PCOS in Perimenopause: More Than Just Irregular Periods

She sat across from me, frustrated and tired. Her weight was creeping up despite healthy eating. She was irritable, her memory unreliable, and she often lost words mid-sentence. Nights were broken, sugar cravings were stronger, and blood tests showed rising sugars and liver markers. What puzzled her most was her cycle. For decades her periods had been irregular, sometimes absent for months, yet now in her mid-40s they were suddenly appearing more regularly.

PCOS Meets Perimenopause

This is a common but under-recognised story. In women with polycystic ovary syndrome, rising follicle-stimulating hormone in the perimenopausal years can drive the ovaries to ovulate more often. After years of little ovarian activity, this sudden change can feel like a second puberty. The brain prefers hormonal steadiness, so these fluctuating oestrogen levels can cause brain fog, mood swings, irritability, and problems with focus and word finding.

The Metabolic Picture

PCOS already carries a higher risk of insulin resistance and type 2 diabetes. In perimenopause, the decline in oestrogen reduces muscle mass and increases visceral fat. This combination makes metabolic health even harder to manage. Women may notice sugar cravings, fatigue, and weight gain that seems out of proportion to their lifestyle. Blood tests often confirm this pattern, with higher HbA1c , triglycerides, or liver enzymes. Importantly, PCOS also increases the lifetime risk of cardiovascular disease, which means careful monitoring and prevention are essential at this stage of life.

Why MHT Matters

Menopausal hormone therapy is not only safe for women with PCOS, it can be highly effective. By providing a steady baseline of oestrogen, MHT can smooth out the unpredictable hormonal swings of perimenopause. This helps with brain fog, mood, and sleep, and can restore a sense of stability. Beyond symptom relief, MHT can reduce the risk of cardiovascular disease and lower the incidence of type 2 diabetes. It is a treatment that protects as well as relieves.

Micronised progesterone provides endometrial protection and also has calming benefits, often improving sleep. For some women, a progestogen-only pill such as Cerazette is added to prevent ovulation and further reduce hormonal volatility.  Another option is SlinMetformin may also be used to improve insulin sensitivity, helping energy levels, sugar cravings, and weight management.

Psychological Wellbeing

The benefits of treatment are not just physical. Stabilising hormones often restores motivation, lifts mood, and improves self-belief. Many women describe a renewed capacity to engage in exercise, social connection, and self-care. For those who have felt trapped by symptoms, this can be life-changing.  PCOS itself is linked with higher rates of depression and anxiety, so recognising and treating these hormonal and metabolic shifts in perimenopause is especially important. Addressing them early can reduce emotional distress and protect long-term wellbeing.

The Takeaway

For women with PCOS, perimenopause is not simply a continuation of irregular cycles. It brings new challenges, from sudden hormonal shifts to increased metabolic and cardiovascular risk. With the right support, these changes can be navigated safely. Menopausal hormone therapy and targeted metabolic care not only ease symptoms but also reduce long-term health risks, helping women move forward with confidence and vitality.