Perimenopause: why your blood test was normal and you still feel awful

The most common sentence in my clinic is some version of: "I asked to be tested and they said my hormones were normal." It is said with a particular kind of defeat, because the implication people take from it is that the symptoms are imagined.

They are not. The test was simply the wrong test.

Why FSH is unhelpful over 45

In perimenopause, ovarian function does not decline smoothly. It fluctuates, sometimes dramatically, from one cycle to the next. A follicle-stimulating hormone level taken on a Tuesday can be firmly in the postmenopausal range and, three weeks later, entirely premenopausal. You have not changed. The sampling day has.

This is why national guidance advises against relying on FSH testing to diagnose perimenopause in women over 45 with typical symptoms. The diagnosis is clinical: it is made from the pattern of symptoms and the change in the menstrual cycle. A blood test in that group can only mislead, and the direction it usually misleads in is toward doing nothing.

When blood tests do matter

Under 45, they matter a great deal. Menopause before 45 is early menopause, and before 40 it is premature ovarian insufficiency. Both need confirming, both have implications for bone density and cardiovascular health, and in both the argument for treatment is stronger rather than weaker. If you are under 45 with these symptoms, I will test you, usually twice, several weeks apart.

I also test where the picture is atypical — because thyroid disease, anaemia and depression all look a little like perimenopause and all are treatable in their own right.

The symptoms nobody attributes to it

Flushes and night sweats are well known. The ones that get treated separately, by different clinicians, for years, are:

• Broken sleep, particularly waking at three or four and not getting back over.
• Low mood, irritability and anxiety — often the first symptom, often treated as primary depression.
• Joint and muscle aches, especially in the hands and shoulders on waking.
• Brain fog and word-finding difficulty, which frightens people considerably more than they admit.
• Recurrent urinary symptoms and vaginal dryness, which respond very well to local treatment and are almost never raised.
• A changed tolerance for alcohol.

When a woman has been given a sleep hygiene leaflet, an antidepressant, and a physiotherapy referral in the same eighteen months, it is worth someone stepping back and looking at the whole picture.

Perimenopause is not a diagnosis of exclusion. It is a pattern, and it is usually recognisable if someone takes the history properly.

How I approach the HRT decision

By going through your personal history, your family history, your blood pressure and your own priorities, and then setting out the risks in numbers rather than adjectives. The size of any risk depends on which type of HRT, taken by which route, at what age, and for how long — which is why any single sentence about "the risks of HRT" is close to meaningless.

Transdermal oestrogen, for instance, does not carry the venous thrombosis risk that oral preparations do, which changes the calculus for a lot of women who were told years ago that HRT was not for them.

If HRT is not appropriate for you, there is a real non-hormonal toolkit and we go through it properly: cognitive behavioural therapy has good evidence for flushes and for the sleep disruption, and there are specific non-hormonal medications worth considering.

The review is the important appointment

The first dose is rarely the final one. Flushes and sweats often settle within weeks; sleep, mood and joints usually take two to three months. That is why the review is booked at three months rather than at one, and why the appointment where we adjust the dose tends to matter more than the one where we started it.

Taking it back to the NHS

Many women come here for the diagnosis and the first few months of dose-finding, then continue with their NHS GP. That is a perfectly good use of us. We write a full letter setting out the diagnosis, the regimen and the monitoring plan, which is what an NHS colleague needs in order to take it on.

This article is general information, not advice about your situation. If something here applies to you, book an appointment or speak to your own doctor. Ravelston Health is not an emergency service. If you need urgent help call 999, or NHS 24 on 111 when your GP practice is closed.