Perimenopause and HRT: Symptoms, Diagnosis and Starting Treatment While You Still Have Periods
What perimenopause is, why a blood test is usually not needed, why HRT in perimenopause is set up differently from HRT after the menopause, how it fits with contraception, and which bleeding needs checking.
Part of the Complete HRT Guide.
Key fact: You do not have to wait for your periods to stop to start HRT. Symptoms often begin years before the last period, and NICE guidance supports treating them during perimenopause. The difference is which type of HRT is used: while periods are still coming, the progestogen part is usually given in a monthly cycle, and HRT does not replace contraception.
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See HRT treatments →What perimenopause is
The menopause is a single point in time: the day twelve months after your last period. Perimenopause is the stretch of years leading up to it, when the ovaries are winding down unevenly. In the UK the average age of menopause is 51, and perimenopausal symptoms most often begin in the mid-40s. For most women the transition lasts around four years, but it can be considerably longer.
What makes perimenopause confusing is that hormone levels do not fall smoothly. Oestrogen swings between high and low from month to month, ovulation becomes irregular, and progesterone, which is only produced after ovulation, declines. That is why symptoms come and go, why periods can become heavier before they become lighter, and why one blood test on one day tells you so little.
51
Average age of menopause in the UK
~4 yrs
Typical length of perimenopause, though it varies widely
12 months
Without a period before menopause is confirmed
Symptoms, including the ones people miss
Hot flushes and night sweats are the best-known symptoms, but they are not always the first, and some women never have them. Many of the earliest perimenopausal symptoms are easily put down to stress, workload or getting older.
| Group | What it can look like |
|---|---|
| Periods | Cycles becoming shorter or longer, heavier or lighter, skipped months, worse premenstrual symptoms |
| Vasomotor | Hot flushes, night sweats, palpitations |
| Sleep | Waking in the early hours, often with sweats, and difficulty getting back to sleep |
| Mood | Anxiety, irritability, low mood, loss of confidence, feeling unlike yourself |
| Thinking | Poor concentration, forgetfulness, losing words mid-sentence, often called brain fog |
| Body | Joint and muscle aches, headaches or worsening migraine, tiredness |
| Vaginal and urinary | Dryness, discomfort during sex, more frequent urine infections or urgency |
| Sex drive | Reduced libido |
A useful clue is the pattern rather than any single symptom: several of these appearing together, in your 40s, alongside a change in your cycle. Keeping a simple diary of symptoms and periods for two or three months makes the pattern easier to see, and makes a consultation far more productive.
How it is diagnosed, and when a blood test helps
Many women expect a blood test to confirm perimenopause, and are surprised not to be offered one. NICE guidance is clear that for most women over 45 the diagnosis is made from symptoms, not blood results, because hormone levels fluctuate so much during perimenopause that a single test can be normal one week and raised the next.
| Your situation | Is a blood test needed? |
|---|---|
| Over 45, with menopausal symptoms and irregular periods | No. Perimenopause can be diagnosed from symptoms alone |
| Aged 40 to 45, with menopausal symptoms and a change in your cycle | An FSH blood test may be considered |
| Under 40, with symptoms or periods that have stopped | Yes. Two FSH tests four to six weeks apart, to assess for premature ovarian insufficiency |
| Using combined hormonal contraception or a high-dose progestogen | FSH results are not reliable, so the decision rests on symptoms |
Thyroid problems, iron deficiency and depression can cause overlapping symptoms such as tiredness, low mood and palpitations, so a clinician may check for those where the picture is not typical. Home perimenopause test kits measure FSH in urine and share the same limitation: a positive result says your hormones are changing, but a negative one does not rule perimenopause out.
Can you take HRT in perimenopause?
Yes. NICE guidance recommends offering HRT for hot flushes and night sweats, and considering it for low mood that arises with the menopause, and it does not require periods to have stopped first. For many women the most difficult symptoms happen during perimenopause, and there is no benefit in waiting them out.
For most healthy women under 60, the benefits of HRT for symptoms outweigh the risks. The balance of benefits and risks, including breast cancer and blood clots, is set out in HRT facts and myths. HRT is usually started at a low or standard dose and reviewed after about three months, when the dose or type can be adjusted.
