While the menopause occurs as a single day in a woman's life – when the ovaries cease producing hormones – the time leading up to this life-changing event can last for several years. This extended period in a woman’s life is referred to as the perimenopause.
On average, women hit the menopause at 51 years old, so the majority of women will begin experiencing perimenopause symptoms in their mid-40s. And these symptoms can vary wildly between individuals. Hot flushes and irregular, heavy periods are often noted as the tell-tale signs, but they’re not necessarily experienced by everyone.
And even within an individual, the type, frequency and intensity of symptoms are prone to change.
More than 75 per cent of women report suffering from various symptoms and around 25 per cent say the symptoms have a significant impact on their quality of life. These include sleep disturbance, anxiety and weight gain.
But these symptoms have a history of being overlooked by professionals and are often written off as being a result of other medical conditions.
Symptoms and treatments
Trouble sleeping or staying asleep is often the first symptom. This can start as early as in the late 30s or early 40s, and it’s relatively common. Studies show that as many as 60 per cent of women aged 40 and over are affected by insomnia.
Other symptoms can include changes in mood – women may experience unprompted anger, irritability, sadness and depression.
This can be in addition to symptoms such as brain fog, memory issues, difficulty concentrating, joint and muscle pain, vaginal dryness, low sex drive, and discomfort and pain while having sex.
Despite this, women going through the perimenopause often put off seeing a doctor due to embarrassment or not wanting to ‘cause a fuss’. Seeking medical advice is, of course, important, but there are currently no tests for perimenopause or menopause in women over the age of 45.
This means it’s vital to track any symptoms being experienced, to provide a record of what’s happening and when it occurs. Sharing this with a doctor allows them to get a sense of a woman’s experience and determine the best treatment options.
For example, there’s solid evidence that shows the benefits of hormone replacement therapy (HRT) as per guidance from the National Institute for Health and Care Excellence (NICE), in particular to reduce the effect of hot flushes and night sweats.
HRT has also been shown to help some women sleep better and can, in some cases, reduce negative cognitive symptoms. In addition to, or instead of HRT, studies have shown that cognitive behavioural therapy (CBT) can help manage issues with blood flow that also arise, as well as potentially assist in stabilising mood and sleep patterns.
It’s now considered an outdated practice to prescribe the blood pressure medicine clonidine and antidepressants as first-line treatments, however.
Other studies have found that HRT can also help maintain bone-mineral density and reduce the risk of osteoporotic fractures in later life.
HRT is an umbrella term that covers many types of medication – oestrogen, combined oestrogen and progestogen (another female sex hormone), and testosterone. It can be taken in several ways, most commonly via a patch or gel.
The type and dose of HRT depends on the symptoms being managed, the risks to the individual and their preferences. There’s no arbitrary cut-off time or age for taking HRT. It comes down to the benefits outweighing the perceived risks.
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New research
For women taking HRT, there’s the potential additional benefit of a reduced risk of colorectal cancer and type 2 diabetes. And if oestrogen, taken as part of HRT, is started early in perimenopause, studies show there may also be an additional reduced risk of coronary heart disease and Alzheimer’s.
In particular, the benefit of cardiovascular disease prevention is seen only in women starting HRT in their 50s compared to women who started after turning 60.
But HRT isn’t recommended to be started solely for the prevention of cardiovascular disease and dementia. There are known risks for certain types of HRT treatments, including a risk of womb cancer if oestrogen-only HRT is given without protection against the effects of progestogen, and an increased risk of blood clots.
The major concern is the prevalence of breast cancer. This is a very complex area due to old clinical trial data and the variation in risk related to personal and family medical history, as well as lifestyle behaviour such as alcohol consumption and obesity.
This in turn affects the clinical significance of the data to an individual.
Current evidence suggests that oestrogen-only HRT is associated with little or no change in the risk of breast cancer, while combined HRT can be associated with an increased risk of an additional three or four cases per 1,000 women.
Alternative treatments
Topical oestrogen HRT, when applied locally, has been shown to be very effective in managing and preventing significant consequences of vulval and vaginal soreness and dryness, and the occurrence of recurrent urinary tract infections.
Additionally, testosterone treatments, prescribed alongside oestrogen, may also help some women struggling with low sexual desire.
Unfortunately, HRT can’t be touted as a cure for everything, though. A review of current clinical trial evidence hasn’t shown any improvement in the cognitive function, bone density, body composition, muscle strength or psychological wellbeing of the women on the treatment.
And many women may not want to take HRT, such as those with a history of breast cancer.
Previously, alternative treatments have been limited and focused mostly on the use of antidepressants and clonidine. This was found to have limited effectiveness and awful side effects. Recently though, a new non-hormonal drug – fezolinetant – has been licensed to help manage problems with blood flow.
Natural relief
Aside from medication, lifestyle and behaviour changes – sleep, physical activity and nutrition – have no risk factors associated with them and can provide significant benefits.
Sleep is often the best place to start, as it’s much easier to focus on increasing activity and improving diet when you’re getting restful and restorative sleep.
Good sleep hygiene, no screens before bed, a consistent sleep routine, and developing good sleep patterns with the help of CBT have been shown to improve insomnia and other sleep disturbances in women going through the perimenopause.
Raising activity levels is also a great help – focus on exercise that builds and maintains muscle and bone density, such as strength training. This helps to prevent osteoporosis, retain flexibility and reduce insulin resistance.
Long-term heart and brain health can also be improved by aerobic exercise such as running, swimming and cycling. And, as at any stage in life, a balanced diet, consisting of fresh food with minimal ultra-processed products, can be beneficial.
Going through perimenopause can be difficult, but there’s a variety of proven interventions that can make the journey easier to navigate.
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