Question 1

Am I too young?

Accepted Answer

In India, the average age at the last period is 46.6. That's four to five years earlier than in Western studies. The Indian Menopause Society, in its guideline rewritten this February, calls the number a population-level approximation: an average, not a prediction for any one woman. Perimenopause is the years before that last period. In India's largest survey on ageing, 7.4% of women said their last period came before 40, and 17.5% between 40 and 44. Another study, of women in their thirties in India's national family health survey, found that part of this is due to surgery. Among women with the least schooling, menopause before 40 was about seven times as common as among women with the most. Hysterectomy accounted for 73% of that gap. Because menopause comes earlier here, the guideline suggests paying attention to your health from 35, and screening for conditions like diabetes, high blood pressure and bone loss from 40. It notes that trial evidence in Indian women is limited.

Question 2

Will a blood test tell me?

Accepted Answer

At 45 and over, Britain's NICE says perimenopause is recognised without a blood test, from hot flushes or night sweats and a change in the cycle. India's guideline diagnoses natural menopause from a woman's history, and says, at its strongest grade, that FSH, oestradiol and AMH aren't recommended for diagnosing it. Hormone levels fluctuate at this stage. NICE says a result wouldn't change what the doctor does. It also says other tests, like a blood count or thyroid, may still be needed if another cause is suspected. Under 45, the guidance is different. Between 40 and 45, NICE says consider an FSH test. Under 40, it asks for two raised results four to six weeks apart, never one. India's guideline keeps hormone tests for a short list: suspected premature ovarian insufficiency, a decision about hysterectomy, an uncertain menstrual history, fertility counselling, and research. A table further into the same guideline also names women who have already had a hysterectomy as an indication for FSH and oestradiol, which we cover in perimenopause after a hysterectomy. On the combined pill, FSH and oestradiol results are unreliable, because the pill suppresses the hormones the test measures. Neither NICE nor India's guideline recommends a home urine or saliva kit for this, and India's guideline doesn't mention them. There's more on what blood can and can't show in our guide to hormone tests for perimenopause.

Question 3

When does it start, and how long does it last?

Accepted Answer

Perimenopause can start while periods still look regular. The sign researchers use is a difference of seven days or more between the lengths of back-to-back cycles, recurring within ten cycles. A single irregular cycle doesn't count. The late stage starts the first time 60 days or more pass without a period. On average it lasts one to three years. Hot flushes are likely in it. The whole transition runs longer for women who start younger. In SWAN, the median was 8.6 years for the earliest starters and 4.4 years for the latest. There were no South Asian women in that study. Indian women start earlier, so the longer durations are more likely to apply here. Frequent hot flushes and night sweats, on six or more days in two weeks, lasted a median of 7.4 years. For women whose flushes began before or early in perimenopause, more than 11.8 years.

Question 4

Is this symptom part of it?

Accepted Answer

I'd have guessed hot flushes were the most common symptom. Across 19 symptoms studied worldwide, the most common was joint and muscle pain, reported by 65% of women in midlife. Indian studies show the same pattern. Between 70% and 96.6% of women report menopausal symptoms, and body symptoms are the most common. Hot flushes and night sweats ranged from 16.5% to 88% across Indian studies, so no single number applies. Sleep. About a quarter of women in the transition have sleep problems that meet the definition of insomnia. In Indian studies, sleep problems rise from 16 to 42% before menopause to 39 to 47% in perimenopause. Mood. Women in perimenopause have about 40% higher odds of depressive symptoms or a depression diagnosis than women before it. Women past menopause don't. Brain fog. It means trouble with attention, finding words and concentrating. India's guideline calls it temporary and reversible, which is what separates it from dementia. Heart flutters. They're common through the transition. In SWAN, they weren't linked to early markers of artery disease. They still need to be checked by a doctor. Vaginal dryness. About 21% of women report it before menopause and about 45% after.

Question 5

What else could it be?

Accepted Answer

Before putting body symptoms down to perimenopause, India's guideline tells doctors to rule out vitamin D deficiency, anaemia, thyroid disease, autoimmune conditions and osteoarthritis. For memory problems that could be early dementia, it names B12 deficiency and an underactive thyroid as reversible causes to check. Anaemia runs at about 68% in older Indian adults, in pooled estimates. It causes the same tiredness, low mood and foggy thinking. More in our guide to low iron and ferritin. An underactive thyroid shows up in 3 to 7% of postmenopausal women in Indian hospital studies. Lethargy, hair loss, memory trouble and low mood are among its signs. More in thyroid or perimenopause? Vitamin D deficiency is widespread, more so in women. Australia's menopause society says a blood count, ferritin and TSH will usually pick up anaemia and thyroid problems. A woman can have one of them and be in perimenopause at the same time.

Question 6

Can I still do my job?

Accepted Answer

In a study of 280 employed women in southern India, aged 45 and over, 73% had moderate to severe menopausal symptoms. Women whose symptoms reduced their usual activities had nearly twice the odds of poor work ability. Sleep problems and fatigue were each linked to it, separately from other factors. In a UK survey of working women with symptoms, 67% said the symptoms had a mostly negative effect at work. 27% said they had a negative effect on their career progression.

Question 7

So, is this perimenopause?

Accepted Answer

At 45 and over, doctors go by the cycle and the symptoms. Under 45, it may also take a blood test. At any age, there are other conditions to rule out, because they cause the same symptoms and can happen at the same time. If you're not sure who to see first, start with our guide on which doctor to consult. If two doctors have given you two answers, what did each of them go on? Write to me at hello@spotyellow.com.

“Is this perimenopause?”