If you've heard about perimenopause, but are wondering what exactly that means and when does it start, then this is the place for you. Learn about 34 Symptoms Of Perimenopause and know that you are not going crazy, but that your hormones are changing and influencing every system in your body.

What is Perimenopause?

Menopause indicates the end of menstrual cycles. Menopause is when a no periods have occurred for 12 months due to a decline in ovarian hormone production. 

Perimenopause is the 'time around the menopause' and is also known as the menopausal transition. It is the first stage of menopause and is the phase periods still occur but symptoms relating to fluctuating and lower hormones can begin. 

It typically begins around 4-10 years prior to the final period. As the typical age for menopause is 45-55 years, perimenopause can start frm 35 onwards. Many of the 34 symptoms of perimenopause described below may be experienced. Hopefully most will be mild and transient, but if persistant and causing disruption to quality of life, it is important to seek medical advice for helpful treatment and support. 

What are The Causes of Perimenopause Symptoms?

Perimenopause symptoms can occur 4-10 years before the final menstrual period occurs. It can occur prior to a natural menopause around age 51 years or prior to 45 years if they experience premature menopause, which can be more difficult to diagnose.

Here are the reasons women experience symptoms during perimenopause.

1. Ovarian Function and Egg Reserve In Perimenopauses

As a woman enters perimenopause, her ovaries have significantly fewer eggs, and this means it is harder for those eggs to produce estrogen during the menstrual cycle. The brain sends higher levels of FSH hormone to stimulate more estrogen production, so initially in perimenopause there is elevated estrogen levels compared with progesterone.

As ovary function declines further both estrogen and progesterone levels become lower. This is a natural and normal process as the body prepares for menopause, when the woman no longer need to expend energy in fertility cycles or pregnancy. This decrease in estrogen can lead to hair thinning or even hair loss due to changes in hormone levels.

2. Hormonal Changes in Perimenopause

Hormone fluctuations drive perimenopausal symptoms. The hormones fluctuate from day to day but the general trend is that there is an relative decline in progesterone compared with estrogen (often referred to as estrogen dominance), followed by drop in both estrogen, progesterone and testosterone.

Symptoms during early perimenopause tend to be relating to imbalanced hormones, but towards the end of perimenopause women experience low estrogen symptoms.

3. Metabolic Changes in Perimenopause

Some of the most important changes during perimenopause are the changes to metabolism, resulting in rising blood pressure, cholesterol and body composition changes. Without exercise or nutritional support, from at least 8 years prior to menopause women begin to lose muscle and bone mass and this continues for at least 4 to 10 years post menopause.

Women also increase deposition of visceral fat, which is fat around the abdomen and organs such as the heart, liver and pancreas. These body composition and metabolic changes contribute to a reduction in insulin sensitivity and a rising risk from perimenopause onwards of metabolic diseases such as diabetes, heart disease, cancer and Alzheimer's disease.

What are 34 Symptoms of Perimenopause?

Estrogen and progesterone are metabolic hormones that influence every organ system in the body. This is why fluctuating and declining hormone levels causes such a variety of perimenopause symptoms.

The following are 34 symptoms that can be experienced during perimenopause.

Some of these symptoms can also occur in other conditions which can be serious so if you notice changes and you are uncertain if they are caused by perimenopause, check in with your health provider.

1. Hot Flashes or Hot Flushes

Hot flashes are sudden episodes of feeling warm, flushed, or hot all over the body. They are one of the most common symptoms of menopause and are caused by low or changing estrogen levels.

Hot flashes are not just an annoying symptom. Women who experience more severe hot flashes have increased risk of heart disease.

More frequent hot flashes are also associated with insulin resistance (Vasomotor symptoms and insulin resistance 2012).

2. Night Sweats

Night sweats are caused by dysregulation of body temperature and occur at night. Some menopausal women have significant night sweats and need to change the bedding or nightwear due to excessive sweating.

3. Difficulty Sleeping

The symptoms of difficulty sleeping in perimenopause include:

• sleep onset disruption,

• night sweats,

• hot flashes and flushes,

• early morning waking

• increased night-time urination.

Related: Top Sleep Tips

4. Mood Swings and Irritability

Mood swings and irritability are common symptoms of perimenopause. They can include:

• Feeling angry, weepy or sad for no apparent reason

• Experiencing sudden mood shifts

• Becoming easily irritated or frustrated by minor things in life

Both the changes in hormone levels, poor sleep and stress can contribute to and worsen mood symptoms.

Some women notice worsening mood symptoms in the days or week preceeding their period (during the luteal phase). This is due to hormonal changes during this part of the cycle in particular lower progesterone and estrogen. It often mimics a premenstrual syndrome or premenstrual dysphoric disorder (PMDD) type pattern - improving after the period occurs. 

5. Anxiety and Panic Attacks

The symptoms of anxiety and panic attacks in perimenopause is caused by changes in estrogen and it's impacts on stress hormones such as cortisol. The symptoms of anxiety can include:

• Restlessness or feeling on edge.

• Difficulty concentrating or difficulty falling asleep due to constant thoughts.

