There are dozens of signs you’re in it—including some surprising ones.
Mislaid your sunglasses—again? Yup. A bonafide whisker on your face? Uh-huh. Spontaneously sweating during a Zoom interview with a fresh-faced 22-year-old candidate to be your assistant? Sobbing over, well, you can’t remember what in the shower? These symptoms are just a few of the signs that you are going through perimenopause, or what is ominously referred to by the Silent and Boomer generations as the change.
And guess what? There are more signs of perimenopause—at least 34 of them, in fact. Fortunately, you may experience just a few, or none of them, and we wish that for you. But there is a slight chance that you may have many of them at different times, as you make your way through this life stage.
Perimenopause is the transition leading into menopause, a natural process where your ovaries stop producing eggs and you can’t conceive. During this time, estrogen levels start to drop, and you may see some symptoms, most notoriously hot flashes and night sweats.
“The most prominent symptom associated with perimenopause is menses delay,” says Nathan Goodyear, M.D., medical director of Brio-Medical in Scottsdale, AZ. In perimenopause, your periods gradually become less frequent until they stop entirely. One year after you last see red on your TP, you are in menopause.
Some of the symptoms of perimenopause may not give you pause (see what we did there?), but others can be quite literally life-altering. You needn’t just grin and bear it. Pay close attention to what’s going on, says Jerilynn Prior, M.D., a professor of endocrinology at the University of British Columbia, in Vancouver, Canada.
She suggests writing it all down in a journal (or recording it in an app, or whatever works for you.) “Keeping a record of what’s going on gives you at least a sense of control over these changes,” says Prior. It also gives you a detailed account to take to your doctor. If or when you start hormone replacement therapy (HRT, or HT), which can help soothe many of the symptoms of perimenopause, this log can help you and your doctor to determine how well the treatment is working, so they can adjust your dosage if needed.
We’ve kept you waiting breathless long enough…drumroll, please! Behold, the 34 signs of perimenopause, in alphabetical order.
About the Experts
Nathan Goodyear, M.D., is the medical director of Brio-Medical, a holistic, integrative healing center in Scottsdale, AZ. In addition to being board-certified in obstetrics and gynecology, Dr. Goodyear is a Fellow in Functional and Regenerative Medicine.
Jerilynn Prior, M.D., is a professor of endocrinology at the University of British Columbia, in Vancouver, Canada who focuses on, among other things, the menstrual cycle and the study and treatment of vasomotor symptoms.
If that old skiing (or newish pickleball) injury is acting up, or you’re suddenly waking up with stiff joints, it could be connected to your declining estrogen levels.
That’s because estrogen helps reduce inflammation (1). Without it, many women notice more stiffness and swelling around their joints. So-called “menopausal arthritis” can also lead to stiffness in hands and fingers (2).
In addition to HT, if you’re dealing with a lot of hot flashes (more on that below) your doctor might suggest watching your fluid intake. Why? Dehydration can make joint pain worse. Applying heat or soaking in a hot bath can provide relief.
Hormonal changes can affect your emotions, too, according to every woman who has ever been in perimenopause, but also the American College of Obstetrics and Gynecology (ACOG). There’s little research specifically looking at the effect of the hormonal transition on anxiety, but the link is clear.
Worrying about symptoms may add to that anxiety: You might worry about sweating through your blouse at an inopportune time, or whether you can sit through a play if you have to pee every 30 seconds, for instance. In addition to hormone therapy, antidepressant or antianxiety medications can help, as can upping your self-care game.
If you must unbutton your jeans under the table— even though you only ate a modest amount of ramen—you may have “menopause belly.” When estrogen levels spike it can cause your body to retain water, which leads to bloating. You might also be experiencing more gas, thanks to slowed digestion and/or changes to your appetite.
Staying hydrated, avoiding carbonated drinks and known trigger foods ( beans, broccoli, and spicy dishes), and eating smaller meals can all help.
“If a woman has a history of depression, then the downswings in estrogen can trigger it [during perimenopause],” says Prior. Women at the greatest risk are those who have had it before. But as a group, we’re more vulnerable at this time, according to the Menopause Society. That’s because these same hormones also regulate serotonin, the brain chemical that supports feelings of happiness and well-being.
When serotonin drops, along with progesterone and estrogen, feelings of anxiety and sadness often rise. “Talk to your doctor immediately if you are experiencing changes in your mood, as it’s important to rule out an underlying major depressive disorder as well as have a conversation about starting medications such as antidepressants or estrogen therapy, which are known to help improve symptoms of depression during perimenopause,” says Kristen Fuller, M.D. a physician and mental health expert.
