Hot flashes and changing periods are the perimenopause symptoms most people know about. Brain fog, a racing heart, aching joints and mood swings that arrive with no clear pattern get far less attention, and they can be just as disruptive.
Perimenopause is the transition before menopause. It usually starts in the mid 40s, but Cleveland Clinic notes it can begin as early as the mid 30s or as late as the mid 50s. It lasts about four years on average and can run up to eight. Menopause itself is confirmed after 12 months in a row without a period.
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Why do perimenopause symptoms come and go?
Because the hormones behind them do. As the ovaries slow down, estrogen falls and its balance with progesterone shifts. Cleveland Clinic describes the levels as going up and down like a rollercoaster, rather than falling in a straight line.
That is why a symptom can disappear for months and then return. The American College of Obstetricians and Gynecologists (ACOG) notes that perimenopausal mood symptoms can show up at times unrelated to the menstrual cycle and continue for years with no pattern.
Periods often change first. According to The Menopause Society, cycles may get a little shorter at the start, then vary by seven days or more, and later in the transition a period may be skipped for 60 days or longer.
From perimenopause to menopause
- Perimenopause beginsUsually in the mid 40s. It can start as early as the mid 30s or as late as the mid 50s.
- The transitionAbout four years on average, and up to eight. Hormones and symptoms rise and fall.
- MenopauseConfirmed after 12 months in a row without a period.
- PostmenopauseThe years after menopause, when most symptoms ease.
Can perimenopause cause anxiety, mood swings or depression?
Yes, and it is one of the changes people are least prepared for. ACOG reports that about 4 in 10 women have mood symptoms during perimenopause similar to PMS: irritability, low energy, tearfulness, moodiness and trouble concentrating.
Most studies agree that the risk of depression rises during the menopause transition, and The Menopause Society notes that women who had depression earlier in life are at greatest risk. Research on anxiety is thinner, but many women report feeling more anxious in these years.
Life adds its own weight. ACOG points out that the 40s and 50s are often when demanding jobs, children and aging parents all need you at once. Mood changes are worth raising with a provider, because sleep, therapy and medical treatment can all help.
Brain fog, headaches and a racing heart
Forgetfulness in perimenopause is common. The Menopause Society reports cognitive symptoms in 40 to 60% of midlife women, usually trouble finding words or names, losing focus and getting distracted easily. It is also reassuring on this point: the changes are typically mild and within normal limits, and dementia at midlife is very rare.
Headaches can change as well. Swings in estrogen may make hormone related headaches and migraines more frequent. Many women find they ease after menopause, though some continue to have them.
Hot flashes affect up to 80% of women at some point in the transition. A flash usually lasts one to five minutes and can bring sweating, chills, anxiety and, for some women, a rapid heartbeat. Cleveland Clinic also lists a racing heart among the less common symptoms of the transition.
The other changes nobody mentions
Cleveland Clinic and the National Institute on Aging (NIA) list several changes that rarely come up in the short version of this conversation:
- Trouble sleeping, including waking from night sweats or needing to urinate
- Joint and muscle aches
- Dry skin, dry eyes or a dry mouth
- Thinning hair or hair loss
- Breast tenderness and worse PMS
- A sudden need to urinate, or small leaks when you laugh or sneeze
- Weight settling at the waist, with less muscle and more fat
Some symptoms people search for often, such as dizziness, nausea or constipation, do not appear on the symptom lists from Cleveland Clinic, the NIA or The Menopause Society. They have many possible causes, so they deserve a proper look rather than an assumption.
How is perimenopause diagnosed?
Usually from your age, your symptoms, your cycle history and an exam. Cleveland Clinic notes that hormone testing is not necessary to diagnose perimenopause, because levels swing so much that a single result can mislead. A high follicle stimulating hormone (FSH) level can suggest you are nearing menopause, but the next test may look different.
Blood tests still have a place. A provider may use them to rule out other causes of your symptoms, or, as the NIA notes, when periods stop at an unusually early age. A simple record of your cycles and symptoms makes that conversation more useful. If you want to understand which labs answer which questions, see hormone imbalance in women.
When to get checked
Irregular periods are expected in perimenopause, but some bleeding patterns should be checked to rule out other causes. Cleveland Clinic and the NIA list:
- Very heavy periods or large clots
- Needing a new pad or tampon every one to two hours
- Periods that last several days longer than usual, or more than a week
- Bleeding or spotting between periods or after sex
- Periods that come less than 21 days apart
- Any bleeding after a full year without a period
Beyond bleeding, see a provider when symptoms affect your sleep, your work, your relationships or how you feel day to day. You do not need to wait until they become unbearable.