• Intense physical sensations such as chest pain, rapid heartbeat, shortness of breath, nausea, dizziness and numbness or tingling sensations in the limbs.

6. Brain Fog during Perimenopause

Brain fog can occur in perimenopause which is a symptom of reduced cognitive function and can cause:

• difficulty concentrating,

• difficulty focusing and remembering.

• having trouble multitasking.

This can be significantly debilitating for some women, particularly causing difficulty in functioning at work and can be a contributing factor to the reasons around 10 percent of women leave the workforce due to perimenopause/menopause.

7. Vaginal Dryness in Perimenopause

Low estrogen levels contribute to vaginal dryness and symptoms include:

• Dryness and irritation of vagina,

• Dryness of the vulva or urethra

• Increased pain during sex.

• Itching or burning sensation in the vagina.

• Painful urination or difficulty peeing.

Related: Topical Estrogen For Menopause

8. Breast Pain

Breast pain in common in perimenopause.

Breast tenderness is often more pronounced during the luteal phase which is the second half of the menstrual cycle. Breast pain is typically not related to breast cancer but if you have persisting breast pain or concerns about your symptoms it is always a good idea to discuss these with your doctor.

9. Weight Gain during Perimenopause

Weight gain in perimenopause is due to both hormonal and metabolic changes. These include:

• Loss of muscle and bone mass,

• Increasing insulin resistance

• Slowing down of metabolic rate due to loss of estrogen

• changes to appetite

• increased abdominal fat (also known as visceral fat).

Food cravings, which can be hormonally driven, may also contribute to weight gain.

10. Loss of Sexual Interest/Decreased Libido in Menopause

Reduced sexual interest or low libido in perimenopause is often multifactorial, but hormone changes can play a large role. A decline in estrogen and testosterone can result in:

• decreased desire for sexual activity;

• difficulty achieving orgasm;

• difficulty experiencing pleasure during sex;

• lack of arousal or physical attraction to one's partner.

Related: 

• Female Sexual Dysfunction/Low Libido
• Testosterone for low libido in menopause

11. Urinary Incontinence

Low estrogen levels can contribute to urinary incontinence in women. Stress incontinence is associated with a weak pelvic floor, and urge incontinence is often due to irritable bladder wall muscles.

12. Skin and Hair Changes

During perimenopause, many women notice their skin becoming drier and also can experience itchy skin. Some women also develop hormonal acne or flares of their underlying skin conditions such as eczema or psoriasis. Fine lines and wrinkles appear as collagen is lost from the skin. 

13. Digestive Problems

Digestive problems in perimenopause include:

• Excessive flatulence

• Bloating

• Nausea

• Abdominal cramps

• Stomach bloating

• Indigestion

• Diarrhea.

14. Hair Changes

Changes to your hair accompany perimenopause. It can include:

• Thinning hair on the head/other parts of the body

• Increased facial hair

• Dry, brittle, and fragile hair that breaks easily.

• Hair loss and greying of the hair.

15. Bloating

Digestion can slow down during perimenopause, resulting in feeling bloated, and constipation.

16. Irregular periods

During the latter part of perimenopause the length of time between periods increases and periods become irregular and infrequent.

17. Heavy Periods

When estrogen levels are high and progesterone levels are low there is often a high build up of endometrial lining (increased lining) combined with a lack of ovulation (lack of signaling to stop building the lining or to shed the lining). this can result in heavy and prolonged periods.

18. Bone Loss

Bone loss is the gradual and caused by a decrease in estrogen levels. It begins approximately 8 years prior to menopause and continues after menopause. The loss of bone structure results in weak bones, reduced bone density, and bones that are more prone to fracture.

Eventually some women may develop osteoporosis and develop non-traumatic fractures. These occur as the bones are too weak they simply fracture 

19. Painful Periods

During the earlier part of perimenopause when estrogen levels rise, it can cause your uterus to release more prostaglandins, which increase the severity of your period cramps (dysmenorrhea). Also some women develop a condition called endometriosis or adenomyosis which can cause painful bleeding.

20. Sarcopenia, Muscle Aches and Joint Pain

Muscle mass and strength is lost from around 8 years prior to menopause and continues for approximately 4 years after. This breakdown of muscle can cause muscle and joint pain and muscle tension.

The loss of muscle mass and strength is called sarcopenia and is the major cause of frailty in older people. 10 percent of muscle mass in lost over a 3 year period around perimenopause and up to 50 percent of muscle mass lost post-menopause in women who do not train with muscle resistance exercise.

Additionally lower hormones impacts the production of cartilage which can contribute to joint pain in perimenopause and menopause and is often the beginnings of osteoarthritis.

21. Low Energy

Fluctuating hormones, and changes in metabolism and sleep disturbances during perimenopause can all contribute to low energy. Additionally low iron due to heavier periods, and thyroid dysfunction are coomon in midlife so should be assessed. 

22. Infertility

During perimenopause women experience both ovulatory and anovulatory cycles. Women can both be fertile and have reduced fertility. It is important to continue to use contraception until you are post -menopausal if you want to avoid pregnancy and to seek support from your health provider if you are having difficulty conceiving during perimenopause.

