaries, either temporarily or permanently.

Surgical Menopause

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.

Understanding Menopause fact sheet

What are the symptoms of perimenopause and menopause?

The symptoms you may experience will be individual to you. Oestrogen receptors are all over the body, so as oestrogen declines your symptoms can be widespread, and sometimes unusual.

Period changes

Period changes in perimenopause can lead to a lighter bleed, more or less often, or a heavier bleed which could be prolonged.

If you are bleeding heavily with prolonged bleeding please discuss this with your GP. This article about Managing heavy periods NHS shared care is excellent.

Mood and emotions

Symptoms include experiencing low mood, anxiety, irritability, tearfulness, anger and outbursts of rage. It can be difficult to concentrate.

Oestrogen and progesterone affect neurotransmitters, the chemical messengers in the brain which affect mood and ability to focus and concentrate.

Previously diagnosed mental health conditions can worsen, such as generalised anxiety disorder or depression.

Memory changes and brain fog

Poor memory, loss of verbal recall or 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. Please talk with your doctor if you have a family history of early dementia. This article and this International Menopause Society video may be helpful.

Risk factors for dementia that we cannot control include age, female gender and family history. Having a healthy lifestyle with a good nutrition, regular exercise, maintenance of a healthy weight , prioritising sleep and avoiding smoking and excessive alcohol consumption can all help reduce the risk.

Premenstrual syndromes

Premenstrual syndromes PMS, can worsen, or become apparent for the first time.

Worsening Premenstrual syndrome, Premenstrual exacerbation PME or Premenstrual dysphoric disorder PMDD symptoms can occur. These may have been manageable for years but suddenly become worse when hormones change. Please look at our article for more detail about this and further links for support, Premenstrual Syndrome.

Headaches and worsening migraine attacks

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.

Fatigue, tiredness and difficulty sleeping or insomnia

It is common to experience difficulty sleeping or insomnia, this affects 40-60% of women at this stage of life and can leave you feeling tired or fatigued.

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. Please see the article on sleep and menopause.

Vasomotor symptoms – feeling hot, hot flushes or night sweats and chills

Hot flushes and night sweats are called vasomotor symptoms. Oestrogen affects thermoregulation (temperature control).

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 the 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 the article on palpitations and if you are concerned about these please see your GP.

Bowel and digestive symptoms

Symptoms include 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.

Vaginal dryness

Vaginal dryness, vaginal discharge, vulval itch, soreness or burning, feelings of thrush are common.

Please see the article on Genitourinary Syndrome of the Menopause for more information.

Vaginal localised oestrogen can help with these symptoms and is a long term, treatment that can be taken with systemic hormone replacement therapy, or without.

Change in sexual desire

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 oestrogen and testosterone can impact on sexual arousal, receptiveness and pleasure. This could cause distress for you and your partner.

See the article on sexual desire for more information. It gives two books which are fascinating about female sexual desire, which I recommend to all my patients.

Bladder problems and urine infections

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. Gum disease, a change in oral health, a change in teeth and a dry mouth can occur.

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.

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.

Click for further information about acne (spots) and rosacea.

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.

Please see the article on Menopause, skin, hair and nails

Metabolic health, weight change

It is common to gain body weight and to notice a change in body shape, during the menopause transition. Blood cholesterol rises. Muscle mass reduces. Blood pressure rises.

Although we cannot see our heart, as oestrogen falls we are at increased risk of cardiovascular disease like heart attack and stroke.

Arranging 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. Lifestyle changes can reverse this condition and the use of medication and HRT can be beneficial, too.

Bone health

Although we cannot see our bones, as oestrogen falls we are at risk of brittle, thinning bones which more prone to breaking. Exercise for bone health and exercise for health health.

Increasing allergies

Reduced tolerance to alcohol, increasing allergies are more common and this article on histamine intolerance is helpful if you are experiencing these symptoms.

Breast changes

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.

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.

Are blood tests necessary?

Blood tests are not necessary to 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, because the hormones fluctuate greatly at this time.

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.

Lifestyle first

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

Hormonal treatments: HRT or the combined contraceptive pill

Some women choose to take HRT or the combined contraceptive pill to help relieve their symptoms in perimenopause and menopause.

It is important to discuss the benefits, risks and side effects, these are individual for each woman.

Please see the article on Hormone Replacement Therapy for more details.

Vaginal oestrogen

This is a low dose localised oestrogen treatment used either on it’s own, or alongside HRT to help relieve the vaginal and bladder symptoms. It can be given as a cream, gel, pessary, tablet or vaginal ring, and is a long term treatment which is very effective.

Non-hormonal therapies

If hormonal treatments are not possible, due to prescribing contraindications, or not a preferred choice there are some non-hormonal prescribed medications which can be helpful. These are usually given to relieve the vasomotor symptoms, hot flushes and night sweats and include, low dose antidepressants. Newer treatments called Neurokinin B receptor antagonists are available which work on temperature control in the brain.

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.

Other therapies

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

If you are considering these I recommend you see an experienced practitioner to guide you, it is worth investing the money to take treatments which are safe for you.

• The Society of Homeopaths website
• National institute of medical herbalists
• British Herbal medicine association

Contraception

All women can stop using contraception at the age of 55 years.

If you have a natural cycle and are not taking any hormones like HRT or contraceptives, you can 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 52mg LNG IUD, which is we use for a maximum of 5 years as part of HRT.

If you take combined hormonal contraception such as the combined pill or patch this usually is stopped at 50 years. You can transfer to a progestogen only contraceptive like a progestogen only pill or an implant until age 55 years. The combined hormonal contraceptive pill is now available with different forms of oestrogen.

If you use an injectable progestogen contraceptive such as Depo-provera or Sayana press these are usually stopped at 50 years and you can transfer to a progestogen only contraceptive like a progestogen only pill or an implant until age 55 years.

Contraception in the older woman.

Supplements

Many women we see in clinic are spending vast amounts on unnecessary supplements, without understanding the impact of them on the body. We can refer you for tests to look at your genetic SNP’s, and to see a nutritionist which will give you information about what changes you may be able to make to your diet to optimise your health. This may be more cost effective than buying supplements, and better for you. Supplements are not all the same.

Screening

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.

Work matters

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.

• Chartered Institute of Personnel and Development’s Menopause resources

• Faculty of Occupational Medicine’s Guidance on Menopause and the Workplace

• European Menopause and Andropause Society’s Recommendations on Menopause in the Workplace

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

As we age and go through menopause we need to consider our what health conditions affect us. Our bones health, heart and blood vessel health, joint health, brain health and genitourinary health are just things to consider. Making healthy lifestyle choices is important. Please click on the links below to find out more information.

• 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: What is arthritis?
• Brain health: What is dementia?

Premature Ovarian Insufficiency (menopause under the age of 40 years)

• Recommended book: The Complete Guide to POI and Early Menopause
• The Daisy Network charity

Menopause after cancer

• This article on Menopause after breast cancer is helpful
• This article on Family history of breast cancer

• This podcast Menopause and 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.

More information:

Rock my Menopause

Women’s Health concern

British Menopause Society videos

Menopause Matters

Last updated October 2024 Dr Carys Sonnenberg founder of Rowena Health.

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