The years before periods stop — when symptoms start but the connection often isn't made.
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Perimenopause is the transition leading up to menopause, and it commonly lasts four to eight years. Periods are still happening — which is precisely why the symptoms so often get attributed to stress, work or age instead.
Hormone levels do not decline smoothly. They fluctuate erratically, which is why symptoms can be severe one month and absent the next.
Fluctuating and gradually declining oestrogen as ovarian function winds down. It typically begins in the mid-forties but can start in the late thirties.
Smoking brings menopause forward by roughly two years on average. A family history is a reasonable guide to timing.
Perimenopause is diagnosed clinically. Because hormone levels swing erratically during the transition — that erratic swinging is the perimenopause — a single blood test captures one moment and settles nothing.
A normal FSH does not exclude it. Over 45 with typical symptoms, no test is needed at all.
Cycle change plus symptoms that vary across the month. Periods becoming closer together, heavier, or unpredictable, alongside sleep breaking down, mood shifting, or brain fog arriving — and all of it worse in the run-up to a period.
A symptom diary kept across three cycles is more informative than any blood test, and it is free.
Thyroid disease and iron deficiency, both common in the forties and both producing the same fatigue, low mood and poor concentration.
Heavy periods cause iron deficiency, which then causes fatigue — so the two frequently travel together and treating only one leaves you halfway.
The first task is often simply naming it. A great many women arrive having been treated for anxiety or insomnia for two years without anyone raising perimenopause.
Treatment can start during perimenopause — you do not have to wait until periods stop. HRT is effective, and contraception is still needed until twelve months after your last period.
Thyroid disease produces near-identical symptoms and is worth excluding.
Bleeding between periods, after sex, or periods that have become very heavy — soaking through protection hourly or passing large clots — need assessment rather than being written off as perimenopausal.
Pregnancy is still possible until twelve months after your last period — or two years if you are under 50.
HRT is not contraception. That catches people out.
The hormonal coil is worth knowing about: it manages heavy periods, provides contraception, and can serve as the progesterone part of HRT — three problems, one device.
Periods that soak through protection hourly, contain large clots, or stop you leaving the house are not simply perimenopause. They are treatable, and they cause the iron deficiency that makes the fatigue worse.
NHS GPs prescribe HRT, and the HRT prepayment certificate covers a year of prescriptions for a single payment.
NHS Talking Therapies takes self-referrals — useful, because perimenopausal mood change is frequently treated as primary depression when it is not.
The most useful thing about perimenopause is recognising it, and that costs nothing. It commonly begins in the early to mid forties, periods may still be regular, and the symptoms that dominate are frequently not hot flushes — they are anxiety, low mood, poor sleep, brain fog, joint aches and irritability. Those get attributed to stress, work, or depression for years.
That misattribution has real consequences. Women in perimenopause are commonly offered antidepressants for what is a hormonal transition. NICE is explicit that SSRIs should not be offered as first-line for low mood arising from menopause, and HRT frequently helps where an antidepressant has not.
Your NHS GP can diagnose and treat perimenopause free, and the HRT prepayment certificate in England makes ongoing treatment inexpensive.
A blood test is not usually the answer. Hormone levels fluctuate wildly in perimenopause, so a normal FSH does not exclude it — and testing frequently causes confusion rather than clarity. Private clinics that sell hormone panels are selling reassurance rather than information.
Where paying is genuinely worth it is twenty minutes to work through whether this is perimenopause, and to discuss contraception — which is still needed, and where the hormonal coil often solves two problems at once.
NICE NG23, Menopause: diagnosis and management, is the governing guideline. It defines perimenopause and recommends diagnosis based on vasomotor symptoms and irregular periods in women over 45, without laboratory testing.
NG23 is explicit that FSH levels fluctuate during perimenopause and that a single normal result does not exclude the diagnosis.
NG23 recommends against offering SSRIs or SNRIs as first-line treatment for low mood arising as part of the menopause — the basis for the point above about antidepressants.
NG23 recommends HRT for vasomotor symptoms and notes it may improve associated low mood, with CBT as an alternative or adjunct.
FSRH (Faculty of Sexual and Reproductive Healthcare) guidance covers contraception in the perimenopause, including when contraception can be stopped and the use of the levonorgestrel intrauterine system as the progestogen component of HRT.
Yes — that is exactly what perimenopause is. Periods continuing is why the connection so often is not made, and why women are treated for anxiety or insomnia for two years first.
No. Hormones fluctuate erratically through the transition, so one sample can look entirely normal in someone with unmistakable symptoms.
Your symptoms are the diagnosis. A normal FSH should not be used to refuse you treatment.
Yes. You do not have to wait, and waiting has no clinical advantage.
You will still need contraception, since HRT does not provide it.
Falling and fluctuating oestrogen affects mood regulation directly, and anxiety arriving in your forties without an obvious cause is a common presentation.
It is frequently treated as primary anxiety — which is worth questioning if it started alongside cycle changes or worsens premenstrually.
Possibly, and it should be checked. An underactive thyroid produces near-identical symptoms and is treated entirely differently.
Iron deficiency does the same, and heavy perimenopausal periods are a common cause of it.
Commonly four to eight years. That is long enough that "waiting it out" is not a neutral choice.
No. Perimenopause commonly begins in the mid-forties and can start in the late thirties.
Under 45 is worth investigating properly rather than dismissing, because early menopause is managed differently.
A three-month symptom and cycle diary. It converts "I have not felt right" into a pattern, and a pattern is considerably harder to dismiss.
August 23, 2026
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