What exactly happens during perimenopause, and what helps?
Perimenopause brings symptoms caused by hormonal fluctuations, ranging from hot flushes and sleep problems to bone loss and mood changes. Hormone therapy is the most effective approach, with the most favourable profile for women who start within ten years of the beginning of menopause; for those who cannot or do not want to use it, lifestyle changes and talking therapy are alternatives.
Perimenopause begins when the ovaries gradually start working less well. Oestrogen, progesterone and testosterone fluctuate widely, even before production stops entirely. Those fluctuations are responsible for most of the symptoms. The transition lasts an average of four to seven years, but in some women it can continue for more than a decade.
The best-known symptom is hot flushes. The majority of women experience them, and in roughly one in three the symptoms are moderate to severe. Sleep problems are closely linked: poor sleep, more hot flushes and a low mood reinforce one another in a cycle. The risk of anxiety and depressive symptoms rises most sharply in the later stage of the transition, when periods have been absent for longer. Vaginal dryness and pain during sex affect roughly one in three women, and unlike hot flushes, this particular symptom only gets worse without treatment.
Irregular periods, bone loss, an increase in belly fat and unfavourable changes in the body's metabolism also play a role. These symptoms are less often connected to perimenopause in people's minds, but they are linked to it.
Hormone therapy with oestrogen, with or without a progestogen, is the most effective treatment for hot flushes and other menopausal symptoms. For women who start within ten years of the beginning of menopause, the benefits outweigh the risks, provided there are no reasons to avoid it. After seven years of oestrogen-only use, the number of bone fractures fell from 141 to 92 to 113 per thousand women. For women who start more than ten years after menopause, the risks, including those of stroke, blood clots and breast cancer, are higher. Combination therapy raised the risk of breast cancer after 5.6 years from 19 to 20 to 30 per thousand women. Hormone therapy is also not intended as prevention for heart disease or dementia.
Hormone therapy may also have a modest effect on depressive symptoms during perimenopause, although the effect is small and the certainty around it is limited. For those who want to avoid hormones, lifestyle changes and talking therapy are realistic alternatives, though the size of the benefit from individual non-hormonal options is less well documented. Bear in mind that most hormone therapy regimens have not yet been specifically approved for women in perimenopause: studies focusing on this group alone are scarce.
This answer is based on several large combined studies and a broad international guideline base on menopausal symptoms and hormone therapy, plus one overview of twelve studies in people examining hormone therapy and depression. The evidence for the effectiveness of hormone therapy on hot flushes and bone fractures is strong. The evidence for its effect on depressive symptoms is limited: the researchers rate the certainty as low. For non-hormonal options (supplements, lifestyle), the size of the benefit is less well documented in the available sources.
How can you tell you are in perimenopause from your hormone levels?
In perimenopause, FSH rises first and inhibin B falls, while oestradiol initially remains normal or even elevated. A single blood test says little due to the enormous fluctuations; only a sustained pattern or 12 months without menstruation provides reliable guidance.
How do you get your hormone levels tested during perimenopause?
Hormone tests during perimenopause are difficult to interpret: AMH is the most practical option, but does not reliably predict your fertility. Always have results interpreted with the guidance of a doctor.
Which hormone levels are characteristic of perimenopause and menopause?
Characteristic features are an early decline in AMH and inhibin B, followed by a rise in FSH and a late sharp fall in oestradiol. If you have symptoms, do not rely on a blood test alone, as hormone levels fluctuate considerably during the transition; discuss the pattern of your menstrual cycles and symptoms with your doctor.
How do your hormone levels change throughout your menstrual cycle?
Your hormone levels follow a recognisable pattern throughout the cycle: oestrogen and progesterone rise and fall at set moments, with a sharp LH peak around ovulation. Bear in mind that there are large differences between women, and that the pill largely suppresses this pattern.
What does the menopause do to your gut bacteria?
During the menopause, specific bacterial species in your gut shift and your gut bacteria process oestrogen less actively. Eating a varied diet and taking probiotics are practical ways to support your gut bacteria.
Does menopause accelerate skin ageing?
Menopause noticeably accelerates the loss of collagen, moisture retention and skin thickness, but spots and skin cancer are almost certainly caused by sunlight. If you are experiencing skin complaints around menopause, discuss with your doctor whether HRT makes sense for you as an overall package.