According to one study, some 35 percent of perimenopausal participants experienced dizziness at least once a week (3). Fluctuating hormone levels may contribute to changes in metabolism that make blood sugar levels less steady, which can make you dizzy when they dip. “Eating small meals, staying hydrated, and maintaining an exercise regimen can help to keep glucose levels steady throughout the day,” says Fuller.
Research shows that the drop in reproductive hormones can also increase your risk of experiencing vertigo and migraines that can be accompanied by dizziness.
If you’re experiencing vertigo, see your doctor to rule out an inner ear problem. “Staying hydrated, getting on a healthy sleep schedule, and maintaining steady blood glucose levels throughout the day can help with symptoms of vertigo (4) related to hormonal fluctuations in perimenopause,” says Fuller.
So that bloating symptom we talked about earlier? It’s often accompanied by passing gas. If the typical lifestyle adjustments (including not chewing gum, avoiding triggering foods, and reducing salt intake) aren’t working, over-the-counter gas medications might do the trick.
As you head into menopause, the major decrease in estrogen weakens the bladder and causes atrophy of the vagina and urinary tract. This can leave you feeling like you need to pee more often and with more urgency (sometimes called urge incontinence).
Pee leaks when you laugh, cough or jog (called stress incontinence) are common, too. You may also experience more frequent urinary tract infections, a symptom of which is needing to pee all the time (5).
As reproductive hormones fluctuate, you might notice a few new “testosterone-fuelled” coarse hairs on your chin or upper lip (6).
If you want them gone, lean into the tried-and-true hair removal methods you already know and love, like tweezing, waxing, threading, laser, electrolysis and/or depilatory creams.
“For many women, hair is part of the female identity, so hair loss can be devastating to their mental and emotional health,” says Fuller. Unfortunately, it’s not uncommon to notice your ponytail shrinking during this life stage. Since estrogen promotes hair growth, density, and fullness, during perimenopause, it’s normal to notice more shedding, according to the Cleveland Clinic. With age, women are also more likely to experience androgenic alopecia, A.K.A. female pattern baldness, which causes overall thinning and bald spots.
If you are showing signs of major hair loss, talk to a dermatologist who specializes in hair loss. An over-the-counter product containing the ingredient minoxidil might help, or your doctor can suggest other treatments.
For 10 to 15 percent of women, hot flashes, which are thought to be caused by hormonal changes to the brain’s thermoregulatory center, are so intense that they disrupt daily life. This is a huge pain, making you late for everything because you have to change clothes several times before you leave the house, and then strip down to a tank top when everyone else is experiencing sweater weather.
In addition to HRT, acupuncture (7) is a highly effective treatment. Tricks like avoiding triggers (which could include coffee or red wine), wearing layers and even carrying a portable fan can also help.
Hot flashes may last many years, though they tend to be most frequent in the two years after you transition to menopause.
You skipped the tacos, so what gives? The frequent rise and fall of estrogen and progesterone during this stage can trigger IBS symptoms including indigestion, constipation, and diarrhea.
In addition to not eating too close to bedtime, avoid triggering foods and clothing that’s restrictive around your midsection when you down a larger meal. Over-the-counter antacids can help manage heartburn and indigestion.
Between the hot flashes, the need to pee, sleep apnea, and low mood, there are plenty of potential sleep stealers. And, as luck would have it, the sleep deprivation that follows can make the mental health symptoms worse. “Poor sleep, lack of sleep, and interrupted sleep can worsen depressive and anxiety symptoms,” says Fuller.
In addition to hormone therapy, certain medications (like selective serotonin reuptake inhibitors, or SSRIs) might help, Johns Hopkins reports. Getting regular exercise, going to bed at a consistent time, and keeping your bedroom quiet and dark can also set you up for better zzz’s.
About 4 in 10 women notice mood symptoms during this time, according to ACOG, and one of those moods is I Hate Everyone. Oh, and everything. Although it might feel a bit like PMS on steroids, perimenopausal mood instability will come at times unrelated to your menstrual cycle.
HRT will likely help with this, as will getting more sleep, exercising, and doing anything that reduces stress and anxiety, like yoga, journaling, or meditation.
A drop in sex drive isn’t inevitable, but it is common during perimenopause, according to the North American Menopause Society (NAMS). This is partly because the effects of falling estrogen levels aren’t exactly sexy (vaginal dryness, hot flashes, depression, and so on). Studies show that about a third of women report low desire and that low libido is troubling for about one in three of those women.
“If you are affected by low libido or this is becoming a problem in your relationship, it can be a good idea to talk to your doctor as well as a therapist,” says Fuller. A combination of approaches, including couples counseling and possible modifications to any libido-killing medications you may be taking (like antidepressants or blood pressure drugs), may help, according to NAMS.
As your body adapts to the hormonal changes of perimenopause, it’s not unusual to have a few new aches and pains. Lower estrogen levels can weaken the muscles and ligaments that support your spine. Carrying a few extra pounds, a decline in bone density, and the effects of inflammation (which research shows is connected (8) to this life stage) can also lead to low back pain.
