Menopause and perimenopause

Overview

Perimenopause is the time when someone has symptoms of the menopause but their periods have not yet stopped. Menopause is when periods stop altogether. The NHS says menopause usually affects women between the ages of 45 and 55, but it can happen earlier. Symptoms can start months or years before periods stop, and some, such as joint pain and vaginal dryness, can continue afterwards. Hormone replacement therapy is the main treatment, and other options exist for people who cannot or do not want to use it.

Symptoms

What a clinician may find

• Periods that become irregular or less frequent, which is often the first sign of perimenopause.
• Vaginal dryness, which can continue after periods stop.

Complications

• Early menopause raises the chance of bone and heart problems.
• Major bone loss in women happens with the loss of oestrogen at the menopause.

Diagnosis

The NHS says menopause is usually diagnosed in women over 45. For early menopause, a GP may use symptoms, family history and blood tests to check hormone levels.

Treatment

Hormone replacement therapy (HRT) is the main treatment for menopause and perimenopause symptoms. If HRT is unsuitable or not wanted, options include cognitive behavioural therapy (CBT), and a doctor may suggest clonidine or an antidepressant. Herbal remedies and compounded bioidentical hormones are not recommended for menopause symptoms, according to NHS guidance.

Prevention

Natural menopause is a change linked to ageing, so it is not something that can be prevented. Women's Health Concern lists exercise, sunshine and a balanced diet as the basis for bone health.

Key facts

What are perimenopause and menopause?

Perimenopause is the time when someone has symptoms of the menopause but their periods have not stopped. Menopause is when periods stop altogether. The NHS says periods usually become less frequent over a few months or years before they stop altogether. For some people, periods can stop suddenly. Perimenopause can last from months to years. The NHS also says someone reaches menopause once they have not had a period for 12 months.

NHS inform Scotland describes menopause as a change in hormone balance linked to ageing. It says the ovaries make less of the hormone oestrogen and no longer release an egg each month. The NHS says menopause usually affects women between the ages of 45 and 55, but it can happen earlier. Early menopause can follow surgery to remove the ovaries or cancer treatment. The NHS describes the first sign of perimenopause as often being irregular periods, which may come more or less often and be heavier or lighter than before.

What are the symptoms?

A change in the usual pattern of periods is often the first sign of perimenopause. For example, periods may become irregular. The NHS lists mood changes such as low mood, anxiety and low self-esteem among the common symptoms. It also lists poor memory and problems with concentration.

Physical symptoms include hot flushes, sleep problems, palpitations, and headaches or migraines that are worse than usual. Muscle aches and joint pains, skin changes and reduced sex drive are also listed. Joint pain and vaginal dryness can continue after periods stop. Symptoms can last for months or years, and they can change over time. Women's Health Concern says that sleep problems are very common in the menopause transition. Vaginal dryness can also make sex uncomfortable for some women, according to NHS inform Scotland. Bleeding after sex can also be a sign of a health condition, and NHS inform Scotland advises contacting a GP about it.

How are they diagnosed?

The NHS says menopause is usually diagnosed in women over 45. The NHS advises contacting a GP for anyone who thinks they have symptoms of menopause or perimenopause and wants to know the options. It says early advice can help reduce the effects on health, relationships and work.

For early menopause, a GP may use symptoms, family history and blood tests to check hormone levels. The NHS also advises contacting a GP about palpitations, or if bleeding has changed so that it is heavier than before. Bleeding after the menopause needs to be checked by a GP, even if it happens once or is only spotting. Bleeding of this kind can be due to thinning of the womb lining, and less often to womb cancer. NICE updated its menopause guideline in 2024 and says it clarified when to refer people to a healthcare professional with expertise in menopause, fertility, or both.

What is hormone replacement therapy?

Hormone replacement therapy, or HRT, is the main treatment for menopause and perimenopause symptoms. The NHS describes it as an effective treatment for most people going through menopause and perimenopause. It also says HRT can help prevent thinning of the bones, which can lead to fracture (osteoporosis). For people under 60 who have symptoms and are not at high risk of breast cancer or blood clots, the NHS says the benefits are likely to outweigh the risks.

NHS 111 Wales says combined HRT, which contains oestrogen and progestogen, is associated with a small increased risk of breast cancer. NHS guidance says this risk rises the longer HRT is taken and falls after it is stopped. The Wales page says the breast cancer risk is linked to all types of HRT except vaginal oestrogen. The NHS says HRT tablets can increase the risk of blood clots, although the risk is very low. It says patches or gels carry no increased risk of blood clots. The NHS says the decision depends on age, symptoms and personal risk factors.

What other treatments and self-care are described?

If HRT does not work, cannot be taken or is not wanted, the NHS says other types of treatment are available. These include cognitive behavioural therapy (CBT). NICE added menopause-specific CBT in its 2024 update of guideline NG23. It says this can be considered for hot flushes and night sweats, including alongside HRT or when someone prefers not to take HRT. Clonidine is a prescription medicine that can help reduce hot flushes and night sweats. Antidepressants are used for mood symptoms in people diagnosed with depression or anxiety.

Fezolinetant is a non-hormonal medicine taken by mouth for moderate to severe hot flushes and night sweats. MedlinePlus says it blocks a brain chemical called neurokinin B from binding to its receptors in the hypothalamus. NICE guidance covers its use when HRT is unsuitable. Herbal remedies such as red clover and black cohosh have no strong evidence that they work, according to the NHS. Women's Health Concern describes weight-bearing exercise as any exercise on the feet or legs that works against gravity. It stresses regular activity for bone health and lists exercise, sunshine and a balanced diet as the basis of bone health.

What is early or premature menopause?

Early menopause is when regular periods stop before the age of 45. Premature menopause is when this happens before the age of 40, and it is also called premature ovarian insufficiency. It can be natural or be caused by treatment, such as radiotherapy or surgery to remove the ovaries. For most people, no cause can be found.

Early menopause raises the chance of bone and heart problems. The NHS says it is important to replace the missing hormones when menopause starts before 45. The main treatments are the combined contraceptive pill or HRT, and lifestyle changes can also help. Fertility may be affected. The British Menopause Society advises that bone density assessment should be considered when premature ovarian insufficiency is diagnosed. It also says HRT may improve bone health and heart markers more than the combined oral contraceptive pill.

Frequently asked questions