Perimenopause Fatigue Is Real. Here’s What to Do About It
Tired of feeling tired all the time? Here’s how to manage fatigue during this hormonal transition.
Life gets more complex when you hit midlife. The responsibilities and stressors—job pressures, family needs, aging parents—can be draining, making you more fatigued. But if you fall into an energy slump that won’t let up, or you notice big changes in your mental or physical alertness, it might be perimenopause fatigue.
The dynamic effects of hormone fluctuations can make you feel sluggish, run down, and exhausted during the sometimes decade-long menopause transition. A study of over 3,000 perimenopausal women, published in the journal Women’s Health (London), found that nearly 67% of participants suffered from fatigue.1
Fortunately, if perimenopause is playing a role in your fatigue, there are options to help you find relief.
About the Experts
Yves-Richard Dole, M.D., is an OB-GYN at Mercy Medical Center in Baltimore.
Natasha Spencer, M.D., is an OB-GYN at Orlando Health Physician Associates in Altamonte Springs, FL.
Shelly Chvotzkin, M.D., is an OB-GYN in Sarasota, FL.
Kimberly Hood, M.D., is an OB-GYN in Destin, FL.
What Does Perimenopause Fatigue Feel Like?
Fatigue related to perimenopause can feel like physical exhaustion, weakness, and brain fog. Many describe it as:
- Crashing fatigue: Sudden, overwhelming bouts of extreme exhaustion.
- Chronic exhaustion: Moving through every moment of the day with a lack of energy.
- Emotional sensitivity: Feeling easily agitated and/or short on patience.
- Mental fog: Difficulty focusing and/or processing information.
How long does perimenopause fatigue last?
Perimenopause fatigue can last anywhere from a few months to years. Fatigue symptoms usually peak toward the end of perimenopause, says OB-GYN Shelly Chvotzkin.
Causes of Perimenopause Fatigue
Women experience perimenopause fatigue as a result of shifting estrogen, progesterone, and testosterone levels, which help regulate energy and sleep quality.
Because the three hormones are so interrelated, it can be hard for a provider to pinpoint the exact cause of perimenopause tiredness or fatigue, notes OB-GYN Kimberly Hood, M.D. Hormone testing can help determine which root cause of the fatigue needs to be addressed.
Sleep disturbances
One study found that perimenopausal women were 29 percent more likely than premenopausal women to report difficulty sleeping.2 The primary culprit is low estrogen, which is associated with multiple sleep-related issues, including night sweats, insomnia, daytime exhaustion, and yes—perimenopause fatigue.3
Estrogen is believed to influence sleep by regulating the neurotransmitter serotonin in the brain. When estrogen declines, serotonin can follow suit. Low serotonin contributes to mood disorders like anxiety and depression, which can also take a toll on sleep.4 5
Insomnia and sleep issues during perimenopause are also linked with declining progesterone. This hormone makes the brain more responsive to gamma-aminobutyric acid (GABA), a neurotransmitter that calms the nervous system and helps you wind down for sleep. When it declines, sleeplessness can follow.6
Stress
Research suggests hormonal and age-related biological changes during perimenopause can heighten stress sensitivity, leaving many women feeling more fatigued.7
As women age, estrogen and testosterone production shifts from the ovaries and fat cells to the adrenal glands, which also produce stress hormones, including cortisol, explains Hood.
When you’re under stress, the adrenals make more stress hormones and less sex hormones (they can’t do both, and survival comes before fertility), she says. These hormonal changes can contribute to impaired thyroid functioning, which can cause or worsen perimenopause fatigue.
Estrogen and progesterone help offset the negative effects of high cortisol, so if you’re producing less of these hormones, you’ll likely be more sensitive to stress during perimenopause.
The adrenal glands are much worse at producing progesterone compared to estrogen and testosterone, Hood explains. When ovarian progesterone production drops off during perimenopause, the adrenals don’t compensate effectively. This helps explain the occurrence of estrogen dominance. While research is limited, Hood says that estrogen dominance is associated with low energy.
Iron loss
Iron loss appears to be another factor in perimenopause fatigue. Abnormal bleeding is common during perimenopause, with many women reporting increases in menstrual duration and flow.
A 2025 study, published in Menopause, found a link between heavy or prolonged menstrual bleeding during perimenopause and symptoms of fatigue, likely caused by depleted iron levels. Iron deficiency is the leading cause of anemia, a condition where fatigue is a hallmark symptom.8
Iron deficiency can also contribute to fatigue by exacerbating sleep struggles, says Chvotzkin. Studies have linked low-iron anemia to insomnia, poor sleep quality, and night sweats.9
Low testosterone
Unexplained fatigue is one of the most commonly described symptoms of testosterone deficiency in women.10 While testosterone tapers more slowly than estrogen and progesterone, some women also experience a significant drop in testosterone during perimenopause.
How to Manage and Overcome Perimenopause Fatigue
Addressing symptoms like hot flashes, sleep disturbances, and mood changes can help ease perimenopause fatigue.
Since hormonal changes underlie most of what happens during perimenopause, some solutions below target your hormones. Others help decrease symptoms by supporting overall health.
