If you are in your late thirties or early forties and have started to feel like "a stranger in your own body", perimenopause may be part of the picture.

Sleep that used to be solid is suddenly fragmented. Your moods swing in ways you don't recognise, and the smallest disagreement leaves you fuming. Your periods are doing strange things, or they never quite went back to normal after you had children. And you may have been told you are too young for the menopause, that it is probably stress, and offered the contraceptive pill.

Dr Mayoni Gooneratne, PHC's Chief Functional Medicine Officer, wants women to know that this is relevant to them, and that it is important to get help.

Menopause and perimenopause are not the same thing

Menopause is a single day. It is defined as the point at which you have not had a period for 12 months.

Perimenopause is the transition that happens before that, and it is the area Dr Gooneratne is most interested in. It can begin at any point in the eight to ten years before menopause.

Why perimenopause starts earlier than most women expect

In the UK, the average age of the final period is 51. That means for many women, perimenopause begins very quietly in their late thirties or early forties.

Often it is not that it has started early. It is that the symptoms have not been picked up and, in Dr Gooneratne's words, "no one's really joined the dots with you."

Many women do not recognise it because they have been taught that menopause means hot flushes and periods stopping. The early signs are far more subtle.

It is the rollercoaster, not the drop

"It's not about the lack of hormones, it's the erratic nature of hormones," says Dr Gooneratne.

Your ovaries are still working, but they release hormones unpredictably. They respond to signals from your brain, and those signals depend on what your ovaries reported a day or a minute before, and on what your brain perceives to be happening in your life at that moment.

Some months oestrogen can spike higher than it did in your twenties. Other months it drops off a cliff. In her words, "that complete rollercoaster is actually what generates the symptoms."

You do not need to understand every detail of that system. What matters is knowing that the symptoms you are having are likely to be linked.

It also explains why a woman can feel far worse at 42 than her mother did at 52. As Dr Gooneratne puts it, "when your periods stop, actually the calm returns."

The first signs of perimenopause

Dr Gooneratne encourages women to look closely at their cycles. That is not always easy, since many women have been taking the oral contraceptive pill for twenty years or more. The clue is not so much a lack of periods as a change in their rhythm.

Signs to notice include:

  • Cycles becoming longer or shorter
  • Periods becoming heavier or lighter
  • Breast tenderness you never used to have
  • New PMS, or PMS that has changed character, with more irritability, more anxiety and sometimes rage
  • Sleep that breaks at 3am to 4am when nothing is wrong
  • Brain fog
  • Achy joints
  • A new sensitivity to alcohol
  • Headaches around your period that you have never had before

Why sleep is such an important clue

Dr Gooneratne pays close attention to sleep, because the time a woman wakes can tell her different things. Waking between 3am and 4am when nothing is wrong is often hormonal.

What a ten-minute appointment can miss

"I say this with real respect for GPs, the time simply isn't there," says Dr Gooneratne.

A typical ten-minute appointment often focuses on whether this is the menopause or not. That comes down to a definition and a blood test that measures follicle-stimulating hormone (FSH). It does not factor in the years of change that come before.

How Dr Gooneratne approaches perimenopause

Dr Gooneratne spends 90 minutes taking a thorough, full history. "I want to know what changed first, because the sequence often for me tells what's going on."

She also screens out the common mimics, which can produce similar symptoms or make perimenopause harder:

  • An underactive thyroid
  • Low iron
  • Gut dysfunction

Hormonal contraception, including a hormonal coil, can mask everything, because no one is seeing your natural cycle. That is a conversation worth having, rather than accepting that this is just how things are.

If your periods stop before 40, do not wait

Dr Gooneratne is clear on this point. If your periods have stopped or become very infrequent under the age of 40, that needs proper assessment.

Premature ovarian insufficiency, defined as periods stopping completely under the age of 40, has its own specific considerations: bone health, cardiovascular health and the need for hormonal support until at least the average age of menopause.

If that is you, push for a referral, and in her words, "don't be simply reassured about it all."

