What is perimenopause?
'The average age for going through menopause is 51. This is defined as when you have had no period for 12 months, and, from then, you're postmenopausal. So, really, there is one day that counts as "menopause."
What we're usually talking about when we talk about menopause is perimenopause, which is the period of time when you're still having a menstrual cycle, which may be more or less frequent,' says Maisie Hill, a menstrual health expert, author and coach, who trained in Chinese medicine and as a birth doula.
When does perimenopause begin?
While most women will start this phase in their 40s, for some, it might begin in their 30s. It can last anywhere between 2 and 12 years, with the average being 4 years.
So, why does it happen? ‘Perimenopause is the adjustment from your ovaries working normally and producing the correct balance of reproductive hormones to maintain regular periods, to the point when the ovaries stop producing hormones altogether,’ explains Dr Heather Currie, spokesperson for the Royal College of Obstetricians and Gynaecologists and former chair of the British Menopause Society.
You likely first came across Hill when she released her debut bestseller Period Power in 2019. Now, she's here to dose you up on the intricacies of this time between your cycle as you know it and the point at which you transition fully away from having periods, with her new book, Perimenopause Power.
Aside from revealing the truth behind some persistent hormone replacement therapy (HRT) myths, how to manage your symptoms and the significance of tracking your cycle, her headline message is this: that this time can hit earlier than you would imagine. And being prepared is key to riding the waves with as much peace as is possible.
If that sounds nearly utopian to you, know that you're not alone. 'The Change' has an image more negative than Piers Morgan right now. And, truth told, it can be hard. 'The rates of suicide in females peaks between the ages of 50 and 54,' says Hill. '[At this time] 10% of women reconsider their work or consider redundancy. There are lots of challenges in all aspects of life.' But there are positive elements to be found, too.
'The clients that I work with talk about how it's wonderful that they suddenly don't care so much about what other people think of them, that it's easier to say "no" and to prioritise themselves. When your hormones start to shift, and certainly when oestrogen starts to decline towards the end of perimenopause, that's when that can really happen.'
No doubt, this phase is certainly more complex than 'night sweats at 50.' Here's a handful of things you should know about perimenopause. Hopefully, they help you to handle it from a place of knowledge.
7 things you should know about perimenopause
1. The very first symptoms of perimenopause can be subtle
'The classical definition of perimenopause is when your cycle length starts to vary by seven or more days,' says Hill. 'And you have the emergence of symptoms. But some researchers have coined the term, "very early perimenopause," which is different to "early menopause" or "premature menopause." This its when there are more subtle variations happening. So you don't meet the threshold for the classical definition, but there's enough to say that something is starting to shift – that might be that your cycles got a bit shorter, maybe by a few days.'
You could also notice new symptoms around the time that your period starts, such as:
- night sweats
- mood changes
That's the territory that I find myself in at the moment, at the age of 40,' says Hill.
2. So subtle that you might not realise they're connected to your periods
With signs like the above, there's often a million things you can ascribe the blame to. 'Particularly with the pressures of the last year, but even pre-COVID, there's a monumental amount that women in their 30s and 40s are having to deal with. This means there's always something to blame: if you're tired it's because you've been working hard, or because your kids aren't sleeping well, for example.'
3. But cycle tracking can help
The solution to this? Cycle tracking. This way, you can see if your symptoms are following a pattern and are indeed peaking in the days before your period – a signal of the early stages of perimenopause. Note down the days and how you feel with pen and paper, request Hill's free cycle tracker or download one of the many cycle tracking apps (just check their data privacy policies, first.)
4. Your perimenopause symptoms are likely to change
'We often think of menopause as a type of hormonal deficiency. And it is true that your oestrogen levels do eventually decline. But to begin with, your levels of this hormone can be the highest they've ever been.' If you track your cycle and know that on high oestrogen days your skin glows, you feel full of energy and shimmer with an aura of invincibility, this might make you excited.
But, Hill says, while oestrogen is a 'fantastic' hormone, once the body has used it, it wants to lose it. This is because if it is not processed properly, it stays in your body and circulates. This can happen, though, because levels of the hormone progesterone, which works symbiotically with oestrogen, have started to decline.
