Perimenopause

During perimenopause, the ovaries release eggs less regularly and produce changing amounts of estrogen and progesterone. Hormone levels can rise and fall unpredictably. Eventually, ovarian hormone production settles at much lower levels after menopause.

Those fluctuations help explain why symptoms can come and go. You might have several familiar cycles, followed by a shorter cycle, a missed period, or a month of disrupted sleep. Some women experience few symptoms; others have changes that interfere with work, relationships, or daily activities.

Hormonal contraception can change or stop bleeding, so the 12-month rule can be difficult to apply while using it. A hysterectomy also stops periods, but ovaries that remain can continue producing hormones. Removing both ovaries causes an abrupt fall in ovarian hormones. After a hysterectomy, a clinician uses your symptoms and surgical history to assess menopause.

Perimenopause usually begins in the mid to late 40s. The Office on Women's Health gives an average duration of about four years and a range of two to eight years before periods stop permanently. The length varies from person to person.

Hot flashes can continue for years after the final period. Vaginal dryness may also persist after menopause.

If periods change or menopause symptoms begin before age 45, arrange an assessment. Menopause between ages 40 and 44 is called early menopause. Before 40, a clinician may investigate premature ovarian insufficiency, which needs specific testing and care.

Periods become less predictable

Cycles may initially become shorter. Later, the gap between periods can vary more, and you may skip a period or several periods. Bleeding can become lighter, heavier, shorter, or longer. Keep a record of the dates and flow, especially if the change is substantial.

Hot flashes, night sweats, and broken sleep

A hot flash is a sudden feeling of heat, usually across the face, neck, and chest. Sweating, flushing, chills, or a faster heartbeat can accompany it. A hot flash during sleep is called a night sweat. These episodes can wake you, although sleep problems also occur for other reasons, including insomnia and sleep apnea.

Mood and concentration change

Some women notice irritability, anxiety, low mood, or trouble concentrating. Forgetfulness and difficulty finding a word are often described as brain fog. Disrupted sleep can make these problems harder to manage. Persistent anxiety, depression, or memory changes that interfere with daily life deserve an assessment.

Vaginal dryness and discomfort with sex

Lower estrogen can make vaginal tissue drier, thinner, and less elastic, causing burning, irritation, or pain during sex. These symptoms may begin during perimenopause, although many women notice them later. Reduced interest in sex can also accompany pain, fatigue, or changes in mood.

A clinician asks about your age, changes in your periods, new symptoms, medications, and contraceptive method. For otherwise healthy people aged 45 or older who have new hot flashes or night sweats and cycle changes, NICE guidance recommends identifying perimenopause from that history without routine hormone tests.

Estrogen and follicle-stimulating hormone, or FSH, fluctuate during the transition. A blood sample captures the level on that day, which limits how much a single result can tell you about the whole transition. Hormonal contraception can also affect the interpretation of tests.

Testing may be appropriate when symptoms begin between ages 40 and 45 or when ovarian insufficiency is suspected before age 40. Other tests answer different questions: a pregnancy test may explain a missed period, and a blood count can check for anemia when bleeding is heavy. Depending on the symptoms, a clinician may investigate thyroid disease or another cause of irregular bleeding.

You can discuss treatment while you are still having periods. Begin with the problems that are affecting you most, such as waking drenched in sweat, unpredictable heavy bleeding, or pain during sex. Those problems may need different treatments.

Hormone therapy for hot flashes and night sweats

Systemic estrogen, delivered through a pill, patch, gel, or spray, is the most effective treatment for hot flashes and night sweats. Reducing nighttime symptoms may also improve sleep. If you have a uterus, systemic estrogen generally needs to be paired with progesterone or another progestogen to protect the uterine lining from excessive growth and reduce the risk of endometrial cancer.

Before prescribing, a clinician reviews abnormal bleeding and your personal and family medical history. A history of breast or endometrial cancer, blood clots, stroke, heart attack, or liver disease can make systemic hormone therapy unsuitable. Patches may carry a lower risk of blood clots than estrogen pills, although your own risk factors still need assessment. Side effects can include spotting, breast tenderness, bloating, and headaches.

Contraception when you also need pregnancy prevention

If your health history allows the use of combined hormonal contraception, a pill, patch, or ring may reduce hot flashes and make bleeding more predictable while preventing pregnancy. A hormonal IUD can also help with heavy bleeding and contraception. A clinician may consider a levonorgestrel IUD alongside estrogen therapy to protect the uterine lining, after checking that the device and its duration of use are appropriate.

Local treatment for vaginal symptoms

Vaginal moisturizers are used regularly to ease dryness. Lubricants reduce friction during sex. When symptoms continue, a clinician may prescribe low-dose vaginal estrogen as a cream, tablet, insert, or ring. It acts mainly on vaginal tissue, with much less estrogen reaching the bloodstream than with systemic treatment. A history of breast cancer requires a separate discussion about treatment options.

Other prescriptions and treatment for sleep or mood

Certain antidepressants and gabapentin can reduce hot flashes for some patients. The choice depends on other medications, health conditions, and side effects. Cognitive behavioral therapy adapted for menopause can help with the impact of hot flashes, sleep disruption, and associated low mood. Depression and anxiety may also need their own treatment, including therapy, medication, or both.

After starting treatment, agree on how you will judge improvement and when you will review it. NICE recommends a review at about three months, then annually, with an earlier review when side effects or poor symptom control need attention.

Ovulation can still occur during perimenopause, even after several missed periods. Pregnancy can also occur while taking menopausal hormone therapy. If you want to prevent pregnancy, continue contraception and ask your clinician when it is appropriate to stop, taking your age and contraceptive method into account.

If a period is late and pregnancy is possible, take a pregnancy test. Bring up pregnancy plans before starting or changing hormone medication.

Perimenopause can change bleeding patterns, but a new change may also come from fibroids, polyps, a thyroid condition, medication, or a problem with the uterine lining. A clinician can decide whether you need a pelvic examination, blood tests, ultrasound, or an endometrial biopsy.

Arrange an appointment for:

• Bleeding between periods or after sex.
• Bleeding that lasts more than seven days or becomes much heavier than usual.
• Any bleeding or spotting after menopause has been confirmed.

A short record helps your clinician understand what has changed. Write down:

• Period dates, days of bleeding, and whether the flow was light, medium, heavy, or spotting.
• The symptoms affecting you most and how often they occur, including nighttime waking.
• Your medications, supplements, and contraceptive method.
• Relevant medical history and whether you need contraception or are planning a pregnancy.

Describe the effect on your day as well as the symptom itself. For example, tell your clinician how many times night sweats wake you or whether bleeding makes you change plans. That gives you a clear starting point for choosing treatment and assessing whether it helps.