Perimenopause: The Symptoms and the Timeline

Perimenopause is the years of change before periods stop for good. For most women it starts in the mid-forties. It then runs for about four to eight years. Menopause itself is a single point you can only name in hindsight: twelve months in a row with no period. So everything before that point is perimenopause, including the worst of the symptoms.

What is happening#

Ovarian function does not switch off. It becomes erratic. Some cycles still ovulate, some do not. Estrogen swings between high and low instead of dropping in a tidy line. That swing, more than low estrogen itself, causes the classic early symptoms. It also explains the good months followed by bad ones, which many women assume they are imagining.

The order symptoms usually arrive in#

Cycle change comes first for most women. Periods arrive closer together, then further apart. They get heavier or lighter. Or they simply lose their pattern. Skipping periods tends to happen later in the change.

Sleep is the symptom most often missed. Waking at three or four in the morning is very common. Sometimes there is heat with it, sometimes no clear reason at all. It is often blamed on stress or work. Mood changes, irritability, anxiety and foggy thinking are real features too, not coincidence.

Hot flushes and night sweats affect about three quarters of women. But they are not the entry point people expect. These all belong on the same list:

• joint aches
• vaginal dryness
• urinary symptoms
• palpitations
• migraines that change their pattern
• a drop in libido

Why testing usually disappoints#

Are you over forty-five, with typical symptoms and a changing cycle? Then guidelines advise diagnosing perimenopause from that picture, not from a blood test. FSH rises and falls from week to week during the change. So a normal result proves very little.

Hormone testing matters more in three cases:

• symptoms that start under forty-five
• periods that stop early
• another cause, such as thyroid disease, that needs ruling out

A thyroid test is often the more useful one to run. An underactive thyroid can mimic the whole picture.

What helps#

There is more on offer than most women are told.

• Hormone therapy is still the most effective treatment for hot flushes and night sweats.
• Non-hormonal prescription options exist for women who cannot use it, or prefer not to.
• Vaginal estrogen treats dryness and urinary symptoms locally.

All of those are decisions to make with your own doctor, weighed against your own history.

Practical measures matter alongside them.

• Strength training and weight-bearing exercise protect bone and muscle, which both start to decline now.
• Alcohol and caffeine make flushes worse and break up sleep for many women.
• Treating poor sleep head on often lifts mood more than anything aimed at mood itself.

Where to take this next#

Irregular cycles, weight change and unpredictable hormones also fit polycystic ovary syndrome. The two are often confused in the forties. The fuller practical guide to PCOS helps you work out which pattern fits you.