Perimenopause: Making Sense of Your Unpredictable Menstrual Cycle Symptoms
By Dr. Anita Mitra (The Gynae Geek)
The Growing Awareness and Anxiety around Menopause
If there’s a new ‘most frequently asked question’ that has suddenly cropped in clinic more and more over the last few years it’s this: ‘What will my menopause be like?’, and considering the average person will go through menopause aged 51, I find it intriguing that these enquiries are starting from an increasingly younger age, often as young as early 20’s.
Over the last few years there’s been so much talk about the menopause, which I really welcome, because it’s a topic that we all need to be aware of. We are all either going to go through the menopause one day, or care about someone else who will. However, with increasing awareness, there appears to also be increasing anxiety, which is understandable given how many horror stories we’ve all heard about intolerable menopause symptoms, alongside decades of inadequate menopause care from the medical profession, compounded by tabloid-induced fearmongering about the use of hormone-replacement therapy (HRT).
Whilst I can’t undo all of the negativity around the menopause in this short article, what I can do is educate you so that you feel better prepared to recognise and understand the signs and symptoms.
Understanding the Definitions: Menopause vs Perimenopause
Before we get down to it, we must cover a few definitions. ‘Menopause’ means the permanent cessation of menstrual periods, and this can only be confirmed once 12 months have passed since your last period, of course in the absence of any medical conditions that could be causing your periods to stop. The reason that menopause occurs, is because the ovaries run out of eggs and cease production of the ovarian hormones; oestrogen, progesterone and testosterone. The production of these hormones begins to fluctuate and decline gradually over several years, and this is responsible for the change in your menstrual cycle and bleeding patterns as well as the presence of menopausal symptoms, and the name given to this phase is the ‘perimenopause’.
Early Perimenopause: Changes in Your Cycle
One of the earliest symptoms of the perimenopause tends to be increasing irregularity and unpredictability of the timing of your period, which typically happens around the age of 47-48 years (1). To begin with, your menstrual cycle (ie. the time from the start of one period until the start of the next) may shorten overall by about 2-4 days, which is due to slightly earlier ovulation. Whilst oestrogen levels will progressively decline overall during perimenopause, paradoxically, in the early stages, oestrogen levels can become higher than normal due to erratic oestrogen surges. This happens due to unreliable signals and responses between the brain and ovaries as the number of eggs becomes critically low. Ovulation becomes less predictable and therefore progesterone is typically lower than before. Because of these oestrogen surges with lower progesterone, about one quarter of women will notice that their periods become heavier or more painful.
Perimenopause: Hidden Symptoms
It is these hormonal fluctuations that give rise to other less specific symptoms of the perimenopause such as breast tenderness, irritability, mood swings, anxiety, disturbed sleep, bloating and headaches. These are very common, but can be incredibly debilitating, and because they’re not typically recognised as being related to the perimenopause, people frequently feel confused, overwhelmed and dismissed.
Mood-related symptoms are often among the earliest signs of the perimenopause. Existing mental health challenges may intensify, and new symptoms can also emerge. More specifically, I’m increasingly seeing individuals develop new-onset PMS or even PMDD during this transitional phase, which may be the first symptom that they notice. We typically associate symptoms like hot flushes and night sweats (‘vasomotor symptoms’) with the ‘classic’ menopausal symptoms, but these tend to manifest themselves in the later perimenopause, as you get closer to the final period.
Later Perimenopause: Approaching Your Final Period
At this stage, your cycle will likely lengthen, with periods becoming less frequent, maybe missing a few here and there, and often much lighter due to decreasing oestrogen levels. Along with the previously mentioned vasomotor symptoms (hot flushes and night sweats), vaginal dryness also becomes more common, because the vulval and vaginal tissues become more fragile, which also increases discomfort during sex as well as the risk of getting urinary tract infections, urinary incontinence and prolapse symptoms. Mood changes, sleep disruption and brain fog also persist and joint and muscle aches can occur.
Treatment Options
Around 90% of women will experience some symptoms in the lead-up to and after the menopause, and for many, these can last around seven years (2). About one in four women describe their symptoms as severe (3). That said, around 10% of women don’t notice any symptoms at all - their periods just stop, and that’s it. If you are worried about changes in your cycle, or bothered by heavy bleeding, please see your GP because there are things that can be done to help, including both hormonal and non-hormonal medications, and some people may need iron supplements if heavy bleeding causes you to become anaemic. Depending on the other symptoms that you are having you may also want to discuss using HRT, and a common myth is that you can’t take HRT whilst you are still having periods, but this is not the case. You absolutely can! HRT is such a big topic, requiring at least an entire article of its own to explain it fully. If you are interested, drop us a line at DITTO and we’ll get to it! The topic of HRT can be quite divisive – some people are very anti-HRT, usually due to concerns regarding side effects and risks such as breast cancer, whilst others are very, very pro-HRT indeed. There are relatively few individuals for whom using HRT entirely contraindicated, and there is usually something that we can suggest that is relatively safe, as well as non-hormonal alternatives. On the flipside, if you’re not bothered by any menopausal symptoms, you’re not doing yourself a detriment by not taking HRT. But if you’re negatively impacted by symptoms that you suspect may be related to the peri-/menopause, don’t write off HRT as an unsafe solution because of something you read online or in a newspaper.
