“My periods are all over the place, I’m not sleeping and I can’t think straight — is this the change, or something worse?”

NICE NG23 (Menopause: identification and management, updated 2024) advises diagnosing perimenopause clinically in women over 45 with vasomotor symptoms and irregular periods, without FSH testing. Exclude pregnancy where periods are late and contraception is inconsistent. HRT for a woman with a uterus needs oestrogen plus a progestogen for endometrial protection; transdermal oestrogen does not increase VTE risk above baseline and suits women with risk factors. HRT is not contraception. The 52 mg levonorgestrel intrauterine system can provide both the progestogen component of HRT and contraception (check the SPC for licensed duration of use for each purpose). CoSRH guidance on contraception for women over 40 advises continuing contraception until age 55, or stopping after 2 years of amenorrhoea if under 50 (1 year if over 50) when not using hormonal methods. NG23 also recommends offering CBT as an option for vasomotor symptoms and for low mood associated with menopause, and vaginal oestrogen for genitourinary symptoms. Cognitive complaints (“brain fog”) are common in perimenopause and often improve with treatment of vasomotor symptoms and sleep; screen mood and alcohol, and reassess if symptoms persist, especially with a family history of dementia. Work matters: many women do not disclose menopause symptoms at work; occupational health, reasonable adjustments and a fit note with suggested adaptations can help. Risk communication should be balanced and proportionate; for women in their 40s the absolute risks of HRT are small. The hidden agenda here is fear of inherited dementia and of losing her job.