The full list of perimenopause symptoms

Perimenopause can produce a long list of symptoms: changes in your periods, hot flashes and night sweats, poor sleep, mood swings, brain fog, aching joints, vaginal dryness, urinary changes and shifts in weight and body shape. Some women notice almost none of these; others have many at once. Below is the full list, grouped by body system, with what causes them and what helps.

What perimenopause is

Perimenopause, also called the menopausal transition, is the stretch of years before your final period. Menopause itself is a single point, confirmed after 12 months without a period, and the average age at menopause in the US is 51 to 52. Most women begin the transition between 45 and 55, according to the National Institute on Aging, and it may last several years. For the full background, see what perimenopause is.

Researchers divide the transition into two stages. In the early transition, cycle length starts to vary persistently from one cycle to the next. In the late transition, you go 60 days or longer without a period. The late stage lasts on average one to three years, and it is when hot flashes are most likely.

Why the symptoms happen

The usual explanation, “estrogen is running out,” is incomplete. During perimenopause the ovaries respond erratically to signals from the brain, so estrogen swings, sometimes higher than before and sometimes much lower, from one cycle to the next. Ovulation also becomes less regular, and when you do not ovulate you do not make progesterone that cycle.

Estrogen acts on the brain’s temperature center, sleep and mood circuits, joints, skin, the bladder and the vaginal tissues. Progesterone has a calming, sleep-promoting effect. When both become unpredictable, symptoms show up across many systems at once, which is why perimenopause can feel like everything is changing.

The full list

Period changes

• Irregular cycles. ACOG describes cycles that become longer or shorter than usual, and skipped periods.
• Lighter or heavier flow, including heavier and longer periods when ovulation is skipped.
• Spotting between periods. Report it to a clinician; see the red flags below.

Hot flashes and night sweats

• Hot flashes: a sudden wave of heat over the upper body and face, often with sweating and flushing, usually lasting a few minutes. The Menopause Society notes that up to 80% of women have them at some point in the transition.
• Night sweats: hot flashes during sleep, which often wake you and leave you tired the next day.
• Chills after a flash, as sweat evaporates.

Sleep

• Trouble falling asleep, and more often waking in the night or too early and being unable to get back to sleep. Night sweats and a need to urinate add to the awakenings. See why perimenopause wakes you at 3 AM.

Mood and mind

• Irritability and mood swings.
• Anxiety, sometimes new for the first time.
• Low mood or depression. Santoro’s review notes that depressed mood and anxiety increase during the transition, with a sharp rise in the later stages.
• Brain fog: forgetfulness, trouble finding words and difficulty concentrating. The Menopause Society reports that 40 to 60% of midlife women describe cognitive symptoms during the transition.

Body

• Joint and muscle aches and stiffness.
• Fatigue, often from broken sleep, heavier periods or mood changes.
• Heart palpitations: a racing, pounding or fluttering heartbeat.
• Weight gain and a shift of fat to the abdomen.
• Headaches, including hormone-related migraines.

Vaginal, urinary and sexual changes

• Vaginal dryness, thinning and less elasticity, which can cause pain during sex.
• More frequent vaginal or urinary tract infections.
• Urinary urgency, frequency and leakage.
• Changes in sexual desire and arousal.

Santoro notes that vaginal dryness and pain with sex affect about a third of women in the later stages and, unlike hot flashes, will not go away without treatment. Clinicians call this cluster the genitourinary syndrome of menopause.

Skin and hair

• Drier, thinner skin.

To see how your own symptoms fit together, try the symptom check.

What else can cause these symptoms

Many perimenopause symptoms are nonspecific, and several common conditions produce the same picture:

• Thyroid disease. An underactive thyroid causes fatigue, weight gain, low mood and heavier periods; an overactive thyroid causes heat intolerance, sweating, palpitations and poor sleep.
• Iron deficiency and anemia, often from heavy perimenopausal bleeding, causing fatigue, weakness and poor concentration.
• Sleep apnea, which becomes more common around menopause and in women often presents as insomnia and tiredness rather than loud snoring.
• Depression and anxiety disorders.
• Pregnancy. It is less likely in perimenopause but still possible until you have gone 12 months without a period.
• Medications, including some antidepressants, blood pressure drugs and hormonal contraceptives.
• Diabetes or prediabetes, which can cause fatigue, thirst and frequent urination.

What helps, ranked by evidence

Hormone therapy (strongest evidence)

The Menopause Society states that hormone therapy remains the most effective treatment for hot flashes and night sweats, and that it should be considered for women under 60, within 10 years of their final period, who have no contraindications. ACOG likewise describes systemic estrogen as the best treatment for hot flashes and night sweats. For vaginal dryness alone, ACOG notes that local estrogen, as a vaginal ring, tablet or cream, releases small doses of estrogen directly into the vaginal tissue.

Nonhormonal prescriptions (good evidence for specific symptoms)

For hot flashes and night sweats, SSRIs and SNRIs, gabapentin and fezolinetant have Level I evidence in The Menopause Society’s 2023 nonhormone position statement. Antidepressants and psychotherapy treat depression and anxiety. Heavy bleeding has its own treatments, including hormonal IUDs and other medications.

Cognitive behavioral therapy (good evidence)

CBT tailored to menopause reduces how much hot flashes bother you, and CBT for insomnia is the first-line treatment for chronic insomnia.

Lifestyle (supportive, mixed evidence)

Regular exercise, strength training, a consistent sleep schedule, and limiting alcohol help sleep, mood, joints and body composition. They are less effective than medication for hot flashes themselves.

Supplements (weak evidence)

The Menopause Society does not recommend supplements or herbal remedies for hot flashes, because trials have not shown consistent benefit. Correct any deficiency you have actually measured; be cautious with products that promise to “balance hormones.”

When to see a clinician

ACOG advises reporting changes in menstrual bleeding even though they are common in perimenopause, because abnormal bleeding can signal a problem. See a clinician promptly for:

• very heavy bleeding, periods lasting much longer than usual, or bleeding between periods or after sex
• any bleeding after 12 months without a period
• chest pain, fainting or palpitations with shortness of breath
• low mood with thoughts of self-harm (call or text 988, the Suicide and Crisis Lifeline)
• symptoms that disrupt sleep, work or relationships

You do not need to wait until symptoms are severe. How to find a menopause specialist, or search the directory for a clinician near you.