What are menopause and perimenopause?

The menopause happens when a woman stops having periods. It is complete in a woman under 50 years old if she goes for 24 months without a period. For a woman over 50, it is complete when she goes for 12 months without a period. The woman is then postmenopausal.   

The menopause typically happens between your mid-40s to mid-50s, with an average age of 51 years. 1% of women go through the menopause before the age of 40 (premature menopause) and 10% before the age of 45.  

The perimenopause is the phase before a woman’s periods stop and is often associated with a variety of symptoms that can have a huge effect on a woman’s life and wellbeing. Every woman’s experience of the perimenopause will be different. Some women will have no symptoms except a change in her periods, but the majority of women will experience symptoms. These symptoms can start 8–10 years before the menopause, when a woman is in her early 40s. 

In some countries a negative narrative of the menopause has been created, which leads many to fear it. There is no question that the perimenopause can be difficult for many women, but the light at the end of the tunnel is that postmenopause can be a hugely positive time of a woman’s life when she is free from her menstrual cycle where powerful hormones fluctuate daily, free from periods, premenstrual syndrome, and the need for contraception. Many women report a new zest for life once they are postmenopausal. A recent advert on UK TV for incontinence pads referring to the menopause said, ‘Then it ends, and you are more yourself than you ever were.’ Many postmenopausal women can relate to this. 

What are hormone changes that underpin the menopause transition?

From puberty to the menopause, a woman will have a menstrual cycle, which involves four main hormones. These are oestrogen, progesterone, luteinising hormone (LH), and follicle stimulating hormone (FSH). Each menstrual cycle starts with a period, and around the middle of the cycle, the women will have her fertile window of about 6 days when an egg will be ovulated from the ovary, and it is possible she can get pregnant. 

During the perimenopause, the eggs are running out, so ovulation happens less often, the levels of oestrogen and progesterone start to go down and FSH goes up.   

The menopause test involves measuring the levels of FSH in the blood. It is only advisable for women under the age of 40 as they would be experiencing a premature menopause, and in some cases for women aged 40–45. But for women over age 45, a test is not recommended as the levels of FSH fluctuate daily, so a single measurement is not an accurate representation of menopause status. Women may be incorrectly told they are not perimenopausal and then try to figure out why they have so many symptoms, which can be hugely stressful. If a woman over 45 has some of the menopause symptoms below, she should assume that she is perimenopausal.

Long-term and short-term symptoms

There are short-term symptoms which usually resolve postmenopause, and long-term symptoms which persist postmenopause. 

Let’s go through each symptom! 

Menstrual cycle changes

The first change that a woman normally notices is a change in her menstrual cycle; often it may become shorter but then longer, and periods may become lighter, heavier, more painful or less painful and there may be bleeding mid-cycle. These changes occur as the levels of oestrogen and progesterone fluctuate. There may be an increase in premenstrual syndrome, which may correspond with other mood changes. It is advisable to always carry period protection because the period can be unpredictable.   

Hot flushes and night sweats

Hot flashes or flushes can be referred to as vasomotor symptoms. They are experienced by 75% of women during the perimenopause. Hot flushes are a sudden feeling of being really hot that can make women red and sweaty. They can range from a gentle feeling of warmth to a feeling of being unbearably hot all over the body, but especially the neck and face and can bring on a feeling of nausea and dizziness. They can last for a few seconds to five minutes and the number can vary from a few times a week to several a day. They can happen at any time of the day.  

If they happen at night, they are called night sweats and can affect sleep and make women feel tired during the day, so they become more irritable and moody. Hot flushes are not a major medical problem, but they can be inconvenient and make a woman anxious. 

Hot flushes can occur due to non-menopausal reasons, including obesity; dietary problems; alcohol; hyperthyroidism; anxiety; heart problems; fever; tuberculosis; some cancers; and certain medications.  

Effects on mood - psychological symptoms  

The menopause can result in psychological symptoms that are similar to the issues seen with premenstrual syndrome (PMS), including: mood swings; inexplicable emotions; irritability; depression; sadness; anger; anxiety; increased stress; lack of energy; lack of motivation; decreased patience; concentration problems; brain fog; a decrease in memory affecting the recall of words and numbers; disruptions to everyday behaviour, for example losing household items, needing to use memory aids; and forgetting appointments. 

