Diagnosis of peri menopause between 40-45

[apwilson1980]

Would appreciate help understanding NICE guidelines for diagnosis of peri menopause between 40 and 45.

I'm 42, periods have been getting increasingly irregular for about six years, and I've been having loads of symptoms the past 6-9 months. Now haven't had any bleeding at all in 3 months... I want to see if HRT will help with my symptoms (bad sleep, brain fog, irritability, etc.) as I'm starting a new, much more demanding job, in a month.

Went to the GP and was told I'll need to do a blood test for FSH despite symptoms and fact that my mum and maternal grandma both had early menopause (done and dusted by 42 for my mum). I told the GP that I thought diagnosis was to be done on symptoms alone and that the blood test is not reliable marker but she just fobbed me off, told me to get the blood test done and not to worry--also to look for black cohosh🙄 ... Anyway, have looked up NICE guidelines to try to have another go at the conversation about the blood test vs. symptoms-basis. The guidelines say no need for blood tests for those above 45, but it is recommended for those between 40-45 but then doesn't say anything else that I can see.. In other words, how is peri menopause diagnosed in women in that age bracket when the blood tests aren't a clear marker? From what I can read, FSH levels are all over the place during peri and plenty of women will be in that phase in early 40s, so what is the guidelines aside from recommending a blood test? What is to happen if someone in that age bracket has symptoms but blood test is 'normal'?

Similar age, similar maternal history. I argued that the blood tests wouldn't be conclusive, did them anyway. They wanted to rule out thyroid issues (discovered I had underactive thyroid, treated it, didn't help) and sleep apnoea (tested and discharged). I then argued for trying HRT to see if it would help and the GP agreed. It helped.

Thanks cornflakegirl sounds very similar to my situation. I've gone ahead and done the blood test tooit's worth doing, as you say, to check other things. I'm just concerned that if it comes back normal they'll then refuse to treat me on the basis of symptoms alone and I want to be prepared for that discussion if so. How did you go about it? I thought about finding and printing out some studies on FSH in peri menopause or something, but maybe this is overkill?

I didn't know about peri menopause at this age but if I knew then what I know now I'd actually point out to the Gp that I could be given the combined oral pill at that age and yet body identical hrt is more natural and easier to adjust to suit your needs. For example taking utrogestan vaginally rather than orally or using mirena and the cyclical regime can help regulate or move to continuous if periods very irregular and diminishing. Less health risks than COP.

I'd push and ask for a trial. I had to have repeat visits with various ailments and then present tracked symptoms before finally accessing hrt at 44; my periods were relatively regular but v light, and I'd started to over heat at night amongst other things.

Thanks, WarriorN, that's helpful to know and glad to hear some pushing worked eventually in your case. I'd like to avoid a coil as I just had a copper one removed after 11 years, but it's good to know that some options are more flexible than others. Has anyone had experience with the gel patches and finds them effective?

@apwilson1980 I was diagnosed at age 43 but I was more than happy to get my bloods checked. They showed I was indeed peri menopausal although I had minimal symptoms and had only missed 1 period. I started HRT right away.
I think you're worrying about something that hasn't happened yet. I bet your bloods will show you are menopausal especially as you have a strong family history and your symptoms have lasted a long time. I would just get them checked (plus thyroid bloods-I was diagnosed with an under active thyroid at the same time) and take it from there. No point worrying about something that hasn't happened yet.

Thanks thedogdaysareover2 I am doing the blood test and it is worth checking for other things anyway. I just know it can be unreliable and as the GP didn't specify times of day/days of cycle or anything it may well come back as normal and I want to be prepared for a further conversation in that case. Also, I'm preparing now because I want help with symptoms sooner rather than later as I'm worried about a new job starting soon, etc. Thanks for the reassurance, thoughit might well come back showing something in which case my job will be easier!

I had fsh blood tests but they weren't helpful at all. It was symptoms that showed it in the end.

Yes patches and utrogestan (I take it vaginally) have been great.

@apwilson1980 did you intend to cross out your post like that?

FSH should be done on days 2-5 of a cycle, if your cycles are regular. They are less accurate otherwise.

You should have 2 tests on two months.

If your GP refuses to believe this is menopausal, ask for a referral to a menopause gynaecologist, stressing your family history of early menopause.

If necessary, see another GP.

If that doesn't work, consider a private appt with a specialist which ought not to be necessary but the NHS is under such pressure that your case will be way down the list even if your GP agrees to a referral.

I had blood tests and it showed I was peri menopausal (and anaemic actually). I wouldn’t worry about it until you have had the results!

I am in same position as you OP.
Doc sent me for blood tests.
I had them. They showed as not in Menopausal range.
So she diagnosed me as Peri-menopausal.

I'm not sure what happens next! I guess if I want HRT I can ask for it.....

