The Menopause Exchange Blog


You reach the menopause when you haven’t had any periods for 12 consecutive months. You go through the perimenopause in the time leading up to your final period. The perimenopause starts when your periods begin to change and/or when menopausal symptoms appear, so it has a rather vague onset but a very well-defined finish.

This article was included in issue 74 (autumn 2017) of The Menopause Exchange newsletter.

Hormonal changes
The perimenopause involves an interaction of hormonal and neurological changes caused by ageing processes in your brain and ovaries. This ends up with your ovaries no longer producing eggs or the hormone oestrogen.

The average woman is perimenopausal for about three to five years before her last menstrual period. The average age of the menopause is 51, so it’s fair to say that most women in their mid to late 40s will be perimenopausal. Every cell in a woman’s body has the potential to be oestrogen sensitive. Women can feel the lack of oestrogen’s influence in different ways, and this reflects the sorts of symptoms that they begin to experience during the perimenopause.

What happens to your periods?
The only predictable thing about periods during the perimenopause is their unpredictability, although you’re most likely to see a gradual lengthening of your menstrual cycle with longer gaps between your periods. This process often goes on for two to three years until you have your final menstrual period.

An ageing ovary becomes less responsive to follicle stimulating hormone (FSH) and needs higher levels of FSH before it kicks into action to produce an egg. The cycle elongates so there are much longer gaps between periods. Sometimes the hormone that switches off bleeding is slow to respond. This may cause periods to be longer and heavier. Often the menstrual cycles become shorter as the ovary fires off some hormones in an unregulated and uncontrolled way. In many cycles, an egg isn’t actually released but the cycle will occur regardless.

Sleep disturbance is often the first sign of the perimenopause, even before sweats occur. Perimenopausal changes may affect sleep hormones, which then affects the quality and length of sleep. Doctors now realise that sleep has a far greater impact on many other significant medical conditions including heart disease, cognitive function and cancers. Sleep disturbance causes fatigue, a loss of energy, irritability and grouchiness, affects short-term memory and concentration and also contributes to headaches and muscle tension.

Hot flushes are experienced by 88% of perimenopausal women. Their internal thermostat becomes supersensitive, feeling over-heating at a much lower temperature than previously and, equally, feeling more extremes of cold. Two recent American studies found that hot flushes probably last 10 years on average and, not surprisingly, are worse in women who start their hot flushes during the perimenopause. Night sweats are a similar process to hot flushes, except they happen during the night when you may be lucky enough to be asleep so may progress to a sweat before you are woken up.

A lack of oestrogen in your vagina eventually leads to vaginal dryness, pain with intercourse, itching and irritation, discharge and bleeding. The first indication that this is happening may be urinary discomfort, a urinary tract infection and/or a need to get up in the night to go to the loo.

Your brain also suffers from low oestrogen levels and you may notice that your short-term memory is affected. Low mood associated with the menopause is now well recognised, with women developing anxiety, panic disorder, depression and mood swings for the first time in their lives.

A lack of oestrogen affects your bones and skin. Your skin sags, loses elasticity and becomes fragile, dry and wrinkly. You may notice aches and pains in your bones and may develop osteoporosis, which is a direct effect of a loss of oestrogen on your bone turnover system. As you approach the menopause, there’s more destruction of old bone and little replacement with new bone, so your bones become fragile and frail.

Dryness (almost anywhere) is a common complaint, including dry eyes and dry mouth, all due to reduction of normal secretory fluids. Another common complaint around the perimenopause is a loss of libido. Women are much less inclined to want to have sex and it may be harder to reach orgasm. They may say they don’t really care whether they ever have sex again. But that may not be the case for their partners, causing disruption to their relationship.

Do you need tests?
Hormonal blood tests aren’t needed in women in their 40s with typical symptoms and changes in their periods, although doctors will always wish to measure follicle stimulating hormone (FSH) in the 1% of women whose menopause occurs before the age of 40. The only exceptions are thyroid function tests, as thyroid disorder symptoms can mimic symptoms of the menopause.

What about contraception ?
Women’s fertility reduces during the perimenopause but women are advised to use contraception until they have reached 55, or had no periods either for two years if under 50 or one year if over 50. The Mirena is ideal in the perimenopause, as it provides both contraception and the progestogen component of HRT if required. IUDs and barrier methods are suitable but natural family planning isn’t an option, as cycles and ovulation are no longer predictable. The combined pill and injectable progestogen should be stopped at 50, but the minipill and implant can be continued. The progestogen component of patch and pill HRT hasn’t been evaluated for its effectiveness as a form of contraception. So women will need to use contraception as well as taking HRT.

About the author

Dr Jane Woyka is an accredited menopause specialist at the Menopause Clinical and Research Unit, Northwick Park Hospital, and private GP at Harrow Health Care Centre, BMI Clementine Churchill Hospital.

Obstetrics and Gynaecology 2011 May 117(5) 1095-1104. Duration of hot flushes and associated risk factors. Freeman.
NICE 2015 . Guidance NG 23. Menopause diagnosis and management.
Journal of North American Menopause Society Vol 22. Position Statement Sept 2015 Taming hot flushes without hormones: what works, what doesn’t.

Created Autumn 2017

Copyright © The Menopause Exchange 2017

Tags: , , , , , , , , , , , ,

Privacy Policy & Disclaimer | © The Menopause Exchange