How perimenopause is identified

Most often, without any tests. From the age of 45, if you have symptoms, the UK's NICE guideline provides for identifying perimenopause from recent hot flushes and changes in the cycle, and menopause after 12 months without a period, without tests2. In France, the national health insurance (Assurance Maladie) and the Haute Autorité de santé (HAS) also describe a clinical diagnosis3.

Why not a blood test? During the transition, the level of FSH, a hormone that stimulates the ovaries, varies widely: a single test can be misleading4. After 45, NICE also advises against other tests, such as anti-Müllerian hormone (AMH)5. The International Menopause Society (IMS) relies first and foremost on the cycle6.

Between 40 and 45

NICE suggests considering an FSH test to confirm menopause in people with symptoms and a change in their cycle7.

Before 40

Before the age of 40, clinicians look for premature ovarian insufficiency (POI) and its cause8. Guidelines differ: two FSH tests 4 to 6 weeks apart for NICE; a single raised result after at least 4 months of cycle disturbance for the European society ESHRE and the IMS, with a second test in case of doubt9.

On hormonal contraception

Hormonal contraception can mask periods and distort test results: NICE advises against FSH testing in people using combined oestrogen and progestogen contraception10, and the Assurance Maladie recommends neither hormone tests nor an ultrasound scan to decide whether to stop it11. Do not stop contraception without talking about it first: pregnancy is still possible12.

The options described in guidelines

Each option is discussed with its benefits and risks, according to age, situation and risk factors1. The decision is made together, based on your health, how much your symptoms bother you and your wishes13.

Menopausal hormone therapy (MHT)

  • Effectiveness: it is the treatment described as the most effective for hot flushes and night sweats14; it also acts on genitourinary symptoms and limits bone loss while it is being taken15.
  • Composition: oestrogen alone is only suitable if you do not have a uterus; otherwise, a progestogen protects the lining of the uterus16.
  • Risks: they depend on the hormones, the dose, the duration, the route and when treatment is started17. Taken by mouth, it increases the risk of venous thrombosis, which does not seem to be the case through the skin18. Combined treatment increases the risk of breast cancer, more so the longer it lasts, with an absolute risk that remains small19.
  • Timing: the balance of benefits and risks is considered more favourable before 60 or within 10 years of menopause20. There are contraindications, such as a history of breast cancer21.
  • Duration: in France, the HAS calls for the lowest effective dose for the shortest possible time; in Switzerland, the Swiss Society of Gynaecology and Obstetrics (SSGO) considers that the duration should not be limited arbitrarily; both provide for reassessment at least once a year22. Symptoms can return when treatment is stopped23.
  • Bleeding: it is common in the first few months; unexpected bleeding after that is a reason to see a doctor promptly24.

During perimenopause, the Assurance Maladie also mentions a progestogen or a low-dose pill25. MHT is not recommended for managing weight, preventing dementia or as an anti-ageing treatment26, and its effect on the heart is still debated27.

Local treatments for vaginal dryness

NICE provides for vaginal oestrogen, which is mostly absorbed locally, or moisturisers and lubricants, alone or combined; symptoms often return when treatment is stopped28. After breast cancer, non-hormonal options come first, and the oncology team is involved in some cases29. Vaginal laser is not recommended outside clinical trials30.

Non-hormonal medicines

A recent class of medicines, which acts on an area of the brain involved in hot flushes, can be discussed when MHT is not suitable; the HAS reports serious liver injury with one of them31. Others, such as certain antidepressants, have shown an effect in trials, but their place varies between guidelines32.

Cognitive behavioural therapy (CBT)

CBT is a recognised option for bothersome hot flushes; it can also help with mood and sleep, individually, in a group, remotely or as self-help33. For insomnia, the IMS puts a dedicated form of CBT first34.

Lifestyle

Regular physical activity, including muscle strengthening, is recommended for bones, muscles and the heart35. Its effect on hot flushes themselves is less well established, as is the effect of diet36.

Supplements and “custom-made” hormones

The efficacy and safety of unregulated preparations are unknown, and some herbal products interact with medicines: talk about it before taking any37. Custom-made “bioidentical” hormones are recommended neither by the IMS nor by the SSGO38.

Follow-up

NICE provides for each treatment to be reviewed at 3 months and then every year, and for referral to a healthcare professional specialising in menopause if nothing improves39. In France, the Assurance Maladie names your regular doctor (médecin traitant), a gynaecologist and a midwife40; in Geneva, the HUG (Geneva University Hospitals) have a specialist clinic for complex situations, on referral from a gynaecologist41.

