Menopause & Perimenopause
Menopause - A guide to a changing rhythm not a cliff edge
A guide to a changing rhythm not a cliff edge
Clinical review September 2026
Perimenopause is often not a dramatic doorway marked “menopause”. It is more like a rhythm becoming less predictable: periods may change before hot flushes, sleep may unravel before anyone mentions hormones, and symptoms can be annoyingly inventive. Menopause is reached after 12 months without a period when not using hormonal contraception; perimenopause is the transition beforehand.
More than a temperature problem
Falling and fluctuating ovarian hormone production can affect the brain’s temperature regulation, sleep, mood, joints, vaginal and urinary tissues, libido and menstrual pattern. Symptoms vary hugely in type and duration. A hot flush is not a character test, and neither is a good day followed by a spectacularly unhelpful night.
For otherwise healthy people aged 45 or over with typical symptoms, NICE advises that perimenopause and menopause can usually be identified from symptoms and menstrual pattern without hormone blood tests. Tests can be helpful in selected people aged 40–45, or under 40 when menopause is suspected. Hormonal contraception can make both bleeding pattern and blood results trickier to interpret.
Start with the outcome you want to improve
Some people need information, reassurance and practical changes around sleep, alcohol, caffeine, layers or stress; others want active treatment for symptoms that are eroding work, relationships or ordinary enjoyment. Menopause-specific cognitive behavioural therapy can help with hot flushes, sleep and mood for some people. Vaginal oestrogen is highly effective for genitourinary symptoms and is different from systemic HRT; it can often be used long term with review.
Systemic hormone replacement therapy is the most effective treatment for vasomotor symptoms of menopause for many people. Whether it is suitable depends on symptoms, age, medical and family history, uterus status, preferences and risk factors. If a person has a uterus, oestrogen is usually paired with progestogen to protect the endometrium. If they have had a total hysterectomy, oestrogen-only HRT may be used.
Risk conversations should be specific, not scary
The important comparison is not “HRT: good or bad?” but the likely benefit and risk for one person, using one regimen, at one stage of life. Route matters: transdermal oestrogen may be preferred when venous thromboembolism risk is a concern. Breast cancer, previous clots, stroke, liver disease and unexplained vaginal bleeding all change the conversation. Non-hormonal options exist when HRT is unsuitable or unwanted.
Unscheduled bleeding after starting or changing systemic HRT is common initially, but should be discussed—especially if it is heavy, persistent or starts after a period of stability. New bleeding after menopause always deserves assessment.
This is a transition, not an identity
Bone health, cardiovascular health, contraception and sexual wellbeing can all deserve a seat at the review. HRT is not contraception. A later series can explore hot flushes, vaginal and urinary symptoms, sleep, mood, HRT choices and bleeding on HRT in more detail.
Important safety note
This page is for general education and cannot replace individual medical advice. Seek urgent help for severe symptoms, possible pregnancy with pain or bleeding, collapse, confusion, seizure, or any situation in which you feel acutely unwell. A clinician who knows your history can help tailor investigation and treatment.
Further reading