Some women prefer not to take hormones, or cannot. Cognitive behavioural therapy has good evidence for hot flushes, sleep and low mood, and there are non-hormonal medicines too; these are covered in alternatives to HRT.
Why perimenopause needs a different type of HRT
If you still have a womb, HRT needs two parts. Oestrogen relieves the symptoms, and a progestogen protects the lining of the womb, which would otherwise thicken under oestrogen alone and raise the risk of womb cancer. How the progestogen is given is what changes between perimenopause and after the menopause.
| Type | How it works | Who it suits |
|---|---|---|
| Sequential combined HRT | Oestrogen every day, with a progestogen added for 10 to 14 days of each month, producing a monthly withdrawal bleed | Perimenopause, while periods are still coming, even irregularly |
| Continuous combined HRT | Oestrogen and progestogen every day, aiming for no bleeding | Usually once you are postmenopausal; used too early it tends to cause irregular, unpredictable bleeding |
| Oestrogen-only HRT | Oestrogen alone | Women who have had a hysterectomy, or whose womb is protected by a hormonal coil |
A sequential regimen can be built in several ways. A popular option is body-identical HRT: an oestrogen patch such as Evorel or a gel such as Oestrogel, with Utrogestan micronised progesterone taken for part of each month. Patches and gels carry a lower risk of blood clots than tablets. Others prefer a single combined sequential tablet pack such as Elleste Duet. The differences between body-identical and other HRT are explained in body-identical HRT.
After a year or more on sequential HRT, and once you are likely to be postmenopausal, many women switch to a continuous combined regimen to stop the monthly bleeds. Your prescriber will advise when that makes sense for you.
HRT and contraception
HRT is not a contraceptive. Ovulation continues on and off throughout perimenopause, so pregnancy is still possible. Contraception is needed until two years after your last period if you are under 50, or one year after your last period if you are 50 or over. All women can stop contraception at 55.
The good news is that HRT and contraception can be combined, and some options do both jobs at once.
| Approach | How it works with HRT |
|---|---|
| Hormonal coil (52mg levonorgestrel, such as Mirena) plus oestrogen | The coil provides contraception and protects the womb lining, so only oestrogen needs to be added. Often lighter or no bleeding |
| Combined pill, up to age 50 | For women without risk factors, the combined pill can control symptoms and provide contraception, taking the place of HRT until 50 |
| Progestogen-only pill or implant plus HRT | Provides contraception, but does not reliably protect the womb lining, so full HRT including its own progestogen is still needed |
| Copper coil or barrier methods plus HRT | Contraception only; full HRT with a progestogen is still needed |
The progestogen-only pill point catches many people out: desogestrel taken for contraception is not a substitute for the progestogen part of HRT. If you use the mini pill and start oestrogen, you will still need a licensed progestogen alongside it. How the mini pill and combined pill compare is covered in mini pill or combined pill.
Bleeding on HRT: what is expected
On sequential HRT, a withdrawal bleed usually comes towards the end of, or shortly after, the progestogen days each month. It is often lighter and more predictable than perimenopausal periods were. Some irregular bleeding or spotting is common in the first three to six months of any HRT while the body adjusts.
Get bleeding checked if irregular bleeding continues beyond six months of HRT, if it starts after a settled spell, if bleeding is very heavy or prolonged, if you bleed after sex, or if you have any bleeding after twelve months without a period. These need assessment, usually including an ultrasound scan, rather than a change of HRT alone.
Heavy periods are themselves common in perimenopause. If they are a problem before or alongside HRT, a hormonal coil or a non-hormonal medicine such as tranexamic acid can help, and very heavy bleeding should be checked for anaemia.
Mood, anxiety and sleep
Anxiety, low mood and irritability are among the most common reasons women in perimenopause seek help, and they are frequently treated as a stand-alone mental health problem when hormonal change is driving them. NICE guidance advises that HRT should be considered for low mood arising with the menopause, and that antidepressants are not the first-line treatment where low mood is due to the menopause alone.
That is not a reason to dismiss depression. Perimenopause can also coincide with, or trigger, a depressive illness, and both may need treating. Cognitive behavioural therapy helps with mood and sleep whichever is the cause. If you have ever felt that life is not worth living, speak to your GP promptly, or call NHS 111 or the Samaritans on 116 123 at any time.