Preparing for your appointment

The healthcare professional will want to know about your symptoms and their impact, your risk factors and your lifestyle42. A few notes can help:

  • The dates of your periods and how heavy they were, over the last few months.
  • Your symptoms, including sleep: which ones, when, how often, and what they stop you from doing.
  • Your contraception and treatments, including supplements.
  • Your personal and family medical history: breast cancer, thrombosis, heart disease, osteoporosis.
  • What matters to you: getting relief quickly, avoiding hormones, plans for a pregnancy…

The HUG offer an online questionnaire, the Menopause Rating Scale, for rating how intense your symptoms are43.

Questions to ask

  1. Could my symptoms be linked to perimenopause, or should another cause be looked for?
  2. Would an examination or a blood test be useful in my situation, and why?
  3. Do I still need contraception, and until when?
  4. Which options, hormonal or not, could be considered given my medical history?
  5. What are the benefits and risks for me, in figures if possible?
  6. How long would treatment last, and how will it be reviewed?
  7. Should my bone or cardiovascular health be checked?
  8. Who could I be referred to if my symptoms persist?

Sources for this page

Each number leads to a neutral statement and to the documents that support it. We summarise these sources in our own words; the links open the original documents.

  1. 1

    NICE recommends discussing the benefits and risks of each option with each person, tailoring the information to their age, situation and risk factors.

    Recommendation · checked on 18 October 2026

    Back to the text
  2. 2

    In people aged 45 and over who are otherwise healthy and have symptoms, NICE recommends identifying perimenopause (recent hot flushes and changes in the cycle) and menopause (at least 12 months without a period in people not using hormonal contraception, or based on symptoms after a hysterectomy) without laboratory tests.

    Recommendation · checked on 18 October 2026

    Back to the text
  3. 3

    In France, the Assurance Maladie and the HAS describe the diagnosis of menopause as clinical: no tests are needed in a usual situation, and hormone tests are most often unnecessary.

    Expert consensus · checked on 18 October 2026

    Back to the text
  4. 4

    During the transition, FSH levels vary widely: sometimes within menopausal values, sometimes within those of earlier years, so that a single test can be ambiguous or misleading.

    Established fact · checked on 18 October 2026

    Back to the text
  5. 5

    From the age of 45, NICE advises against using anti-Müllerian hormone (AMH), inhibin, oestradiol, follicle count or ovarian volume to identify perimenopause or menopause.

    Recommendation · checked on 18 October 2026

    Back to the text
  6. 6

    The IMS bases the identification of stages on cycle characteristics, following STRAW+10; blood tests (oestradiol, FSH, AMH) serve as a supplementary or main criterion only for people whose cycles do not allow a conclusion to be drawn.

    Recommendation · checked on 18 October 2026

    Back to the text
  7. 7

    NICE suggests considering an FSH test to confirm menopause only between the ages of 40 and 45 in people with symptoms and a change in their cycle, and before 40 when menopause is suspected.

    Recommendation · checked on 18 October 2026

    Back to the text
  8. 8

    Guidelines set out a specific medical approach for menopause occurring before the age of 45: before 40, POI warrants looking for a cause, and a hormone test may be considered between 40 and 45.

    Recommendation · checked on 18 October 2026

    Back to the text
  9. 9

    For POI, NICE requires symptoms and a raised FSH level on two blood samples taken 4 to 6 weeks apart, never a single test; the 2024 ESHRE guideline, adopted by the IMS, uses a single FSH level above 25 IU/l after at least 4 months of cycle disturbance, with a second test in case of doubt.

    Recommendation · checked on 18 October 2026

    Divergence between guidelines: NICE's criterion dates from 2015, ESHRE's from 2024.

    Back to the text
  10. 10

    NICE advises against FSH testing to identify menopause in people using combined oestrogen and progestogen contraception or high-dose progestogen, and points out that menopause is difficult to identify in people taking hormone treatment.

    Recommendation · checked on 18 October 2026

    Back to the text
  11. 11

    According to the Assurance Maladie, neither hormone tests nor pelvic ultrasound are recommended to decide whether to stop hormonal contraception; the doctor explains how to continue it until menopause is confirmed.

    Expert consensus · checked on 18 October 2026

    Back to the text
  12. 12

    Pregnancy is still possible during perimenopause: fertility declines with age but is not zero.

    Established fact · checked on 18 October 2026

    • Ménopause (fact sheet) (new tab) — World Health Organization (WHO), Fact sheet dated 16 October 2024 (French and English versions of the same date) (in French). Passage: Section “Changements associés à la ménopause”, 4th paragraph. Accessed on 18 October 2026.
    • Périménopause (préménopause) : symptômes et contraception (new tab) — Assurance Maladie (ameli.fr), Page updated on 9 April 2026 (in French). Passage: Section “Quelle contraception à l'approche de la ménopause ?”. Accessed on 18 October 2026.
    • Contraception: For Older Women (new tab) — International Menopause Society (IMS), content from Menopause Matters shared with permission, Fact sheet no. 3 (PDF of 11 October 2022). Passage: p. 1, 1st paragraph. Accessed on 18 October 2026.
    Back to the text
  13. 13

    The decision to start hormone treatment is made with the healthcare professional, according to the person's state of health, the effect of symptoms on their quality of life and their wishes.

