As our awareness of menopause grows, so too is our understanding of perimenopause, the transition phase in the years before, which is characterised by fluctuating hormones.
If you’re a millennial, the chances are you are being served endless content on how to prepare for perimenopause, some useful, some sensationalist. So we spoke to reputable perimenopause and menopause experts about what they are seeing in their clinics.
Menopause is officially diagnosed once a woman has gone 12 months without a period, but “in perimenopause we still have ovarian activity, it just becomes more erratic, and as a result you get big highs and lows of hormone levels, predominantly oestrogen and progesterone,” explains Dr Ginny Ponsford, GP and BMS-registered menopause specialist at The Women’s Hormone Clinic.
Symptoms of perimenopause can be similar to those of menopause, but play out in different ways. “Symptoms can be really variable. You might have a couple of weeks when you feel fine, then a few weeks of symptoms, then things might settle down again. It can be very changeable,” Ponsford says. “Menopause tends to be more steady, but that doesn’t necessarily mean no symptoms, as symptoms can be due to low or no hormones.”
What age does perimenopause happen?
According to the British Menopause Society, menopause typically occurs between 45 and 55 – the official average age in the UK is 51 – but for some women it can be earlier. In the years leading up to this, a woman will experience “early perimenopause” and “late perimenopause.” (Early menopause occurs between 40 to 45, and premature menopause under 40).
“It’s pretty common for women to start noticing symptoms in their early forties,” says Dr Susanna Unsworth, NHS and private doctor specialising in menopause and founder of Cambridge Women’s Health. “Perimenopause can begin up to 10 years before menopause, and I do sometimes see women with symptoms in their late thirties, but that doesn’t mean that they are imminently about to go through menopause.” She adds that many women won’t notice any until they are in their mid-forties at least.
Dr Alice Scott, a BMS-registered menopause specialist at Essex Private Doctors in Brentwood, adds: “With perimenopause [prevalent] on social media, I’m seeing younger women coming to the clinic who are concerned that they’re entering it. Some notice worsening PMS-type symptoms, sleep disturbance, or sweats that occur around their period. On their own, these symptoms don’t necessarily mean you need to start treatment – it may be appropriate to monitor patterns, optimise lifestyle factors like sleep, exercise and stress, and seek medical advice if symptoms are affecting quality of life.”
Perimenopause symptoms can be “broad and vague,” adds Unsworth. “Everyone has an individual response to hormonal changes, influenced by genetics and lifestyle – but many symptoms overlap with other conditions so we don’t want people to just assume they’re due to perimenopause. It’s important to rule out thyroid problems or anaemia (iron deficiency), which are two things that we often see in women around this time.”
Symptoms can be due to no hormones, says Dr Ginny Ponsford“In younger women with early perimenopausal symptoms, it’s very important we recognise cases of premature ovarian insufficiency, which can have more significant implications for somebody’s future health and is often misdiagnosed or undiagnosed,” Ponsford says.
The symptoms you might not expect
It’s true that some women experience more unusual perimenopause symptoms, beyond hot flushes and brain fog which are now well-recognised. “We’ve got hormone receptors on every cell of our body, so when we go through fluctuations, it pretty much can affect every cell of our body,” Ponsford says.
Most will experience some changes in their cycle. “Changes in regularity are one of the traditional defining features of perimenopause, although we’re recognising now that women can develop symptoms before notice cycle changes,” Unsworth notes. “Tracking your cycle is really helpful because it makes it easier to notice minor changes.”
In perimenopause, oestrogen and progesterone production becomes less predictable, Scott explains. “Progesterone is often the first hormone pattern to become less consistent as ovulation becomes irregular, so you may have shorter or less consistent progesterone exposure, which can affect how the womb lining sheds. At the same time, oestrogen levels can fluctuate. That hormonal instability can lead to changes in bleeding patterns – periods may become lighter, heavier, shorter or more irregular.”
Experts stress, though, it’s crucial to have any irregular bleeding or spotting during your cycle investigated by a doctor and ensure your smear is up-to-date, to rule out other potential reasons, including infections, and not just put it down to the perimenopause.
Anxiety, rage and sleep disruption
Some women report “not feeling themselves,” or “losing their sense of self”. Many report feeling more emotionally reactive or experiencing sudden waves of irritability, notes Scott.
“Anxiety is something I see a lot and it can come on quite insidiously,” says Unsworth. “Something women often say to me is that they start feeling really anxious about driving, or in the workplace, women in senior roles suddenly feel anxious about being able to do their job. Mental health issues can be an early symptom and are often misdiagnosed. Some start to notice sleep disturbances, finding it harder to fall asleep or waking up a lot.”
These changes may be down to a drop in progesterone, Ponsford observes: “We know progesterone helps with sleep, mood and to relieve anxiety symptoms.” That said, she adds, anxiety and sleep issues can be related to many other lifestyle factors, too. “Most perimenopausal women live quite busy, stressful lives – it’s not always down to hormones – so it may be that they need to first address lifestyle factors.”
