You might think of the menopause as something mysterious and far off in the future; you might be in the throes of it right now; or maybe you’re somewhere in between.
But if you’re a cis woman or vulva owner aged anywhere from your mid-30s upwards, it’s helpful to know what the difference between perimenopause and menopause is, and what symptoms you might experience during this transition – especially if you’re noticing changes in your sex life.
Officially, the menopause is when you haven’t had a period for one year: the average age for this is 51 years. The ‘perimenopause’ is the term for everything menopause-related that comes before that point: the transitional time when your periods start to change in nature or frequency, and you begin to experience menopausal symptoms. The ovaries slow down and then eventually stop producing eggs, resulting in a decline in the levels of estrogen, progesterone and testosterone in your body, which causes a wide variety of physical changes as well as affecting your mind and emotions.
When does perimenopause begin?
Perimenopause most commonly starts around 45 years of age, and that’s when people tend to start looking out for symptoms. But it is not unusual for individuals to notice changes in their early 40s or even 30s. Everyone is different when it comes to menopause. Some people don’t notice anything until their late 40s, while others could start to spot subtle symptoms as early as their mid-30s, since the perimenopause can last as long as 10 years for some people.
If you are under 45 years when your periods actually stop, this is classed as an early menopause. If you are under 40 years, it is classed as ‘Premature Ovarian Insufficiency’. Either of these can run in the family for some people.
If you have had surgery to remove your uterus or ovaries, or have had medical treatment that has stopped your ovaries functioning, you will go through a ‘surgical’ menopause. This often causes symptoms to come on suddenly and progress quite quickly.
How do I know if I am perimenopausal?
The first sign of perimenopause is often a change to your periods – either a change in the pattern or flow. Hot flushes and night sweats are the most widely recognised of all the symptoms, and they also might include dizziness and heart palpitations when they happen.
Other common symptoms involve emotional changes such as feeling angry, irritable, tearful, or anxious and low in mood. A fogginess in your thinking skills and concentration levels are frequently frustrating for individuals, especially at work. Getting a good night’s sleep is often problematic and lack of estrogen can cause joint pains, muscle aches, worsening headaches or migraines and dry and itchy skin.
Reduced levels of estrogen are also responsible for changes to your urinary tract, vulva and vagina. You might need the toilet more often and get desperate very quickly, which can mean the occasional accident for some. You may notice more episodes of cystitis or thrush. Vulval tissue becomes less plump and drier – which can lead to soreness; the vagina produces less natural lubrication and becomes less stretchy. These can be the symptoms that vagina-owners find most impactful on their sex lives, but changes to your mood and levels of tiredness can obviously play a large part in that too. Changes in sex drive can also cause issues, with low libido being one of the biggest reported sex-related problems for people going through this transition.
There are also implications to your future health because of the long-term effects of living without estrogen. Your risk of getting osteoporosis (bone-weakening disease) increases, as does your risk of developing disease in your heart or blood vessels.
Do I need a diagnosis to get treatment for the perimenopause?
You may have been mentally checking off a few or more of these symptoms as I have described them and you might be thinking ‘yes, this is definitely me – what do I do now?’
If you are over 45 years old, diagnosing the perimenopause does not need to be done by a blood test – the account of your symptoms alone should be enough for a doctor or nurse to identify that you are perimenopausal and discuss treatments with you.
If you are under 45 years, health professionals may want to rule out other causes first, particularly if you have any medical conditions. Once those are ruled out, a blood test to check if you have high levels of follicle stimulating hormone (FSH) may be useful, but as hormones fluctuate dramatically around this age, it may come back normal, and diagnosis is still best based on symptoms.
Under the age of 40, you should have blood tests – two to check FSH level about six weeks apart – and should also have thorough investigations to rule out other causes. But if you have classic menopausal symptoms, everything else has been ruled out, and your blood tests are normal, I would still consider trying HRT to see if it helps. If it does, the diagnosis is made.
If you feel that your health professional doesn’t take you seriously – or assumes you are depressed – ask to see someone different. It’s really useful to take a detailed account of your symptoms with you. You could complete the ‘Greene Climacteric Scale’ questionnaire before your appointment, which is available online as well as in the balance app.
What are my treatment options?
While this description of perimenopausal symptoms may sound worrying, the good news is that there is help available. First, having a healthy diet and an active lifestyle are really important and can lay the foundation for a healthier menopause with fewer health problems as you age.
The most effective way of relieving actual symptoms is to replace the hormones that you no longer produce by taking Hormone Replacement Therapy (HRT). For most individuals, the benefits of taking HRT outweigh the risks and it also lowers your chances of developing osteoporosis and heart disease in the future.
Some people find cognitive behavioural therapy (CBT) or other types of talking therapy helpful for the psychological changes, such as anxiety and low mood, especially if they are impacting on their relationships. Finding time to do the things that you enjoy and that help you relax is also vital – for me, that is yoga.
There are many alternative remedies for menopausal symptoms on the market, but scientific evidence of their effectiveness is unfortunately limited.
In my next blog, I will go into more detail about genital and urinary problems in the perimenopause – the symptoms that are most likely to affect your sex life – but for now, I want you to know that there is really effective help available for these problems.
There is help for all these issues
The use of local or topical estrogen – which is applied (or released) directly to the vagina and vulva – can be very beneficial and is available on prescription. This helps reverse some of the tissue changes I described earlier. Over-the-counter lubricants are also very useful if stimulation or vaginal penetration is painful, and specialist non-hormonal moisturisers can be good at easing general discomfort throughout the day.
In short, it’s good to be prepared for perimenopause, and it’s good to spot the symptoms early, because there is plenty you can do to ensure you continue to have an enjoyable sex life throughout this transition.
Dr. Louise Newson is a GP (family practitioner) and menopause specialist. She developed the Menopause Doctor website and is the founder of the ‘balance’ menopause app. Louise created both platforms to empower individuals with evidence-based information and provide tools to access safe and effective treatments for the menopause.