Perimenopause: what is happening, and when it starts

Articles in this cluster

• Hot flushes and night sweats: what actually helps
• Night sweats and broken sleep: practical measures that help
• Sleep in midlife: why it breaks, and what helps

What is actually happening

Perimenopause is not a single event. It is the transition: the point at which the ovaries begin producing less of the hormones that have been driving the menstrual cycle, so both the timing and the character of periods start to shift. The usual first sign is a change to your periods — more often or less often, heavier or lighter — and eventually they stop altogether.¹

The symptoms are not only about periods, which is why the transition is so often missed:

• Periods — timing, flow and duration all change, and can keep changing month to month.
• Hot flushes and night sweats — a sudden hot or cold feeling in the face, neck and chest, often with sweating, palpitations, dizziness or anxiety; they can last several minutes, and happen at night as well.
• Sleep — difficulty getting to sleep or staying asleep, which is often worse when night sweats interrupt the night.
• Mood, memory and concentration — mood swings, low mood, anxiety, and the “brain fog” people describe; these often feel worse when sleep is poor and you are exhausted.
• Physical changes — weight gain, often around the stomach and upper body; vaginal dryness, burning or irritation, which can make sex painful; more urinary infections or symptoms that feel like one; joint and muscle aches; headaches and migraines that are worse than usual; hair thinning; dry or itchy skin; sensitive teeth or gums; a reduced sex drive.²

Two things that are commonly missed. First, symptoms continue after the menopause itself — the transition ends, the symptoms do not necessarily. Second, experience varies widely: it can have a large impact on relationships, work and daily life, or be barely noticeable. Ethnic background also plays a part: women from a Black ethnic background are more likely to have severe hot flushes that continue for longer.²

There is no routine test for perimenopause or menopause, and a doctor may reach the diagnosis on age and symptoms alone. Early menopause, or premature ovarian insufficiency, can happen before the age of 45, sometimes after surgery to remove the ovaries and sometimes for no known reason.³

What you can influence

This is what published UK guidance says can help. It is not a treatment plan, and it is not a substitute for discussing your options with a clinician.

• Sleep and routine. Keeping to regular sleep routines, and getting as much rest as you can, is the first thing the guidance lists.
• Eating well. A healthy, balanced diet, with calcium-rich foods such as milk, yoghurt and kale for bone health, and plenty of fruit, vegetables and whole grains.
• Movement that carries weight. Regular activity with a focus on weight-bearing and resistance exercise — walking, dancing, running, or working with weights or bands. This is the intervention with the clearest evidence behind it for protecting bone as hormone levels fall.
• Cooling measures for flushes. Lightweight clothing, a cool bedroom, a cool shower or a fan, a cold drink, and reducing known triggers: spicy food, caffeine, hot drinks, smoking and alcohol.
• Stress and mood. Relaxation practices such as yoga, tai chi or meditation, and regular exercise. Cognitive behavioural therapy (CBT) is specifically recognised in the guidance as helping with hot flushes, low mood, anxiety and sleep problems.
• Vaginal dryness. Over-the-counter moisturisers and lubricants are available, and a pharmacist can advise in private. If you use condoms, choose a water-based lubricant — oil-based ones damage them. Prescribable treatments also exist, which is a conversation for your GP.
• Bones. Alongside weight-bearing exercise: enough calcium, some sunlight on the skin for vitamin D, vitamin D supplements, not smoking and cutting down on alcohol.

What the guidance also says plainly: do not smoke, because it can make symptoms worse, and keep within the recommended alcohol limits, because alcohol can affect symptoms. And talk to a doctor before taking any herbal supplement or complementary medicine.⁴

What needs a professional

Nothing on this page tells you what is happening in your own body. Some things need a clinician, and a few need one promptly. Contact your GP if:

• You have any vaginal bleeding after 12 months without a period. This needs checking even if it happened once, even if it was only spotting or a pink or brown discharge, and even if you have no other symptoms. It is not usually serious, but it can be a sign of cancer, and cancer is easier to treat when found early.
• Your bleeding pattern has changed and you are bleeding more, not less, than before, while you still have periods.
• You have a fast or noticeable heartbeat (palpitations), or symptoms you are worried about.
• You want to talk through your options — including hormone replacement therapy, its risks and its benefits for someone with your history. Prepration helps: the guidance is explicit that care should be tailored to the individual and that decisions should be shared.⁵
• You need contraception. Pregnancy is still possible during perimenopause. Guidance is to continue contraception for one year after your final period if you are 50 or over, and for two years if you are 40 to 49. The combined pill is not recommended at 50 or over.

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