Low progesterone symptoms
This can cause troublesome symptoms like:
- breast tenderness
- heavy periods
- painful periods
- frequent periods
Low oestrogen symptoms
As you go through perimenopause, though, oestrogen does then starts to decline. That's when you get symptoms like:
- joint pain
- vaginal dryness
- memory changes
- verbal recall issues
- absent/ irregular periods
- low desire for sex
- hair loss on the head
Not that it's always going to occur in a super-linear fashion. 'It can be a bit back and forth,' says Hill. 'You can start off with progesterone decline, and you get those symptoms; then oestrogen declines, you get those symptoms. You can also have a different experience in each cycle.'
5. You should read up on HRT
Disclaimer: the decision to take or to not take HRT is super personal, and one that you should research yourself and discuss with a trusted medical professional. At the same time, says Hill, the past couple of decades have seen the treatment – designed to relieve some of the above symptoms by adjusting hormone levels – equated with a significantly greater risk of breast cancer. After reviewing the evidence on offer, she says this should be interrogated.
'All of those scary headlines that we've seen for the last 20 years? The majority of them came from one particular large study that was run in America. This was a flawed study in its design, with participants who should have been excluded because they don't meet the standard definition of a "healthy participant," says Hill. (Side note: she prefers the term 'Menopausal Hormone Therapy' (MHT), because the term 'replacement' implies that we should have these hormones. 'But we’re not replacing them, because they shouldn’t be there in the first place.')
'The data was also analysed incorrectly.' When early findings from this trial were released to health journalists in 2002, the statistics published in the press were enough to put anyone off the treatment: that HRT causes a 26% increase in breast cancer, a 29% increase in heart attacks and a 41% increase in stroke among women using a combination of synthetic oestrogen and progesterone.
Naturally, after that, far fewer women took the treatment. But, Hill says, when the end trial data was released, it was less alarming. In fact, the increase in breast cancer was deemed not 'statistically significant.'
While she notes that we should consider the potential risks of using hormone therapy, which, like all things, might vary between people, she writes in the book that there is a stronger association between drinking more than two units of alcohol a week and breast cancer than using such treatments. 'But 'nobody is up in arms about radically changing drinking behaviour,' Hill notes.
If you do have a conversation with a medical pro such as your GP and do not feel supported, when it comes to exploring help for perimenopause symptoms, give feedback and request another appointment.
6. Take steps to support yourself
'Often, what sets the stage for a not so great experience of perimenopause is being exhausted and stressed,' says Hill. Of course, if you're trying to navigate a pandemic while working 40+ hours a week, caring for kids and trying to make time to check in on older relatives, nixing these problems is tricky to actualise. But, certain practices can help. Start to think about the below.
- make time to check in on yourself and to get clear on what you want your life to look like (a journaling or meditation practice might help, with this)
- eat a diet full of healthy fats (like avocado and extra virgin olive oil) and protein (beans, nuts, eggs) without restricting entire food groups, like carbs
- reduce your alcohol intake (aside from the sleep and mental health implications, if your liver is busy dealing with alcohol, it's less able to support processing oestrogen)
- prioritise your sleep (no blue light from devices an hour before bed)
- create boundaries (happily saying 'no' to things you do not have time for – to free up more time for yourself, so you can work on the above)
- Exercise frequently (like you know, a winner for supporting a good mood. The NHS recommends at least 150 minutes of moderate-intensity activity a week – jogging, cycling, yoga, strength training)
7. It's vital you work on your bone health
'Oestrogens have a major role to play in your bone health,' says Hill. When this hormone declines, later in perimenopause, bone loss starts to occur – around 10 to 20% in the years after menopause. This, like you know, can lead to Osteoporosis, meaning fragile bones and so an uptick in fractures. No fun.
Work to support yourself now by eating plenty of protein (The European Society for Clinical and Economic Aspects of Osteoporosisand Osteoarthritis recommends that women over the age of 50 eat 20–25 grams of high-quality protein at each main meal – you can get 20g of protein in half a block of tofu; three large eggs or one salmon fillet). The body also recommends taking 800IU of vitamin D and 1000mg of calcium, daily.
You should also, Hill notes, factor in strength training sessions every week, to support your bone density in your postmenopausal years.
How does perimenopause feel?
By Sarah Graham
In the months before turning 40, Women’s Health Editor-In-Chief Claire Sanderson felt that something was... off. ‘At first, my symptoms were physical. My time of the month – which had always come like clockwork – started to fit more into the category of irregular periods, my breasts were really painful and I was starting to carry more weight around my waist. Things felt so off that, even though my husband has had a vasectomy, I began to think I must be experiencing pregnancy symptoms,' she says.
