In short
- Diagnosed on your cycle, not your blood. Over 45 it is a change in cycle length with or without symptoms. A high FSH is not required.
- That is why “your tests are normal” is so common. Levels swing week to week and cannot rule it out.
- Flushes start before the periods stop. About 40 percent in the early transition, rising to 60 to 80 percent in the late transition.
- Depression risk is 2.5 times higher during the transition than in the premenopausal years.
- Heavy bleeding is not automatically hormonal. It gets assessed rather than explained away.
Condition Overview
How it is actually diagnosed
In women over 45, perimenopause is diagnosed from a change in the interval between periods, with or without symptoms such as flushes, sleep disturbance, low mood or vaginal dryness.
A high follicle stimulating hormone level is not required, and a normal one does not exclude it. That single fact explains most of the frustration women describe.
Between 40 and 45 the diagnosis is the same, except that other causes of cycle disturbance are excluded first: pregnancy, raised prolactin and thyroid disease.
What changes first
- The cycle. In the late reproductive years the first half of the cycle shortens, so periods come closer together before they become irregular.
- Then the interval becomes unpredictable, which is the defining feature.
- Bleeding generally lightens over the transition, though some women have heavier or longer bleeding, particularly in the late transition.
Symptoms, and how common they are
| Symptom | Frequency |
|---|---|
| Hot flushes, early transition | Around 40 percent |
| Hot flushes, late transition and early postmenopause | 60 to 80 percent |
| Difficulty sleeping, early transition | 32 to 40 percent |
| Difficulty sleeping, late transition | 38 to 46 percent |
| New onset depression | 2.5 times more likely than premenopausally |
Flushes can begin while you are still having regular periods, clustering at the point in the cycle when oestradiol is lowest. Those early ones are usually mild.
Why “your bloods are normal” happens so often
During the transition, oestradiol and FSH swing widely from week to week. A sample taken on a good week looks entirely normal in a woman whose symptoms are unmistakable.
The tests that do add something are thyroid function, a full blood count with iron studies, and a pregnancy consideration where relevant. Those are ordered. Repeat oestradiol and FSH generally are not.
The mood point
The increased risk of depression during the transition is real and measurable, and it is most marked in women with a previous history of depression or mood problems.
That is worth naming, because it means low mood in this phase deserves proper assessment rather than being labelled hormonal and left.
What is not automatically perimenopause
- Heavy or prolonged bleeding, meaning more than seven days or unusually heavy, which needs assessment. Fibroids and obesity both contribute.
- Bleeding between periods or after sex.
- Memory symptoms that are progressive rather than fluctuating.
- Fatigue with no other menopausal features, where thyroid disease and iron deficiency are more likely.
When to See a Doctor
- Your cycle has changed in length, regularity or heaviness and new symptoms have appeared alongside it.
- You are waking regularly at night, or feel anxious and irritable in a way that follows your cycle.
- You have flushes, night sweats, low libido or vaginal dryness while still having periods.
- You have been told your hormone blood tests are normal but you are certain something has changed.
- You have bleeding between periods, bleeding after sex, or periods heavy enough to cause flooding, clots or tiredness from anaemia.
- You are under 40 and your periods have become very infrequent or stopped, which needs assessment for early menopause and other causes.
- You have new migraine with aura, severe low mood or thoughts of self harm, which need medical assessment promptly.
How Dr. Felix Assesses This
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1
Symptom and cycle history
Dr. Felix maps how your cycle has changed and which symptoms track with it: flushes, sleep, mood, anxiety, concentration, energy, libido, vaginal dryness, headaches and premenstrual symptoms. The pattern across the month is usually more informative than any single measurement.
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2
Medical and family history
Medical history, medication, current contraception, previous pregnancies, surgery, migraine type, clotting and cardiovascular history, family history of breast cancer and screening status are reviewed. Whether you might still want a pregnancy is asked directly, since it shapes the plan.
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3
Examination and selective tests
Blood pressure, weight and a relevant examination are done in the clinic. Over 45 the diagnosis is clinical, because hormone levels fluctuate too much to interpret reliably. Tests are used where they change the decision, such as thyroid function, ferritin with heavy periods, or hormone levels under 45.
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4
Diagnosis and plan
Dr. Felix explains what your symptoms represent and sets out the options, covering symptom treatment, bleeding control and contraception together. You leave with a written plan, an idea of what to expect in the first cycles and a review date.
