My periods are changing and I am in my forties

Perimenopause is the ovaries winding down unevenly. Some months an egg is released and some months not, so the hormones swing rather than fall, and the swings are what you feel. Cycles shorten first, then stretch out. Bleeding gets heavier for a while because the lining builds up longer between periods. Hot flushes and night sweats come from the temperature control in the brain reacting to the swings. Sleep, mood and concentration follow. Vaginal dryness and bladder irritability come a little later and, unlike the flushes, they do not pass on their own.

The changes that are not simply perimenopause, and are always looked into, are bleeding between periods, bleeding after intercourse, periods that flood or last more than a week, and any bleeding after a year without periods. Most of these turn out to be a polyp, a fibroid or a thickened lining, and are treated simply, but they are checked every time.

Symptoms before 45 are looked at more carefully, because a thyroid problem, a change in weight, stress, and some medicines can imitate perimenopause, and because an early menopause has its own consequences for the bones and the heart and is treated differently.

The story, in detail: your periods over the last two years, the bleeding pattern, the flushes and the nights, sleep and mood, dryness and intercourse, bladder and bowels. Your general health, medicines, family history, and what bothers you most, because that is where treatment starts. Then an examination, and a scan of the uterus and ovaries where the bleeding pattern is unusual. Blood tests are done where they will change something: thyroid, haemoglobin if the bleeding is heavy, and sugar and cholesterol, because this is the decade when those begin to matter. Hormone levels are not usually needed to make the diagnosis in the mid-forties, and are done when you are younger than that.

You leave knowing what is expected and what is not, with anything unusual on a list to be looked at, and with a conversation begun about what would help.

• Naming it. Many women feel better simply from being told that the sleep, the mood and the memory are part of one thing with a name, not three separate failures.
• For the bleeding. The same tablets and the same small hormonal device that treat heavy periods at any age; the device is particularly useful here, because it also protects the lining and can form half of hormone therapy later.
• Hormone therapy, for flushes, sweats, sleep and mood where they are affecting your life. It is one of the most effective treatments for those symptoms. For most healthy women in their forties and early fifties the benefits outweigh the risks, and for some women it is not suitable; which you are is worked out from your own history, and the decision is yours once you have the honest version of both sides.
• Local oestrogen for dryness and bladder symptoms: a cream or a pessary, used a couple of times a week, that acts where it is placed. It is safe for almost everyone and it is under-used.
• Non-hormonal options for flushes where hormones are not wanted or not suitable, and for sleep and mood; plain measures that work, and a few medicines that do too.
• Bones and heart. Calcium and vitamin D, weight-bearing exercise, a look at blood pressure and cholesterol, and a bone density scan where the history calls for it. This is the visit to begin that, not the one ten years on.

You have bled after months, or a year, of nothing. Come. Bleeding after a year without periods is checked every time, with a scan and sometimes a small sample of the lining. It is usually something simple. It is checked because occasionally it is not, and found early it is treated well.

You are 44 and the periods are chaotic. That is perimenopause doing what it does, and it is still worth a visit: to make sure the bleeding is not from a polyp or a thickened lining, to sort out the flooding, and to talk about the flushes and the sleep before they wear you down.

You have been told you are too young for this. Perimenopause in the early forties is common and in the late thirties it is not rare. If your periods and your nights have changed, it deserves looking at, whatever your age, and if it turns out to be your thyroid instead, that is treated too.

• Bleeding after a year without periods, at any amount
• Bleeding between periods, or after intercourse
• Flooding, clots, or periods lasting more than seven days
• Symptoms of menopause before 45, and especially before 40
• Pain with intercourse that is stopping you having it
• A cervical screening test that is overdue

Where the scan shows a thickened lining or a polyp, a small sample of the lining is taken in the clinic, or a hysteroscopy is done to look inside the uterus and remove the polyp at the same time. Both are short and neither needs a stay. You are told who will do it and where, before anything is booked.