This annoying symptom affects up to 50 percent of perimenopausal women (9). Managing weight gain and staying active, particularly with mobility-related exercise like yoga and stretching, can help.
You forgot to log into a meeting, can’t remember the name of that actor, and have arrived at the market with no idea what you’re supposed to be shopping for. Welcome to midlife brain fog—yes, it’s a thing.
The depletion of estrogen and progesterone affects the brain, too, basically scrambling our circuitry related to memory function (10). Brain fog is common, but you can push back with a brain-supportive diet rich in polyunsaturated fatty acids (found in eggs, seeds, fish, and nuts), doing what you can to support better sleep and getting regular exercise to destress and boost emotional wellbeing.
For women who deal with migraines, the hormonal fluctuations during perimenopause can trigger more frequent and severe attacks.
The good news is that once you reach menopause, and estrogen and testosterone levels reach a steady low, your migraines should mellow out, or even stop completely. Until then, taking a magnesium supplement might help, or talk to your doctor about starting or adjusting an existing prescription medication for migraines.
And if you are considering HRT to manage your other symptoms, it’s worth noting that it may worsen migraines if you experience auras, per the AMF. In that case, combined oral contraceptives can be helpful for women under age 50. Ask your doctor for more info.
As many as 20 percent of women may experience mood symptoms during perimenopause, according to ACOG. For some it’s irritability, tearfulness, or low energy that can seem virtually identical to PMS, says Fuller. The big difference is that these symptoms can strike at times seemingly unrelated to your menstrual cycle.
Although these aren’t directly tied to hormone levels, your other symptoms and the unpredictability of this life stage are bound to make you moody. The major predictors of mood symptoms in midlife are stress, poor overall health, and a history of depression.
If you’re waking in the wee hours drenched in sweat, you’re not alone. According to Goodyear, night sweats are one of the most common symptoms of perimenopause. Between 20 and 40 percent of women suffer these sudden, intense waves of body heat accompanied by flushing and sweating that last several minutes and often strike during the nighttime (11).
To get relief, wear lightweight pajamas, use a cooling pillow, plug in a bedroom fan, and sip cold water throughout the night. There is also medication you can take for hot flashes, so ask your doctor if you’re a candidate for that or HT, which can also help.
This disease that weakens bones and increases the risk of fractures, often starts slowly, after the age of 30, as bone breakdown starts to outpace bone buildup. There is a direct link between the lack of estrogen during perimenopause, and menopause, and a loss of bone mass. Women over the age of 50 are at the greatest risk of developing osteoporosis. HRT is believed to help prevent or slow bone loss and reduce the risk of fractures (12).
Some women experience vaginal dryness as a side effect of estrogen loss. This, along with a thinning of the vaginal walls and vulva can make sex uncomfortable, according to the NAMS, or even painful as the tissues become more fragile and susceptible to tearing during sex. This can sometimes cause light bleeding or spotting after intercourse.
If using lubricants doesn’t make sex enjoyable again, your doctor can prescribe vaginal hormone creams, rings, or suppositories that can help.
If you’ve ever felt your heart suddenly start pounding, fluttering, or racing while doing something unexciting like waiting in line at the grocery store, you’ll know how unnerving this symptom can be.
Heart palpitations are a common sign of perimenopause and a direct result of lower estrogen levels (13), which can lead to an overstimulation of the heart. Luckily these episodes are usually harmless, but don’t ignore them if they happen to you. Your doctor may want to run some tests to rule out any possible underlying problems with your ticker.
The shifts in hormone levels, along with the other symptoms of perimenopause can leave many women feeling troubled, anxious, and even panicky. But experiencing frequent feelings of high anxiety or panic attacks (which include symptoms like chest pain, dizziness, heart palpitations, and shortness of breath) can be a sign that you’re developing panic disorder, which some women do during menopause, reports NAMS.
If you were prone to anxiety in the past or had postpartum depression, you may be more likely to experience panic attacks now. If you experience a panic attack, focus on slowing down your breathing until it passes. Then, tell your doctor about it. “Panic attacks are very distressing and should be properly managed and treated,” says Fuller. Some medications can help, including HRT.
If you’ve experienced an unpleasant prickling feeling, like an army of ants crawling under your skin, this is called formication. It can be accompanied by pins and needles and itching. “It is likely related to a very increased level of the central stress hormone norepinephrine, which increases with estrogen downswings in perimenopause,” says Prior. Antihistamines and HRT may help to squash the creepy crawlies, and moisturizer can help if dry skin is making it worse.
So you’re eating the same healthy diet from a decade ago, but gaining weight? You can thank the drop in estrogen for messing with your metabolism, too.
