Perimenopause: symptoms, age and when a test helps

Perimenopause is the phase in which your ovaries make fewer hormones and your cycle turns irregular. We call that run-up to menopause the perimenopause. For most women it starts between the ages of 40 and 45.

You are 43, your cycle has been all over the place for a few months and you sleep badly. You have a shorter fuse than you recognise in yourself. Your GP says your blood values look fine.

Yet you feel something is shifting. Sound familiar? This is how the phase often announces itself.

Many women think of hot flushes the moment menopause comes up. That is why they miss the years that come before it. Perimenopause hides behind complaints we blame on stress, busyness or age.

Below you read what happens and which signs belong to it. You also read when a blood test adds value and what you can do yourself.

What is perimenopause?

Perimenopause is the transition phase toward menopause. Menopause is the moment you have not had a period for a year. In this phase your ovaries produce increasingly variable amounts of estrogen and progesterone. Those fluctuations cause the complaints.

The treacherous part is the unpredictability. One month you feel fine, the next you sleep badly and feel irritable. Because you are still menstruating, you often do not link it to menopause. Read also about the five phases of menopause, from perimenopause to postmenopause.

What is the difference between perimenopause and premenopause?

The two words get used interchangeably, and that confuses people. Premenopause usually refers to the whole fertile span before the change. Your cycle was still regular then.

Perimenopause is the phase after that: you still menstruate, but your hormones already fluctuate.

In practice many websites use premenopause as a synonym for perimenopause. So look at what is being described rather than at the word itself.

The most common perimenopause symptoms

The first signs often revolve around your cycle and your sleep. They appear before hot flushes begin. Not every woman has everything, and the order differs. Often a combination of complaints is the first real clue.

• A changing cycle: shorter, longer or more irregular than you are used to
• Sleeping worse or lying awake at night
• Mood swings, irritability or more anxiety
• Fatigue that does not match your sleep
• Palpitations, sometimes without a clear cause
• A foggy head or trouble concentrating
• Vaginal dryness or pain during sex

Vaginal dryness usually arrives later than the cycle complaints. It belongs to an estradiol that is structurally lower, not to the fluctuations themselves.

Many of these complaints also fit stress, an underactive thyroid or iron deficiency. That is why they are so easy to miss. Unsure whether it is menopause or something else? Read our article on menopause or burnout.

Restless legs belong on this list too, and they often track your iron.

A dry mouth is a less familiar symptom that many women do recognise.

At what age does perimenopause start?

Perimenopause starts for most women between 40 and 45, but it can be earlier. The average age of menopause in the Netherlands is around 51. Perimenopause precedes it by an average of four to eight years. For some women the phase runs on to about ten years.

If it starts before you are 40, discuss it with a doctor. It may point to an early menopause. According to the Dutch GP guideline and the NVOG, that needs extra attention.

An early menopause has long-term effects on your bones and your heart. We set out the symptoms of early menopause separately. Read also about the average age of menopause.

Which hormones change, and in what order?

Menopause is not an on-switch but a spectrum. The hormones shift in a rough order, though it differs per woman. The table below shows what changes and when measuring makes sense.

Remember this: in perimenopause your hormones fluctuate by their nature. A single measurement is a starting point, not a diagnosis. The pattern over two or three measurements tells you more than one result.

Track your cycle and complaints

A single blood value says little in this phase. Your own account is therefore often the best thing you bring to your GP. The Dutch GP guideline puts your story and your cycle at the centre.

What is worth tracking for a few months:

• The length of your cycle and how it shifts
• How heavy your menstruation is and whether unusual bleeding occurs
• When hot flushes, bad nights or mood swings occur, and how often
• What you notice around ovulation and in the week before your period

After two to three months you often see a pattern. In single weeks it goes unnoticed.

Can you test for perimenopause?

A single blood value does not establish perimenopause, precisely because your hormones fluctuate. Still, a measurement can help. That is true above all to rule out other causes, or in case of an early onset. FSH rises gradually in this phase, but can differ month to month.

It is often worth looking at your thyroid and iron alongside your hormones. They can cause the same complaints. The Menopause Check looks at the hormones that belong to this phase.

If you want a broader view, the Women's Hormones panel brings more values into view. Read also which hormones to test around menopause.

Why do the hormones fluctuate so erratically?

That hormonal rollercoaster is what makes perimenopause so confusing, and it has an explanation. In your fertile years an egg matures each month. As the number of follicles declines, that process falls out of step.

So your estradiol does not fall calmly, but swings back and forth. Sometimes your body makes extra estrogen, and a week later it has dropped deeply. Those peaks and dips cause much of the trouble, not just the low level. Progesterone meanwhile is often already low, because there are fewer ovulations.

That is how the ratio between estrogen and progesterone falls out of balance. For measuring it means two things. One: the timing in your cycle matters. Two: a measurement captures only a moment of a moving picture.

Is it menopause, or something else after all?

Many complaints in perimenopause are not unique. Fatigue, low mood, palpitations and a foggy head also fit an underactive thyroid. Iron deficiency or long stress gives those complaints too.

Precisely because they overlap, it is worth looking more broadly when in doubt. For the palpitations themselves, read when palpitations in menopause call for testing.

So include your thyroid and iron when you have your hormones tested. That prevents you from overlooking a treatable cause. If you are torn between menopause and exhaustion, read our article on menopause or burnout.

Which complaints fit which phase?

It can be hard to work out where you stand. A rough sketch per phase helps you recognise your own pattern.

• Early perimenopause: your cycle becomes shorter or more irregular, progesterone falls and you sometimes notice PMS-like complaints. FSH may still be normal.
• Late perimenopause: longer periods without menstruation, clearly raised FSH, falling estradiol with fluctuations, hot flushes and sleep problems.
• Menopause: twelve months without a period, FSH structurally raised and estradiol structurally low.
• Postmenopause: stable low hormone levels, complaints gradually ease for most. Read more about what happens after menopause.

What can you do yourself?

Perimenopause is a natural phase and not an illness. The complaints are often well manageable. Attention to sleep, movement and stress makes a difference for many women. It does not replace medical treatment, but it helps you keep a grip.

• Sleep: keep a fixed sleep rhythm, including at the weekend. Make sure your bedroom is cool and dark.
• Movement: move regularly, with attention to strength and your bones. Walking, stairs and strength training support your bone density, which falls faster after menopause.
• Nutrition: the Dutch Nutrition Centre advises varied food with enough protein and calcium. For women aged 50 and over the Gezondheidsraad advises extra vitamin D.
• Stimulants: watch alcohol and caffeine, which can disrupt hot flushes and sleep.
• Support: talking to others in the same phase helps. Stichting Menopauze offers good information.

What makes the biggest difference differs per woman. If you sleep badly, read about poor sleep in menopause. If you gain weight unexplainably, read about weight gain in menopause.

If your complaints interfere with daily life, discuss the options with your GP. Read also about hormone therapy in menopause. According to the NHG it can help with bothersome complaints.

When to see your GP?

See your GP if your complaints affect your daily life. Do so too if they start before you are 40, or in case of unusual bleeding. The Dutch GP guideline and Thuisarts.nl describe how GPs here view these complaints.

With Lunara you have your blood drawn without a referral at a location near you. Each value in your result gets an assessment from a BIG-registered doctor. So you know what your values may mean in your situation. A blood test does not replace a talk with your GP, but it gives you a solid starting point.

Further reading

• Menopause supplements: what works and what you can measure
• Lenzetto spray: experiences and how it works
• Femoston: experiences and side effects
• Estradiol patch: how it works and who it suits
• Mirena IUD in menopause