Hot flushes are just the beginning. New research is revealing that perimenopause, the years-long hormonal transition before menopause, affects cognition, cardiovascular health, bone density, and mental wellbeing. So why did medicine take so long to talk about it?
A transition hidden in plain sight
Somewhere between her late thirties and her early fifties, a woman’s reproductive hormones begin their final, complex negotiation. This is perimenopause: a phase that can last anywhere from two to twelve years, characterised not by a steady decline in oestrogen but by wild, erratic fluctuation that sends hormonal signals ricocheting through almost every system in the body.
The lived experience of perimenopause (the disrupted sleep, the cognitive fog, the sudden anxiety, the joint pain, the irregular bleeding, the heart palpitations that send women to A&E convinced they are having a cardiac event) has been documented by women themselves for decades. What medicine offered in return was, for much of the late twentieth and early twenty-first century, very little.
‘I saw eight different doctors over three years before anyone mentioned perimenopause,’ says Davina McCall, whose 2021 Channel 4 documentary Sex, Mind and the Menopause sparked a national conversation that clinicians and policymakers had largely failed to initiate. Her experience, anecdotal but representative, reflects a systemic failure that researchers and clinicians are only now beginning to formally acknowledge and address.
The WHI shadow, and what we got wrong
The modern history of perimenopause and menopause medicine is inseparable from the 2002 Women’s Health Initiative (WHI) study, arguably the most consequential and most misread clinical trial of recent decades. The WHI found that hormone replacement therapy (HRT) was associated with increased risk of breast cancer and cardiovascular disease. Headlines were global and catastrophic. HRT prescriptions collapsed overnight. Women were told to stop. Many did.
What followed was a decade of unnecessary suffering. Subsequent reanalysis of the WHI data, along with a wave of new studies, revealed that the original findings had been significantly misinterpreted. The study had enrolled women whose average age was 63, meaning many were a decade or more past menopause; the findings were not straightforwardly applicable to women in their forties or early fifties beginning perimenopause. The type of HRT used was also important: synthetic progestin, used in the WHI, carries different risk profiles from the body-identical progesterone now typically prescribed in the UK.
The British Menopause Society, the Royal College of Obstetricians and Gynaecologists, and NICE have all since updated their guidelines to reflect a more nuanced risk-benefit picture. For most healthy women under 60 who begin HRT within ten years of menopause, the evidence now suggests that the benefits of treatment (symptom control, cardiovascular protection, preservation of bone density, and reduction in all-cause mortality) substantially outweigh the risks.
‘Women were told to just get on with it. We would never accept that standard of care for any male-pattern condition of equivalent prevalence and impact.’
The wider health picture medicine missed
The fixation on hot flushes, real and frequently debilitating as they are, has masked a broader perimenopause picture that medicine is now playing catch-up to understand. Oestrogen receptors exist throughout the body: in the brain, the cardiovascular system, the bones, the gut, the bladder, and the skin. The hormonal volatility of perimenopause therefore has systemic implications that extend well beyond vasomotor symptoms.
Cognitive symptoms are among the most distressing and least acknowledged. A significant proportion of perimenopausal women report memory difficulties, word-finding problems, and reduced concentration, sometimes severe enough to lead to workplace difficulties and, in some cases, misdiagnosis of early dementia. Research from the University of Rochester found that verbal memory declined measurably during the perimenopause transition before stabilising post-menopause, a pattern that may partly explain the subjective experience many women describe as ‘brain fog’.
Cardiovascular risk is another underappreciated dimension. Women’s cardiovascular disease rates, lower than men’s for most of adult life, begin rising in perimenopause as oestrogen’s cardioprotective effects diminish. Heart disease is the leading cause of death for women over 60 in the UK; a fact that remains poorly understood by many women and, troublingly, by some clinicians.
Mental health is equally implicated. Research published in JAMA Psychiatry found that the risk of first-onset depression increases twofold during the menopause transition, even in women with no prior psychiatric history. For those with a history of premenstrual dysphoric disorder or postnatal depression, conditions linked to hormonal sensitivity, the risk is higher still.
The GP consultation problem
A 2023 survey by the Menopause Charity found that 44 per cent of women who consulted their GP about perimenopause symptoms were not offered any information about HRT. Twenty-seven per cent were offered antidepressants as a first-line treatment for symptoms that were hormonal in origin. These numbers reflect a training gap with real consequences: a 2022 audit of UK medical schools found that the average training time devoted to menopause across a five-year medical degree was 17 hours.
The NHS Menopause Care Improvement Programme, launched in 2022, and NICE guideline updates in 2015 and 2023 have sought to address this. The appointment of England’s first Women’s Health Ambassador in 2021, and the publication of the Women’s Health Strategy in 2022, represent genuine institutional progress. But change at the level of clinical culture is slow. Women seeking perimenopause support still frequently report being dismissed, undertreated, or directed toward generic mental health support when what they needed was hormonal assessment.
What good care looks like
The evidence base for perimenopause and menopause care has matured considerably. Body-identical HRT, licensed formulations of oestrogen and progesterone that are chemically identical to hormones produced by the body, is now available on the NHS. Transdermal oestrogen (applied as a patch or gel rather than taken orally) carries a lower risk of blood clots than oral preparations and is typically the preferred form for most women without contraindications.
Non-hormonal options (including SSRIs, cognitive behavioural therapy (which has evidence for hot flush management), and certain blood pressure medications) offer pathways for women who cannot or choose not to use HRT. Lifestyle interventions including resistance exercise, dietary protein adequacy, and alcohol reduction all have evidence for mitigating perimenopause symptoms and long-term health risks.
The fundamental requirement, however, is that women can access individualised, informed conversations with clinicians who understand the menopause transition in its full complexity, not simply as an inconvenience to be managed, but as a significant life-stage with real health implications that deserve the same quality of clinical attention as any other.
‘Women were told to just get on with it,’ says Dr. Louise Newson, a GP and menopause specialist who has become one of the most prominent advocates for improved menopause care in the UK. ‘We would never accept that standard of care for any male-pattern condition of equivalent prevalence and impact.’
She is right. And thirty years is long enough to have waited for that conversation to begin.