Perimenopause: the signs you might not recognise

It usually starts subtly. Perhaps you are sleeping a little worse than before, or your mood swings more than you are used to. Perhaps your joints are stiffer in the morning, or your concentration is not what it was. You might think it is stress, too little sleep, or just a busy life. What many women do not know is that these can be the first signs of perimenopause, the phase where the body begins its gradual transition toward menopause.

What is perimenopause?

Perimenopause is the period before menopause, the time when hormones begin to change but menstruation has not yet stopped completely. For most women it starts in the mid-forties, but it can begin as early as the mid-thirties. The average age of menopause in Norway is 53, and perimenopause can last 4 to 8 years, sometimes even longer.

What makes perimenopause distinctive is that hormones do not simply fall; they fluctuate. Oestrogen levels can go from low to very high within a single cycle. It is precisely these fluctuations that produce many of the symptoms, and it is also the reason blood tests rarely provide useful information during this phase.

The first signs

The very first sign is usually changes in menstruation. Perhaps it comes a little more or a little less often than usual. A change of seven days or more in cycle length is considered an early sign that the transition has begun. Bleeding may become heavier or lighter, and duration may change.

But many of the other signs are less obvious, and this is where the confusion arises. Sleep problems that develop gradually can easily be attributed to stress. Mood swings and irritability may seem like a natural reaction to a busy life. Anxiety and unease that appear seemingly without cause can be interpreted as mental health problems. Brain fog and concentration difficulties can make you wonder if something is wrong with your mind. Joint and muscle pain are often blamed on age or too little exercise.

And then there are the symptoms that genuinely surprise many women: palpitations, tingling in the fingers, and a general sense of dread that can come out of nowhere. Three out of four Norwegian women experience some form of complaints during menopause, and for many, they start long before anyone thinks of hormones as an explanation.

Why is it so often misdiagnosed?

Here comes one of the most frustrating aspects of perimenopause. Nearly 40 per cent of women who see a doctor for these symptoms report feeling misdiagnosed. More than half were treated for anxiety, depression, panic attacks, or mood swings without hormonal changes being considered as a cause. A third received an anxiety diagnosis, and 39 per cent of those diagnosed with depression felt the diagnosis was wrong.

This happens for several reasons. The symptoms of perimenopause overlap with many other conditions: depression, thyroid disease, anxiety disorders, burnout. Standard blood tests may look completely normal. And the fact that menstruation is still occurring leads many to rule out perimenopause. But regular menstruation does not mean hormones are stable. You can have significant hormonal fluctuations long before menstruation begins to change noticeably.

Only 26 per cent of women learned about perimenopause from the healthcare system. Most find the information themselves, which means many go for years with symptoms they do not understand.

Do you need blood tests?

The short answer for most women is no. The British NICE guidelines, which are internationally recognised, are clear: for women over 45, the diagnosis of perimenopause and menopause is made based on medical history alone, without blood tests. FSH levels fluctuate so much during perimenopause that a single measurement has limited value.

The Norwegian perspective is consistent with this. As NHI.no puts it: typical complaints in women of the right age usually make this a straightforward diagnosis. Blood tests are primarily relevant for women under 45 where early menopause is suspected, or to rule out other causes of symptoms.

What can you do?

The first and most important step is to recognise the symptoms for what they are. Simply understanding that it is hormones, and not stress or mental illness, can make an enormous difference to how you experience the situation.

Tracking your symptoms over time provides valuable insight. Research suggests that women who record symptoms daily experience a significant reduction in physical complaints over time, probably because increased awareness gives a sense of control. Keep track of cycle length, sleep quality, mood, energy, and any hot flushes or night sweats. This information is also invaluable if you visit your doctor.

Lifestyle measures such as regular exercise, good sleep hygiene, and stress reduction make a real difference for many women. And if the symptoms are troublesome enough, there are good treatment options available. Talk to your doctor, and do not accept a diagnosis that does not feel right, because you know your body best.

The key takeaway

Perimenopause is a natural phase that most women go through, but it is poorly understood and often overlooked. If you are in your forties and experiencing changes in sleep, mood, energy, or menstruation, perimenopause may well have begun. It is nothing to fear, but it is something to know about. The better you understand what is happening, the better you can take care of yourself through the transition.