A woman comes in at forty-one. She has not slept properly in eight months. Her periods are still regular. She is irritable in a way that does not feel like her, she cannot find words mid-sentence, and her anxiety has gotten noticeably worse for no reason she can identify.
She has already been to two doctors. One offered an antidepressant. The other ordered an FSH level, told her it was normal, and said she was too young for menopause.
She is not too young. And the FSH was never going to answer the question.
Symptoms start before the calendar says they should
There is a formal staging system for reproductive aging called STRAW+10, and it remains the gold standard. It stages women primarily by what their menstrual cycles are doing — how regular they are, whether cycles are being skipped — with blood tests treated as supporting information rather than the diagnosis itself.
Here is what has become clear more recently, and what matters enormously for the woman sitting in front of me: symptoms frequently begin before a woman meets the criteria to be called perimenopausal at all.
The International Menopause Society addressed this directly in its 2025 recommendations, noting that the onset of menopausal symptoms is frequently earlier than STRAW+10 staging would suggest. In the Women Living Better Survey, there was less than a ten percent difference in the prevalence of a range of symptoms between women in the late reproductive stage and women formally classified as perimenopausal or early postmenopausal.
Read that again. Women whose cycles are still regular — who by the staging criteria have not entered the transition — are experiencing symptoms at nearly the same rate as women who have.
So when a forty-one-year-old with regular periods is told she is too young, the staging system is being used to dismiss a symptom pattern the staging system was never designed to rule out.
Why the blood test does not settle it
This is the single most common thing I have to undo.
The diagnosis of menopause and the menopause transition is a clinical diagnosis. It is made from the history — the symptom pattern, the menstrual pattern, the timeline. FSH, estradiol and AMH are supportive criteria, used for staging in women who cannot be staged by cycle characteristics. They are not the test that tells you whether you are perimenopausal.
And in perimenopause specifically, hormone levels fluctuate dramatically. An FSH drawn on one day can look entirely normal and be drawn again three weeks later looking quite different. A single normal result rules out almost nothing.
If you have been told your hormones are normal and therefore this is not perimenopause, that conclusion does not follow from that test.
The symptoms women do not connect
Hot flashes and night sweats are the ones everyone knows. They are also, for many women, not the first thing that shows up.
Sleep. Waking at three in the morning, night after night, sometimes without any flush at all. This is often the earliest and most disabling symptom, and it drives much of what follows.
Mood. Irritability, anxiety, low mood, a shorter fuse than you recognize in yourself. This gets diagnosed as depression frequently, and sometimes it genuinely is — but the timing relative to the menstrual pattern matters, and nobody asks.
Cognition. Word-finding difficulty, losing the thread mid-sentence, walking into a room and forgetting why. Women describe this with real fear because they assume it means something worse.
Cycle changes. Heavier bleeding, shorter cycles, occasional skipped cycles. Often the first objective sign, and often dismissed as normal.
Joint pain. Genuinely common, genuinely underrecognized.
Genitourinary symptoms. Vaginal dryness, discomfort with intercourse, urinary urgency, recurrent urinary tract infections. Rarely volunteered, rarely asked about, and highly treatable.
Palpitations, headaches, changes in body composition despite no change in habits.
“Any one of these alone means little. The pattern is the diagnosis.”
What treatment actually looks like
The Menopause Society's 2022 position statement is clear that hormone therapy remains the most effective treatment for vasomotor symptoms and for genitourinary syndrome of menopause, and that it prevents bone loss and fracture.
The benefit-risk framing matters. For healthy women under sixty who are within ten years of the onset of menopause and who do not have contraindications, the benefits of treating symptoms with hormone therapy outweigh the risks. For women initiating therapy more than ten to twenty years out, or at sixty and older, the balance shifts less favorably.
That is a real clinical conversation, and it depends on your age, your timing, your history and your goals. It is not a yes-or-no question, and it is certainly not one that fits into the last two minutes of an appointment.
For genitourinary symptoms that have not responded to nonhormone approaches, low-dose vaginal estrogen is recommended, along with other approved options.
For women who cannot use hormone therapy or who prefer not to, the Society's 2023 non-hormone position statement provides thirty-nine evidence-based recommendations. There are real options. "Nothing can be done" is not accurate.
One caution. Compounded hormone preparations — particularly pellets and troches — are marketed heavily and carry documented concerns: minimal regulation, over- and under-dosing, impurities and sterility issues, an absence of efficacy and safety data, and labels that do not disclose risks. If someone has recommended pellets to you, that conversation deserves a second opinion.
Why this gets missed
Not because your doctor does not care.
This diagnosis lives entirely in the history. There is no scan for it and no blood test that settles it. It requires asking about sleep, mood, cognition, cycles, joints and sexual function, and then connecting a pattern across all of them.
In a fifteen-minute visit built around one complaint, that conversation cannot happen. So the sleep gets a sleep aid, the mood gets an antidepressant, the joint pain gets ibuprofen, and nobody stands back far enough to see that these are one thing.
What I do differently
I built Rawq Medicine so that this visit can take an hour if it needs to.
I am completing certification through The Menopause Society, and perimenopause and menopause care is included in membership rather than sold as a separate program. When you come in with this, the entire visit is about this — the pattern, the timeline, the options, and a plan we build together.
You are not too young. You are not imagining it. And there is considerably more that can be done than you have likely been told.
Sources
The 2022 Hormone Therapy Position Statement of The North American Menopause Society (now The Menopause Society). Menopause. 2022 Jul 1;29(7):767–794. DOI: 10.1097/GME.0000000000002028
The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society. Menopause, 2023.
International Menopause Society Recommendations, 2025. Climacteric. DOI: 10.1080/13697137.2025.2585487
STRAW+10 — Stages of Reproductive Aging Workshop +10 staging criteria, endorsed by the IMS as the gold standard for staging reproductive aging.
Women Living Better Survey and the Australian Women's Midlife Years (AMY) Study, both cited in the IMS 2025 recommendations regarding symptom onset in the late reproductive stage.
Patient-facing resources are available at menopause.org.
Nada Farooqui, M.D.
Dr. Nada Farooqui, MD
Board Certified Family Medicine · Rawq Medicine, Hillsborough NJ. A Direct Primary Care practice — a flat monthly fee, no insurance in between, and time enough to explain things properly.