Perimenopause symptoms: how not to miss the start of your menopause.

There is a lot of conflicting information about perimenopause out there, and most of the symptoms can be caused by something else. So how do you make sure you don’t miss the start of this transition? When does it start? The average woman spends about 4 years in perimenopause, but the time can vary from […]

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There is a lot of conflicting information about perimenopause out there, and most of the symptoms can be caused by something else. So how do you make sure you don’t miss the start of this transition?

When does it start?

The average woman spends about 4 years in perimenopause, but the time can vary from a few months to 10 years. This stage is missed in induced menopause (after surgery, cancer treatment, hormone blocking drugs or removal of the ovaires), where your hormone levels drop overnight and you enter menopause more abruptly and severely.

The average age for menopause in the UK is 51.

1 in 10 women will have their last period between 40-45yrs.

1 in 100 women have their last period under the age of 40.

If you then count back another few years to the start of perimenopause, you can see how easy it is to miss this if you think that hot flushes, brain fog and changes in sexual function will only kick in in your late forties or early fifties.

What symptoms should I be looking for?

When women miss that perimenopause is the unifying diagnosis to explain their symptoms, it can cause lots of anxiety: we see women who have been afraid they have early onset dementia, who have left relationships and jobs, or had suicidal thoughts. We also see people wrongly diagnosed with fibromyalgia, chronic fatigue, anxiety and depression – who feel much better when we add back hormones.

You have hormone receptors all over your body – so symptoms can pop up anywhere. All of them can have other causes – so if we don’t look for perimenopause, we can easily miss it.
Here are some of the symptoms you might experience:


The changing hormone levels affect temperature regulation in the brain, and triggers sympathetic (fight:flight) nervous system activation, leading to:

  • Hot flushes
  • Night sweats
  • Change in headache pattern/migraines
  • Palpitations
  • Dizziness
  • Chills


Hormones directly impact our autonomic nervous system (fight:flight) and our GABA nervous system (which usually sedates and calms us, but women with PMS/PMDD have the opposite reaction leading to irritability and negative mood). MRI brain images show structural changes after menopause – cognitive changes have a real, biological basis and can be intensely unsettling.

  • Anxiety
  • Brain fog
  • Low mood/depression
  • Fatigue
  • Irritability
  • Lack of motivation
  • Loss of concentration
  • Loss of confidence/self esteem
  • Mood swings
  • Panic attacks
  • Short term memory loss
  • Sleep changes and insomnia
  • Worsening PMS/PMDD
  • Worsening ADHD
  • Worsening PTSD/trauma memories
  • Increased difficulties in neurodiversity – masking becomes more difficult

Musculoskeletal, & Skin/Hair/Eyes

Oestrogen influences collagen repair and is associated with thicker skin, and higher collagen content. We also have collagen in our bones, muscles, tendons and cartilage – so changes in this are felt throughout our bodies. Progesterone can increase the laxity in tendons and ligaments (as anyone who has experienced pubic symphysis pain in pregnancy can vouch for) – and most women who engage in sport notice fluctuations in performance through their menstrual cycle. Perimenopause can therefore have significant impacts through this system – and the drop in sex hormones accelerates the process of muscle loss (sarcopenia) and bone density loss (leading to osteoporosis) that starts in our mid thirties and (if left unchecked) ultimately contributes to frailty and loss of independence as we age.

  • Joint pain
  • Loss of bone density
  • Muscle tension
  • Tingling hands/feet
  • Changes in sporting performance/injuries
  • Acne
  • Changes in skin texture/feel
  • Body odour
  • Electric shock/prickly skin sensation
  • Dry eyes
  • Itchy skin/crawling skin sensation (formication)
  • Nail changes
  • Thinning hair
  • Rashes (new ones, or worsening of existing ones)

Respiratory system

Oestrogen impacts our immune system (it is not by coincidence that auto-immune disease is more prevalent in women) and impacts inflammation. These changes can show up in the lungs.