I went to the GP at 43 and was told that bloods are unreliable and was given the coil to help with horrendous, heavy periods. Spoke to the gp again 6 months later as i was by then having hot flushes and aching joints and was put straight on patches again with no bloods. The combination of the coil and patches has been a lifesaver for me, helped me feel human again.

No, I didn't mean to cross out above and not sure how it happened (or how to edit it now 🙄sorry!)... thanks for the tips, though--obviously trying to get it taken care of as simply and quickly as possible but these are good options to consider if this goes awry.

Thanks for this info -- what was it in the tests that indicated you were perimenopausal out of curiosity? I've seen that if FSH is elevated > 30 it indicates menopause. Did they decide that because you were near that you were menopausal? Did they do two tests or just one?

Thanks! This is an interesting sort of flip -- if it doesn't indicate menopause then you must be "peri" (based on symptoms I guess?) which doesn't seem at all to be what my GP is looking for!

Thanks -- good to hear that coil and patches have been helpful for you!

I've just turned 43 and suspected peri for a while. I initially saw the GP as I was having periods every other week. She arranged bloods and a scan. By the time I'd had the scan my periods had gone two months apart (now three months and counting). Follow up call said bloods confirmed peri menopause (or full on menopause) as FSH elevated and estrogen low.
My symptoms (periods aside) have been waves of heat, increased sweating and occasional sweeps of dread. She says this all backs it up. I've managed to cope ok so far but I'm due a review in 3 months. She will prescribe HRT if I need it. Currently taking a more holistic approach. So supplements, diet, exercise etc and will see how I go.
I've had blood tests before that didn't show anything, so I wonder now whether I'm more menopause than peri. All the women in one line of my family tree that we know of, have been late thirties / very early forties.
Take it as it comes and try not to worry x

What would people suggest if you have a number (a LOT) of perimenopausal symptoms (the worst is night sweats) but nothing hard to confirm it? I had FSH measured on cycle day 3 and it was 9, which I think is just inside the normal range. Normal oestrogen. Normal cycle length (28-30 days). But joint pain, very heavy bleeding and lots of clots, fucking night sweats, rerun of adolescent acne etc. GP seems to think she's proved that I'm not perimenopausal (I'm 43) so has told me only to come back if my cycle changes dramatically.

I'd firstly do everything I could to support my symptoms naturally, so diet, exercise, supplements etc. so I was lessening symptoms with what was in my power, then I'd probably seek a second opinion.

I emailed my Drs for the name of the female health specialist and then made an appointment with her. Had a telephone consultation and then bloods and a scan. Then a follow up. She was much more on the ball with it than my previous attempt. The whole process has taken a good few months though as they're so busy. The scan was to check for fibroids (as I was initially bleeding so much) and then took ages to come through.
Can you afford to go private for an initial consultation? This worked well for my husband with a condition he was diagnosed with.

Keep advocating for yourself as much as you can.

If bloods inconclusive or "normal" you could still ask GP for a 3 month trial of HRT. Simply say, "I understand the blood tests are inconclusive, but my symptoms indicate I am perimenopausal. I would like to trail HRT for 3 months, ideally <insert your preferred HRT> please". Provided them with a written list of your symptoms. Have things like periods/hot flushes at the top of your list (particularly flushes/night sweats - even if they are only occassional - as this is what HRT is licenced for). Have mood/anxiety/lowness at the bottom of your list. If you start with your mood the GP will hear these as the biggest symptom and naturally start thinking depresssion/anxiety.

Be polite/calm and open minded. Talk factually. Like a business meeting - state your aims. I would like to trial HRT. It is not a counselling session where you can examine your emotions. Or coffee with a friend where you can offload some woes.

If they say no, ask politely why not, and ask them to document on your record why they are refusing to let you have a trial. Then (politely) ask what would have to change for them to prescribe you (eg different bloods? different symptoms? your age). Can you be referred to Gynae/Meno team. Can you have further tests in 3 months? Can you seek a second opinion.They are not (at 42yo) breaking NICE guidelines.

If they try to prescribe Anti-depressants remind them that you are not depressed - but your symptoms/age and family medical history all point to you being hormonally deficient, and these symptoms would be allieviated with HRT. Anti depressants would not help.

Actually there is evidence that fluoxetine helps menopausal symptoms.
HRT is not magic. It's just hormones, and it can cause more problems than it cures in some cases.

Ye Gods. GPs are bloody useless at this sort of thing. Premature menopause is a thing in our family too. Me and DM. DGM died in her early 30's so I don't know about her though

Peri at your age and with your family history should be something they are taking proper note of, not fobbing you off with nonsense. You could always ask for a referral to a gynaecologist.

I love HRT vigilantes. It'll make my job so much easier.
I'm going to stop bothering to investigate causes of abnormal bleeding - you know, cancer and the like. And I won't bother to ask questions about brain fog. Who cares if it might be a brain tumour, or underlying depression. And forget those flushes and sweats, never mind lymphoma.

