What is perimenopause? Signs to look for in your 40s

Key takeaways

• Perimenopause is a phase, not a single event. Menopause is the one day that marks 12 months without a period; perimenopause is the years leading up to it.
• In an Indian Menopause Society survey, perimenopause began at about 44.7 years on average, and natural menopause came at about 46.2 years, earlier than in Western women.
• Hormones do not fall in a straight line. They swing, which is why symptoms come and go.
• For women over 45 with typical symptoms, guidelines say diagnosis is based on symptoms and period pattern, not a blood test.
• You can still get pregnant in perimenopause, and heavy or irregular bleeding still needs checking.

What actually happens in perimenopause?

People don't understand what is peri and what is menopause. Most women think menopause is the day the periods stop, and that everything before it is "normal". But the years before that day are where so much happens.

Through your 30s, the ovaries release an egg most months and produce estrogen and progesterone in a fairly steady rhythm, like a well-tuned clock. As the number of eggs falls, that rhythm becomes unreliable. Some months you ovulate, some months you don't. Some months estrogen spikes higher than usual; other months it drops low. The youthful estrogen we had all our lives stops arriving on schedule.

See, I'll tell you what this looks like in real life. So often a woman in her early 40s comes in saying her periods are suddenly heavier, her sleep is broken, and she snaps at her children over small things. Her reports are normal. She feels dismissed. Nothing is "wrong" on paper, but her hormones are on a seesaw, and her body is reacting to every swing.

Perimenopause ends when periods have stopped for a full 12 months. After that, you are postmenopausal.

At what age does perimenopause start in Indian women?

Indian women tend to reach this stage earlier than the figures you read in Western articles. A pan-India survey by the Indian Menopause Society, covering 2,108 women across 21 cities, found:

These are averages. Mayo Clinic notes that some women notice changes in their late 30s, and others not until their 50s. If you are 40 and noticing a cluster of the signs below, it is reasonable to ask whether this is perimenopause.

What are the signs of perimenopause in your 40s?

The NHS lists a wide range of symptoms. Most women have a few, not all. The ones I hear about most at my desk are:

Period changes - Cycles getting shorter (for example every 21 to 24 days instead of 28), then later longer and more irregular - Heavier flow, clots, or periods lasting longer than before - Worse premenstrual symptoms: bloating, breast tenderness, irritability

Body temperature and sleep - Hot flushes: a sudden wave of heat over the face, neck and chest, often with sweating - Night sweats and waking at 2 or 3 am, unable to fall back asleep - Palpitations, a fluttering or racing heartbeat

Mind and mood - Anxiety that feels new or out of proportion - Irritability, low mood, tearfulness - Brain fog: forgetting words, losing your train of thought, struggling to concentrate

Other changes - Joint and muscle aches, especially in the morning - Weight settling around the middle - Dry skin, thinning hair, vaginal dryness, more frequent urine infections - Headaches or migraines that change pattern

The line I hear most often is simple: "I don't feel like myself anymore." That sentence matters more to me than any single symptom.

How is perimenopause diagnosed?

The UK's NICE guideline (NG23) is clear. In women over 45, perimenopause is diagnosed from symptoms such as hot flushes plus irregular periods. Blood tests for FSH, AMH or estradiol are not needed and can mislead, because hormone levels swing from day to day in this phase. A normal result on Tuesday does not rule out perimenopause on Friday.

Testing is more useful in certain situations: - If you are 40 to 45 with symptoms and period changes, an FSH test may be considered. - If you are under 40 with symptoms, tests are needed to check for premature ovarian insufficiency. - If symptoms could be from something else, tests for thyroid, anaemia, vitamin D, sugar or other conditions help sort that out.

You can read more in Do you need a hormone blood test to diagnose perimenopause?

What else could it be?

Several common conditions overlap with perimenopause, which is why a proper consultation matters:

• Thyroid problems can cause fatigue, weight change, palpitations and period changes.
• Iron-deficiency anaemia, very common in Indian women, causes tiredness, breathlessness and poor concentration, and heavy periods make it worse.
• Diabetes and prediabetes can cause fatigue and frequent urination.
• Depression and anxiety disorders can exist alongside perimenopause or independently.
• Fibroids, polyps or a thickened lining can cause heavy or irregular bleeding.

Symptoms are symptoms. The point is to find out what is driving them, not to label everything as "age" or "stress".

What can you do about perimenopause symptoms?

Treatment depends on which symptoms bother you and on your health history. Broadly, the options are:

1. Understanding and tracking. Note your period dates, flow, sleep, flushes and mood for two or three months. A simple phone note is enough. It makes your consultation far more useful.
2. Lifestyle foundations. Strength training, enough protein (dal, paneer, curd, eggs, soya, chana), less alcohol, and a regular sleep routine help energy, mood and weight.
3. Menopausal hormone therapy (MHT). For many women, MHT is the most effective treatment for hot flushes and night sweats. It is a prescription decision made after assessing your personal risks. See Menopausal hormone therapy explained.
4. Non-hormonal medicines and therapies. For women who cannot or prefer not to take hormones, there are options such as certain antidepressant-class medicines at low dose, gabapentin and cognitive behavioural therapy. See Non-hormonal treatments for hot flushes.
5. Treating the specific problem. Heavy bleeding, low iron, poor sleep or anxiety may each need their own plan.

How I approach this at Dr Tvacha

At Cocoon × Dr Tvacha on the 2nd floor of Suraj Arcade, Thane West, I take a long consultation that goes through every symptom, order only the tests your history points to, and explain each option before you decide anything. The Right Stop Programme for women 40 and above begins with a Midlife Women's Health Check; you can read how it works on our women's health page or find the centre on our centres list.

Written by

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

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