    Expert consensus · checked on 18 October 2026

    Back to the text
  14. 14

    Menopausal hormone therapy is described as the most effective treatment for hot flushes and night sweats.

    Established fact · checked on 18 October 2026

    Back to the text
  15. 15

    Hormone therapy also acts on genitourinary symptoms and limits bone loss and the risk of fracture while it is being taken; this effect on fractures decreases after stopping.

    Established fact · checked on 18 October 2026

    Back to the text
  16. 16

    Oestrogen alone is only suitable for people without a uterus; when there is a uterus, a progestogen is added to protect the lining of the uterus.

    Established fact · checked on 18 October 2026

    Back to the text
  17. 17

    The risks of hormone therapy vary according to the type of hormones, the dose, the duration, the route of administration, when it is started and whether or not a progestogen is added.

    Established fact · checked on 18 October 2026

    Back to the text
  18. 18

    Taken orally, hormone therapy increases the risk of venous thrombosis; according to NICE, this risk is not increased with the transdermal route (through the skin), although the HAS considers the level of evidence for these data to be weak.

    Recommendation · checked on 18 October 2026

    The HAS also notes that the summaries of product characteristics do not distinguish between the risks of the two routes.

    Back to the text
  19. 19

    Combined treatment (oestrogen and progestogen) increases the risk of breast cancer; the increase grows with duration, decreases after stopping and remains small in absolute terms. According to NICE, oestrogen alone causes little or no increase.

    Established fact · checked on 18 October 2026

    The Swiss sources differ on the skin route: the HUG write that the increase is not found with the skin route, the SSGO expert opinion that it exists whatever the route, and the SSGO patient leaflet limits it to combined treatments lasting more than 5 years.

    Back to the text
  20. 20

    The balance of benefits and risks is considered more favourable when hormone therapy is started before the age of 60 or within 10 years of menopause, in the absence of contraindications.

    Recommendation · checked on 18 October 2026

    Back to the text
  21. 21

    Hormone therapy has contraindications, for example a history of breast cancer or established coronary heart disease.

    Established fact · checked on 18 October 2026

    Back to the text
  22. 22

    The duration of hormone therapy is approached differently: in France, the HAS calls for the lowest effective dose for the shortest possible time, with reassessment at least once a year; in Switzerland, the SSGO expert opinion considers it neither necessary nor appropriate to limit the duration arbitrarily, with yearly reassessment; NICE asks for it to be discussed from the outset and then at each review.

    Recommendation · checked on 18 October 2026

    Divergence between national guidelines, to be reported as it stands.

    Back to the text
  23. 23

    Symptoms can return when hormone therapy is stopped; according to NICE, stopping gradually or immediately makes no difference to symptoms in the long term.

    Recommendation · checked on 18 October 2026

    Back to the text
  24. 24

    NICE states that vaginal bleeding is common during the first 6 months of systemic hormone therapy or within 3 months of a change, and that unexpected bleeding after that calls for prompt medical advice.

    Recommendation · checked on 18 October 2026

    Back to the text
  25. 25

    In France, the Assurance Maladie states that, during perimenopause, a progestogen treatment or a low-dose oral contraceptive can relieve some symptoms, in the absence of contraindications.

    Expert consensus · checked on 18 October 2026

    Back to the text
  26. 26

    Hormone therapy is not recommended for managing weight, preventing dementia or as an anti-ageing treatment.

    Recommendation · checked on 18 October 2026

    For cognitive decline, the IMS makes an exception for POI or early menopause; the NICE recommendation concerns people aged 40 and over.

    Back to the text
  27. 27

    The effect of hormone therapy on the heart is presented differently: NICE states that it does not increase the risk of coronary heart disease but should not be offered to prevent cardiovascular disease; the IMS and the Swiss expert opinion describe a favourable effect when it is started early, which the SSGO patient leaflet calls “debatable”.

    Uncertain · checked on 18 October 2026

    Disagreement between guidelines on how to interpret the same studies.

    Back to the text
  28. 28

    For genitourinary symptoms, NICE recommends offering vaginal oestrogen, mostly absorbed locally, alone or with moisturisers or lubricants; the latter are an option for people who cannot or do not wish to use oestrogen, and symptoms often return when treatment is stopped.

