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  • Recognising Perimenopause

    Perimenopause can be a confusing and often overwhelming time for many people, as the symptoms can vary so much, fluctuate over time and mimic many other conditions.

    Every Person’s Experience is Unique

    It’s important to remember that no two experiences of perimenopause are the same. Some people don’t notice much in the way of symptoms at all, while others may experience severe physical and emotional changes. Some might feel relieved when their periods stop, while others may mourn this ending of their menstrual cycles. It can be an isolating time, as friends may go through it at a different time and in a different way.

    Common Symptoms of Perimenopause

    Here are some of the most common signs to be aware of:

    • Changes in Your Cycle: You might notice your periods becoming heavier or lighter, longer or shorter, more frequent or erratic.
    • Worsening PMS
    • Mental Health Effects: Anxiety, depression, low self-esteem, and irritability are unfortunately all very common. 
    • Cognitive Effects: Brain fog and altered concentration can be especially challenging at work.
    • Fatigue and low energy
    • Sleep Disturbances
    • Hot Flushes and Night Sweats
    • Vaginal Dryness and Changes in Bladder Function

    Less Commonly Known Symptoms

    While some symptoms are widely recognized, others can be more subtle and can catch us out:

    • Dizziness and Palpitations
    • Joint Pain
    • Central Weight Gain
    • Headaches 
    • Bloating
    • Hair, Skin, and Nail Changes

    Symptoms Can Fluctuate

    It’s common for perimenopausal symptoms to fluctuate over time. One day you might feel fine, while the next day a symptom may flare up. If you’re experiencing anxiety or low mood, let your healthcare professional know if the symptoms seem intermittent. This fluctuation in mood is often a hallmark of perimenopause. Although the low mood associated with perimenopause can be just as severe as clinical depression, it can also come and go, offering valuable clues to the underlying cause of your symptoms.

    Track Your Menstrual Cycle

    Keeping track of changes in your menstrual cycle, if you have one, can provide valuable insights into your experience. Even subtle changes, like a cycle shortening from 28 days to 27 days or a period lasting one day longer than usual, can be telling. Tracking these changes over several months can help both you and your healthcare professional understand where you are in the process. If you can, look back at your cycle from a year ago to see if there are noticeable patterns.

    You can go old school and use a diary, or ticksheet, or one of the numerous apps now available. I would say though, that some of us can become more anxious by focusing on all that is not going so well. We have enough of a negativity bias as is, so tracking is not for everyone.

    Be Open About Your Symptoms

    If you suspect that your symptoms are related to perimenopause, it’s okay to let your healthcare professional know. While many signs point to hormonal changes, other underlying conditions might also need to be considered. For example, if you’re experiencing widespread joint pain, your healthcare professional may need to assess whether arthritis is a possibility in addition to menopause. However, if you’ve linked your joint pain to other symptoms like changes in your menstrual cycle or vaginal dryness, this could be a strong indicator that perimenopause is at play.

    Online Consultations

    In today’s digital age, online consults can be a great tool for sharing your symptoms with your healthcare professional. With the ability to explain your experiences in your own time, they allow you to provide a comprehensive picture of your symptoms. They also give you the opportunity to mention minor symptoms that might otherwise go unreported but that could contribute to the overall diagnosis. Symptoms such as vaginal dryness, low libido, urinary incontinence, or intrusive thoughts can sometimes be difficult to discuss in person, writing them down might make it easier for you to share.

    The Role of Healthcare Professionals

    Many symptoms of perimenopause can have numerous causes. A person experiencing symptoms like dizziness and palpitations may not immediately connect them to perimenopause, and healthcare professionals must rule out serious conditions, such as heart arrhythmias, whilst also considering menopause as a potential cause.

    There is sometimes not enough understanding of the role hormones play, and this is partly due to the biases women face in healthcare. The male body is the default normal body, and the male experience of illness is the one that we learn about at medical school. I started at medical school in 1994. It was only the year before I started, 1993, that it was mandated that women had to be included as participants in research; before that, they were usually excluded as the variability of women’s results complicated everything. So my learning, and a whole generation of clinicians like me, was based on the male experience. This has had significant impacts on women’s health outcomes and research into women’s health. We understand now that women respond differently to drugs and present differently with illnesses, and hormones play a really big role in everything!

    And although at medical school I did learn about menopause, I didn’t learn about perimenopause. I learned about menopause affecting women in their 50s whose periods had stopped, not understanding it could affect us much earlier. So, clinicians are on the back foot a bit when it comes to understanding perimenopause. But the situation is improving..

