Menopause & Perimenopause: Symptoms, Diagnosis & Assessment

This page covers the symptom domains to screen for, the consultation, and how the diagnosis is made. For definitions and physiology, see Overview. For treatment, see Menopause Treatment: MHT & Non-hormonal. For menopause before 40, see Premature ovarian insufficiency.

Symptom domains

Menopause is more than hot flushes — ask about each domain systematically, since women often under-report:

• Vasomotor — hot flushes, night sweats (the symptoms most responsive to MHT). Also palpitations, lightheadedness, migraine.
• Genitourinary syndrome of menopause (GSM) — vaginal dryness, dyspareunia, urinary urgency/frequency, recurrent UTI (responds to local vaginal oestrogen).
• Sleep — insomnia, often driven by night sweats.
• Mood & cognition — low mood, anxiety, irritability, tearfulness, “brain fog”, poor short-term memory, loss of confidence, decline in libido.
• Musculoskeletal — non-specific arthralgia, and longer-term bone health.
• Skin & other — dry skin, formication, new facial hair, breast tissue atrophy, unusual tiredness, headache.

The consultation

Take a menstrual, gynaecological, contraceptive, sexual and general medical history, and ask about mood, sleep, smoking/alcohol and social context. Consider all women at menopause to be at risk for cardiovascular disease, cancer (especially breast, ovary and cervix), diabetes and osteoporosis — seek a family history of each, and elicit the woman’s own priorities to guide shared decision-making.

Examination: blood pressure; height, weight, BMI, waist circumference; consider breast, abdominal and vaginal exam, and cervical screening if due.

Investigations to consider: FBC and iron studies if bleeding is heavy or prolonged; fasting lipids and glucose, LFTs, TSH; urinalysis if urinary symptoms; screening mammography if due; transvaginal ultrasound if abnormal bleeding; bone density if risk factors are present.

Making the diagnosis

• Age >45 with typical symptoms → clinical diagnosis. FSH is not required (it fluctuates widely in perimenopause and does not change management).
• Age 40–45, or atypical features → FSH is helpful (repeat once, 4–6 weeks apart, ideally off hormonal contraception).
• Age <40 with menstrual disturbance → assess for premature ovarian insufficiency, which has its own diagnostic criteria.
• Perimenopause is diagnosed on changing cycle length plus vasomotor/other symptoms; a woman can still be fertile, so address contraception — continue until 55, or 12 months of amenorrhoea if over 50 (24 months if under 50).
• Hormone testing is not required for menopause diagnosis over 45, and anti-Mullerian hormone (AMH) is not currently recommended for this purpose because of cost and variable sensitivity. In women with amenorrhoea from a hysterectomy, endometrial ablation, or a levonorgestrel IUD, FSH/oestradiol can help — but most progestogen-only methods are not expected to suppress FSH, and data on the drospirenone-only pill’s effect on FSH in perimenopause are lacking, so a low FSH on the drospirenone POP does not reliably exclude menopause.
• Practical rule for women on continuous hormonal contraception or MHT: bleeding pattern plus age can substitute for a formal work-up. Most are considered postmenopausal if amenorrhoeic on a combined pill/MHT and aged over 58, or if hot flushes/night sweats appear during the hormone-free week of a combined pill.
• Retrospective diagnosis is confirmed after 12 months of amenorrhoea (see Overview).

Differential diagnosis

Depression, anaemia, thyroid dysfunction, hyperparathyroidism, diabetes, medication effect (e.g. SSRIs), and gynaecological disorders (e.g. dysfunctional uterine bleeding).