23. Gum and Teeth Issues

Gum and mouth issues associated with perimenopause include:

• Gum disease

• Soreness, redness, or bleeding of the gums.

• Changes in tooth sensitivity or appearance (e.g., yellowing).

• Increased incidence of tooth decay or loss of teeth due to decreased saliva production during menopause.

24. Acid Reflux

Heartburn and acid reflux are common in perimenopause due to hormonal fluctuations. It can be improved with changes in diet and lifestyle.

25. Nail Changes

Changes to the nails during perimenopause are common and includes:

• Dry, brittle nails that break easily

• Discoloration of the nail beds

• Thinning or loss of cuticles.

26. Dizziness

Fluctuating hormone levels can cause changes in blood pressure and heart rates, and blood sugar levels and can contribute to dizzy spells.

Additionally vertigo from causes such as Meniere's can be triggered cyclically during periods of lower estrogen levels (Menopause and Vertigo 2024). 

27. Bacterial Vaginosis

Some women experience increased episodes of bacterial vaginosis due to changes in vaginal estrogen. A lack of estrogen reduces lactobacillus which usually helps to keep the vagina acidic and keeps out bacteria that usually colonise the gut. It can cause a change in the vaginal odour.

Related:

• Stop Recurring Bacterial Vaginosis
• Chronic BV Diet

28. Formication

Some women experience the sensation of bugs crawling under their skin or on their skin.

29. Urinary Tract Infections (UTI)

Lack of estrogen to the bladder and urethral and vulva tissues changes the bacterial flora of these intimate areas. It also increases the fragility of the tissue and increases the likelihood of infection especially urinary tract infections. This is a part of genitourinary syndrome of menopause. 

30. Headaches

Fluctuating hormone levels can cause tension headaches and migraines. They can worsen headaches in women who get them prior to perimenopause and can cause new onset of headaches in women who rarely had them.

Headaches and migraines can be particularly worse premenstrually or in the few days prior to getting a period.

31. Autoimmune Diseases in Perimenopause

Hormonal changes during perimenopause cause changes to the immune system and make women more susceptible to developing autoimmune disorders such as thyroid autoimmune diseases like Hashimoto's, Graves and other conditions such lupus and rheumatoid arthritis (Desai 2019).

32. Allergies During Perimenopause

Allergies can worsen or new allergies can develop during perimenopause. These include allergy related disorders including eczema, hayfever and asthma.

Fluctuating estrogen levels and low progesterone levels during perimenopause can trigger alter the immune system and trigger an increase in allergic responses, including mast cell release of histamines. (Shah 2012).

33. Irregular Heartbeat

Fluctuations in hormone levels can cause changes to heart rhythm and function. This can be experienced as:

• palpitations or skipped beats,

• racing heartbeat

• shortness of breath or

• chest pain.

It is important to speak to your doctor if you experience any of these symptoms during perimenopause.

34. Burning Mouth Syndrome

Burning mouth syndrome occurs in some perimenopausal women. It described as burning, tender, tingling, hot, scalding, and numb sensation in the oral mucosa.

Frequently Asked Questions about Perimenopause: FAQ

How is Perimenopause Diagnosed?

1. Use a validated questionnaire such as the Australian Menopause Society score card found here as our Menopause Symptom Quiz.

2. See your doctor who can:

• discuss your symptoms,

• examine you and perform blood tests to rule out other causes of your symptoms

• discuss treatment options.

Do Perimenopausal Symptoms Stop After Menopause?

Most women find that their symptoms reduce a few years after menopause. Some postmenopausal women experience ongoing menopausal symptoms for many years. For example some women experience menopausal hot flashes for decades after menopause.

Additionally genitourinary syndrome of menopause is common and without menopausal hormone therapy persists for at least 80 percent of women for life.

Related: Is HRT funded in New Zealand?

What Treatments Are Available For Perimenopause Symptoms?

Your healthcare provider may recommend supplements, menopause hormone therapy or other medications to ease perimenopause & menopause symptoms. Individualized care is best for perimenopause based on your symptoms, health risk factors and potential benefits of each treatment option.

What Is The Best Way To Prepare For Perimenopause?

1. Learn as much as you can about what to expect during perimenopause. Join our Menothrive Program.

2. Follow the 6 pillars of lifestyle medicine: fuel and nourish your body, move and lift heavy, sleep well, rest and relax, cultivate connections, and avoid toxic substances.

3. Seek advice from your heath professional to discuss diet, exercise, sleep and stress reduction support. You can also discuss hormone replacement therapy (HRT) and other supportive supplements to work out which options are best for you.

This list of 34 symptoms of menopause transition is not exhaustive but gives you an idea of the body-wide effect of hormonal changes during perimenopause.

Dr Deborah Brunt is a menopause doctor at Rebelle Health and would love to support you through the perimenopause and menopausal stages, supporting all aspects of your health and wellbeing.

Join our Menothrive Programs to feel great and love your life during peri and menopause.

Dr Deborah Brunt | Rebelle Health | Book Appointment