    Know Your Options

    Menopause resources

    When discussing perimenopause with your healthcare professional, it’s helpful to know what you’re looking for. Are you seeking to understand your symptoms better? Are you interested in exploring lifestyle changes, trying hormone replacement therapy (HRT), or considering non-hormonal treatments? There’s a wealth of information available through books, podcasts, and websites, though it can feel overwhelming. I’ve shared some of my favourite resources on my website, and I’d love to hear about yours, too!

    Conclusion

    Navigating perimenopause can be challenging, but by staying informed, tracking your symptoms, and working closely with your healthcare professional, you can find the support and solutions that work best for you. Whether you’re exploring lifestyle changes, treatments, or simply seeking understanding, you’re not alone in this journey.

    Here at Rethink, my approach is simple – to support you with what you need to thrive at menopause.

    Contact me today to find out more.

  • Understanding your hormones: A Deep Dive

    Following on from last month’s blog about the menstrual cycle, let’s take a deeper look at hormones—how they impact our health and why understanding them is crucial, especially when we are navigating hormonal transitions like menopause.

    I want to start by acknowledging that not all women were assigned female at birth and that some trans men and non-binary people will also experience these hormonal effects.

    The Gender Health Gap: Why We Need to Talk About Hormones

    Women in the UK live longer than men, but we also spend a significantly greater proportion of our lives in ill health and disability. This disparity is partly due to the lack of focus on hormones and the underrepresentation of women in clinical trials. For years, the male body has been the “default” in healthcare, and the male experience of illness is what we typically learn about in medical school.

    When I began medical school in 1994, it had only been a year since it was mandated that women must be included in clinical research. Before that, they were usually excluded as the variability of women’s results was deemed too complicated everything. So my learning, and a whole generation of clinicians like me, was based on the male experience. This has had significant impacts on women’s health outcomes. We understand now that women respond differently to drugs, and present differently with illnesses, and hormones play a really big role in everything!

    The Significance of Hormonal Transitions

    Hormonal transitions are some of the most significant periods in a woman’s life. Puberty, the postnatal period, and perimenopause each bring dramatic shifts, both physically and emotionally.

    Some of us, for example if we have PMS or PMDD, are particularly sensitive to fluctuations in hormone levels across the menstrual cycle and may experience much worse symptoms at hormonal transition times.

    We know trauma impacts our hormonal experience too, and for example, if we have experienced childhood trauma we are more likely to experience depression at menopause.

    Additionally, the diagnosis of neurodiversity in women peaks during puberty and perimenopause, times of hormonal transitions. Understanding hormones and what happens at these transitions is key to understanding why women’s experiences of health can be so different from men’s.

    What Are Hormones?

    Hormones are chemical messengers that have many different roles and functions. For this blog, let’s focus on three key sex hormones: oestrogen, progesterone, and testosterone. These hormones affect everything from mood and energy to metabolism and reproductive health, yet many of us don’t fully understand what they do and how they work. Let’s break it down:

    Oestrogen

    Oestrogen, described by Maisie Hill as the “Beyoncé” of hormones, is the hormone that makes us feel unstoppable. When we’re in an oestrogen-dominant phase, we’re typically more confident, talkative, and sociable. If we think about this through the reproductive lens, basically oestrogen helps us find a partner. 

    And although we probably all know about its role in puberty and reproduction, there’s so much more. Oestrogen receptors are present throughout our body, which is why it affects so many aspects of our health:

    • Bone and Muscle Health: Oestrogen helps build and repair tissues, including muscle and bone. It keeps our joints supple too.
    • Sleep and Mental Health: Oestrogen stimulates serotonin (the feel-good neurotransmitter), improves mood, and blocks cortisol (the stress hormone). It regulates sleep and many of us will have had worse sleep with our period when oestrogen levels are lower.
    • Metabolism and Cardiovascular Health: Oestrogen helps our metabolism and reduces inflammation. It has great metabolic effects on glucose, lipids, and blood vessels and we’re really protected from cardiovascular disease by oestrogen. Oestrogen regulates nitric oxide, which is a vasodilator. This effect is one of the reasons migraines are more common in women when they have less oestrogen.
    • Body Temperature: Oestrogen helps regulate body temperature, which is why many women experience hot flushes and night sweats at menopause.
    • Gut Health and Allergies: Oestrogen helps the gut microbiome and maintains bowel function. Often in a menstrual cycle, we notice diarrhoea with our period when oestrogen levels are lower. It regulates our appetite, and food cravings are common when oestrogen levels are lower with your period. Oestrogen has an anti-inflammatory effect. It stimulates histamine release, which can affect allergies.
    • Genito-urinary Health: Oestrogen increases libido, lubricates the vulvovaginal tissues and helps the vaginal microbiome. The most common time for thrush is just before our period when oestrogen levels are lower. Oestrogen also improves bladder function and reduces urinary infections.
    • Skin and Hair: Oestrogen reduces moisture loss from our skin and produces melanin. It stimulates hair and nail growth.

