When you think about perimenopause and menopause, you probably think of hot flashes (aka hot flushes), night sweats, trouble sleeping, perhaps weight gain. These are the most well-known symptoms, but there are many others that your doctor and your mother probably never told you about.
Research shows that most women, and even many medical professionals, don’t know how to recognize the signs of perimenopause.1 This is partly due to a lack of education and understanding about what perimenopause entails, but it is also because the signs and symptoms of perimenopause and menopause can be ambiguous.
Are your brain fog and forgetfulness related to menopause, or are they simply signs of aging? Are you feeling anxious because your estrogen is plummeting or because you’re trying to balance the demands of a career, parenting teenagers, and caring for an elderly parent (during a pandemic, no less)?
There is no test for perimenopause, so women often don’t recognize that they are in perimenopause until they have been experiencing symptoms for a number of years. Only in hindsight do they see how their seemingly disparate issues are related. To add to the confusion, perimenopause and menopause can look wildly different from person to person. Some people skate through with relatively few issues, while others have debilitating symptoms that severely disrupt their quality of life.
All this ambiguity means that many people don’t talk to their doctors about the changes they’re going through, despite feeling that something is wrong. And unfortunately, even if they do bring it up at their next check-up, their doctors may write off their symptoms as “just getting older.” That’s why it’s important to spread the word about some of the less notorious—but still meaningful—signs of perimenopause and menopause in order to get the best treatment possible.
What is Perimenopause?
Before getting into the symptoms, let’s do a quick refresher on perimenopause, menopause, and the difference between the two.
Perimenopause begins when your menstrual cycle starts to become irregular. Once this happens, you’re considered perimenopausal until a full year goes by without having a period, at which point you are officially in menopause. This whole phase is often referred to as the “menopausal transition.”
While the conventional wisdom is that perimenopause starts for most women sometime in their mid-40s, hormone changes can start much earlier. In fact, some experts argue that perimenopause actually begins for most women in their mid-30s and lasts for two to three decades.2 On average, women usually hit menopause in their early 50s. However, the length of the menopausal transition, symptom type and severity, and age of menopause are all affected by race and ethnicity, overall health, socioeconomic variables, and other factors.345
During perimenopause, estrogen and progesterone levels decline overall, although they can fluctuate up or down, sometimes dramatically, from day to day. Once you hit menopause, estrogen and progesterone are consistently much lower than during the premenopausal years. Erratic and declining hormones, especially estrogen, are probably responsible for most unwanted perimenopause symptoms.
6 Surprising Symptoms of Perimenopause and Menopause
Each of the following issues increases during the menopausal transition thanks to the aforementioned hormonal changes. Aging, stress, dietary issues like micronutrient deficiencies, or other health problems can also exacerbate them. As I said, that makes it difficult to pinpoint whether (peri)menopause or something else is to blame.
If you are a woman in your mid-30s or beyond, and you’re experiencing any of these symptoms, it’s worth asking your doctor about treatment options. Hormonal therapy seems to offer relief for each of these issues, at least for some women, but it may not be right for you. In that case, there are always other treatments available.
Dry, Itchy Skin
Estrogen plays a central role in keeping skin hydrated, supple, and elastic. When estrogen levels fall during the menopausal transition, you may notice that your regular skincare routine no longer seems to cut it. All of a sudden, your skin becomes dryer, and new wrinkles appear. (You can thank a precipitous decline in collagen for the wrinkles, another casualty of both age and declining estrogen.) You could also see an uptick in acne outbreaks thanks to your hormones being all over the place. Some women also experience formication, an extremely unpleasant sensation of bugs crawling on their skin.
For immediate relief, the usual dry skin advice applies:
Use body lotions or oils to moisturize the skin
Try oatmeal baths
Avoid very hot water
Topical hydrocortisone cream may help, or you might need to ask your doctor for something stronger for more severe itching. For a longer-term remedy, collagen supplementation can alleviate dryness and wrinkles and improve skin elasticity.
