Perimenopause: What To Expect During The Final Years Of Your Periods

You’re boiling, irritable – and, yes, you still have your period. Welcome to the perimenopause, where you’ll have mood swings, hot flushes and other symptoms of menopause, but with regular monthly bleeding, too.

It’s a condition that can occur years before the menopause, and is relatively rarely discussed. “There is still so little awareness of perimenopause,” says Rachel Lankester, creator of The Mutton Club – an online magazine and community empowering women over 40.

Even if women are aware of perimenopause, they’re often unaware of when to expect it. “When women do know about it, they don’t seem to know when it can start and are often not expecting changes to start until their mid-50s,” notes Lankester. “For most women, menopause is over by then.”

What Is Perimenopause And Its Symptoms?

Menopause is technically the term used to describe when a woman’s periods have completely stopped for a year or longer. In comparison, perimenopause is the name given to the transition women experience before the menopause, explains Dr Alex Eskander, consultant gynaecologist at The Gynae Centre.  

“During this time, the level of oestrogen in the body fluctuates, and due to this, many women experience hot flushes, reduced sex drive, anxiety, vaginal dryness, problems with sleep and mood swings,” he explains.

Perimenopause can last for just a few months or can continue for years, and people experience it at different ages: it usually begins in your 40s, but some women can experience symptoms as early as their mid-30s. 

“This can happen when the ovaries cease producing normal levels of oestrogen – otherwise known as premature ovarian failure,” Dr Eskander explains. 

This can be caused by a number of conditions, including chromosomal abnormalities, autoimmune disease and some infections like malaria. It can also be caused by cancer treatment like radiotherapy or chemotherapy, and can run in families, he adds. 

What Happens To Your Periods?

At first, your periods may not change during perimenopause, which is why many women don’t recognise symptoms like mood swings and sleeping problems until further down the line. 

Women’s periods decrease at different rates, explains Joan Pitkin, a retired consultant gynaecologist and trustee of the British Menopause Society . However, for most women, they’ll experience their periods gradually getting lighter and more spaced apart. 

“Periods may be every three to four months or only one or two per year,” she says. “I have had some women who have been bleed-free for up to 10 months and have thrown away sanitary protection, only to be caught out and have regular monthly bleeds for the next five months.” 

Sometimes, women with spaced out periods can have a very heavy flow with flooding, which is called Perimenopausal Dysfunctional Bleeding (DUB).

It’s important to check with your doctor if you experience heavy flow to make sure you understand its cause. “It is a mistake to assume this heavy bleeding is [necessarily] hormone-related as cancer of the uterus can occur in the late 40s and does not only present with post-menopausal bleeding,” she says. “Unexplained heavy bleeds should always be investigated.”

Do You Still Need To Use Contraception?

Contraception is a “grey area” of perimenopause, says Pitkin. The Family Planning Association (FPA) advises women over 50 to wait until they have been period-free for a year before stopping contraception. If you’re under 50, the advice is to wait until you’ve been bleed-free for two years. 

“This is because conception only requires one rogue ovulation,” Pitkin explains. “Stories of women who were told they were menopausal and then found out they were pregnant are not infrequent.”

Depending on your individual symptoms and overall health, some women may be advised to take a low dose 20ug contraceptive pill by their doctor.

“The pill would provide regular bleeds, contraceptive cover and synthetic oestrogen, which would control sweats and flushes, though hormone replacement therapy (HRT) is more effective for this and bone protection,” says Pitkin. 

Women who are not advised to take the pill by their GP should stick to another form of contraception, such as condoms, to avoid pregnancy. Even post-menopause, women should consider this to avoid STIs. 

What Does It Feel Like To Experience? 

Every woman’s experience of perimenopause is different. While for some, symptoms can have a negative impact on day-to-day life, Lankester didn’t notice any symptoms until a fertility test confirmed she’d reached menopause aged 41. 

“At first it was pretty devastating as I’d been trying for another child. I also felt catapulted into middle age,” she says. “But with time and some reflection I eventually realised I had bought into all the negative narratives around menopause and midlife in general. I was still the vibrant woman I’d always been and perimenopause/menopause didn’t change that at all.” 

She believes many women fear perimenopause because of lack of knowledge “and also because in the west we worship youth”. 

“When perimenopause kicks in women can be very concerned about what it means and what the impact on them will be,” she says. “But only one-third women have a difficult experience with perimenopause/menopause. For many women, it isn’t a problem at all.”

What Should You Do If You Think You’re Perimenopausal? 

Women who are struggling with symptoms associated with permimenopause should visit their GP, who will be able to recommend the best course of treatment. This may be the contraceptive pill, or it may be hormone replacement therapy (HRT), of which there are many different types – it comes in tablets, skin patches, gels and vaginal creams, pessaries or rings.

Lifestyle changes such as exercising more and committing to meditation or mindfulness may also help when it comes to coping with symptoms including mood swings and sleeping problems. 

Lankester also believes it’s crucial that women are positive during this time in their lives. “We’ve dealt with our wombs all our lives and now is not the time to start fighting them. Don’t believe society’s negative narratives about menopause and being an older woman – midlife is your time to shine,” she argues. 

“It’s no surprise that post menopause there are many wonderful dynamic women doing great things in their lives, once we are free of the monthly hormonal roller-coaster.”