Burning mouth, crawling skin and itchy ears
Some of the more unusual – but not necessarily uncommon – symptoms include burning mouth syndrome. “Some women experience a burning or tingling feeling in the mouth, tongue, or lips. Some people get very dry skin or a prickly, crawling feeling all over their skin,” Ponsford says. “We don’t really know why, but we think it’s to do with the fluctuations of hormones that affect things like our saliva production, our nerve sensitivity, as well as collagen production.”
Scott says she sees women with itchy ears from time to time. “Oestrogen has a role in maintaining skin hydration, so hormonal changes can make skin more dry. But there are other common causes, including dermatitis or eczema in the ear, so symptoms shouldn’t automatically be attributed to perimenopause.”
Dry or watery eyes
Dry eyes is another commonly reported symptom, according to Ponsford. “Hormone fluctuations can cause dry, gritty, sore eyes but it can also cause watery eyes,” she explains. “You can get this paradoxical issue, the tear ducts are not working properly and then they suddenly go into overdrive so you get watery eyes. It can be one of the lesser-known early presentations of our hormones starting to change.”
Loss of sex drive or sex feeling different
Loss of sex drive is commonly reported by some women in perimenopause, but is perhaps lesser-talked about, says Ponsford. “It can be to do with hormone drops, but we first have to establish if it is your sex drive or if it is of or decreased arousal or discomfort? Libido is much more complicated than just hormones – it’s heart, head and hormones.” Other symptoms may include vaginal dryness and vaginal soreness.
Feeling cold and body odour changes
We often think of hot flushes and night sweats but it can make some women less tolerant to cold, Ponsford observes. “Hormones can affect our hypothalamus, our body’s thermostat, so it’s more difficult to regulate temperature, whether that’s in a hot or cold environment.”
Some women notice changes in body odour, she adds, “which can also be related to our body temperature controls and different sweating patterns, but also hormones.” Hormone fluctuations can also affect the skin’s pH or microbiome, Scott adds.
Tinnitus and headaches
There are many potential causes of tinnitus, or a ringing in the ears, but it may be triggered hormonally for some women. Unsworth notes it is something she sees in clinic, along with women who notice headaches or migraine problems worsening. If you are experiencing this, it’s important to see your doctor.
Heart palpitations
Heart palpitations, or feeling like your heart is racing, is another symptom which has been associated with menopause and hormones changing, Unsworth notes. She adds that this is yet another example of symptoms which ought to be checked out by a doctor.
If you feel like your heart is racing, it should be checked by a doctor (Photo: Susanna Unsworth)Joint pain and stiffness
Joint aches, pains and stiffness are commonly associated with perimenopause. “There’s a whole collection of symptoms under what is known as the musculoskeletal syndrome of the menopause,” explains Ponsford. “It’s related to how our hormones keep our muscles, tendons and ligaments healthy, so fluctuations influence things like joint pain and frozen shoulder (when the tissues around your shoulder becomes inflamed, causing pain or stiffness).” While frozen shoulder isn’t considered an “official” symptom of menopause, it is commonly experienced by women in their forties and fifties.
Is there a test for perimenopause?
There is no simple test for perimenopause. “Perimenopause is difficult to diagnose because hormones are fluctuating,” Ponsford says, so tests for things like FSH (follicle-stimulating hormone) and LH (luteinizing hormone) are often considered unreliable. “If someone is over 45 and experiencing typical symptoms, guidelines state you don’t need to do tests to give a diagnosis, you can go on their symptom history and age.”
If you’re under 45 and having symptoms, “the key is first rule out other health conditions and ensure premature ovarian insufficiency hasn’t been missed,” she reiterates. “There’s so much information out there, which is great, but a lot of the information is driven by the sale of products, so it’s hard for women to know the facts.”
Unsworth echoes this caution: “I very rarely do hormonal blood tests in my clinic,” she says. “There are lots of companies out there marketing tests but it really doesn’t work like that, and women are being misled thinking these tests will give them some kind of answer.”
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The best way to monitor perimenopause symptoms is to track your periods and make a list of any symptoms you’ve been experiencing to look for patterns, Scott advises. There are many online menopause questionnaires to help you do this.
Some people may feel a sense of dread if they suspect they are entering perimenopause, but think of it as an opportunity to take control of your health and wellbeing. “Look at lifestyle optimisation – it is often a real crux time in women’s lives, they might be juggling work, children, aging parents, there’s a heavy mental load, which can lead to higher stress, and stress can exacerbate symptoms (and also mimic some of them),” says Scott.
Think about stress management, exercise, particularly resistance training, improve diet and try to prioritise sleep as much as possible,” Scott continues. “If you feel symptoms are impacting your life day-to-day, speak to your doctor. You don’t have to wait for periods to stop before you consider having treatment for menopause.”
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