What is perimenopause?
Before menopause, there is a transitional period known as perimenopause, where your body experiences many changes.
During this time, your hormone levels change. Ovarian function decreases, and you will see numerous different changes physically and emotionally and in how you metabolize things. It can affect your daily life in ways you may not expect. The average age at which this transition starts is approximately 47. Still, it can be sooner or later, depending on you as an individual, and menopause (defined by no period for twelve consecutive months) usually occurs between 51 and 52 years of age. The average duration of this transition is 4–8 years, but some women may have this transition in as little as 2 years or as many as 8 years.
An erratic, slow decrease in oestrogen and progesterone throughout the body is the primary cause of this gradual decline over the years. Your ovaries do not just shut off; they wind down at different rates of speed, which is the reason that the symptoms are unpredictable during this time. Some months may have an otherwise normal cycle, while some may have abnormal cycles, which could include shorter cycles, longer cycles, heavier or absent cycles, etc.
Perimenopausal symptoms are quite variable in individuals and groups, making it difficult to diagnose the condition accurately. One test alone cannot provide 100% certainty in the diagnosis of perimenopause.
If you think that you are now experiencing the symptoms of perimenopause, the best thing you can do at this point is to schedule an appointment with your doctor. The doctor will provide you with all the important information you need regarding each of the symptoms associated with perimenopause.
The complete symptom checklist
Up to 90% of women will experience perimenopausal symptoms that may impact various organs at once. Still, many are not able to identify that the issue they are experiencing is actually hormonal. The checklist below contains the five different groups of symptoms to help you determine what is happening to your body.
| Category | Symptoms |
| Menstrual changes | Shorter or longer cycles, heavier or lighter periods, irregular or skipped periods, spotting between periods, longer or shorter gaps between cycles. |
| Vasomotor symptoms | Hot flushes, heart palpitations, night sweats, sudden flushing, chills following a hot flush, sweating during the day |
| Mood and cognitive symptoms | Fatigue and low energy (affecting up to 96% of women), memory problems (93%), difficulty concentrating, low mood, anxiety, irritability, and mood swings. These are among the most prevalent yet least recognised symptoms of perimenopause. |
| Physical symptoms | Disrupted sleep and insomnia, joint and muscle aches, headaches, weight gain, particularly around the abdomen, changes to skin and hair texture, hair thinning, breast tenderness, bloating, dizziness |
| Sexual and urinary symptoms | Vaginal dryness, discomfort during sex, reduced libido, urinary urgency, increased frequency of urination, urinary incontinence, and recurrent urinary tract infections are collectively known as genitourinary syndrome of menopause, affecting up to 50% of women. |
These symptoms may not necessarily apply to every woman, as some women will only experience some symptoms at once, while other women will experience clusters or isolated symptoms. Research has shown that the stress of many of these symptoms may begin as early as a woman’s mid-thirties, which is many years before most women think they are starting to go through perimenopause. If you experience several of the following symptoms, you should not assume that they are due to stress or ageing, and you should consult your doctor.
Early vs late perimenopause: – what changes
There isn’t just one way to go through perimenopause; there are two ways to go through perimenopause, both of which are associated with different types of hormones (hormonal patterns) and types of symptoms (symptom profiles). Knowing where you are in your transition gives you a better idea of what’s going on and what to expect next.
According to the STRAW+10 Staging System — the accepted standard for determining how old someone is in terms of their reproductive stage — early perimenopause typically occurs when a woman has a range of cycle lengths that vary from one cycle to the next at least seven times (variability in length). Transitioning into the latter stage of perimenopause occurs when a woman starts having irregular periods (no period for 60 days or longer).
During early perimenopause, the length of your cycles will become unpredictable and, as such, your periods will not stop altogether. You also may find that your cycles become shorter in length; you are experiencing more aside from just the first signs of vasomotor symptoms (hot flashes, night sweats, disturbed sleep) – you will likely also have fluctuations in your mood, experience anxiety, and feel fatigued; often doing so before any changes to your menstrual cycle occur.
There will be more dramatic hormonal changes during late perimenopause due to the continual increase in FSH levels and decrease in oestradiol levels. Stabilisation of hormone levels occurs approximately two years after a woman has her last menstrual period. Vasomotor symptoms will peak at this stage, and as a result of a significant decrease in the amount of oestrogen being produced, genitourinary symptoms (vaginal dryness, discomfort during sex, changes in bladder function) will also be observed more frequently.