Treatment Options
HRT Consultation
What this appointment decides Three things, in order. Whether your symptoms are hormonal. Whether hormone therapy suits your medical history.…
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Perimenopause Treatment
What is different about treating perimenopause rather than menopause? In perimenopause your ovaries still produce oestrogen, but in an unpredictable…
View Treatment
Hormone Replacement Therapy
What HRT actually replaces Oestrogen. As the ovaries stop producing it, the symptoms follow, and systemic oestrogen is the most…
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Why Early Treatment Can Matter
Perimenopause is frequently missed, and the cost of that is usually several years of poor sleep, low mood and reduced confidence at work, often attributed to stress or treated as something else entirely.
Naming it early changes that. Symptoms can be treated while they are still manageable, heavy bleeding can be controlled before it causes iron deficiency, and contraception can be sorted out rather than left uncertain. It is also a natural moment to review blood pressure, weight, alcohol, training and bone health. A consultation about hormone therapy gives you the full picture before symptoms take over.
Why Early Treatment Can Matter
Perimenopause is frequently missed, and the cost of that is usually several years of poor sleep, low mood and reduced confidence at work, often attributed to stress or treated as something else entirely.
Naming it early changes that. Symptoms can be treated while they are still manageable, heavy bleeding can be controlled before it causes iron deficiency, and contraception can be sorted out rather than left uncertain. It is also a natural moment to review blood pressure, weight, alcohol, training and bone health. A consultation about hormone therapy gives you the full picture before symptoms take over.
Sleep and mood restored
Treating early means fewer years spent functioning below your normal level.
Heavy bleeding managed
Controlling heavy periods prevents iron deficiency and the fatigue that follows it.
One plan, not three
Symptoms, bleeding and contraception decided together in a single consultation.
Cost & Consultation Investment
The assessment is priced as consultation time with Dr. Felix, covering your symptom and cycle history, examination, the treatment and contraception discussion and the written plan you leave with. Any laboratory tests are billed by the laboratory, and prescribed medicines or devices are separate. Ongoing hormonal care is arranged as a programme or membership rather than visit by visit. Current details are on the pricing page.
Frequently Asked Questions
Not reliably. Over 45 the diagnosis is made from your cycle pattern and symptoms. Oestradiol and FSH swing widely week to week, so a normal result does not exclude it and a high one is not needed to confirm it.
Because a sample taken during a good week looks normal in a woman whose symptoms are obvious. That is a limitation of the test, not evidence that nothing is happening.
Yes, and it is common. Flushes often begin during the transition and can even appear in the late reproductive years, clustering at the point in the cycle when oestradiol is lowest.
Thyroid function, a full blood count with ferritin, and a pregnancy consideration where relevant. Those genuinely change management. Repeat hormone panels usually do not.
It may be. The risk of new onset depression is 2.5 times higher during the transition than premenopausally, most markedly in women with a previous history. That is why mood is assessed properly rather than labelled and left.
Bleeding usually lightens across the transition, but heavier or longer bleeding does occur, particularly in the late transition. It still needs assessment, because fibroids and other causes are common and treatable.
Possibly, since irregular cycles can still be ovulatory. HRT is not contraception. That is discussed explicitly, and contraceptive decisions are referred to a gynaecologist.
There is no reliable way to predict the final period. Women in the late transition are closer to it than those in the early transition, but no test gives a date.
Yes, where symptoms justify it. Treatment during the transition differs from postmenopausal treatment, and a hormonal coil is sometimes used as the progestogen component while also managing heavy bleeding.
Usually not. Cognitive symptoms during the transition are typically transient, and no decline in cognitive function was found in the largest cohort study. Persistent or worsening symptoms get their own assessment.
No. Between 40 and 45 the diagnosis is the same, except that pregnancy, prolactin and thyroid causes are excluded first. Menopause before 45 is early menopause and is managed differently.
It depends on which investigations are needed and whether treatment follows, so a single figure would be misleading. You get the full cost in the consultation before anything is arranged.
Evidence
Where this information comes from
Every figure on this page is taken from the sources below. All of them are free to read, so you can check them yourself.
This page is general medical information and does not replace a personal consultation. Trial results are averages across large groups, not a prediction for any one person.