What to do next

You do not need to wait for your periods to stop to take these changes seriously. Start by noticing the rhythm of your cycle, how you are sleeping and how your mood has shifted. Those signals are the start of the window in which you can act.

If you are also noticing that your energy, recovery and weight no longer respond the way they used to, read why your body feels different in your 40s.

Frequently Asked Questions

What are the first signs of perimenopause?

Early signs of perimenopause are often subtle. They include cycles becoming longer or shorter, heavier or lighter periods, new breast tenderness, new or changed PMS with more irritability, anxiety or rage, waking at 3am to 4am, brain fog, achy joints, a new sensitivity to alcohol and headaches around your period that you have never had before.

At what age does perimenopause start?

Perimenopause can begin at any point in the eight to ten years before menopause. With the average age of the final period in the UK at 51, many women start to notice changes quietly in their late thirties or early forties.

Am I too young for perimenopause?

Probably not, if you are in your late thirties or early forties. Perimenopause can start up to ten years before menopause. Often it has not started unusually early; the symptoms have simply not been picked up, because many women expect menopause to begin with hot flushes and periods stopping.

I have been told I am fine. Could it still be perimenopause?

Yes. A short appointment often focuses on whether you are menopausal, which comes down to a definition and an FSH blood test. That does not account for the years of change before menopause. If your sleep, mood or cycle have changed, it is worth a fuller conversation that looks at what changed first.

What is the difference between perimenopause and menopause?

Menopause is a single point in time, defined as 12 months without a period. Perimenopause is the transition that comes before it, when hormones fluctuate and the first symptoms appear, often years before periods stop.

Why do perimenopause symptoms come and go?

Perimenopause is driven by erratic hormones rather than simply falling hormones. Some months oestrogen can spike higher than it did in your twenties, and other months it drops sharply. That rollercoaster is what generates the symptoms, which is why they can vary so much from month to month.

Can a blood test show perimenopause?

A blood test measuring follicle-stimulating hormone (FSH) can show whether you are menopausal. Perimenopause is the window before that point, so a full history, including what changed first and in what order, together with your cycle, sleep and mood, tells you far more.

Can the contraceptive pill or a coil hide perimenopause?

Yes. Hormonal contraception, including a hormonal coil, can mask the signs of perimenopause because your natural cycle is not visible. If you are using hormonal contraception and something has changed, it is worth discussing rather than accepting it.

Why do I wake at 3am in perimenopause?

Dr Mayoni Gooneratne notes that waking between 3am and 4am, when nothing else is wrong, is often hormonal. Sleep that was once solid and is now fragmented is one of the most common early signs of perimenopause.

Can perimenopause cause rage and anxiety?

Yes. Many women notice new premenstrual symptoms, or PMS that has changed character, with more irritability, more anxiety and sometimes rage. These changes can be an early sign of perimenopause rather than simply stress.

Is it perimenopause or just stress?

Many women are told their symptoms are probably stress. Stress does play a part, because the signals your brain sends to your ovaries are shaped by what your brain perceives to be happening in your life. But fragmented sleep, changing cycles, new PMS and brain fog together are likely to be linked, and are worth looking at as possible perimenopause rather than being put down to stress alone.

What is premature ovarian insufficiency?

Premature ovarian insufficiency is defined as periods stopping completely before the age of 40. It needs proper assessment because it has specific implications for bone health, cardiovascular health and hormonal support until at least the average age of menopause. If your periods have stopped or become very infrequent before 40, push for a referral.

Can I still get pregnant during perimenopause?

Yes, it is still possible. During perimenopause your ovaries are still working, releasing hormones erratically rather than stopping altogether, so pregnancy can still happen. If you do not want to become pregnant, talk to a clinician about contraception until menopause has been confirmed.

Do I really need to do anything about perimenopause?

You do not have to wait for your periods to stop. Perimenopause is a window of opportunity, when the changes are starting and you can begin to do something about them. Rather than accepting that this is just how things are, it is worth having the conversation and looking at the whole picture, including your cycle, sleep, mood and the common mimics such as thyroid, iron and gut health.