Perimenopause

Perimenopause means "around the menopause". It starts when your cycle begins to change, runs through the years your hormones rise and fall unevenly, and ends a year after your last period.

Menopause itself is a single day: your final period. You only know which day it was looking back, once a full year has passed without another.

Researchers call the same stretch the menopausal transition. The STRAW+10 staging system, which the Pakistan Menopause Society uses, marks its start with a change in your cycle: a persistent difference of seven days or more between one cycle and the next.

The few Urdu leaflets that mention perimenopause either borrow the English word, پیری مینوپاز, or describe it instead. Roshara uses both: the word, and a leaflet's description, mahwari band hone ke aas paas ka waqt, the time around the periods stopping.

When it starts

Women's Health Concern, the patient arm of the British Menopause Society, says perimenopause can begin in your late 30s or early 40s. The NHS website says menopause usually comes between 45 and 55, but the Pakistan Menopause Society puts the average age in Pakistan between 45 and 49, lower than among Caucasian women. Age at menopause sets out where those numbers come from.

Our reading: if your last period is likely to come in your mid to late forties, the years of change can start in your early forties. Know the signs at 40, not 50.

The Pakistan Menopause Society lists the symptoms of early perimenopause, and says they may begin before the final period:

• Periods: irregular cycles, bleeding that is heavier or further apart, months with none.
• Heat: hot flushes, night sweats and palpitations.
• Mind and mood: broken sleep, fatigue, irritability, anxiety, low mood and brain fog.
• Body: headaches, joint and muscle pains, breast tenderness and bloating.

In real life it is the dupatta you keep taking off, or snapping at the children without knowing why. Each one is easy to explain away. Together they are a pattern, and a pattern is what a doctor can recognise.

Women's Health Concern explains that through your fertile years your ovaries make estrogen. As you get older your store of eggs runs down and estrogen falls, but not overnight: it takes years, which is why symptoms come and go. It says this fluctuating stage is often when symptoms are most noticeable. A good month followed by a terrible one is not you imagining things.

How a doctor recognises it

If you are 45 or over and otherwise healthy, NICE NG23 says perimenopause is identified from your symptoms and changes in your cycle, with no blood test needed (1.3.1). The Pakistan Menopause Society agrees (Table 3). Between 40 and 45, NICE says a doctor may consider an FSH blood test (1.3.6). Under 40, changes like these are looked into as possible premature ovarian insufficiency. How menopause is diagnosed goes through each case.

Two places to start on Roshara

• Where am I? asks six questions about your age, your periods and what you have noticed, and names the STRAW+10 stage your answers point to. It is orientation, not a diagnosis.
• The symptom score rates 27 symptoms, so you walk into your appointment with a record instead of "I'm fine".

The symptoms are what guidance treats. NICE NG23 and the Pakistan Menopause Society both list HRT as a first-line option for hot flushes and night sweats, in women who can take it (NICE 1.5.1; PMS 7.1.1). Whether it suits you is for your doctor to weigh against your history. Each symptom page covers its own options.

If the changes are getting in the way of your sleep, work or family, that is reason enough to book.

Some things should not wait. The Pakistan Menopause Society lists bleeding after sex, unexplained bleeding between periods, and sudden heavy or prolonged bleeding as red flags, and asks doctors to investigate them rather than put them down to menopause. It also lists symptoms before 40 that could point to premature ovarian insufficiency, and severe depression or thoughts of suicide. If your mood has dropped that far, see a doctor straight away.

When your cycle turns unpredictable, so does the rhythm of prayer and fasting that follows it. Women ask how to tell a period from spotting, and what that means for salah or a fast. Those are questions for a qualified scholar. What the bleeding is, medically, is a question for your doctor.

At home, the hard part is often having no word to use. Mahwari band hone ke aas paas ka waqt is plainer than perimenopause, and it gives the people around you something to understand.