It’s 3am and you’re awake again. Yesterday you lost a word halfway through a sentence at work, and this evening you snapped at someone you love over something tiny. Each of these is easy to explain away. You’re busy, you’re tired, life is a lot. But when they start to pile up, you begin to wonder whether something else is going on, and whether it’s worth trying to see a doctor about perimenopause symptoms or whether you should wait until things get worse. My answer is simple: you don’t need to wait.
Many of the women I see have been coping quietly for months, sometimes years. They put the poor sleep down to work, the short temper down to family life and the forgotten words down to being tired. I want us to move away from the idea that you have to be struggling before you’re allowed to ask for help. Wanting to understand what is happening is reason enough.
I’m Dr Katy Kasraie, a Family Medicine Doctor (GP) and BMS-certified Menopause Specialist at 10 Harley Street, London. I’m a Member of the Royal College of General Practitioners (MRCGP), and I have more than 20 years of clinical experience across the UK, Ireland and the United States.
Perimenopause rarely arrives the way you expect
Perimenopause is the transition leading up to the menopause. During this time, oestrogen and progesterone don’t decline in a smooth line. They rise and fall unpredictably. That’s why a calm month can be followed by several difficult weeks, and why symptoms can come and go for no obvious reason.
The menopause itself is your final period, and it can only be confirmed looking back, once you’ve gone 12 months without one. In the UK, the average age of menopause is 51, and perimenopausal changes most often begin in the mid-forties. Some women notice them earlier, and the normal range is wide, so age alone should never decide whether your symptoms are looked into. You can read more in my guide on when perimenopause usually starts.
Oestrogen acts on the brain, bones, skin, bladder and blood vessels, so perimenopause is rarely just about hot flushes. Your periods may come closer together or further apart, or become lighter or heavier. You may have hot flushes, night sweats, or broken sleep with early waking that’s hard to recover from. New or worsening anxiety, irritability, tearfulness, low mood, brain fog and struggling to find words are all common. So are joint aches, muscle stiffness, tiredness, headaches, palpitations and changes to your skin and hair.
Vaginal dryness, discomfort during sex, urinary symptoms and a lower sex drive can develop too. They are far more treatable than many women realise. And regular periods don’t rule perimenopause out. Some women notice poor sleep, anxiety or brain fog well before their cycle changes in an obvious way.
It's time to see a doctor about perimenopause symptoms when they're getting in your way
There is no level of suffering you have to reach first. A conversation with a doctor is worthwhile if:
- broken nights and daytime exhaustion are affecting your work or family life
- anxiety or low mood is new, getting worse, or seems to follow a monthly pattern
- hot flushes or night sweats are frequent, embarrassing or keeping you awake
- vaginal dryness, pain during sex or repeated urinary symptoms have appeared
- your periods have become much more irregular, heavier or more painful
- you are under 45 and have menopausal symptoms, because these deserve proper assessment
- you’d like to plan ahead and talk about HRT, contraception, or your bone and heart health, especially if you have a family history of early menopause, osteoporosis or heart disease
One situation comes up often. You may have been offered an antidepressant for low mood and wondered whether hormones are playing a part. A menopause-focused review can help work out whether hormonal change is part of the picture, because low mood linked to the menopause may be helped by HRT.
Some symptoms should be checked straight away
Some symptoms should be checked promptly rather than put down to perimenopause:
- bleeding between periods
- bleeding after sex
- very heavy bleeding that soaks through protection
- any bleeding after 12 months without a period
- bleeding on HRT that is unexpected or continues after the first three to six months
- a new breast lump
- severe pelvic pain
Most of the time the cause is not serious. But these symptoms need an examination, and sometimes further tests, to be sure.
You probably won't need a blood test
For most women, diagnosis comes from a careful conversation rather than a blood test. Perimenopause can be diagnosed in women over 45 who have hot flushes or night sweats together with irregular periods, without any hormone testing.
A follicle-stimulating hormone (FSH) test can be considered for women aged 40 to 45 with menopausal symptoms, including a change in their cycle, and for women under 40 when premature ovarian insufficiency is suspected. Because hormone levels swing from week to week during perimenopause, a single normal result doesn’t rule it out. FSH is also not a reliable guide if you are taking combined hormonal contraception or high-dose progestogen. This causes a lot of confusion. Many women have been told “your hormones are normal” when they are very much in perimenopause.