    So all in all, it’s pretty amazing, and no wonder we notice the effects of the levels falling, whether that’s with our period each month, or at menopause.

    Progesterone

    Then progesterone, well it’s quite different. So when we ovulate, the remains of the follicle in the ovary form the corpus luteum, which produces progesterone. From that reproductive lens progesterone is there to nourish us and support a pregnancy. progesterone slows everything down, we want to rest and eat. In the second half of our cycle, the progesterone dominant luteal phase we may be more introspective, craving a hot bath and an early night! 

    Calming for most of us, it helps us sleep. I say most because around 10% of women have quite a different experience with progesterone and find it has the opposite effects.

    Progesterone also supports bone health, and the uterus lining. So if at perimenopause we don’t ovulate we will have less progesterone, our cycle will extend and we may experience spotting before our period, and then our period when it comes will be heavier and longer. In terms of mood unfortunately our bodies try to compensate for less progesterone by increasing cortisol and adrenaline, so there’s a double whammy of losing the calming effects of progesterone and gaining more cortisol.

    Testosterone

    Testosterone is described by Maisie Hill as the Serena Williams of our hormones. Produced by the ovaries and adrenal glands, testosterone contributes to feelings of ambition, competitiveness, and physical vitality. Testosterone levels naturally decline from our 30s. The effects of a lower testosterone are much more pronounced in early menopause and after removal of the ovaries.

    Thanks to Davina testosterone is known for its effect on libido, but the other effects are still being debated. Women who use testosterone as part of HRT often report improved mood, energy, strength, memory, and vaginal health. However, studies on testosterone’s broader effects in women are still very limited, and more research is needed to confirm its full benefits.

    The Problem with Hormone Testing

    Many women seek blood tests to understand their hormonal balance, but these tests provide limited insight. Hormone levels fluctuate throughout the day and the month, and a single test doesn’t capture your average levels over time. Tracking your menstrual cycle can offer a more accurate picture of how your hormones are performing. Your menstrual cycle is a vital sign—its length, regularity, and any changes can indicate shifts in your hormonal health.

    Conclusion

    Understanding your hormones is key to navigating health and wellness throughout the different stages of life. From puberty to menopause, hormonal changes influence everything from your mood to your metabolism. By learning more about how your hormones work, you can take control of your health and make informed choices that support your well-being. Here at Rethink I can support you with all queries hormone related, find out more at rethinkmenopause.com/services/.

    Resources for more information

  • Testosterone treatment in menopause


    Testosterone advice and treatment is one of the most common reasons for women to book a consultation with Rethink. In this blog, I’ll help you understand what testosterone can help with, what to expect if you’re considering a trial of treatment, aswell was the situation with regards to who can prescribe it for you.


    The role of testosterone

    Described by Maisie Hill as the Serena Williams of our hormones, with testosterone on board we feel ambitious, competitive, and active.

    Not just for men, testosterone is produced by the ovaries and adrenal glands, and usually declines from our 30s, although in a more gradual way than oestrogen and progesterone. The effects are more pronounced for women with POI (premature ovarian insufficiency) and those who have had their ovaries removed surgically. Interestingly testosterone levels increase again at around age 65, it’s not yet known why or how. 

    Thanks to Davina, testosterone is known for its effect on libido. The other effects though are still being debated. Women using testosterone as part of their HRT often report improvements in mood, memory, concentration and energy levels, aswell as strength and vulvovaginal health. These effects have not yet been proven in studies, but the studies done to date have not been of very high quality, so more research is needed. Observational studies have shown improvements in metabolic function, with positive effects on blood pressure, glucose and lipids. For some women adding testosterone certainly seems to significantly improve their quality of life.


    Indications for testosterone HRT

    Both the National Institute Clinical Excellence (NICE) and the British Menopause Society (BMS) agree that testosterone can be considered at menopause for women with low libido after a biopsychosocial approach has excluded other causes of a low libido, for example antidepressant medication.

    If testosterone treatment is being considered, firstly, it is important to ensure that HRT is optimised – for example if oral oestrogen is being used, this would be changed to transdermal oestrogen as a patch/gel/spray, to increase the amount of circulating testosterone. Blood tests to look at the level of oestrogen being absorbed from the HRT are important, aswell as blood tests to assess the testosterone levels.

