5 Surprising Symptoms of Perimenopause

You knew about hot flashes and mood swings. But what about these other less-common issues?

Worried woman

Medically reviewed in August 2022

Updated on August 4, 2022

Hot flashes, changes in sex drive, and irritability are all common signs of perimenopause, the stage during which women transition to menopause. But they’re not the only signs. Thanks to shifting hormone levels, women can experience a wide variety of changes to their body and mental state.

Many women 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 they can differ from person to person and they're often mistaken for normal 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 producing eggs on an erratic basis. "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 normal once you’ve hit 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. Your risk of vaginal infections also rises due to tiny tears in the tissue and pH balance changes in the area. 

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

Anxiety increases. If you already have anxiety, you may start to have panic attacks during which you feel fear disproportionate to the circumstances. Symptoms include difficulty breathing, a racing heart, dizziness, and sweating. 

Mental illness becomes more acute. This is especially true of people with depression, bipolar disorder, or schizophrenia.

What to do about perimenopause symptoms
Because you've lost the predictability of your 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, heavy flow," she says. This is especially key because the symptoms you experience may not be the same from cycle to cycle. Just because you have heavy flow or an especially bad migraine one month doesn't mean you'll have the same symptoms with your next period. 

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

If your perimenopause symptoms worsen or are unmanageable, you have difficulty with your day-to-day activities, or good sleep eludes you, 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 relieve your discomfort, including whether hormone replacement therapy is a good 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.

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