Symptoms affect everyone differently, so how can you tell whether you’re in perimenopause, and when should you seek help?

What are the symptoms of perimenopause?

When people talk about the symptoms of menopause, they are actually talking about perimenopause symptoms, which can be physical, mental and emotional.

Common symptoms include:

Why are symptoms so variable?

Some symptoms clearly point to perimenopause, such as changes to the menstrual cycle, while others are harder to define, like brain fog and muscle or joint pain.

“Some of those things you just put down to getting older,” Messenger says.

“It’s a time when women are often very busy in terms of career, family – often both ends, so kids and parents. So they don’t necessarily think of it as being [about] their hormones, they think of it as being all those other things that are happening for them that are contributing to their symptoms.”

Some women don’t experience any symptoms until their periods stop for good. Some don’t experience hot flushes, while others get cold flushes.

“Other people [get] years of fluctuating temperature and impossible-to-control bleeding that’s haywire, you get these sudden [mood] swings to being irrational or irritable.”

Some symptoms are worsened by a lack of sleep due to hot flushes, or poor sleep can be a symptom in itself.

“If you’re not sleeping you’re going to have no concentration and you’re not going to be able to remember things, but sometimes that brain fog is a symptom in its own right,” Messenger says.

“That’s why it all becomes really difficult to unpick, because it’s not necessarily straightforward even within one person – because if you look at where you have oestrogen receptors, it’s everywhere.”

Dr Rachael Sumner, a neuroscientist and senior lecturer in biomedicine and medical diagnostics at the Auckland University of Technology, says perimenopause is similar to puberty in that it changes the body’s reliance on certain hormones.

“Just like puberty, we all know people who breezed through it with minimum discomfort, but we also all know people [for whom] that adjustment period was really tough on the body and it was really tough on their mental health.

“Perimenopause is a little bit like that… because some people’s bodies do accommodate it relatively healthfully, but there’s these massive changes that leave space for disorders to come in… like unhappy changes to skin, vaginal dryness, but also mental health.”

She says it’s similar to how people can have different experiences on the same medications.

“Drugs and hormones all go into the bloodstream, and there are parts of the brain and the body that attract them and they bind into those various areas and have activity… we all have individual differences in how many of those receptors we have, where they are, how dense they are. We also have differences in our liver that determine how quickly we break down drugs, but also hormones.”

What is the mental impact of perimenopause?

Symptoms don’t just have a physical impact – they can affect intimate, family and workplace relationships and friendships.

“People can withdraw socially. If you’re feeling really tired, if you’re feeling irritable with things, you’re probably not going to want to go out, and then that doesn’t actually help your mood and wellbeing,“ Messenger says.

“[Exercise and strength training may be] things you’ve never quite got round to, and now they’re incredibly hard to prioritise when you feel busy and overwhelmed by all the other things that are happening.”

Perimenopause also has an impact on brain health, Sumner says.

That’s because it changes the levels of oestrogen and progesterone, which are essential hormones for healthy brain function.

“Oestrogen is really important for memory and the brain is coming off its dependence on one form of oestrogen and it’s going on to its dependence on another form of oestrogen,” she explains.

“From that perspective, it’s [like] adding or removing a drug in the body, and the real impact of that is changes in our ability to concentrate, our ability to learn, our ability to remember.”

How is perimenopause diagnosed?

“There isn’t a blood test we can do that goes, this is perimenopause,” Messenger says.

That’s because during this phase, hormone levels vary at different times in the cycle, making blood tests hard to read.

She says a more effective tool is a modified Greene scale, which lists symptoms for women to score according to their own experience.

“Sometimes it’s still not really clear… it looks like perimenopause, we’ll give some oestrogen, get them to repeat the score, [and if] things are looking better, we’re like, ‘Great, [it’s] perimenopause, we’re on the right treatment’.

“Sometimes the score isn’t any better, so is that because it’s not perimenopause or is it because we haven’t got the dose right yet?”

How can you treat perimenopause?

There are multiple funded types of hormone therapy available in New Zealand, which means finding the right treatment can sometimes involve trial and error.

And hormone therapy isn’t necessarily right for everyone, Messenger says.

“If you have symptoms then yes, I would say you probably should go and have a conversation with somebody about what you might do about it. But it depends on how much your symptoms are affecting you.

“We certainly are not at the point where we would say everyone in perimenopause ought to be on treatment, unless they’re under 45 at menopause. Women who are menopausal before the age of 45 should be on hormone therapy – we have really good evidence that it’s going to improve outcomes for them. For everyone else, it’s not so clear-cut.”

There are also risks that come with hormone therapy. Combined hormone therapy, which includes oestrogen and progesterone, is known to slightly increase breast cancer risk.

Oestrogen given alone without progesterone to balance it can overstimulate the cells lining the uterus, which can lead to uterine cancer. Taken in tablet form, the hormone increases the risk of lung and leg blood clots, while patches don’t pose that risk.

“There’s a lot of perception out there that [perimenopause is] a natural part of life or that it’s not that bad, because for some people it really isn’t,” Sumner says.

“But for some people it is medically bad and they deserve help, and there are things that are worth trying.”

Bethany Reitsma is a lifestyle writer who has been with the NZ Herald since 2019. She specialises in all things health and wellbeing and is passionate about telling Kiwis’ real-life stories.