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Women's Health Guide

Perimenopause & Menopause

What no one tells you

51
average age of menopause in the UK - but perimenopause can begin years earlier
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Medical disclaimer

This page provides general health information. It is not a substitute for personalised medical advice, diagnosis, or treatment. Every person's situation is different. If you have concerns about your health, please speak to your GP or a qualified healthcare professional.

Perimenopause is the transitional phase leading up to menopause. It can begin in the late 30s or early 40s and typically lasts 4-8 years. Menopause itself is defined as 12 consecutive months without a period - in the UK, the average age at which this occurs is 51. Everything before that point is perimenopause.

The symptoms of perimenopause and menopause extend well beyond hot flushes. NICE NG23 and the British Menopause Society recognise a wide range of symptoms including joint pain, brain fog, heart palpitations, anxiety, skin changes, and changes to libido and sexual function. These are physiological symptoms with physiological causes and, in most cases, effective treatments.

Too many women are still being told to 'just get on with it'. The evidence for treatment is clear, the options are better than ever, and no one should be left to manage the menopause alone.

Symptoms to know

Irregular periods
Cycles that shorten, lengthen, become heavier or lighter, or become unpredictable. This is often the first sign that perimenopause has begun, as oestrogen levels start to fluctuate.
Hot flushes and night sweats (vasomotor symptoms)
Sudden waves of heat, often with flushing and sweating. These are the most well-known symptoms and are caused by the effect of declining oestrogen on the body's temperature regulation. Night sweats can significantly disrupt sleep.
Sleep disruption
Difficulty falling asleep, waking in the night, or waking early. Often compounded by night sweats but also occurs independently. Chronic sleep deprivation has downstream effects on mood, cognition, weight and cardiovascular health.
Brain fog and cognitive changes
Difficulty concentrating, poor word retrieval, feeling mentally slower. This is a recognised symptom of perimenopause, thought to be related to the effects of oestrogen fluctuation on the brain. It typically improves with hormonal treatment. It is not a sign of early dementia.
Mood changes and anxiety
New or worsening anxiety, low mood, irritability, or emotional volatility. The hormonal fluctuations of perimenopause directly affect serotonin and GABA neurotransmitter systems, producing genuine changes in mood. These symptoms can be mistaken for primary depression and may not respond to antidepressants alone.
Joint and muscle pain
Oestrogen has anti-inflammatory properties. As levels decline, joint stiffness and aching - particularly on waking - is common. NICE guidelines lists musculoskeletal symptoms as a recognised feature of perimenopause.
Genitourinary syndrome of menopause (GSM)
Vaginal dryness, irritation, discomfort during sex, and urinary symptoms including urgency and recurrent UTIs. This affects around 50% of postmenopausal women (British Menopause Society) and is chronically undertreated. Vaginal oestrogen is safe, effective, and life-changing for many women.

What actually helps

Find out if HRT is right for you
Hormone Replacement Therapy (HRT) replaces the oestrogen (and usually progesterone) that the ovaries are no longer producing. NICE guidelines states that for most women under 60 who start HRT within 10 years of menopause, the benefits on symptoms, bone health, and quality of life outweigh the risks. A personalised, informed conversation with a clinician is essential - not a blanket yes or no.
Know that vaginal oestrogen is a separate treatment
Vaginal oestrogen (available as pessaries, cream or a ring) is a local treatment for GSM. It is not the same as systemic HRT. NICE guidelines and the British Menopause Society state that vaginal oestrogen carries negligible systemic absorption and can be used safely by women who cannot or choose not to use systemic HRT - including most women with a history of breast cancer, in consultation with their oncologist. It should be offered to any woman with vaginal or urinary symptoms.
Prioritise sleep
Poor sleep in perimenopause is both a symptom and an amplifier of other symptoms. Treating night sweats (with HRT or non-hormonal options such as fezolinetant, now approved by MHRA), maintaining consistent sleep timing, avoiding alcohol in the evening, and keeping the bedroom cool can all help. Cognitive Behavioural Therapy for Insomnia (CBT-I) has strong evidence for chronic insomnia and is recommended by NICE.
Resistance training is one of the most important things you can do
Bone density declines after menopause, and muscle mass reduces with age. Resistance training (weights, resistance bands, bodyweight) is the most effective intervention for both. NICE guidelines recommends weight-bearing exercise for bone health. Aim for at least 2 sessions per week. The benefits extend to cardiovascular health, mood, and metabolic function.
Reassess your relationship with alcohol
Alcohol disrupts sleep architecture, worsens vasomotor symptoms (hot flushes), and is associated with increased breast cancer risk. UK Chief Medical Officers' guidelines recommend no more than 14 units per week. This is worth revisiting during perimenopause, as many women find alcohol makes their symptoms worse.
Track your symptoms before appointments
Perimenopause is a clinical diagnosis - blood tests (FSH and oestradiol) are unreliable because hormone levels fluctuate significantly day to day during the transition. NICE guidelines recommends that FSH testing is not used alone to diagnose perimenopause in women over 45. Keeping a record of your symptoms, their frequency and severity, is the most useful thing you can bring to an appointment.

