You’re 43. You’re not sleeping. Your joints ache. Your anxiety has appeared out of nowhere. You feel like a different person in your own body. You go to your GP and ask, “Could this be perimenopause?”
They run your FSH and oestradiol. The results come back “normal.” And so you’re told: “You’re not perimenopausal.”
This happens every single day in South Africa. And it’s wrong.
Perimenopause Is a Clinical Diagnosis
Let me be clear about this: perimenopause is diagnosed based on your symptoms and your stage of life, not on a blood test. This is not my personal opinion. This is the position of every major menopause society in the world, including NICE, the International Menopause Society, and the British Menopause Society.
The reason is straightforward. During perimenopause, your hormones don’t decline in a neat, linear fashion. They fluctuate wildly. Oestrogen can swing from very high to very low within the same cycle. FSH can be elevated one week and normal the next. A single blood draw on a single day cannot capture that chaos. It’s like taking a photograph of the ocean and trying to determine the tide pattern.
When a GP uses a “normal” FSH result to rule out perimenopause, they are applying the wrong tool to the question. And the consequence is that women are left without answers, without treatment, and without validation for what they’re experiencing.
The Symptoms Nobody Talks About
Most women know about hot flushes and irregular periods. But perimenopause is far broader and stranger than that.
Musculoskeletal symptoms are incredibly common and rarely discussed. Frozen shoulder in a woman in her mid-40s with no injury? That’s a hallmark perimenopausal presentation. Joint pain, stiffness, new onset of aches that feel like early arthritis, and loss of grip strength can all be driven by declining oestrogen.
Neurological and cognitive symptoms catch many women off guard. Brain fog, difficulty finding words, poor short-term memory, and a sense that your thinking has become slower or less sharp. These are not signs of early dementia. They are signs of fluctuating oestrogen.
Psychological symptoms are often the most distressing. New-onset anxiety (sometimes severe), rage or irritability that feels disproportionate, low mood, loss of motivation, and a creeping sense of not recognising yourself. Many women are prescribed antidepressants during this window without anyone asking whether hormones might be contributing.
Sleep disruption goes beyond night sweats. Some women simply stop sleeping well, waking at 3am with a racing mind, unable to fall back asleep. Progesterone, which naturally declines during perimenopause, is one of the brain’s key calming and sleep-promoting hormones.
Other symptoms that often get missed include heart palpitations, tinnitus, burning mouth syndrome, electric shock sensations, crawling skin, sudden onset of allergies or histamine intolerance, changes in body odour, and urinary urgency or recurrent UTIs.
How I Approach It Differently
In my practice, I don’t use blood tests to diagnose perimenopause. I use them to rule out other things that can mimic or overlap with it, like thyroid dysfunction, iron deficiency, or metabolic changes. That’s an important distinction.
What I do rely on is a thorough symptom assessment. I use a structured symptom scoring tool, the Menopause Symptom Score (a modified Greene Scale), which allows us to quantify the burden of symptoms across physical, psychological, and vasomotor domains. A score of 15 or above often warrants treatment consideration, but the score also gives us a baseline to track against.
This is where monitoring becomes powerful. Rather than chasing hormone levels that change from day to day, I track how symptoms respond to treatment over time. Are you sleeping better? Has the anxiety lifted? Are the joint pains improving? Has your brain fog cleared? These are the metrics that matter.
Why This Matters So Much
Perimenopause can begin in your early 40s, sometimes even late 30s, and the transition can last 7 to 10 years. That’s a significant portion of a woman’s life. And for many women, it coincides with some of the most demanding years: career peaks, raising children, caring for ageing parents, managing households.
To be told “your bloods are normal, there’s nothing wrong” during this time is not just unhelpful. It’s harmful. It delays treatment, erodes trust, and leaves women questioning their own experience.
You are not imagining it. Your symptoms are real, they have a physiological basis, and they deserve to be taken seriously.
The Bottom Line
If you’re a woman in your late 30s to 50s experiencing a cluster of the symptoms above, you may well be perimenopausal, regardless of what a blood test says. The right approach is a clinician who listens to your symptoms, scores them, tracks them, and treats the whole picture.
Dr Robyn Bradfield is the founder of Bloodfields, a virtual investigative blood analysis practice. If you’d like a thorough perimenopause assessment based on your symptoms rather than a single blood test, you can book through our website.