Perimenopause vs menopause: what is the difference?

Key takeaways

• Perimenopause is a process. Menopause is a date you only know looking back, after 12 months without a period.
• In perimenopause, hormones fluctuate wildly. After menopause, estrogen stays low and steady.
• Symptoms such as hot flushes often peak in the late transition and can continue for years after menopause.
• You can get pregnant in perimenopause but not after menopause is confirmed.
• Any bleeding after menopause is not normal and should be checked promptly.

What are the three stages, side by side?

People don't understand what is peri and what is menopause. Everyone uses "menopause" to mean the whole experience. Doctors use the words more precisely, and the difference matters, because the risks, tests and treatment options change from stage to stage. I explain it like a train journey. Perimenopause is the journey itself, with all its jolts. Menopause is one station. Postmenopause is the rest of the line after that station.

The Indian ages come from a pan-India survey by the Indian Menopause Society, which found perimenopause beginning at about 44.7 years and natural menopause at about 46.2 years on average. Individual women vary a lot.

How do doctors tell which stage you are in?

The international staging system used by researchers and clinicians (called STRAW+10) relies mainly on your periods, not on blood tests:

• Late reproductive years: periods still regular, but cycles may become a little shorter.
• Early menopause transition: your cycle length changes persistently by 7 days or more. For example, a 28-day cycle becomes 21 days one month and 35 the next.
• Late menopause transition: you go 60 days or more without a period at least once. Hot flushes are most common around here.
• Menopause: confirmed after 12 months with no period.

The NICE guideline (NG23) follows the same logic. For women over 45, perimenopause is diagnosed from symptoms plus irregular periods, and menopause from 12 months without a period, without needing hormone tests.

Why do symptoms feel worse in perimenopause than after?

This surprises so many women. You would expect symptoms to be worst once estrogen is at its lowest. In practice, it is the swings themselves that cause much of the trouble.

See, I'll tell you how I explain it. In perimenopause, one week your estrogen may be higher than it ever was in your 30s, causing sore breasts, heavy bleeding and irritability. The next week it drops sharply, bringing hot flushes, poor sleep and low mood. The body is constantly readjusting, like a car that keeps braking and accelerating in Thane traffic. After menopause, estrogen is low but stable, and for some women the roller-coaster settles.

That said, symptoms don't always stop at menopause. In the large SWAN study, women with frequent hot flushes had them for a median of 7.4 years in total, and they continued for a median of 4.5 years after the final period. Women whose flushes started early, while periods were still regular or only just changing, had the longest duration.

Does the stage change your treatment?

Yes, in several practical ways.

Hormone therapy regimen. If you still have a womb and still have periods, combined hormone therapy is usually given in a sequential pattern, which produces a monthly bleed. Once you are postmenopausal, a continuous combined pattern is usually used, aiming for no bleeding. Women who have had a hysterectomy usually need estrogen alone. See Menopausal hormone therapy explained.

Contraception. Perimenopausal women still need contraception if they want to avoid pregnancy. Hormone therapy at menopausal doses is not a contraceptive.

Bleeding. Irregular or heavier bleeding is common in perimenopause, but some patterns still need investigation (see Heavy periods in your 40s). After menopause, any bleeding, even a small spot, needs prompt assessment.

Long-term health. Once estrogen stays low, bone loss speeds up and heart risk factors such as cholesterol tend to shift. This is when a bone density (DEXA) scan, blood pressure, sugar and lipid checks become more important.

Why does the "wait one year" approach cause problems?

Many women are told to wait until their periods have stopped for a year, and then come back. The trouble is that the worst symptoms often happen before that year is over. A year of no sleep, a year of snapping at your family, a year of struggling at work.

Waiting a full year to confirm menopause before treating is like getting down one stop after yours. You do reach somewhere, but you have to walk back a long way for no reason. Perimenopausal symptoms can be assessed and treated while you are still having periods. Guidelines do not require you to reach menopause first.

What do the words you may hear actually mean?

• Climacteric: an older term for the whole transition.
• Surgical menopause: menopause caused by removal of both ovaries.
• Premature ovarian insufficiency (POI): ovaries stopping before 40.
• Early menopause: menopause between 40 and 45.
• Vasomotor symptoms: the medical term for hot flushes and night sweats.
• Genitourinary syndrome of menopause: dryness, discomfort and bladder changes due to low estrogen.

How I approach this at Dr Tvacha

At Cocoon × Dr Tvacha in Thane West, I work out your stage from your periods and symptoms, check for anything else that could be contributing, and explain which options fit that stage. You don't need to wait for your periods to stop before coming in. The Right Stop Programme for women 40 and above is described on our women's health page, and you can read more about the early phase in What is perimenopause?

Written by

Dr Anagha KarkhanisGynaecologist and Fertility Specialist · Reg. No. 2006/02/1187

Leads midlife women's health at Cocoon × Dr Tvacha, Thane.