  • Breathing difficulties
  • Allergies can worsen
  • MAST cell activation (sex hormones can trigger allergic type reactions)


There are receptors for sex hormones (including testosterone) throughout the vulva, vagina, bladder, pelvic floor muscles and perineum.  Oestrogen directs blood flow to the pelvis, is involved in the nighttime reflex erections of the clitoris which keep it healthy, and makes it possible to feel arousal and lubrication when we have sexual thoughts or touch.

When we lose oestrogen, the tissues here thin and shrink (yes, the clitoris shrinks!) and they can itch, bleed or give rise to painful sex. This is part of perimenopause and menopause that is still poorly discussed and understood: as sexologists, we feel passionate that women need to understand the changes here in order to make informed choices about looking after this aspect of their health going forward.

  • Bladder weakness
  • Changes in sex drive
  • Decreasing fertility
  • Irregular periods
  • Changes in the flow of your periods – often heavier (don’t put up with this if it is disruptive, and remember to check you aren’t becoming anaemic as a result)
  • Recurrent urine infections
  • Changed vaginal odour
  • Changed vaginal discharge
  • Vaginal dryness
  • Reduced arousal during sex
  • Difficulty climaxing
  • Worsening stress incontinence (leaks)
  • Increased urinary frequency
  • Change in vulval structure – loss of size in clitoris/labia
  • Changes in vulval skin


Oestrogen and progesterone receptors exist throughout breast tissue and we have more blood flow here in our fertile years. Changing levels can cause fluctuating symptoms.

  • Changes in breast size
  • Sagging of breast tissue
  • Breast tenderness or lumpiness (but still get all lumps checked!)
  • Reduced sexual pleasure from nipple stimulation or breast play

Digestive system

As any woman who has experienced the constipation of early pregnancy, or a sudden loosening of her motions at the onset of a period can attest, our hormones impact our bowel habits. Progesterone slows bowel transit. Sex hormones affect gut biome. It is always important to report changed bowel habit and exclude anything serious, but I find often women don’t realise this can be part of perimenopause.

  • Bloating (but always report this to exclude ovarian problems)
  • Burning mouth syndrome
  • Changes in taste and smell
  • Dental problems
  • Dry mouth
  • Nausea
  • Weight gain
  • Changes in bowel habit (though we should always exclude more serious causes)

Do blood tests help?

People often ask us about blood tests, and whilst these can be helpful for women under the age of 45, the NICE guidance is not to routinely offer them over this age. Bloods give a snapshot in perimenopause, meaning that if they are normal, it doesn’t mean we can rule out you being in it. Under 45 we tend to check them. It can also help to check iron and thyroid, as problems with either of these things can mimic perimenopause symptoms.

When is “too early” to treat symptoms?

We know that there is a “golden window” to start hormone replacement therapy, if this is what you want to do. Most of the research supports the idea that HRT should be started within 10 years of the last period, or before the age of 60, in order to secure the biggest beneficial impact on things like bone health, dementia and heart health. It is not necessarily harmful to start later, but it is better to start early.

For those women who don’t want (or can’t have) HRT, there is still a lot that can be done proactively to support healthier ageing. Oestrogen protects our cardiovascular systems, bones, muscle health and brains. To stay strong and healthy after menopause means paying attention to nutrition, alcohol intake, stopping smoking, and developing good exercise habits that include strength training, balance and flexibility work, weight bearing and impact, and cardio. Understanding this is an important transition is key, and knowing when you are going into the “zone” is a big part of staying one step ahead of the process.

online menopause consultations
Online consultations available to help you with:
HRT & HRT Alternatives
Surgical Menopause
Menopause After Cancer

A note on our language

Throughout this website, we use the term women when describing people who experience hormonal symptoms. However, we acknowledge not only those who identify as women require access to menopause and hormone health information. For example, some trans men, non-binary people, intersex people or people with variations in sex characteristics may also experience menopausal symptoms and PMS/PME or PMDD, and we warmly welcome everyone who needs this support in our clinic.

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