The Perimenopause Puzzle: Why Diagnosis Can Be So Difficult

As a British Menopause Society accredited advanced menopause specialist, Dr Lorraine is incredibly passionate about helping women navigate the often turbulent waters of perimenopause. There's nothing more rewarding than seeing someone's quality of life dramatically improve after finally understanding what's happening to their body and finding effective treatment.

But here's a frustrating truth she sees all too often: by the time women reach her clinic, they've often been through the diagnostic wringer. Multiple appointments, countless tests, and still...no clear answers. Why is perimenopause so often missed or misdiagnosed?

The 10-Minute Time Trap

One of the biggest hurdles is the time constraints in many healthcare settings. In the NHS, GPs often have just 10 minutes per patient. Perimenopause is a complex process with a wide range of symptoms, from subtle to debilitating. Trying to connect all the dots in a 10-minute appointment is a herculean task, especially when many doctors haven't received adequate menopause training.

Let's paint a familiar picture:

Palpitations: A woman presents with heart palpitations. She undergoes ECGs, possibly more extensive cardiology tests, only to be told it's likely anxiety and prescribed antidepressants or beta blockers.

Joint Pain: Another visit, this time for persistent joint pain. X-rays come back normal, leading to physiotherapy and painkillers, but no lasting relief.

Itchy Skin: Yet another appointment, this time for itchy skin. Emollients are prescribed, and blood tests screen for underlying diseases, but the itching persists.

Heavy Periods: Then there are investigations for heavier periods, scans, and referrals to gynaecology.

It's a cycle of symptom management without addressing the root cause. This can be incredibly frustrating and disheartening for patients.

The Blood Test Bind

Many women understandably suspect their symptoms are hormonal, and often request blood tests. The doctor orders the blood tests. The patient feels happy that something is being done. The blood tests are taken. The patient won't hear back as the results are normal. They phone the reception, and are told bloods are normal.

How does that feel? It's not a relief, it's a feeling that your body is gaslighting you. How can they be normal when you have so many symptoms affecting your every day functioning? She may book another appointment, and may be lucky that she sees a doctor who recognizes her symptoms, or she may be told she's too young, bloods are normal, and she's not got vasomotor symptoms of flushes and night sweats so therefore this isn't menopause.

But here's the crucial point: blood tests aren't always the answer.

Many rely on the FSH (follicle-stimulating hormone) test, which indicates menopause (the cessation of periods) – not perimenopause (the symptomatic time leading up to menopause where hormones fluctuate). FSH levels fluctuate wildly during perimenopause, so a "normal" result doesn't necessarily rule it out. As your ovaries gradually decline, sometimes they might have a surge, and other times have low levels, this is why we cannot rely on the tests.

Furthermore, there's no established standard for oestrogen levels during perimenopause. Symptoms don't correlate with specific blood levels, and blood tests don't dictate treatment dosage.

Ageism in Action

Another frustrating issue is the assumption that perimenopause only affects women in their late 40s and 50s. While that's the most common timeframe, it's important to remember that:

* 1 in 10 women experience menopause before the age of 45 (early menopause).

* 1 in 100 experience menopause before the age of 40 (premature ovarian insufficiency or POI).

Considering that perimenopausal symptoms can last for an average of seven years, some women may start experiencing them in their late 30s. Too often, these women are dismissed as being "too young" for it to be perimenopause. I have seen this in my own practice. I have had a 45 year old patient who has had a change in her periods for 3 years, many severe perimenopausal symptoms, but her GP said she was too young and was very reluctant to prescribe her hormones.

When Do Blood Tests Matter?

While perimenopause is primarily a clinical diagnosis (based on symptoms), blood tests do have a role in certain situations:

Aged under 40: If a woman under 40 is experiencing perimenopausal symptoms, an FSH test is crucial to rule out premature ovarian insufficiency (POI). Early menopause or POI requires HRT to protect the bone and heart health.

Women aged 40-45: FSH testing can be considered for women in this age range, but ultimately, if a woman is symptomatic and safe to start HRT, a trial of treatment is often more informative than the blood test.

Monitoring High-Dose Transdermal Oestrogen: If a woman is using high-dose transdermal oestrogen (patch, gel, or spray) and not responding as expected, testing oestrogen levels can help determine if she's absorbing the medication properly. In this case, we may change the route to tablets.

Testosterone Levels: We always test testosterone levels before starting testosterone treatment. It is important to know the baseline. Also, if someone has a high level of testosterone, then they tend not to respond so well to treatment so the level can affect management.

A Clinical Diagnosis, Not a Lab Result

The key takeaway is that perimenopause diagnosis is primarily based on a woman's symptoms and medical history. We need to understand that "normal" blood test results don't invalidate their suffering.

We treat the symptoms, monitor the response to treatment, and adjust the plan accordingly. It's about individualised care, empathy, and a willingness to think outside the box.

If you suspect you're in perimenopause, we can help at the clinic. You can book in with Dr Lorraine for a full assessment of your symptoms, and for a personalised, bespoke treatment plan, based on evidence based medicine.

For menopause awareness month we are offering 10% off appointments with Dr Lorraine for

October and November.

Usually £195, now £175

for an hours initial consultation.

You can book by clicking on the link below.

Book Here