Sleep often improves once night sweats are controlled. Body-identical progesterone taken at bedtime can have a mildly sedating effect, which some women find helpful.
Early menopause and POI
Menopause between 40 and 45 is called early menopause. Before 40 it is called premature ovarian insufficiency, or POI, and it affects around one woman in a hundred. Both matter beyond symptoms: losing oestrogen early increases the long-term risk of osteoporosis and heart disease.
For women with POI, HRT, or in some cases the combined pill, is recommended until at least the average age of natural menopause, around 51, to protect bones and the heart, not only to relieve symptoms. POI also needs specialist assessment, and because ovarian function can return unpredictably, pregnancy is occasionally still possible. If your periods have stopped or become very irregular before 40, see your GP rather than starting treatment online.
When to get help
Speak to a pharmacist or GP about perimenopause if symptoms are affecting your sleep, work, relationships or wellbeing, or if you would like to discuss HRT or its alternatives. See your GP rather than a pharmacy service if:
- you are under 40 and your periods have stopped or become very irregular
- you have bleeding after sex, between periods that persists, or after twelve months without a period
- you have very heavy periods, flooding or symptoms of anaemia
- you have had breast cancer, a blood clot, a stroke or liver disease, as HRT may need specialist advice
- you have low mood that is severe, or thoughts of harming yourself
If HRT is not suiting you, the common early side effects and how they are managed are covered in HRT side effects.
Think You Are Perimenopausal?
Our pharmacist independent prescribers can assess your symptoms, medical history and contraception needs, and recommend sequential HRT, body-identical options or alternatives after a GPhC-regulated online consultation.
See HRT treatments →Frequently Asked Questions
Do I need a blood test to diagnose perimenopause?
Usually not. NICE guidance advises that women over 45 with menopausal symptoms and irregular periods can be diagnosed from their symptoms, because hormone levels fluctuate too much in perimenopause for a single blood test to be reliable. An FSH test may be considered between 40 and 45, and is recommended under 40 to assess for premature ovarian insufficiency.
Can I start HRT while I still have periods?
Yes. HRT can be started during perimenopause, while periods are still coming. If you have a womb, sequential combined HRT is usually used, with oestrogen every day and a progestogen for part of each month, which produces a regular monthly bleed. Continuous combined, period-free HRT is usually kept until you are postmenopausal.
Will HRT stop my periods in perimenopause?
Not usually. Sequential HRT, the type normally used in perimenopause, produces a monthly withdrawal bleed, which is often lighter and more predictable than perimenopausal periods. Some spotting in the first three to six months is common. Bleeding that persists beyond six months, starts after a settled spell, or happens after sex should be checked.
Which contraception works alongside HRT in perimenopause?
HRT is not a contraceptive, so contraception is still needed until two years after your last period if you are under 50, or one year if you are 50 or over. A hormonal coil such as Mirena can provide contraception and protect the womb lining, so only oestrogen needs adding. The progestogen-only pill provides contraception but does not replace the progestogen part of HRT.
Can perimenopause cause anxiety?
Yes. Anxiety, irritability and low mood are common in perimenopause and are often the first symptoms women notice. NICE guidance advises considering HRT for low mood that arises with the menopause, and cognitive behavioural therapy can also help. Severe low mood or thoughts of self-harm need prompt medical advice.
How long does perimenopause last?
For most women around four years, but it varies widely and can last considerably longer. It ends at the menopause, which is confirmed once you have gone twelve months without a period. The average age of menopause in the UK is 51.
References
- National Institute for Health and Care Excellence. Menopause: identification and management (NG23). nice.org.uk
- National Institute for Health and Care Excellence. Clinical Knowledge Summary: Menopause. cks.nice.org.uk
- Faculty of Sexual and Reproductive Healthcare. Contraception for Women Aged Over 40 Years. fsrh.org
- British Menopause Society. Tools for clinicians and consensus statements on HRT. thebms.org.uk
- NHS. Menopause and perimenopause. nhs.uk
- Women’s Health Concern. Premature ovarian insufficiency factsheet. womens-health-concern.org
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. HRT is not suitable for everyone, does not provide contraception, and needs a progestogen if you have a womb. Unexpected vaginal bleeding should always be assessed. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.