Mood swings are defined as an emotional response that is inappropriate to its trigger and they can be extreme. A very small event can provoke a huge response.  

Genital and urinary problems

These include vaginal dryness; itchy genitals; pain during sex; an increased risk of genital infections; issues with the urinary system such as incontinence and an increase in the frequency of urination.   

Sexual difficulties 

More than 80% of women find sex painful during and after the menopause. The symptoms that affect the vulva and vagina described above in (4) can make sex uncomfortable.  There are several menopausal changes that can affect a woman’s libido (sex drive).  

Joint and muscle pain

Perimenopausal joint pain may include aches; pain; warmth; stiffness; or swelling of a joint. It affects the hips, hands, fingers and knees the most, but can also affect the back. Most women will find these pains are worse in the morning.  

Women may also experience unexplained muscle pain during the perimenopause. Muscles may give twinges of pain, cramps, fatigue, feel tense or tight, tender or spasm. As we age, our muscle mass decreases.   

Weight gain

During the menopause, some women find that they put on weight, especially around their stomach, hips and thighs and it is hard to get off. But we have to remember that this also happens to men. 

Metabolic syndrome - which involves conditions such as weight gain and high blood pressure, cholesterol and blood sugar - can increase a person's risk of cardiovascular disease and diabetes. Women are often vulnerable to the onset of metabolic syndrome when they go through the menopause and those who are overweight and lead sedentary lifestyles are more at risk.

Looking at long-term symptoms, these would be:

Osteoporosis

Osteoporosis means 'porous bones' and causes significant bone loss that increases the risk of fracture. Women account for 80% of osteoporosis sufferers so millions of women worldwide suffer and about half of women over 50 will have an osteoporosis-related fracture at some time. Thin and small-framed women are more at risk, but there is also a hereditary and ethnicity link. 

Many women do not realise they have osteoporosis until they have a fracture, back pain or notice a change in their posture. Spinal compression fractures are the most common. These are small fractures that can cause the vertebrae to collapse and alter the shape of the spine. Wrist, pelvic, hip and other fractures are also common. 

Cardiovascular disease

Cardiovascular disease (CVD) usually refers to narrowing or blocked heart blood vessels that can lead to a heart attack, stroke or angina (chest pain caused by a lack of blood to the heart muscles). There are four main types of CVD: coronary heart disease (CHD); strokes; peripheral arterial disease; and aortic disease.   

More women die of heart attacks than men and CVD is the leading cause of death in postmenopausal women with almost half of women over 50 dying from CVD. More than one in three women have some sort of CVD.  

Urinary incontinence  

Urinary incontinence is the accidental leakage of urine. It affects up to 1 in 3 women at some point in their lives, although it is more common postmenopause. 

Stress incontinence; occurs during coughing, laughing, exercise and sneezing. The urethra, which leads from the bladder to the outside, is unable to stay closed in response to increased pressure inside the abdomen, resulting in leakage of urine. This is the most common type of incontinence in women. 

Urgency urinary incontinence; when there is a sudden urge to urinate, often meaning that the person cannot reach the toilet in time. It is caused by an overactive bladder wall muscle (detrusor muscle). This condition is also known as detrusor overactivity, or overactive bladder. It is more common after the menopause.  

Other urinary disorders include nocturia (the need to urinate during the night), and urgency (an increase in the urge to urinate). 

Pelvic organ prolapse

The female pelvic organs are held in place by ligaments, muscles and skin. These structures can weaken and result in a prolapse (falls out of place) of the uterus, urethra, small bowel, rectum (large bowel), bladder and vagina. 

Prolapse can happen at any age but is more common after the menopause, due to loss of oestrogen. Prolonged labour, vaginal delivery of a very large baby, smoking and being overweight, all increase the risk. 

The most common types of prolapse seen in women involve the womb (uterine prolapse), bladder (cystocoele) or bowel (rectocoele). These are caused by weakness in the pelvic floor muscles and ligaments holding the womb and the top of the vagina in place. The prolapsing organ bulges into the vagina, causing a variety of symptoms. After a hysterectomy (operation to remove the womb), the top of the vagina can bulge downwards.  

