Menopause and perimenopause

Menopause is a single point in time, identified only in hindsight: the date of the final menstrual period, confirmed once twelve months have passed without another. Everything before it is perimenopause; everything after is postmenopause. Most of what women experience and seek help for happens in perimenopause — precisely the phase with no clear marker and no report to point to.

Physiologically the ovary is running down its remaining supply of follicles. As that pool shrinks, ovulation becomes irregular, and oestrogen production stops being a steady monthly rhythm. It becomes erratic — high in some cycles, low in others — before settling at a low level. The pituitary responds by pushing FSH higher, which is why FSH rises but bounces about unhelpfully during the transition. Most symptoms of perimenopause come from that instability rather than from low oestrogen alone, which is why they can be severe while periods are still arriving.

Indian studies suggest women here reach menopause earlier than Western populations, with medians commonly reported in the range of 46 to 48 years, though figures vary between studies and regions and the reasons are not fully settled. Working backwards, that places the start of perimenopause for many women in their late thirties or early forties — an age at which symptoms are routinely attributed to stress, children, work, thyroid or simply "getting older", and at which the transition itself is rarely the first thing considered.

Two consequences run quietly underneath the symptoms, and both are neglected in India. Bone loss accelerates around the final period, fastest in the first few years afterwards; Indian women often begin that decline from a lower peak bone mass, on a lower calcium intake and with widespread vitamin D deficiency. Cardiovascular risk also rises after menopause, and the risk pattern in South Asian women — central weight, insulin resistance, raised triglycerides with low HDL — tends to worsen through this decade. Neither is felt at the time. Both are why midlife is a useful moment to look at the whole picture rather than only at the flushes.

One further change deserves an explanation rather than advice. Body shape shifts in midlife for reasons that are biological: falling oestrogen redistributes fat from the hips and thighs towards the abdomen and the viscera, muscle mass declines steadily from the forties, resting energy expenditure falls with it, and insulin sensitivity worsens. The same eating and the same activity produce a different result. That is a change in the machinery, not a failure of willpower, and it responds best to changes aimed at muscle and metabolism rather than at the scale.

ⓘThis information is educational and not a diagnosis.

The transition announces itself first through the cycle. Periods become shorter or longer, closer together or further apart, lighter or considerably heavier. Heavy or prolonged perimenopausal bleeding is common and worth reporting rather than tolerating, both because it causes iron deficiency and because it sometimes has another explanation.

Beyond bleeding, the symptoms cluster in groups. Vasomotor: hot flushes and night sweats. Some Indian studies report these less frequently than Western cohorts, though the data is limited and under-reporting is difficult to separate from genuine difference. Sleep: waking in the small hours and lying awake, with or without sweats, is one of the most disabling features and drives much of the daytime fatigue and irritability. Musculoskeletal: aching, stiff joints and muscles, worst on waking and easing with movement, are among the most frequent presenting complaints in Indian clinics — and are commonly labelled as arthritis or as vitamin D deficiency without menopause being considered at all. Cognitive: brain fog, losing a word mid-sentence, mislaying things. This frightens women more than anything else on the list, and usually settles. Mood: irritability, tearfulness, anxiety and low mood, frequently attributed to family circumstances that happen to coincide. Other: palpitations, hair thinning, dry skin, dry eyes, and a reduction in libido. Weight that arrives without any change in eating belongs on this list too — falling oestrogen shifts storage toward the abdomen, so the waist frequently moves further than the scale does.

The group least often mentioned deserves naming directly. Genitourinary syndrome of menopause covers vaginal dryness, burning and itching, discomfort or pain with intercourse, urinary urgency and frequency, and recurring urinary infections. It arises from thinning, less elastic tissue with reduced blood supply. Unlike flushes, it does not resolve with time — untreated, it usually progresses. It is rarely volunteered in an Indian consultation and rarely asked about, which is a shame, because it responds to treatment as reliably as anything else here.

Duration is worth stating plainly, because women are often told this lasts a few months. Longitudinal studies of vasomotor symptoms report a median of around seven years, longer for those whose symptoms begin early in the transition. Sleep and mood tend to follow the same arc. Knowing that at the outset changes how a woman decides whether to treat.

The features listed below are of a different kind and warrant prompt assessment.