Lifestyle shifts
- Try mind-body exercise. Activities like yoga and meditation increase relaxing parasympathetic activity and reduce stress. Research indicates they have a positive influence on fatigue in perimenopausal women.11
- Survey your sleep habits. “Avoid caffeine and caffeinated drinks after five o’clock, and don’t take your phone to bed with you. Sleep in a dark room, and have the temperature just slightly on the cool side,” Dole recommends.
- Stay active. Moving during the day helps you feel sleepier at night. Although the conventional wisdom has long been to avoid exercising in the evening, a 2018 study published in the journal Sports Medicine suggests that some people benefit more from evening workouts, as long as you cut off vigorous workouts at least one hour before bedtime.12
Vitamins and supplements for perimenopause fatigue
Vitamins and supplements might help manage different aspects of perimenopause fatigue. Here are some that might be worth trying, according to Chvotzkin. Check with your physician before you start using these or any supplements.
- Black cohosh, which is made from a plant related to buttercups, is a popular herbal remedy for perimenopause and fatigue.13
- Vitamin D, for energy and immune support (plus many people are chronically low, especially if you live in a northern climate).
- B-complex vitamins, for energy, stress management, mood balance, and cognitive functioning.
- Valerian, for sleep quality.
- Iron, since iron-deficiency anemia associated with heavy menstrual bleeding can cause fatigue.
Medications
- Hormone replacement therapy (HRT) can ease perimenopause fatigue caused by estrogen dominance, says Hood, who notes that a blood test can help determine if this is the case. HRT includes estrogen alone or combined with progesterone. Since fatigue during perimenopause often stems from low or imbalanced hormones, HRT might help. Though direct research on its connection to fatigue is limited, HRT has been shown to improve sleep quality, which may indirectly reduce tiredness.14 And there’s evidence linking progesterone therapy with improved sleep in menopausal women.15
- SSRIs: Antidepressants such as escitalopram (Celexa) and paroxetine (Paxil), can also help minimize sleep-stealing hot flashes, adds Dole.
- Fezolinetant (Veozah): This non-hormonal, prescription-only medication is FDA-approved for moderate to severe vasomotor symptoms (VMS) associated with menopause, such as hot flashes and night sweats.16
The Bottom Line
Fatigue is a common problem during perimenopause, mainly due to hormonal shifts and the resulting physiological and mental effects. While it can last for years, women can minimize its impact with treatment options like HRT and lifestyle changes like sleep hygiene.
Harper Joyce C, et al. (2022). An online survey of perimenopausal women to determine their attitudes and knowledge of the menopause
↑Howard Kravitz, et al. (2005). Relationship of day-to-day reproductive hormone levels to sleep in midlife women
↑Jamie Coborn, et al. (2022). Disruption of Sleep Continuity During the Perimenopause: Associations with Female Reproductive Hormone Profiles
↑Philip Eichling, et al. (2005). Menopause related sleep disorders
↑Rebecca Thurston, et al. (2012). Vasomotor Symptoms and Menopause: Findings from the Study of Women’s Health Across the Nation
↑Haufe Annika and Leeners Brigitte. (2023). Sleep Disturbances Across a Woman’s Lifespan: What Is the Role of Reproductive Hormones?
↑April Falconi, et al. (2017.) The Longitudinal Relation of Stress during the Menopausal Transition to Fibrinogen Concentrations: Results from the Study of Women’s Health Across the Nation
↑Sioban Harlow, et al. (2025). Abnormal uterine bleeding is associated with fatigue during the menopause transition
↑Gulden Sincan, et al. (2021). The Effects of Iron Deficiency Anemia on Sleep and Life Qualities
↑Scott Alice and Newson Louise. (2020). Should we be prescribing testosterone to perimenopausal and menopausal women? A guide to prescribing testosterone for women in primary care
↑Hong Xu, et al. (2024) Effects of mind-body exercise on perimenopausal and postmenopausal women: a systematic review and meta-analysis
↑Stutz Jan, et al. (2018). Effects of Evening Exercise on Sleep in Healthy Participants: A Systematic Review and Meta-Analysis
↑National Institutes for Health (n.d.) Black Cohosh
↑Sanja Borozan, et al. (2024.) Hormone replacement therapy for menopausal mood swings and sleep quality: The current evidence.
↑Coborn J, et al. (2022). Disruption of Sleep Continuity During the Perimenopause: Associations with Female Reproductive Hormone Profiles
↑Stubbs C, et. al (2017) Do SSRIs and SNRIs reduce the frequency and/or severity of hot flashes in menopausal women
↑
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The Edge upholds the highest standards of health journalism. We source research from peer-reviewed medical journals, top government agencies, leading academic institutions, and respected advocacy groups. We also go beyond the research, interviewing top experts in their fields to bring you the most informed insights. Every article is rigorously reviewed by medical experts to ensure accuracy. Contact us at support@honehealth.com if you see an error.
About the author
Theresa Fisher is a health/science writer, editor and content strategist based in Manhattan. She's led content for health-tech brands and contributed to various publications.
About the reviewer
Dr. Shelly Chvotzkin, D.O., F.A.C.O.O.G., is a physician board certified in obstetrics and gynecology. She is a member of the American College of Osteopathic Obstetricians and Gynecologists (ACOG), the American Osteopathic Association (AOA), the American Society for Colposcopy and Cervical Pathology (ASCCP) and the Menopause Society (formerly known as the North American Menopause Society or NAMS).
