8 surprising symptoms of perimenopause

Hot flashes and mood swings can be typical symptoms of perimenopause. But what about these other less-common issues?

Worried woman

Updated on January 3, 2024.

Hot flashes, changes in sex drive, and irritability are all common signs of perimenopause, the transitional stage to menopause. But they’re not the only signs. Shifting hormone levels can also contribute to a wide variety of changes in your body and mental state.

Many people overlook less-common perimenopause symptoms, says JoAnn Pinkerton, MD, OBGYN professor and director of the Midlife Health Division at the University of Virginia. This is partly because these symptoms can differ from person to person and they're often mistaken for typical aging.

So, what should you keep an eye out for, beyond hot flashes and mood swings? If any of these sound familiar, you may be in perimenopause:

Your period stops for 3 to 6 months, then starts again. Menopause occurs when you haven’t menstruated for a year. It typically happens in your late 40s or early 50s. Unpredictable periods around this time suggest you’re in perimenopause—that your ovaries have started releasing eggs at irregular intervals. "Another signal is flooding," Dr. Pinkerton says. "You start to become irregular—you may have a spotty period and then go through times of very heavy periods." Though period changes are typical once you’re in perimenopause, you should still let your healthcare provider (HCP) know what’s happening. Sometimes, bleeding abnormalities can indicate a separate health issue.

Sleep changes. You may have trouble falling or staying asleep. Night sweats and mood swings can contribute to this issue.

Breast tenderness intensifies. Hormonal changes can cause your breasts to ache. To note: While breast pain is not a common symptom of breast cancer, if your pain is acute, concentrated in one area, or you feel a change in the tissue, speak with an HCP. Swelling on one side is another reason to reach out.

Migraines worsen. Some people get migraines before or after their periods. During perimenopause, these painful headaches can be more severe and happen more often.

Vaginal tissue changes. Perimenopause can cause the lining of your vagina to thin out, feel dry, and lose elasticity. This could make sex uncomfortable. Changes in your vagina can also lead to tiny tears in the tissue and changes in pH balance in the area, which can increase your risk of vaginal infections.

Urinary tract infection (UTIs) risk increases. This occurs because your urethra—the tube through which you urinate—can become irritated or inflamed. You might find yourself using the restroom more often, as well.

Anxiety increases. If you already have anxiety, your symptoms may increase or you may start to have panic attacks, with symptoms that can include fear disproportionate to the circumstances, difficulty breathing, a racing heartbeat, dizziness, and sweating.

Mental health conditions may become more acute. This is especially true of people with depression, bipolar disorder, or schizophrenia.

What to do about perimenopause symptoms

Without the predictability of regular periods and symptoms, it's important to keep a menstrual calendar, Pinkerton advises. "Note when you have a period and come up with shorthand for a headache, breast tenderness, and heavy flow," she says. This is especially key because the symptoms you experience may not be the same from cycle to cycle. Although you may have heavy flow or an especially painful migraine one month, you may not have the same symptoms with your next period.

Keep in mind, too: Though fluctuating hormones contribute to many perimenopause symptoms, other typical midlife stressors—like family and work problems—can cause or exacerbate health issues, as well.

If quality sleep escapes you or your perimenopause symptoms worsen or become unmanageable—such as having difficulty with your day-to-day activities— discuss solutions with an HCP. Make sure the HCP knows about all of your symptoms so you can receive appropriate treatment. Together, you can talk about ways to become more comfortable, including whether hormone replacement therapy is the right option for you.

Article sources open article sources

American College of Obstetrics and Gynecologists. The Menopause Years. Accessed August 4, 2022.
Mayo Clinic. Menopause. October 12, 2020. 
Mayo Clinic. Headaches and hormones: What’s the connection? Dec. 10, 2020. 
Zhao FY, Fu QQ, Spencer SJ, et al.  Acupuncture: A Promising Approach for Comorbid Depression and Insomnia in Perimenopause. Nat Sci Sleep. 2021 Oct 12;13:1823-1863. 
Johns Hopkins Medicine. Perimenopause. Accessed July 19, 2022. 
Bondarev D, Finni T, Kokko K, et al. Physical Performance During the Menopausal Transition and the Role of Physical Activity. J Gerontol A Biol Sci Med Sci. 2021 Aug 13;76(9):1587-1590. 
Delamater L, Santoro N. Management of the Perimenopause. Clin Obstet Gynecol. 2018 Sep;61(3):419-432.
NIH: National Institute on Aging. Sleep Problems and Menopause: What Can I Do? Last reviewed September 10, 2021.
Santoro N. Perimenopause: From Research to Practice. J Womens Health (Larchmt). 2016 Apr;25(4):332-9. 
BreastCancer.org. Mastalgia (Breast Pain). Last updated June 29, 2022.
The North American Menopause Society. Changes in the Vagina and Vulva. Accessed August 4, 2022.
The North American Menopause Society. Going Mad in Perimenopause? Signs and Solutions. Accessed August 4, 2022.
Li R, Ma M, et al. Perimenopausal syndrome and mood disorders in perimenopause: prevalence, severity, relationships, and risk factors. Medicine: August 2016 - Volume 95 - Issue 32 - p e4466 
Tanya Peisley. Does menopause affect mental health? SANE.org. August 2, 2017.
NIH: National Institute of Mental Health: Mood and Psychosis Symptoms During the Menopause Transition. May 19, 2020.
Harvard Health Publishing. Menopause and mental health. March 1, 2020.

More On

What can I do if I feel pain during sex?

video

What can I do if I feel pain during sex?
Obstetrician and gynecologist Jennifer Ashton, MD, explains what a woman should do if she feels pain during sex.
7 factors that can affect fertility

slideshow

7 factors that can affect fertility
Not everyone becomes pregnant when they plan to. Here’s what might be getting in the way and what you can do about it.
How can vitamin D work to prevent fibroids?

video

How can vitamin D work to prevent fibroids?
OB/GYN Jennifer Ashton, MD, discusses the positive benefits of taking vitamin D regularly and how much to take.
Mammograms & the vaccine: what top docs need you to know

video

Mammograms & the vaccine: what top docs need you to know
Vaccinated women's mammogram screenings may show swollen lymph nodes. For that reason, some doctors recommended waiting six to eight weeks after the f...
What are the treatment options for endometriosis?

video

What are the treatment options for endometriosis?
Endometriosis is a disorder in which tissue that lines the uterus can be found on the ovaries, fallopian tubes, or intestines. Patricia Geraghty, MSN,...