Research supports the finding that vasomotor symptoms and vaginal dryness are the most significant clinical indicators of perimenopause; they occur five and two and a half times, respectively, more frequently during this transition than they do before perimenopause. If you can identify which stage you are currently in, your doctor will have valuable information that will enable them to provide you with the best possible care.
Is this perimenopause? Self-assessment framework
Perimenopause’s symptoms can be troublesome because they mimic other conditions, including thyroid disorders, gallbladder problems, anaemia, depression, and chronic stress. To make sense of your similar symptoms before seeing a doctor, consider:
- Age and Cycle: Perimenopause should be the first possible explanation for a woman aged 40 to 45 with symptoms relating to menopause if she has noted changes in her menstrual cycles. (Before performing blood tests to measure hormone levels.) If you are experiencing menopause-like symptoms before age 40, early menopause must be ruled out.
- How symptoms coexist: Women during perimenopause have symptoms that co-occur over an extended time (except women postmenopause). If you have identified changes to your cycle and are also experiencing other menopause-like symptoms such as hot flashes, disrupted sleep, and/or mood changes, it matters and is considered clinically significant.
Ask yourself these four questions.
Have you noticed an irregularity, shortening, lengthening, increasing in heaviness or frequency of your periods within the last 6 months? Are you experiencing sleep disruptions, mood changes and hot flushes (especially ones that have changed or feel different)? Are these symptoms having an impact on your daily life, relationships and/or work? Have other possible explanations like thyroid problems, iron-deficiency anemia, or stress been ruled out?
A recent study concluded that anxiety and depressive symptoms were found in 58.9% and 68.7% of perimenopausal women, respectively; therefore, if you are experiencing changes to your emotional state along with physical changes, you should keep this in mind. If you answered ‘yes’ to two or more questions above, contact your GP/Primary Care Physician for an appointment and also take the checklist with you when you do so.
Symptoms are often mistaken for something else.
Women often experience frustration while going through the menopausal transition and often receive the wrong treatment for their symptoms. On average, 40% of females who go through the perimenopausal transition report being misdiagnosed and treated for clinical depression or anxiety disorder without addressing the root cause of their symptoms (which are caused by hormone fluctuations during perimenopause). Three errors are frequently made during the process of diagnosing perimenopausal females:
Misdiagnosed Generalized Anxiety Disorder. Generalized Anxiety Disorder (GAD) is often diagnosed in women during perimenopause due to estrogen levels being unpredictable and fluctuating; this has an immediate effect on the central nervous system and brain chemistry, resulting in the symptomatology of GAD (anxiety, poor sleep, heart palpitations, fogginess, and mood swings). If you begin to experience symptoms of anxiety after age 40 without a known cause, you may want to consider the possibility that you are going through perimenopause rather than receiving an erroneous psychiatric diagnosis.
Fatigue that is misdiagnosed as a thyroid malfunction. Both conditions can result in chronic fatigue, weight loss or gain, and low energy, and they may both be present at once. Many women are misdiagnosed with having a thyroid disorder when they really just have a persistent issue with low Vitamin D, B12, iron, and magnesium levels, which negatively affect the hormonal balance and increase fatigue during perimenopause. It is always wise to request a complete blood panel to rule out all of these possibilities before jumping to any conclusions.
Brain fog that is misdiagnosed as occupational burnout can also be attributed to falling estrogen levels in women due to the memory problems associated with being unable to concentrate on tasks and having difficulty with language, such as when talking to someone or searching for the right word to use. If cognitive symptoms coincide with changes in your cycle, then it would be a good idea to discuss this with your doctor.
When Symptoms Need Medical Attention
Most of the symptoms experienced during the perimenopause stage of life are due to the natural transition of hormones; however, there are situations where medical attention should be sought immediately rather than just waiting to see if the issue resolves itself over time.
Heavy bleeding is the primary reason to seek medical care. If you have heavy bleeding, periods that go longer than usual, large blood clots, spotting between periods, or bleeding after having sexual intercourse. These are not normal for perimenopause, and you should have these checked by your doctor, as fibroids, polyps, or hormonal imbalance could cause them. You should also seek immediate medical attention if you have had a period after 12 consecutive months without a period.
If any mental health changes are more than just mood fluctuations, you should seek immediate medical attention. If you have had persistent feelings of depression, panic attacks, or thoughts about harming yourself, then you should reach out for help from a medical professional, as these feelings cannot be treated on your own and are not strictly caused by hormonal imbalances.
If you experience any symptoms of perimenopause before the age of 40, you should have them checked by a doctor right away. You should also consult with a medical professional regarding premature ovarian failure, thyroid problems, and/or other health conditions that could lead to more serious long-term problems regarding your health.
