The Change, The Pause, and Everything In Between: Initial Overview to Perimenopause

Perimenopause vs. Menopause: Spot the Difference

Think of perimenopause as the rocky road and menopause as the destination.

Perimenopause (The Transition)

• The Old Definition: We used to think this phase only started when your periods went crazy (irregular, stopping, starting / 2 in a month/ or none/ spotting/ heavy bleeding, we can see it all happening in perimenopause) as per a classic representation I have found online (see above).

• The Reality: We now know perimenopause is far more insidious. It can sneak up on you while your periods are still running like clockwork.

• When does it start? Often in your early 40s.

• How does it start? The "neuro" symptoms like anxiety, sleep fragmentation, and mood swings, often arrive first. Then the general symptoms like: tiredness, no matter what you do or you don’t do (some patients disclose how, despite sleeping well, they wake up unrefreshed and tired), you crash after lunch and energy levels plummet much faster than before. Or if you are not in this category, you might notice achy muscles/joints, hair thinning, acne/rosacea starting or gaining weight despite being very careful with your calorie intake.

This is all because your hormones are fluctuating behind the scenes, even if your bleeding pattern hasn't caught up yet.

• How long? It varies. It can be a few months or a decade. We are all so different.

• Fertility: Warning: You can still get pregnant. Do not throw out the contraception just yet!

Menopause (The Destination)

• What is it? It is actually just ONE day. You are officially "in menopause" when you have gone 12 consecutive months without a period.

• The Aftermath: After that one day, you are "post-menopausal" for the rest of your life.

• Hormones: Oestrogen has left the building (levels are consistently low).

• Fertility: The factory is officially closed, but depending on your age, there are different rules regarding stopping contraception (more on this in the next few blogs)

• Age: The average age for UK women is 51.

2. Is It Hot in Here? Or is it just me? (The Symptoms)

How many times in a day do you catch yourself thinking this cheesy pick-up line? I know, I know…I couldn’t help it, it fits too well into our list of symptoms!

Symptoms can overlap between the two phases. There are over 100 recognised symptoms, talk about overachieving! Roughly 25% of women get them severely.

We group them into four main camps:

• The Heatwaves (Vasomotor Symptoms/VMS): The classic sign. If you are waking up in a pool of sweat or turning red at a dinner party, this is VMS. It includes hot flushes and night sweats.

• Mood & Mind: Feeling rage over a loaded dishwasher? That’s the psychological toll. Anxiety, low mood, irritability, and the dreaded "brain fog" (walking into a room and forgetting why) are very common, especially early on.

• The 'Down Below' (Genitourinary Symptoms/GSM): As Oestrogen drops, things dry up. You might experience vaginal dryness, pain during sex, or needing the loo constantly. These can crop up years after your periods stop.

• The Body Aches: Sore joints, insomnia, and headaches often join the party.

I have put together a tick box list of symptoms to see how many you have. Go and download it for free from my resources, or click on this link.

3. Sorting It Out: Treatment Strategies

There is no "one size fits all" here. We look at the whole picture—lifestyle, medical, and non-hormonal options.

A. Hormone Replacement Therapy (HRT): Medical treatment

• Why use it? It does help with flushing, night sweats, low mood, and anxiety. It also protects your bones and heart, particularly if you start before age 60 or within 10 years of menopause.

• Can I start now? Yes, you can start during perimenopause (there's still a bit of debate about starting before or after 45 years of age, but I recommend you discuss this individually with your GP/ family doctor/ specialist).In very simple terms, if you have a uterus, we give you combined HRT (Oestrogen + Progesterone) to protect the lining. If you’ve had a hysterectomy (or have an IUS like Mirena coil), you generally only need Oestrogen.

• How long? There is still a debate among various specialists about how long it should be used; it all depends on individual cases, symptoms, risk factors, and the patient's own choice. I, for example, discuss this at the initial appointment and re-evaluate the risk factors for my patients at yearly HRT reviews.

• Local issues: If your main gripes are vaginal dryness or bladder issues, vaginal Oestrogen is a game-changer. It stays local, so it’s very safe to use long-term, including in older age ladies > 70 or even 80’s.

B. Lifestyle and Wellbeing Approaches also work well (we will expand on this extensively as we move onwards)

You cannot supplement your way out of a bad lifestyle. Here is what helps:

• Move it or lose it: Resistance exercise and weight training are brilliant for bone density and muscle mass. Plus, it burns off some of that "menopausal rage."

• Walks in nature: enjoy a walk in the park, woods or on the beach, catch some sun and get that natural light. In return, this will increase your melatonin and will help you sleep better.

• Food for thought: Focus on a balanced diet with plenty of Calcium and Vitamin D for your bones. Since periods can get heavy in perimenopause, keep an eye on your Iron intake. Supplement if you have too.

• Mind over matter: Cognitive Behavioural Therapy (CBT) is surprisingly effective for sleep issues and managing how much flushing bothers you.

C. Alternatives (If HRT isn't for you)

Some women can't take hormones, or simply prefer not to.

• Herbal Remedies: Things like Black Cohosh or Red Clover (Isoflavones) help some women, but the science is a bit patchy. Be careful with quality and watch out for liver side effects with Black Cohosh.

• The New Kid on the Block: There is a new class of non-hormonal drugs called neuromodulators (like fezolinetant). They work on the brain's temperature control centre to turn down the heat without using hormones.

The Bottom Line

Remember, this period of your life is biologically considered normal. You are normal, and your body is amazing. It got you here, hasn’t it?

But compared with our mums and grandmas, you don't have to "just get on with it." There are many approaches to improving these symptoms, and I am here to show you as many as possible.