Age and Timing: When Menopause Happens (Including Early Cases)
The average age for your periods to stop entirely is 51, usually happening somewhere between 45 and 55 years. About 5% of us will experience menopause before 45 which is called ‘Early menopause’ and about 1% before 40 which is called ‘Premature menopause’, also referred to as primary ovarian insufficiency (POI) or premature ovarian failure (POF). Blood tests to diagnose the menopause are generally unhelpful over the age of 45, because most, if not all of us are perimenopausal at this time so hormone levels will already be fluctuating making the results unhelpful. Treatment is based on symptoms at this point. There are a few situations in which checking levels of follicle stimulating hormone (FSH) levels might be helpful, such as if an early or premature menopause is suspected, as well as blood tests such as checking thyroid function and vitamin D levels to rule out other correctable causes for some of the more non-specific menopausal symptoms. I just have to point out at this point that there aren’t any blood tests that can be used to predict the timing of a future menopause.
Genetic factors have been shown to influence the timing of menopause however, so I would definitely encourage you to have a conversation with your Mum, if possible, about when her periods stopped to get an idea of when you might expect it to happen to you. If your mum or sister went through early or premature menopause, you’re more likely to as well — in fact, your chances could be up to six times higher than average (4). Several environmental and lifestyle factors can also influence the timing of menopause. Women who smoke, work night shifts, or have a lower body mass index (BMI) tend to experience menopause slightly earlier than average. In contrast, a higher BMI has been associated with a modest delay in the onset of menopause (5-7).
The Honest Answer: Predicting Your Personal Journey
You’re probably still waiting for me to answer the original question: “What will my menopause be like?” The honest answer is - I don’t know. While there’s strong evidence for a genetic influence on the timing of menopause, the link between genetics and the severity of symptoms is less clear. There may be a genetic tendency when it comes to hot flushes and night sweats - so if your mum had a tough time, you might too - but it’s by no means guaranteed. Research has identified some personal characteristics that are associated with more intense menopausal symptoms, such as smoking, having a higher BMI, experiencing more severe PMS, and living with higher levels of perceived stress (8). But even population-based data can’t fully predict your personal journey. The most important thing is knowing what to expect and recognising that support and treatment are available if you need them.
Important Warning: Post-Menopausal Bleeding
Let me finish with a very important public health message: There is no such thing as a period after the menopause. When you’re done, you’re done.
Whilst bleeding after the menopause is common, experienced by about 1 in 10 women, it is not normal and it’s important that it’s given proper attention, because about 10% of cases are due to cancers of the endometrium (lining of the uterus) (9). If you, or someone you know experiences bleeding after the menopause, however heavy or light it may be, the GP should be the first port of call, and they will take this seriously. Gosh, this article got a bit heavier than anticipated, and I don’t mean to end on such a frightening note, but the more informed we are, the more empowered and prepared we are to take better care of our health.
References
1.McKinlay SM, Brambilla DJ, Posner JG. The normal menopause transition. Maturitas. 2008;61(1-2):4-16.
2. Avis NE, Crawford SL, Greendale G, et al. Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Intern Med. 2015;175(4):531-539.
3. Hamoda H, Moger S, Morris E, Baldeweg SE, Kasliwal A, Gabbay F. Menopause practice standards. Clin Endocrinol (Oxf). 2024;100(1):50-55.
4. Cramer DW, Xu H, Harlow BL. Family history as a predictor of early menopause. Fertil Steril. 1995;64(4):740-745.
5. Zhu D, Chung HF, Pandeya N, et al. Relationships between intensity, duration, cumulative dose, and timing of smoking with age at menopause: A pooled analysis of individual data from 17 observational studies. PLoS Med. 2018;15(11):e1002704.
6. Stock D, Knight JA, Raboud J, et al. Rotating night shift work and menopausal age. Hum Reprod. 2019;34(3):539-548.
7. Zhu D, Chung HF, Pandeya N, et al. Body mass index and age at natural menopause: an international pooled analysis of 11 prospective studies. Eur J Epidemiol. 2018;33(8):699-710.
8. Gold EB, Block G, Crawford S, et al. Lifestyle and demographic factors in relation to vasomotor symptoms: baseline results from the Study of Women's Health Across the Nation. Am J Epidemiol. 2004;159(12):1189-1199.
9. Crosbie EJ, Kitson SJ, McAlpine JN, Mukhopadhyay A, Powell ME, Singh N. Endometrial cancer. Lancet. 2022;399(10333):1412-1428