After months of struggling to fall asleep, PMT that was off the scale and ridiculous arguments with her husband, Claire began to open up to other women – and once she did, their stories kept coming. It wasn’t until Claire confided in a friend who’s a practising doctor that she heard the word perimenopause, a diagnosis later confirmed by her own doctor.
Katie Taylor, a the former charity marketing manager, experienced what she calls ‘the brain fog’ at 43 years old. She put it down to getting out of the wrong side of the bed. When it hadn’t shifted weeks later, she became convinced she was losing her edge at work. ‘I’d always been sharp in the office, really on the ball, then this fog descended and I couldn’t think straight,’ she explains. ‘I felt overwhelmed by budgets and simple tasks I used to do with my eyes closed. I’d be discussing something very basic, then suddenly I couldn’t concentrate and I’d struggle to recall specific words.’
It’s a similar story for Jane Hallam, founder of Esteem menopause clothing and a former manager in education. For Jane, it was the mood swings that hit hardest. At 47, she was mother to a self-sufficient 16-year-old daughter and, after a turbulent few years during which she became a widow, life, at last, felt pleasantly predictable. But although she appeared sorted, something wasn’t quite right.
It was on her drive home one evening that she suddenly burst into uncontrollable tears. She put it down to delayed grief, but when symptoms persisted for weeks, she became convinced she was having a nervous breakdown. ‘I wasn’t interested in work and I couldn’t enjoy anything. I existed in a state of total apathy,’ she recalls.
‘It reached the point where I convinced myself that my colleagues would think I was stupid, a fake. The day I quit my third marketing job in the space of just a few years, I came home, sat on my bed and just cried.’
Can perimenopause affect your relationship?
From avoiding social plans for fear of snapping at friends to choosing outfits based solely on how well they minimise sweat marks, life has changed for mother-of-two Toni-Marie Downes-Connor since she started the perimenopause at 39 – and even her rock-solid relationship has ended up in the fallout zone. ‘I’ve lost my libido, I’m constantly sweating and grumpy, which isn’t very sexy, and we argue all the time,’ she says.
‘It’s hardly surprising that it’s affected our dynamic as a couple.’ But it’s confronting the reality that she is ageing that has been the biggest challenge for Toni-Marie. ‘To me, it feels like the end of being a “real woman”. Even though my partner and I weren’t planning to have any more children, the idea that that phase of my life is ending makes me feel old, like it’s all over for me now.’
Illogical as it might sound, it’s an all-too-common reaction to being dealt a diagnosis that includes the ‘M’ word. ‘There’s still a big taboo around ageing, and the menopause carries a badge of “I’m old” that many people find hard to acknowledge,’ explains Dr Carla Croft, a clinical psychologist specialising in women’s health at The Mindworks, a therapy clinic in London. And accelerated ageing isn’t the only reason why perimenopausal symptoms can trigger mental health issues.
‘Difficulty with mood and anxiety is one of the most common symptoms of perimenopause,’ says Dr Croft. ‘Aside from your hormones, the situation can be complicated by all the other things that often affect you during midlife – be that having young children, ageing parents or a high-powered job. Considering perimenopause can impact your weight and your sleep – both of which influence the way you feel about yourself – it makes sense that a number of perimenopausal women develop low mood, stress or anxiety. They become so ground down from trying to manage it.’
How to treat perimenopause
So, how can you get back to your A-game? While many women report multiple GP visits before the word ‘perimenopause’ is mentioned, once you have a diagnosis, treatment will follow, the most effective of which, according to Dr Heather Currie, spokesperson for the Royal College of Obstetricians and Gynaecologists and former chair of the British Menopause Society, is hormone replacement therapy (HRT), which replaces depleted oestrogen in the body. For Katie – who was eventually diagnosed as perimenopausal after half a dozen visits to her doctor – starting HRT ‘changed everything’.
‘I now have an oestrogen implant and it’s like I’m back operating at full capacity,’ she says. ‘I’m working full-time again and running a busy family home. I’ve got so much energy; I really feel like I’ve got my life back.’ She has since founded a Facebook group and website which is an online resource and community for perimenopausal women who, like her six years ago, have all the symptoms and none of the answers.