The Complete Perimenopause Symptoms List: What's Normal, What's Not

What Is Perimenopause and When Do Symptoms Start?

Perimenopause is the transition leading up to menopause, the point when your periods have stopped for 12 months in a row. It usually starts in your mid-40s, around age 47. It can also begin in your early 40s, or even your late 30s. It lasts about four years on average, and up to eight. During that time your ovaries gradually make less estrogen and progesterone. Our guides to when perimenopause starts and how long it lasts go deeper.

Estrogen plays a role in almost every system in your body, from your brain to your bones to your bladder. So its swings can produce a wide and sometimes baffling range of symptoms. Naming them is the first step to managing them.

Hot Flashes and Night Sweats: The Best-Known Symptoms

Vasomotor symptoms, the medical name for hot flashes and night sweats, are the hallmark of perimenopause. About 80% of women get hot flashes around menopause, according to the FDA. They happen because the hypothalamus, your body's internal thermostat, becomes more sensitive as estrogen levels shift. Our hot flashes guide covers triggers and treatments.

Hot Flashes

A hot flash is a sudden wave of heat in the face, neck and chest. Flushing and sweating often come with it. A flash can last from 30 seconds to several minutes. Some women have a few mild flashes a week. Others have dozens a day that upend work and sleep.

Night Sweats

Night sweats are hot flashes that happen during sleep. You may wake up drenched and need to change your pajamas or sheets. Then you feel chilled as your body cools down too far. Even if you fall back asleep quickly, the interruption breaks up your sleep and leaves you exhausted.

How Do Your Periods Change in Perimenopause?

Changes in your period are often the first outward sign that perimenopause has begun. No two women's experience is exactly alike, but any of the following can be normal during this transition.

• Shorter or longer cycles: a cycle that was reliably 28 days may become 21 or 35 days
• Heavier or longer periods, sometimes with clots
• Lighter or shorter periods
• Skipped periods: an occasional missed period is common. Twelve months in a row with no period marks menopause
• Spotting between periods

When is irregular bleeding a reason to call your doctor?

The CDC counts bleeding as heavy when it soaks through a pad or tampon every hour for several hours in a row. Bleeding that heavy needs prompt medical care. So does bleeding after sex, or any vaginal bleeding after you have reached menopause. These are not typical perimenopause patterns. For more on what is normal, see our guides to erratic periods in perimenopause and heavy periods.

Sleep Problems and Fatigue

Poor sleep is one of the most common and most draining perimenopause complaints. It is rarely just one thing. Night sweats, anxiety and hormonal changes all work against a full night of rest. Our perimenopause insomnia guide covers what helps.

• Insomnia: difficulty falling asleep even when you're tired
• Frequent waking: waking multiple times through the night, with or without sweating
• Early-morning waking: waking well before your alarm and being unable to return to sleep
• Unrefreshing sleep: sleeping a full night but waking feeling exhausted
• Fatigue: persistent low energy throughout the day, separate from poor sleep. Our perimenopause fatigue guide covers the causes to rule out.

Progesterone, which helps you sleep, often drops before estrogen does in perimenopause. That makes sleep problems one of the earliest symptoms many women notice.

Mood Swings, Anxiety and Brain Fog

Estrogen affects serotonin, dopamine and other brain chemicals. As levels swing, many women notice emotional and thinking changes that can feel alarming. They are recognized, treatable parts of perimenopause.

Mood Changes

• Irritability or a shorter fuse than usual, sometimes sudden perimenopause rage
• Anxiety that is new or worse than before; see perimenopause anxiety
• Low mood or depressive episodes, which can differ from clinical depression; see perimenopause depression
• Mood swings that arrive without an obvious trigger
• Tearfulness or emotional sensitivity

Brain Fog and Cognitive Changes

• Trouble finding words: the word is there, just out of reach
• Short-term memory lapses: walking into a room and forgetting why, losing your train of thought mid-sentence
• Difficulty concentrating or staying focused
• Mental fatigue that feels different from physical tiredness

Research consistently shows that thinking and memory changes in perimenopause are real and hormone-related, not early dementia. For most women, they improve after menopause. Our brain fog guide explains why.

Vaginal, Bladder and Sex Life Changes

Lower estrogen affects the tissues of the vulva, vagina and urinary tract. Doctors call this group of changes genitourinary syndrome of menopause, or GSM. Unlike many perimenopause symptoms that ease after menopause, GSM tends to worsen over time unless treated.