    Although much is said about the potential benefits of testosterone, the BMS state “randomised clinical trials to date have not demonstrated beneficial effects of testosterone therapy for cognition, mood, energy and musculoskeletal health.” The National Institute Health Research (NIHR) recently announced a planned trial of testosterone vs placebo to look into other potential benefits in more detail.

    Women who have experienced an earlier menopause, and women who have experienced a surgical menopause seem to show particular beneficial effects in research studies. Testosterone use is not advised unless testosterone levels are low on blood tests.


    Testosterone treatment is not recommended 

    • If you are/could be pregnant  
    • If you are breast-feeding  
    • If you have had hormone-sensitive breast cancer  
    • if you have active liver disease
    • If you are a competitive athlete

    Testosterone is an unlicensed medication

    Currently in the UK there are no testosterone preparations specifically licensed for use in menopause care, so its use is described as “off licence”. This does not mean there are concerns about the safety or effectiveness of the treatment.

    Other medicines are also used outside of their licence. Prescribing must meet criteria set by the General Medical Council (GMC) and the Medicines and Healthcare products Regulatory Agency (MHRA). 

    Off licence means that the manufacturer cannot advertise or make any recommendations about using the gel for women. When using a medicine off licence it does not mean that you are part of a clinical trial. Testosterone gel for women has been shown to be effective, and use is supported by expert groups.

    Previously available licensed preparations were discontinued for commercial (not medical) reasons. The safety and effectiveness of testosterone replacement in women has been demonstrated in randomised studies which have followed women for up to 12 months and reported significant improvements in sexual function. Due to the lack of availability of licensed female testosterone preparations, products which are manufactured and licensed for use in men have been used outside their product licence. The use is therefore “unlicensed”, which means that the manufacturer of the medicine has not specified it can be used in this way. 


    The testosterone leaflet

    As the treatments are licensed for use in men, the leaflet is written to support this use, in men. The dosing instructions on the leaflet inside the box do not apply to testosterone use in women.


    How to use testosterone HRT

    “Male preparations in female doses” 

    The female equivalent dose is 1/10 the male dose, usually 5mg/day, so a sachet used daily for men is used over 10 days for women.

    Testogel testosterone treatment

    Testogel® comes as a gel in a sachet. One 40.5mg Testogel® sachet should last around 8 days. You roll the top and seal it with a clip between uses, storing it in the fridge between uses. 3 months treatment on a private prescription costs around £14.

    Tostran testosterone treatment

    Tostran® 2% gel, in a pump dispenser, given as one     measured pump (10 mg testosterone) usually used three times a week or alternate days. Each canister should last 240 days (4 months). It is currently unavailable in the UK

    Testim testosterone treatment

    Testim® comes as a gel in a small tube with a screw cap. One 50mg tube should last around 10 days. The tube should be kept in the fridge between uses. 3 months treatment on a private prescription costs around £14.

    .

    AndroFeme testosterone treatment

    AndroFeme® is licensed in Australia for women. It comes with a measure for female dosing and is recommended to be used daily. It is only available on private prescription in   the UK, 3 months treatment costs around £95.


    Whichever preparation is used, it should be rubbed onto clean dry skin on the lower abdomen or thighs or inner forearm and allowed to dry before you get dressed. You should not have contact with any other person while it is drying (approximately 10 minutes), and wash your hands immediately after the gel has been applied. The area that it is applied to should not be washed for three hours after application to allow the gel to be absorbed. 


    How long will it take to work?

    It can sometimes take a few months for the full effects of testosterone to work, so a 3-6 month trial is recommended. Treatment helps around two thirds of women.


    What if I forget to use it?

    If you miss a dose, take it as soon as you remember. If it is close to the time your next dose is due (within a day) do not take the missed dose and continue with your normal dosing. It is important not to take two dosages of the gel to make up for missing one.


    Do I need more blood tests?

    Blood tests are taken before starting treatment, repeated after 3-6 months on treatment, and then usually every 12 months. Blood tests are best taken between 8 and 10am. Testosterone should not be used on the morning of a blood test.


    Can my GP take over the testosterone prescription on the NHS?

    The situation is different throughout the UK, according to the local prescribing formularies.

    In Bristol, North Somerset and South Glos testosterone is classified as an amber drug on the prescribing formulary for treatment of low libido causing distress in women with optimised HRT and with either early menopause (age 45 and under) or surgical menopause. So to qualify for NHS prescribing, women need to meet these criteria, be referred to a specialist for initiation of testosterone, and then after the first 3 months the prescription can be continued by the GP, if the GP agrees.


    What about side-effects?

