Symptoms and solutions

The thing nobody tells you

For most women, perimenopause does not arrive as hot flushes. It arrives as a list of small, strange things that don’t obviously belong together. You start to feel that something has changed without being able to name what. Your hair feels different. Your skin itches. You wake up at 3am. You forget words. You become weepy at things that didn’t use to make you cry.

By the time the hot flushes arrive, you may have been in perimenopause for years. Nobody told you that. The leaflet skipped that part.

By the time the hot flushes arrive, you may have been in perimenopause for years. Nobody mentioned this. That isn’t your fault.

The big ones everyone knows about

• Hot flushes and night sweats. The headline ones. Sudden waves of heat, often with sweating, often with a racing heart. They can last 30 seconds or several minutes.
• Disrupted sleep. Waking at 3am, drenched. Or just waking at 3am for no reason. Or not getting to sleep at all.
• Periods changing. Heavier, lighter, irregular, gone for three months and back. All of it.
• Brain fog. Walking into rooms and forgetting why. Losing words. Re-reading the same paragraph six times.
• Mood changes. Anxiety, low mood, irritability, rage. All of it without an obvious cause.

The quieter ones, that you might not have connected

• Joint pain and muscle aches. Especially in the morning.
• Dry eyes, dry mouth, dry skin. The whole body running drier.
• Itchy skin. Sometimes itchy scalp. Sometimes a creeping sensation under the skin (formication, real word, real thing).
• Heart palpitations. Often at rest. Often disturbing.
• Tinnitus and changes to hearing.
• Increased sensitivity to alcohol. Two glasses of wine now means three days of hangover and brain fog.
• Sensitivity to noise, light, labels on clothes, perfume, anything sensory.
• Loss of confidence. Sometimes catastrophic, in someone who has never lacked it before.
• Imposter syndrome arriving for the first time in your 40s or 50s.
• Urinary urgency and frequency. UTIs that keep coming back.
• Vaginal dryness and pain during sex. See Dryness, pain and what helps.
• Loss of libido. See When the desire goes.
• Hair changing. Thinning on the head. Appearing in places it didn’t before.
• Weight redistribution. The same diet, a different shape. Often around the middle.
• Restless legs at night.
• Dizziness. Sometimes vertigo.
• A new kind of tiredness that sleep doesn’t fix.

“I thought I was losing my mind”

Most women have a version of this moment. You sit in the car park before going into the supermarket and cry, and you don’t know why. Or you can’t remember your colleague’s name in a meeting. Or you have a heart palpitation in bed and convince yourself you are dying. Or you read the same sentence eight times and still can’t hold it.

It is not dementia. It is not depression on its own. It is not a personality change. It is, very often, perimenopause doing its quiet work. Tell your GP. Ask for a proper conversation. Don’t accept five minutes and a generic antidepressant.

It is not dementia. It is not you becoming a worse person. It is a body running on different chemistry, asking for help.

What actually helps

For most women, the most effective single thing is HRT, prescribed properly. It isn’t the only thing, and it isn’t right for everyone, but it is the conversation worth having first.

• HRT. Modern body-identical HRT (patch or gel for oestrogen, separate progesterone if you still have a womb) is safer and gentler than the older versions, and works on most of the symptoms above.
• Vaginal oestrogen, separately, for the dryness and pain. Different thing. Almost everyone can have it. See Dryness, pain and what helps.
• Sleep, protected fiercely. Everything is worse without it.
• Strength training, twice a week. The single most underrated thing for women in midlife.
• Protein at every meal. Fist-sized portion, three times a day.
• Reducing alcohol. Most women find this gets harder around 45. Not a moral failing.
• CBT for menopausal symptoms. Actually evidence-based, especially for hot flushes and sleep. Available on the NHS in some areas.
• See Lifestyle and self care for the longer version.

How to have the GP conversation

Don’t soften your symptoms. Don’t apologise. Write a list before you go. Bring it.

Say the word menopause out loud. Say perimenopause out loud, especially if you are under 50. Say what is happening, and how long, and how much it is affecting your life.

If your GP dismisses you, say: “I would like to be seen by another GP, or referred to a menopause specialist.” You are allowed to ask.

If you can stretch to it, a one-off private menopause appointment can be the thing that unlocks NHS treatment afterwards.

Our Letter Generator can draft a letter to your GP in advance, if the words aren’t coming.

When to push harder

If you have been dismissed more than once. If you have been told you are too young (perimenopause can start in your late 30s). If you have been offered antidepressants without anyone discussing HRT. If your symptoms are seriously affecting your work or family life. These are all reasons to ask, firmly, for a different conversation.