The symptoms include a feeling of ‘pulling down’ or dragging in the pelvis, a bulge in the vagina, difficulty completely emptying the bladder (bladder prolapse), sometimes requiring either standing or placing fingers into the vagina to press on the front wall to help, difficulty completely emptying the bowel (bowel prolapse), sometimes requiring placing of fingers into the vagina to press on the back wall to help, and difficulties during intercourse, including discomfort and pain. 

Dementia and Alzheimer’s

Dementia is a syndrome associated with ongoing decline in brain activity, memory loss and difficulties with thinking and problem solving. Dementia is caused when the brain is damaged by diseases, such as Alzheimer’s disease or a series of strokes. People affected by Alzheimer’s disease have clumps of damaged proteins called plaques in their brains. Alzheimer’s disease and dementia affects women more than men and has a more profound affect in women. Since it usually happens when the woman is postmenopausal, researchers have tried to look for a link between menopause and Alzheimer’s.  

Four pillars of wellbeing

Every woman is different. About 20% of women have no perimenopause symptoms. And for many of women, their symptoms can be controlled by key lifestyle improvements. But some women will have severe symptoms and will need medical assistance. 

Women should never suffer severe perimenopause symptoms without getting advice and any necessary treatment. The UK's National Institute of Clinical Excellence (NICE) guidelines say that we need to ‘adopt an individualised approach at all stages of diagnosis, investigation and management of menopause’. 

There are four pillars of wellbeing that women should address during all stages of their life, but especially during the peri and postmenopause: 

1. Nutrition (including alcohol)
2. Exercise
3. Sleep
4. Mental health. 

These have all been found to influence short- and long-term perimenopause symptoms. It is never too late to make changes that can have a profound effect on all aspects of the menopause and long-term health. 

Nutrition

Nutrition has a huge effect on menopause symptoms. This should include a diet low in red meat, caffeine and alcohol, eating moderate amounts of fish, high amounts of fruit, vegetables and fibre, and being sure to get enough calcium, and vitamins B, C, D, E and K, ideally through food rather than supplements. The Mediterranean diet and ‘eating the rainbow’ is ideal. Alcohol consumption can increase many perimenopause symptoms but also increases the risk of cancer, heart disease and dementia. Smoking is obviously not advisable.  

Exercise

Exercise reduces the risk of cancer, heart disease, hypertension, stroke, diabetes, dementia, anxiety, depression and perimenopause symptoms. Women globally exercise less than men. It is important for everyone to keep up an exercise regime to improve our health, especially as we age. Inactive people are at a 20–30% increased risk of death compared to active people.    

Exercise boosts energy levels, increases self-esteem and confidence, and if done with friends, can prevent loneliness.   

The World Health Organisation suggest 150 minutes of moderate activity or 75 minutes of vigorous activity a week, which can be increased to 300 minutes of moderate activity for additional health benefits. I appreciate that many women find it difficult to make the time to exercise, but the bottom line is, it is really important for our health. 

Sleep

Many women have trouble sleeping during the perimenopause. Sleep deprivation has a huge effect on all aspects of our life, as it can make us angry, depressed, irritable, affects concentration, energy levels and more. It can also lead to obesity, heart disease and diabetes.  

We need to make our bedroom our sanctuary and turn off all electronics at least 30-60 minutes before we go to bed, so we can get our 8 hours. Alcohol, diet and lack of exercise can seriously affect the ability to sleep. There are many apps to help people sleep. I use one that sends me to sleep in minutes.  

Mental Health

Our nutrition, exercise, and sleep and our fluctuating hormones during the perimenopause, all affect our mental health. Mindfulness, which includes meditation and being in the present moment, is recommended to help reduce perimenopause symptoms. Taking time to think about our breathing and being still can give women the time to reset.  

If women are balancing their four pillars of wellbeing but are still experiencing perimenopause symptoms, they should seek medical help. 

Medical Care

The main treatment for perimenopause symptoms is hormone replacement therapy (HRT), which consists of oestrogen and progesterone for women who have a womb and just oestrogen for those who do not. There are many different ways of administering HRT and they can be tailored to the individual.  

For women who do not want to take HRT or are not able to (it is not recommended for those who have had breast cancer), there are other medications that can be used, as well as cognitive behavioural therapy (CBT) and alternative and complementary therapies. 

It is important to not suffer alone, but to talk to friends and family, and if required, seek professional help.