    Recommendation · checked on 18 October 2026

    Back to the text
  29. 29

    After breast cancer, NICE recommends first offering non-hormonal moisturisers or lubricants, considering vaginal oestrogen if symptoms persist, and exploring options with the oncology team for people taking aromatase inhibitors.

    Recommendation · checked on 18 October 2026

    Back to the text
  30. 30

    NICE advises against vaginal laser outside clinical trials, and the IMS considers the evidence insufficient to recommend it.

    Recommendation · checked on 18 October 2026

    Back to the text
  31. 31

    A recent class of non-hormonal medicines, which acts on neurokinin receptors in the hypothalamus, reduces the frequency and severity of hot flushes, with efficacy somewhat lower than hormone therapy; NICE includes one of them as an option when hormone therapy is not suitable, and the HAS reports serious liver injury observed with this medicine.

    Recommendation · checked on 18 October 2026

    Back to the text
  32. 32

    Other non-hormonal medicines (certain antidepressants, gabapentin, oxybutynin) have shown an effect on hot flushes in trials, mostly without authorisation for this use; their place varies: NICE advises against offering them as first-line treatment for hot flushes alone, whereas the North American society recommends several of them.

    Expert consensus · checked on 18 October 2026

    Their place varies between guidelines; in France, the HAS mentions their off-label use in line with the recommendations of the CNGOF and GEMVi.

    Back to the text
  33. 33

    Cognitive behavioural therapy (CBT) is recommended as a non-hormonal option for bothersome hot flushes and also improves mood, sleep and quality of life; NICE proposes menopause-specific CBT, in individual or group sessions, in person, remotely or as self-help.

    Recommendation · checked on 18 October 2026

    Back to the text
  34. 34

    For sleep problems during the transition, the IMS recommends CBT adapted to insomnia (CBT-I) as the first-line treatment.

    Recommendation · checked on 18 October 2026

    Back to the text
  35. 35

    Regular physical activity is recommended for the health of bones, muscles and the heart; the IMS cites at least 150 minutes of moderate-intensity activity per week, with two muscle-strengthening sessions.

    Recommendation · checked on 18 October 2026

    Back to the text
  36. 36

    The effect of lifestyle changes on hot flushes themselves is not well established: the North American society does not recommend exercise, yoga, cooling or avoiding triggers for this symptom, and the IMS notes that trials do not confirm the value of dietary changes.

    Uncertain · checked on 18 October 2026

    The Assurance Maladie presents physical activity as a way of easing perimenopause symptoms; the IMS mentions possible weight loss in some people, on limited data.

    Back to the text
  37. 37

    The efficacy and safety of unregulated preparations are unknown; some herbal products can interact with medicines, and it is advisable to talk to a healthcare professional before taking them.

    Recommendation · checked on 18 October 2026

    Back to the text
  38. 38

    So-called “bioidentical” hormones that are custom-made are not recommended by the IMS, owing to a lack of quality control and of evidence of safety and efficacy; the SSGO does not recommend mixtures prepared individually in pharmacies either.

    Recommendation · checked on 18 October 2026

    The SSGO also uses “bioidentical” for authorised hormones (such as oestradiol), which is not the same as custom-made preparations.

    Back to the text
  39. 39

    NICE recommends reviewing each treatment at 3 months and then every year, and referring to a healthcare professional with expertise in menopause if symptoms do not improve or if side effects persist.

    Recommendation · checked on 18 October 2026

    Back to the text
  40. 40

    In France, the Assurance Maladie names the regular doctor (médecin traitant), the gynaecologist and the midwife as the main people to turn to.

    Established fact · checked on 18 October 2026

    Back to the text
  41. 41

    In Geneva, the HUG (Geneva University Hospitals) offer a specialist menopause clinic for complex situations or a second opinion, on referral from the treating gynaecologist.

    Established fact · checked on 18 October 2026

    • Mieux vivre votre ménopause (new tab) — Geneva University Hospitals (HUG), Department of Gynaecology, Page updated on 19 August 2026 (in French). Passage: Page introduction. Accessed on 18 October 2026.
    Back to the text
  42. 42

    During a menopause consultation, the doctor asks about risk factors (cardiovascular, venous, cancers, osteoporosis, diabetes), symptoms and their impact, and lifestyle.

    Established fact · checked on 18 October 2026

    • Mieux vivre votre ménopause (new tab) — Geneva University Hospitals (HUG), Department of Gynaecology, Page updated on 19 August 2026 (in French). Passage: Section “Comment se déroule la consultation ménopause ?”. Accessed on 18 October 2026.
    Back to the text
  43. 43

    The HUG offer an online questionnaire, the Menopause Rating Scale, for rating the severity of symptoms such as hot flushes, sleep, mood, fatigue or sexuality.

    Established fact · checked on 18 October 2026

    Back to the text