Menopause is defined as the point at which you have not had a natural period for 12 months. The transition up to this point is often referred to as perimenopause or premenopause. Many women who do not have a regular period will not know when this is. For example: those on progesterone-only contraception such as POP or IUS; patients who have had their heavy periods treated with endometrial ablation/myomectomy; or those without a womb but whose ovaries remain. 
Often perimenopausal symptoms will develop gradually and can start at any age! Our advice would always be do not to wait until you have missed periods for 12 months to seek advice. Seek advice as soon as you start to feel you might be developing any of the symptoms of hormone imbalance as early treatment can be beneficial.

Menopause symptoms and perimenopause symptoms can be very similar as they are often due to low or fluctuating levels of important women’s hormones oestrogen, progesterone and testosterone. Due to the widespread presence of sex hormone receptors throughout the body the symptoms and signs can literally impact us from head to toe.

Headline menopause symptoms include, changes to menstrual cycles and periods, hot flushes/flashes, night sweats, weight gain and vaginal dryness.

Often the first signs of menopause and perimenopause are subtle. Early premenopausal or peri-menopause symptoms include new or increasing anxiety, feeling tense or overwhelmed, panic attacks, irritability, mood swings, loss of interest in things, difficulty sleeping, low mood, loss of confidence and self-esteem, memory problems, difficulty concentrating, and brain fog. Early physical symptoms include changes to cycle length, duration and flow during periods, difficulty maintaining weight, night sweats or feeling hot at night, daytime hot flashes/flushes, tiredness, fatigue, low energy, skin, hair and nail changes, palpitations or thumping sensations in the chest, difficulty breathing, increased headache frequency, joint and muscle aches and pains, numbness and pins and needles, recurrent thrush, cystitis and urinary tract infections, painful sex, libido loss and changes to sexual arousal.

Hormone replacement therapy is replacing the reproductive sex- hormones that fluctuate during perimenopause and replaces the hormones that are persistently low postmenopause: most commonly 17beta-estradiol, estriol, progesterone and testosterone. Broadly, we need these to maintain normal function in all the cells of the body! Hence the wide range of symptoms that affect all systems of the body when in insufficient/deficient state.

There is no defined time frame and the accepted advice is that a person can stay on HRT for as long as they require provided regular review to ensure ongoing prescriptions remain in the patients best interests. An annual review for individualised management taking into account the risks vs benefits is best practice. It can be helpful to have a regular “break” to determine if symptoms have settled to a tolerable level. The aim is always to ensure the lowest necessary dose of HRT to manage symptoms effectively.

You should not need to suffer unnecessarily for any duration of time if you have symptoms that are causing you difficulties. Unfortunately, there are many health care professionals who  were taught through their training that HRT was not safe and as such many patients cannot access appropriate treatment due to fear of harm being caused. If you are being asked to wait for a defined period of time before you will be allowed the treatment you require, I would consider seeking a private perimenopause assessment. We can often tailor a treatment plan and request your NHS GP to take on prescribing of this once your symptoms have been stabilised.

HRT remains the most effective way of managing the root cause of perimenopause and menopause symptoms. However, there are additional and alternative things to consider alongside or in place of HRT. These are particularly important for women who are unable to use HRT for safety reasons.

Anti-anxiety and anti-depressant medications help women struggling with mental health issues and hot flushes and can be taken alongside or instead of HRT. There are new drugs in development on the horizon too. Calcium, Vitamin D and bisphosphonate medications are important for bone health particularly for women who cannot safely use HRT.

Specialist Women’s Health and Pelvic Physiotherapists are a valuable resource to consider for Musculo-skeletal and pelvic health problems.

There are  “4 pillars” that are relevant to non-hormonal health too:

Nutrition: broadly, aim for stable blood sugar levels and a diverse gut microbiome by eating a high-fibre, whole-food and plant-rich diet with plenty of omega-3’s and calcium. We get very little vitamin D in the diet so  a supplement at 1000iu daily unless you are deficient. Cut down or cut out alcohol – it really doesn’t help with symptoms or health and well-being in the long term. If you have a healthy varied diet you are likely to get enough of the micronutrients that you need but if you are looking for supplements consider one that as well as Vitamin D contains B6 and b12, magnesium and maybe collagen. There is no strong research evidence supporting the use of specific herbal supplements.

Movement & Exercise: move as much and often as possible and try to introduce a variety of activities to challenge the body in broader ways. Pilates, yoga, strength and weight-training, conditioning, steady-state cardiovascular exercise and low-intensity movement such as walking are all important to consider.

Sleep: prioritise it. Avoid late night blue-light. Increase early morning and daytime daylight to naturally improve melatonin levels. Avoid caffeine after lunch and avoid alcohol which disrupts sleep. Get regular exercise and arm yourself with some relaxation and mindfulness techniques. Consider guided online CBT for insomnia.

Stress-management: Notice thoughts and feelings and how they affect your body and breath. Learn some breathing, relaxation and mindfulness exercises to help down-regulate your stress response. Recognise your warning signs and take pre-emptive action. Snatch moments of mindfulness, sprinkle in and micro-dose with acts of self-care. Share and cultivate nourishing relationships in which you can be honest. Be kind to yourself and approach challenges with Curiosity. Learn to say no, set boundaries, and stick to them.