A thorough assessment also looks for other causes of similar symptoms, such as thyroid problems, iron deficiency, low vitamin D, sleep apnoea, stress and depression. If you’re unsure which stage you’re in, my guide on perimenopause or menopause and how to tell where you are may help.
One thing I recommend before any appointment: for two weeks, jot down a few notes each day. For example, the time you woke in the night, how many flushes you had, a day your mood dipped, and the dates of any bleeding. Then write down your top three concerns. It takes a minute a day, and I promise those notes add up. They make it much easier to see the pattern together and agree on what matters most to you.
There is more than one way to feel better
When you come to see me, we’ll talk through your symptoms, often using a validated questionnaire to track them over time. We’ll also cover your periods, contraception and cervical screening history, and your personal and family history, including blood clots, breast cancer and heart disease. I’ll check your blood pressure and BMI, examine you where that’s needed, and arrange blood tests only when they will genuinely help. You’ll leave with a clear plan and a review about three months after starting any treatment, as NICE recommends.
HRT replaces the oestrogen your ovaries are producing less reliably. If you still have a womb, you also need a progestogen to protect the womb lining. Oestrogen can be taken as tablets, or through the skin as patches, gels or sprays. It can help with hot flushes, night sweats, sleep, mood and vaginal symptoms, and it can be started while you are still having periods.
HRT has risks as well as benefits, and you deserve to hear both honestly. Combined HRT is linked to a small increase in breast cancer risk, which relates to how long it is taken. Oestrogen tablets raise the risk of blood clots, but patches, gels and sprays do not appear to at standard doses. For most women under 60, the British Menopause Society advises that the benefits generally outweigh the risks. HRT is not suitable for everyone, though, particularly some women who have had certain cancers or blood clots.
Vaginal oestrogen is a separate, low-dose local treatment for vaginal dryness and bladder symptoms, and it can be used on its own or alongside HRT. Vaginal moisturisers and lubricants can also ease dryness.
If HRT isn’t right for you, or you’d simply rather not take it, you still have real options. I know it can be disheartening to hear that the usual first choice is off the table (I know this can be hard!), but you have not run out of help. NICE recommends cognitive behavioural therapy (CBT) as an option for hot flushes and night sweats, sleep problems and low mood related to the menopause.
In 2026, NICE recommended fezolinetant for moderate to severe hot flushes and night sweats when HRT is unsuitable. It is not suitable if you currently have breast cancer or liver disease, and it needs liver blood tests before you start and regularly during the first months of treatment. Elinzanetant is a newer non-hormonal medicine licensed in the UK for hot flushes, including for women taking hormone-blocking treatment after breast cancer. NICE has not yet assessed it, so for now it is available privately rather than on the NHS.
Contraception still matters, too. Pregnancy is still possible in perimenopause, and HRT is not a contraceptive. If you’re not using hormonal contraception, we advise to continue contraception for two years after your last period if you’re under 50, or one year if you’re over 50. All women can stop contraception at 55.
Everyday habits support your bones, heart and metabolism through this stage. These include regular muscle-strengthening and weight-bearing exercise, enough protein, less alcohol, stopping smoking and a steady sleep routine. Falling oestrogen affects bone density and heart health, so this is also a valuable moment to review your blood pressure, cholesterol, weight, bone health and cancer screening.
You don't have to wait until it's "bad enough"
Putting off help can cost you months or years of poor sleep, lost confidence at work and strain on your relationships, and none of it has to happen. Many women assume they simply have to put up with it. They don’t. Whether HRT turns out to be right for you or not, there is good, evidence-based support available, and the best time to ask for it is when you first start wondering.
You can read more about my menopause and hormonal wellness service.
In one unhurried 45-minute consultation at 10 Harley Street, Dr Katy Kasraie will look at your health history, your goals and every suitable option, including approaches that do not involve medication. No referral needed, and most major insurers are accepted. Click here to book your appointment.