I'll just whack everyone on HRT because Davina says so.
After all, I'm a GP and we're "bloody useless" anyway so what the hell.

I sometimes wonder why I bothered to train for 10 years when a TV documentary, a bit of googling, and the opinion of MN manages to make everyone a doctor!

Firstly, I have not said unexplained bleeding etc shouldn't be investigated (though it took me pushing my GP to have a scan after nearly 14 months of bleeding....but hey...) The OP has not said she has this....

Just as there are HRT vigilantes there are also many patronising, untrained in menopause, all too keen to hand out anti-depressants GPs.

For me, it is nothing to do with Davina. And I am not sure where, in my post you got vigilantism - with my suggesting that the OP ask calmly to try HRT and to understand why her GP said no.

Oh, and in case you were not aware, NICE says
1.4.7 Ensure that menopausal women and healthcare professionals involved in their care understand that there is no clear evidence for SSRIs or SNRIs to ease low mood in menopausal women who have not been diagnosed with depression (see the NICE guideline on depression in adults).

So yes, fluoxetine may help flushes - and useful for women who cannot take HRT. But if a woman has symptoms of meno/peri, her family history indicates early menopause, there are no contra-indications to taking HRT, surely it is fair enough for her to ask?

@PantyMcPantFace I don't like the way you talk about GPs as if you know exactly what we're all thinking and what you have to say to bend us to your will.

Whether you watch Davina or not, she has told the female UK population that HRT will make them feel wonderful, and now we're inundated with inappropriate requests for it. I've had women in their 20s with regular periods ask for it, despite having no symptoms other than feeling stressed at work or unhappy in their relationship!

I think GPs should be trusted to know what they're doing and prescribe appropriately.
I've been prescribing multiple different forms of HRT for 25 years and in my experience many women stop taking it because it doesn't help, or it makes them gain weight, or they get breast cancer.
I think this idea that it's a magical cure-all needs to be stopped.

It can be great but it can be useless, and GPs have to consider other possibilities when considering diagnosis and management.

@Sarahcoggles but if there is no mandatory training for GPs in the menopause why should we just go with your opinion that "I think GPs should be trusted to know what they're doing and prescribe appropriately."

Are you seriously telling me that Every.Single.GP knows what they are doing with menopausal symptoms? Like the one who did not prescibe my sister with any form of progesterone (she still has a uterus) until I flagged it to her?
Are you seriously telling me that No.GP.Ever prescribed antidepressants for a patient who would probably be better off trying HRT?

Are you telling me that No.GP.Ever dismissed a woman's symptoms because the bloods told her so?
No.GP.Ever been patronising and acting like an almighty being?

So my advice - to the OP - was to approach the conversation calmly and ask for what she wants.

Not demand it. Not to get the GP to bend to her will.

But to facilitate the conversation - to make it clear what she would like to try.

We, as women, can be very good at underplaying what we are experiencing and bad at verbalising what we want. We can sit there in the waiting room a bit anxious, (or even worse in these days of phone conversations, be on edge all morning waiting for the "phone call from 8.30am) so when we eventually speak to the GP, and the first thing we say is what we are immediately experiencing "I feel rough - keep getting anxious, can't hold thoughts together - gets me upset". The GP (understandably, starts thinking MH/Anxiety).

And actually, that is the least of what we are feeling compared to the myriad of other symptoms. Sweats/Flushes/Missed Periods/aches/pains whatever. But we feel apologetic for taking up the GPs time....so don't necessarily list them...

If we do not state what we would like to try how can the GP know that this is where you think you are at/how you would like to think about allieviating the symptoms?

Or, because we know it can be a battle - we go in all cross, angry and combative. Not condusive to a productive appointment - whether that is to come away with HRT - or to come away with other course/action points. Understood by the patient.

If you are so very cross at Davina I think that is sad. Yes, of course, there will be inappropriate requests. And ill informed 20 year olds. But maybe you should actually be thanking her. Davina maybe helped that 20 year old pick up the phone/do an e-consult because she wasn't feeling well mentally. So how can the Davina effect a bad thing on the whole? For making women realise that actually, they feel like shit and can ask if something can be done. HRT may not be the answer - but there may be something that can be done for their horrific periods/palpitations. We, as women have put up with so much "it is just your age". Too right we should be saying, hang on....I still have 20 years left to work - I need help to do so. Unless you don't like the Davina effect because it means work for you?

Maybe think about your attitude to these women asking for HRT? And how you talk to them? You sound so very, very dismissive of them. The stupid women hung up on Davina. The vigilantes? They are possibly cross and angry because we have put up with crap women's health provision for decades. GPs not even expected to be trained in something 50% of their patients will experienc? Support them. And I don't mean by giving HRT if not appropriate. But really. Think about your attitude rather than worrying about mine. Think about how you talk to your patients rather than how a stranger on the internet talks about GPs.