Myths worth busting

Myth
“HRT causes breast cancer”
The relationship between HRT and breast cancer is nuanced and depends on the type of HRT used and a woman's individual risk profile. The British Menopause Society and NICE guidelines note that body-identical progesterone (micronised progesterone) appears to have a more favourable breast cancer risk profile than older synthetic progestogens. For many women, the absolute risk increase is small and is outweighed by benefits - but this should be an individualised, informed discussion with a clinician, not a blanket refusal to prescribe.
Myth
“Menopause only happens in your 50s”
The average age of menopause in the UK is 51, but perimenopause can begin in the late 30s or early 40s. If you are under 45 and experiencing perimenopausal symptoms, this may represent premature ovarian insufficiency (POI), which affects approximately 1 in 100 women under 40 and requires specific assessment and management. NICE guidelines and the NICE guidelines POI guideline address this.
Myth
“You just have to push through it”
Effective, evidence-based treatments exist. NICE guidelines states clearly that HRT should be offered to women with menopausal symptoms after appropriate discussion. The 'just get on with it' approach has a real cost - to quality of life, relationships, career functioning, and long-term health including bone and cardiovascular health.
Myth
“HRT is only for hot flushes”
HRT treats the full range of perimenopausal and menopausal symptoms, including brain fog, mood changes, joint pain, sleep disruption, and genitourinary symptoms. NICE guidelines also notes evidence-based benefits on bone health and reduced cardiovascular risk when HRT is started at the appropriate time in appropriately selected women.

Frequently asked questions

What age does perimenopause start?
Perimenopause most commonly begins in the mid to late 40s, but it can start as early as the late 30s. The average age of menopause in the UK is 51 (Office for National Statistics). If you are experiencing perimenopausal symptoms before the age of 45, a clinician should assess for premature ovarian insufficiency (POI). NICE guidelines provides guidance on the investigation and management of both perimenopause and POI.
How do I know if I am in perimenopause?
Perimenopause is primarily a clinical diagnosis based on symptoms and menstrual pattern, not a blood test. NICE guidelines explicitly states that FSH measurement should not be used to diagnose perimenopause in women aged 45 and over, because levels fluctuate significantly. Classic features include irregular periods, hot flushes, night sweats, sleep disruption, mood changes, and brain fog.
Is HRT safe?
For the majority of women, yes. NICE guidelines states that the benefits of HRT outweigh the risks for most women with menopausal symptoms who are under 60 and within 10 years of their menopause. The risk profile varies by type of HRT, personal and family medical history, and timing of initiation. This is why a personalised, informed discussion with a clinician is essential - the British Menopause Society has a helpful risk checker tool on its website.
What is the difference between perimenopause and menopause?
Menopause is a specific point in time - 12 consecutive months without a period, caused by the ovaries ceasing to produce significant amounts of oestrogen. Perimenopause is the transitional phase leading up to this, during which hormone levels fluctuate and symptoms occur. After menopause, you are postmenopausal. When people talk about 'going through the menopause', they usually mean the perimenopausal transition.
Can perimenopause cause anxiety?
Yes. Fluctuating oestrogen levels affect serotonin and GABA neurotransmitter systems, which regulate mood and anxiety. New or worsening anxiety during perimenopause is a recognised and common symptom, listed in NICE guidelines. It often responds to HRT. If anxiety is severe or persistent, a combination of hormonal treatment and psychological support (such as CBT) may be most effective.
What is genitourinary syndrome of menopause and can it be treated?
Genitourinary syndrome of menopause (GSM) describes changes to the vagina and lower urinary tract caused by declining oestrogen - including vaginal dryness, discomfort during sex, itching, and urinary symptoms including urgency and recurrent infections. It affects around 50% of postmenopausal women (British Menopause Society) and is very treatable with local vaginal oestrogen. NICE guidelines recommends vaginal oestrogen should be offered to women with these symptoms and states it is safe even for women who cannot use systemic HRT.

Sources & references

All clinical claims on this page are grounded in current evidence and published guidelines. Links open external websites.

  1. NICE NG23: Menopause - diagnosis and management (2015, updated 2019)
  2. British Menopause Society
  3. NHS: Menopause
  4. Menopause Charity: Symptoms of menopause
  5. UK Chief Medical Officers' Low Risk Drinking Guidelines

Last reviewed: July 2026. This page will be updated as guidelines change. If you spot an error or an outdated reference, please get in touch.

Dr Hiba Sher Khan
© 2026 Dr Hiba Sher Khan · drhiba.co.uk