If you identify a symptom of perimenopause that is harming your sleep, job, relationships, or daily life, you should immediately seek medical attention. You are going through a medical transition and should not simply be expected to “tough it out.”
Treatment options overview
To effectively manage your symptoms throughout perimenopause, you will need to coordinate different options that work for you specifically, as there is no single effective option for everyone.
A great place to start is by making some changes to your lifestyle. Regularly completing physical activity (including aerobic exercise and strength training) is beneficial for maintaining bone density, improving mood, and improving the quality of your sleep throughout perimenopause. The Menopause Society provides evidence-based non-hormonal options for you to use to manage your symptoms, including lifestyle changes, mind-body therapies (such as cognitive behavioural therapy), and dietary changes, which are effective at managing both vasomotor and mood-related symptoms. You may also find relief by reducing coffee and alcohol and dealing with chronic stress, so these are worth addressing as well.
The use of supplements during perimenopause is common, and several of them have solid trials confirming their researched capabilities. Certain supplements—namely magnesium bisglycinate, omega-3 fatty acids, and vitamin E—have been shown to effectively decrease both frequency and intensity of hot flashes in a subset of women. Typically, magnesium, omega-3s, B vitamins, and vitamin D are safe to administer concurrently with HRT, and they may improve the response to HRT.
Hormone replacement therapy (HRT) remains the most effective form of treatment for women who experience very debilitating symptoms that are harming their quality of life. A research review done in 2024 concluded that hormone therapy is effective at treating these symptoms and has a lower risk of side effects when treatment is started before age 60 in women who do not have any contraindications to using HRT.
Frequently Asked Questions
Reference: –
Charafi, L., Bolling, K., Schroader, B. K., & Halvorson, L. (2025). Characterization and Treatment Patterns of Peri/Menopausal and Postmenopausal Women with and Without Vasomotor Symptoms in a Retrospective Database Study. Women’s Health Reports, 6(1), 742–751. https://doi.org/10.1177/26884844251366113
Clustering of > 145,000 symptom logs reveals distinct pre, peri, and menopausal phenotypes | Scientific Reports. (n.d.). Retrieved 30 June 2026, from https://www.nature.com/articles/s41598-024-84208-3
Gibson, C. J., Ajmera, M., O’Sullivan, F., Shiozawa, A., Lozano-Ortega, G., Badillo, E., Venkataraman, M., & Mancuso, S. (2024). Epidemiology and clinical outcomes of vasomotor symptoms among perimenopausal women and women aged 65 years or older in the US: A systematic review. Women & Health, 64(9), 687–703. https://doi.org/10.1080/03630242.2024.2392136
Khan, S. J., Kapoor, E., Faubion, S. S., & Kling, J. M. (2023). Vasomotor Symptoms During Menopause: A Practical Guide on Current Treatments and Future Perspectives. International Journal of Women’s Health, 15, 273–287. https://doi.org/10.2147/IJWH.S365808
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Metcalf, C. A., Duffy, K. A., Page, C. E., & Novick, A. M. (2023). Cognitive Problems in Perimenopause: A Review of Recent Evidence. Current Psychiatry Reports, 25(10), 501–511. https://doi.org/10.1007/s11920-023-01447-3
NICE. (2015, November 12). Overview | Menopause: Identification and management | Guidance | NICE. https://www.nice.org.uk/guidance/ng23
Okpete, U. E., & Byeon, H. (2025). Optimizing perimenopausal mental health by integrating precision biomarkers, digital health interventions, and psychosocial care. World Journal of Psychiatry, 15(7), 101906. https://doi.org/10.5498/wjp.v15.i7.101906
Reisel, D., Crockett, C., Glynne, S., Kamal, A., & Newson, L. (2024). Prevalence of Cognitive and Mood-Related Symptoms in a Large Cohort of Perimenopausal and Menopausal Women. BJPsych Open, 10(Suppl 1), S204–S205. https://doi.org/10.1192/bjo.2024.497
Anna Haotanto is the Founder of Zora Health and a passionate advocate for women’s empowerment. Anna’s personal experiences with egg-freezing, PCOS, perimenopause and the challenges of fertility have fueled her mission to provide high-quality information, financing, and support to help women and couples navigate their fertility journeys with confidence. She is also recognised for her achievements in finance, entrepreneurship, and women’s empowerment, and has been featured in various media outlets. You can also follow her on Linkedin or Instagram.
