Perimenopause and Menopause: Hormonal Changes Explained

Perimenopause vs menopause

It’s common to use these terms interchangeably, but perimenopause and menopause refer to different stages of a woman’s reproductive journey.  
 
Perimenopause is the transitional phase leading up to menopause. It can last for several years, typically beginning in a woman’s 40s, but sometimes earlier. During this time, hormone levels (especially oestrogen) start to fluctuate irregularly, causing many of the noticeable symptoms. You still have periods through perimenopause, but they may become irregular. The duration of perimenopause can vary significantly from person to person, but it’s usually between 4 and 8 years. 

Menopause is diagnosed when you haven’t had a period for 12 consecutive months. This marks the end of your reproductive years. The average age in the UK for menopause is 51, but it can occur naturally anywhere between 45 and 55.

Hormones explained

The symptoms you experience during perimenopause and menopause are primarily driven by significant oestrogen, progesterone, and testosterone changes. 

Oestrogen is a hormone that’s produced by the ovaries. It begins to fluctuate erratically, then steadily declines during perimenopause, eventually reaching low levels after menopause. This drop is responsible for many classic symptoms like hot flushes and vaginal dryness.  

Progesterone also fluctuates and eventually declines – this hormone particularly impacts the regularity of your cycle.  

Testosterone is often thought of as a male hormone, but women also produce it. The levels decline with age, and this can affect energy, mood, and libido.  

To understand these changes, your doctor may recommend a test to measure your follicle-stimulating hormone (FSH) levels during perimenopause. As oestrogen levels drop, your body produces more FSH to try and stimulate the ovaries. Elevated FSH levels, particularly alongside symptoms, can indicate you’re in perimenopause or menopause.  

Other hormones, like cortisol and insulin, also play a role. Stress can exacerbate symptoms, while insulin resistance (often linked to lifestyle) can impact your overall wellbeing during this transition.

Common symptoms of perimenopause and menopause

The decline and fluctuation of hormones lead to a diverse range of symptoms. While some women experience few, others can find them debilitating. Common symptoms include: 

• Hot flushes/night sweats 

• Mood changes 

• Brain fog 

• Sleep issues 

• Joint pain 

• Heart palpitations

Genitourinary symptoms

Hormonal changes don’t just affect general wellbeing; they can also have a specific impact on the urinary and genital systems. These are collectively known as genitourinary syndrome of menopause (GSM), sometimes referred to as vaginal atrophy.  

Common genitourinary symptoms include: 

• Vaginal dryness – a common symptom which can lead to discomfort, itching, and irritation 

• Painful sex (dyspareunia) - vaginal dryness and thinning tissues can make intercourse painful 

• Recurrent urinary tract infections (UTIs) – the thinning of the vaginal and urethral tissues can make women more prone to recurrent UTIs 

It’s important to know that these symptoms are treatable, and you shouldn’t suffer in silence. Localised oestrogen therapy, like creams, pessaries, and rings, can be very effective.

How to manage perimenopause and menopause

There are various approaches to managing perimenopause and menopause symptoms, from medical interventions to lifestyle adjustments.

Hormone replacement therapy (HRT)

HRT involves replacing the hormones (primarily oestrogen) that your body is no longer producing.  

HRT can be oestrogen-only (for women who have had a hysterectomy) or combined oestrogen and progestogen (for women with a uterus, to protect the womb lining). It’s available in various forms, including patches, gels, sprays, tablets, and vaginal tablets or creams. HRT isn’t suitable for everyone, so it’s important to speak to your GP to find the correct treatment for you.

Non-HRT options

For those who can’t take HRT, prefer an alternative or wish to use something alongside it, there are other options available: 

• Lifestyle changes – diet, exercise, and stress management play a huge role in managing the symptoms 

• Cognitive behavioural therapy (CBT) - this can be very effective for managing psychological symptoms like mood changes, anxiety, and sleep issues 

• Supplements – certain supplements are sometimes used, though their effectiveness can vary. You can speak to your GP or pharmacist for recommendations

Your weight and metabolism

Many women experience midlife weight gain during perimenopause and menopause, particularly around the abdomen. This is often due to hormonal changes, a slowing metabolism, and lifestyle factors.  

The hormonal shifts can also contribute to insulin resistance, making it harder for your body to manage blood sugar effectively. Engaging in regular strength training for menopause is particularly beneficial, as it helps build and maintain muscle mass, which boosts metabolism and improves insulin sensitivity. A balanced diet and consistent activity are crucial during this time.

Bone and heart health

The drop in oestrogen during menopause significantly impacts long-term health, particularly bone density and heart health.  

Oestrogen protects bones, so its decline can lead to accelerated bone density loss and an increased risk of osteoporosis. Regular weight-bearing exercise, adequate calcium or vitamin D intake (through diet or supplements), and potentially medication, if it is suitable for you (including HRT), are vital for maintaining bone strength. DEXA scans may be recommended to monitor bone density.  

While women are often protected from heart disease by oestrogen before menopause, this protection decreases afterwards. Monitoring cholesterol changes, maintaining a healthy blood pressure, staying active, and eating a heart-healthy diet become even more important.

Work and lifestyle

Managing perimenopausal and menopausal symptoms can impact all areas of life, including work and social activities.  

Workplace adjustments

 Many employers in the UK are becoming more aware of the impact of menopause and offering workplace adjustments to support employees. This can include flexible working, access to cooling facilities, or quiet spaces. 

Sleep hygiene

Establishing good sleep hygiene (a consistent bedtime, a dark and cool room, and avoiding screens before bed) is crucial for combatting insomnia and fatigue.  

Exercise

 Regular exercise continues to be important in managing symptoms, improving mood, energy, sleep, and overall health. Find activities you enjoy and make them a regular part of your routine.