• Vaginal dryness: reduced natural lubrication, which can make sex uncomfortable or painful
• Vaginal atrophy: thinner, less stretchy vaginal tissue
• Urinary urgency: a sudden, strong need to urinate
• Needing to urinate more often
• Urinary incontinence: leaking with coughing, sneezing, or urgency
• More urinary tract infections, or UTIs
• Decreased libido: lower sex drive, which may be physical, hormonal or both; see perimenopause and libido

GSM is very common and very treatable. Low-dose estrogen placed in the vagina can help. So can vaginal moisturizers and lubricants. Our guide to perimenopause discharge, yeast infections and UTIs goes deeper.

Physical Changes: Joints, Weight, Skin, and Hair

Estrogen plays wide roles in metabolism, inflammation and tissue upkeep. So its decline can show up in ways that don't feel obviously hormonal.

Joint and Muscle Pain

Estrogen calms inflammation. When levels drop, joints can become achy, stiff or swollen, especially in the hands, knees and hips. This is sometimes called menopausal arthralgia, meaning joint pain. It can look like early arthritis, which is worth ruling out. Our guide to perimenopause joint pain covers stiff fingers, knees, back pain and frozen shoulder.

Weight and Body Composition

• Metabolic slowdown: your body burns calories more slowly
• Fat redistribution: fat shifts from hips and thighs to the belly; our perimenopause weight gain guide explains why
• More difficulty losing weight, even without changes in diet or exercise
• Bloating or abdominal fullness

Skin Changes

• Increased dryness and less skin hydration
• Thinner skin that bruises or gets irritated more easily
• Faster collagen loss: collagen is the protein that keeps skin firm. The American Academy of Dermatology says skin loses about 30% of it in the first five years of menopause
• New or deeper fine lines, especially around the eyes and mouth
• Adult acne in some women. As estrogen falls, male-type hormones called androgens have more effect on the skin

Hair Changes

• Gradual thinning, especially at the crown and temples; see our hair loss guide
• Changes in texture: hair may feel finer, drier or more brittle
• More shedding in the shower or on the brush
• In some cases, more facial hair as the balance between androgens and estrogen shifts; see perimenopause facial hair

Less Common Perimenopause Symptoms You Might Not Expect

Perimenopause has a longer symptom list than most women, or their doctors, realize. These less-discussed experiences are real and documented.

Heart Palpitations

A racing or fluttering heartbeat can catch you off guard, often alongside hot flashes. In most women without heart disease, perimenopause palpitations are harmless and hormone-related. But palpitations with chest pain, dizziness, fainting or shortness of breath need emergency care. Our heart palpitations guide covers the rest.

Headaches and Migraines

Estrogen fluctuations are a known migraine trigger. If you are prone to migraines, they may get worse in perimenopause. Some women get migraines for the first time. Headaches often line up with the drops in estrogen during your cycle.

Phantom Smells

Some women in perimenopause smell odors that aren't there, often smoke, something burning or a sweet smell. This is called phantosmia. An NIH study found it is more common in women, and in midlife. The link to estrogen is still being studied. If phantom smells are frequent, lasting or come with other nerve symptoms, get them checked. Our guide to phantom smells in perimenopause covers the likely causes and the patterns that need prompt care.

Breast Tenderness, Skin Sensations and Other Changes

• Breast tenderness: sore or swollen breasts as hormones swing; see perimenopause breast tenderness
• Tingling, itching or crawling skin: odd skin sensations, and sometimes eye twitching; see perimenopause skin sensations and burning sensations
• Nausea and bloating: digestive changes that can come and go; see perimenopause nausea and bloating
• Allergies and food reactions: hay fever, flushing or wine reactions that get worse; see perimenopause and histamine
• The stranger ones: dizziness, ringing in the ears, a metallic taste or a new body odor; see our list of weird perimenopause symptoms

Which Perimenopause Symptoms Need a Doctor Right Away?

Most perimenopause symptoms are uncomfortable but not dangerous. Some can signal a serious problem. Don't wait and see with any of these.

• Chest pain or pressure, with or without palpitations
• Sudden severe headache unlike any you've had before
• Shortness of breath not related to a hot flash
• Unusual vaginal bleeding: very heavy bleeding, bleeding after sex, or any bleeding after 12 months with no period
• Brain and nerve symptoms: sudden confusion, vision changes, weakness or trouble speaking

Can Perimenopause Symptoms Be Treated?

Recognizing your symptoms is step one. Effective options exist for nearly every symptom on this list, from hormone therapy to targeted treatments for specific concerns. You don't have to white-knuckle your way through perimenopause.