For a woman over 45 with typical symptoms and changing periods, menopause is a clinical diagnosis. Blood tests are not required to make it, and the temptation to order a hormone panel often produces confusion rather than clarity. FSH fluctuates dramatically through perimenopause; a value in the normal range on the day of the test does not exclude the transition, and a raised value does not confirm it.

Testing earns its place in three situations. First, under the age of 45, and especially under 40, where premature ovarian insufficiency is possible — here FSH measured twice several weeks apart, alongside oestradiol, matters a great deal, because it changes long-term bone and cardiovascular management. Second, to exclude conditions that imitate the transition: thyroid disease, iron deficiency anaemia, vitamin D and B12 deficiency and diabetes all produce fatigue, low mood, aches and palpitations. In India, where vitamin D deficiency and low dietary calcium are widespread and vegetarian diets carry a high rate of B12 deficiency, these are worth checking rather than assuming. Third, to assess consequence: a DEXA scan where osteoporosis risk factors are present, and a lipid profile and blood pressure for cardiovascular risk.

Bleeding is assessed on its own terms. Heavy or erratic perimenopausal bleeding usually warrants a pelvic ultrasound and, depending on the endometrial thickness and the pattern, an endometrial biopsy. Bleeding that occurs after twelve months without periods is investigated in every case — most causes turn out to be benign, and the reason for the rule is the minority that are not.

A practical note on cost. A thyroid profile, full blood count and vitamin D at a chain laboratory in an Indian city are inexpensive; a DEXA scan costs considerably more and is not available in every district hospital, which is a fair argument for ordering it where risk is real rather than routinely.

Treatment here is about symptoms now and about bone and heart later. The two are considered together.

Menopausal hormone therapy (MHT), often called HRT. It replaces the oestrogen the ovary has stopped producing. Where the uterus is present, a progestogen is given alongside, because oestrogen unopposed thickens the endometrium; where the uterus has been removed, oestrogen alone is used. Systemic forms — tablets, patches, gels and sprays — treat flushes, sweats, sleep, mood and aches, and protect bone. Local vaginal oestrogen, as a cream, pessary or ring, treats genitourinary symptoms with very little reaching the bloodstream, and its risk profile is materially different from systemic therapy.

The history matters, because it still shapes what women are told. The Women's Health Initiative results published in 2002 were reported in a way that produced alarm out of proportion to the findings, and a generation of women were denied treatment. Later re-analysis showed that the trial population was older than the women who typically seek help, that risks differ substantially by preparation and route, and that starting within roughly ten years of the final period, or under the age of 60, gives a more favourable balance — the "timing hypothesis". MHT suits some women less well, including those with certain breast cancers, active liver disease, or a history of clots or stroke, where the discussion changes. None of this is a recommendation for or against it. It is a conversation to have with a doctor who knows your history, and no article can substitute for that.

Non-hormonal options with evidence. Cognitive behavioural therapy has genuine trial support for flushes, sleep and mood, and is under-used. Several prescription non-hormonal medicines reduce vasomotor symptoms for women who prefer not to take hormones or for whom hormones are unsuitable, and a newer class acting on the brain's temperature pathway has recently added to the options. Vaginal moisturisers and lubricants help genitourinary symptoms and can be used alongside anything else. The supplement market around menopause is large and largely unsupported by good trials — worth knowing before spending on it.

The parts that carry the rest. Resistance training two or three times a week is the single most useful intervention for muscle mass, bone and insulin sensitivity together. Adequate protein at each meal — dal, curd, paneer, eggs, chana, soya — is frequently the missing piece in Indian vegetarian diets. Calcium intake in Indian women is often well below requirement, and vitamin D deficiency is very common, both of which compound a low peak bone mass to begin with. Weight-bearing activity, sleep, moderating alcohol and stopping smoking each act on bone and heart at once.

Follow-up. Symptoms, blood pressure, lipids and bone risk are reviewed periodically, and any treatment is reviewed for whether it is still doing what it was started to do.

Much of the difficulty in these years comes from not having the pieces connected — aches, sleep, mood, cycle and weight treated as five separate problems when one shift underlies them all. Naming the transition tends to change what gets treated, and in what order.

If you would like to understand what your own reports say — thyroid, haemoglobin, vitamin D, B12, glucose, lipids — and how they fit against this stage of life, the Learning Session below works through reading blood reports in a small group.

If your symptoms began before 45, or your bleeding pattern needs assessing, that is a conversation for a consultation rather than an article.