    Usually, there are no side-effects of treatment.

    Some extra hair growth can sometimes be seen where the gel is applied. To minimise this, it is recommended to vary the site of application and spread the gel thinly.

    Weight gain is seen in some women. There can be some acne, and effects on hair growth patterns.

    A deepening of the voice and enlargement of the clitoris can be seen if high doses are used, which push blood test levels above usual women’s range. It is very important not to increase the dose of testosterone without discussion with your clinician and blood test monitoring.

    There is less information on any long-term effects of testosterone treatment than other forms of HRT. Currently data is limited to around 5 years of use.


    Looking after your medicine 

    The instructions on how you should store your treatment will be on the pharmacy label. Keep it out of the sight and reach of children. Do not use after the expiry date stated on the packaging. 


    Resources with more information

  • Hormone blood tests at perimenopause and menopause

    Hormone blood tests samples

    I completely understand the rationale to want to have hormone blood tests checked to see where you are in the menopause transition, and understand your experience.

    Unfortunately the tests we currently have available often aren’t that helpful. They give a level at the particular point in time the test was taken, not an average, and those levels can fluctuate significantly during perimenopause.

    Hormone blood tests for menopause diagnosis

    Current guidance is that the FSH blood test is considered for those aged under 45 with symptoms of menopause. This test cannot be done if you are using a method of contraception containing oestrogen like the combined pill. It can be done on other forms of contraception including progesterone pills, the implant and the hormonal coil. With the contraceptive injection it is best timed when the injection is due rather than when it has recently been given.

    Two blood test results showing FSH levels over 30 are used to diagnose menopause. In the perimenopause though the level does not usually reach 30. It can sometimes be normal, sometimes be on the higher side (15-20). Labs often report levels under 30 as being normal to GPs. There is no agreed level of FSH to diagnose the perimenopause. Normal FSH levels do not exclude perimenopause.

    Blood tests can be really helpful if it is difficult to know what is happening because you don’t have a cycle for example after a hysterectomy it is common to enter menopause earlier even if your ovaries are conserved, but without the change in cycle sometimes it is much more tricky to recognise a perimenopause presentation of fatigue, anxiety and poor sleep for example. Similarly if you are using a hormonal method of contraception that changes your cycle like the hormonal coil and you’re experiencing symptoms blood tests can be useful.

    hormone blood tests can be used to assess when to stop using contraception

    Hormone blood tests & contraception

    Blood tests can be used to help us know when we can safely stop using contraception. Using age alone, it is recommended to continue with contraception until age 55. If we are not using a hormonal method and our periods stop, we can stop contraception 2 years after our last period if it occurs under the age of 50, and 1 year after our last period if we are over the age of 50. 

    If we are not having periods, for example with the hormonal coil, and think we are menopausal and do not want to continue with the coil, the FSH level can help in knowing whether that is the case, and so can stop using contraception.

    Hormone blood tests for understanding symptoms

    Blood tests can also be really helpful in assessing symptoms that could have a number of causes. For example, fatigue is a very common symptom of perimenopause, as is a change in cycle towards longer, heavier periods. Blood tests in this scenario could be useful to check for anaemia and low iron levels.

    There are very few blood tests that are routinely recommended in NHS care, they are largely used to assess for specific causes. When screening blood tests are done sometimes we will find results that are not in the “normal” range, which can cause anxiety. In many situations, for example a slightly low vitamin D level, the result may be difficult to interpret and aiming to normalise the numbers does not always lead to any improvement in how we feel or our long-term health or wellbeing. They may be “normal” for us! There are of course other situations where it is certainly helpful to aim to optimise results.

    Hormone blood tests to assess oestrogen absorption from HRT

    The other main reason for blood tests at menopause is to help with understanding how medications are working for us. They are not needed in most cases, as the best way of knowing if HRT is helping is whether symptoms have improved.

    For example, we know approx 20% of people don’t absorb oestrogen well through the skin and blood tests to measure the oestradiol levels can help us know if this may be the case. Blood tests can’t be used to assess the effects of oral oestrogen, only transdermal oestrogen in the gel, patch or spray.

    Hormone blood tests for testosterone treatment

    Blood tests for testosterone levels are important if testosterone is being considered for use as part of HRT. Before starting testosterone baseline blood tests for testosterone levels help to assess whether levels are low and our oestrogen is optimised, and then during treatment we need to make sure that blood tests for testosterone levels are being kept within the usual range to avoid rare but potentially very significant and irreversible side-effects.

    Further info about hormone blood tests

    Women’s Health Concern leaflet Menopause

    Women’s Health Concern Testosterone