During perimenopause, you are prone to losing muscle mass, which slows your calorie burn and leads to packing on pounds, mostly around the middle. To counteract your sluggish metabolism, you may need to start moving more (including doing more strength training) and eating less. To keep your current weight, you’ll probably need to cut 200 calories per day.
Some women start snoring during perimenopause. This may be in part due to the drop in estrogen and progesterone, which are thought to be protective against snoring, but it’s often connected to menopausal weight gain (14).
Weight gain increases your risk of developing obstructive sleep apnea (a condition where your breathing pauses for short spells while you are asleep), which may require a breathing apparatus called a continuous positive airway pressure (CPAP) device to keep you breathing normally through the night. If you think you’ve started snoring—or your partner insists that you have!—talk to your doctor.
Hormonal fluctuations commonly cause breast pain, also called mastalgia (15). This is because changes in estrogen cause fluid to build up in the breasts, making them feel swollen and tender.
If you’ve experienced boob tenderness in the past around your periods, it’s common to notice this symptom intensify during perimenopause, when hormone swings are even more dramatic. You might feel a dull ache or even a burning pain. It’s also common for breasts to get bigger or smaller. The good news is that once your periods stop altogether, so should breast pain.
As estrogen levels plummet, there can be a thinning of the lining of the urethra (the tube that passes urine from the bladder), and it’s natural for pelvic muscles to begin to weaken with age. Next thing you know, you’re peeing yourself in your Pilates class.
Although urinary incontinence is common, according to NAMS, it doesn’t have to be your new normal. Exercises like Kegels can help to strengthen the area and prevent leaks. Talk to your doctor or a pelvic floor physiotherapist about your treatment options.
The same changes to your urethra and bladder described above can make you more vulnerable to urinary tract infections (UTIs), too, according to ACOG. A weakened urethra makes it easier for bacteria to enter and move up to your bladder, plus estrogen raises the level of healthy bacteria that normally live in the area, so without it, you have less defense against harmful bacteria. A vaginal estrogen or low-dose antibiotic can help prevent recurring UTIs.
During the years leading up to menopause, it’s common to experience issues with vaginal dryness, says Goodyear. As your estrogen levels decline, the tissues of the vulva and the lining of the vagina can become drier, thinner, and less elastic (which is known as Genitourinary Syndrome of Menopause (GSM) and used to be referred to as vaginal atrophy).
At least half of women will experience this during perimenopause and menopause. In addition to HRT and vaginal estrogen, personal lubricants can give you some relief.
Vaginal dryness can be accompanied by an itching or burning sensation. In many cases, a lubricant or vaginal moisturizer can help. But if you experience intense irritation, talk to your doctor to rule out other possible causes (which may or may not be related to perimenopause) like a UTI, inflamed bladder, or prolapsed bladder, for example, which would require treatment.
By menopause, about 31% of women have some varicose veins. Estrogen and progesterone contribute to vascular health, so has their levels drop during perimenopause, you become prone to malfunctioning vein valves and an increased chance of blood collecting in your legs and ankles, in particular, causing veins in those areas to puff up to the surface of the skin. (They can also pop up in the pelvic area, especially if you’ve had a baby.)
In addition to wanting to cover them with makeup, varicose veins can also be uncomfortable, causing burning, itching, and swelling. (There are medical procedures that can help, so be sure to talk to your doctor about your options.)
There’s a reason why an expanding waistline is a classic sign of midlife. Some extra pounds are thought to be related to the drop in estrogen during perimenopause because this slows your metabolism.
Managing a chronic illness like diabetes, polycystic ovary syndrome, or sleep apnea can also put you at higher risk for weight gain as you move into menopause. If you can’t seem to get your gains under control with a healthy diet and exercise, talk to your doctor about the possibility of a secondary issue like a side effect of a new medication or thyroid problem.
Poor sleep is a major complaint for many women during perimenopause. As many as 46% of women have difficulty catching enough zzz’s during this time, and one of the culprits is vivid dreaming, per the National Sleep Foundation.
Decreased estrogen and progesterone can lead to more hours in REM sleep, the stage where most dreams happen. And because you’re closer to waking during this sleep cycle, your dreams can feel more real. And then all the physical changes and stress swirling around this life phase can provide lots of material for a strange, and sometimes upsetting dream life.
In general, vivid dreaming isn’t a concern unless it’s causing you stress or keeping you awake. If your weird dreams are keeping you up at night, talk to your doctor.
If you’ve noticed a major change to your cycle and can nod knowingly at several of the signs in this list, talk to your doctor. There’s no definitive test to confirm when you are in perimenopause, but you and your doctor can determine if you’ve arrived at the change. “If the timing, age, symptoms and cycle delay match, then the appropriate perimenopause stage is identified,” says Goodyear.
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