Hormonal Headaches and Migraines
Falling estrogen is a well-known migraine trigger, so it shouldn’t be a surprise that migraine frequency and severity can increase during perimenopause and menopause, especially for women who are already prone to migraines.67 That’s not always the case, though. Some lucky women get fewer migraines, especially once they are in menopause. It’s not obvious why some women’s migraines get worse, others’ get better, and still others’ stay the same. Sometimes hormone therapy helps, but unfortunately, exogenous hormones may also make things worse.8
Whatever the reason, headaches can be more disruptive to women’s lives than other menopausal symptoms, even though you’re more likely to hear about how awful hot flashes and night sweats are. When researchers surveyed 418 women and asked them to rate their experience with 25 different menopausal symptoms, they said headaches were the most severe. They also reported experiencing headaches more frequently than hot flashes or sweating, although only 8 percent were aware that headaches could be a symptom of perimenopause.9
Many women notice that their hair starts thinning during their 40s. Over the next couple of decades, hair changes can range from mild thinning to significant hair loss and alopecia. These issues tend to increase with age.10 Not surprisingly, hair loss is often chalked up to “normal aging” rather than menopause-related hormone shifts—declining estrogen and progesterone and the subsequent rise in androgens.
That said, lots of things can contribute to hair loss during this period. A temporary loss of hair called telogen effluvium can follow any stressful event, or even significant weight loss or a major dietary change that your body perceives as stressful. Before trying over-the-counter hair growth serums or supplements, it’s best to talk to your doctor and ask them to check your levels of key nutrients like iron, zinc, vitamin D, and selenium, which all play a role in hair and follicle health.11 More generally, it’s always a good idea to make sure you are eating a well-balanced diet that contains sufficient protein and micronutrients.
This is perhaps one of the more surprising symptoms on the list, but multiple studies demonstrate that lung function decreases during menopause and that this is not just a function of getting older. For example, in one study of nearly 1,500 women, lung function declined significantly during late perimenopause and early menopause, more than would be expected purely based on age.12 Not just significantly—the data showed, “The effect size for FEV1 [a measure of lung function] was comparable with smoking 20 cigarettes per day for 2 years, and for FVC [another measure of lung function] to smoking 20 cigarettes per day for 10 years.” That’s pretty dramatic, to say the least. The researchers postulated that this decline might be driven by systemic inflammation associated with low estrogen levels.
Another study compared over 400 women in the menopausal transition to same-aged women who were still menstruating. The menopausal women had poorer lung function and more respiratory symptoms like wheezing and shortness of breath.13
If you are finding it harder to breathe during exercise, or you wake up feeling like someone is sitting on your chest, that could be related to menopause. In addition to the standard recommendation to talk to your doctor, breathing exercises and yoga may help.14 They can also improve other menopausal symptoms ranging from hot flashes to depression, according to some studies. If nothing else, you’ll get relaxation and stress-busting benefits.
Perimenopausal and menopausal women have more urinary symptoms like overactive bladder and urge incontinence, which is a euphemistic way of saying that we struggle not to pee on ourselves. Many women chalk it up to having had babies or participating in impact sports like running. However, any woman can deal with incontinence, leaking, and waking up to pee multiple times per night, thanks once again to hormonal shifts. These symptoms can also indicate a more serious issue called genitourinary syndrome of menopause (GSM).15 If you are struggling with pain, low libido, or sexual dysfunction in addition to incontinence, definitely see a doctor.
Incontinence is not something we just have to live with, having boxes of special undergarments discretely shipped to our doors for the rest of our lives. A pelvic floor specialist can help diagnose the root cause and recommend treatment options.
Burning Mouth Syndrome (BMS)
This is exactly what it sounds like—a persistent burning or tingling sensation in the mouth. BMS symptoms last for at least four to six months, often longer, and are sometimes accompanied by numbness, dry mouth, or changes in taste. While BMS many things cause BMS, including allergies, nutrient deficiencies, and certain medications, it is much more common in perimenopausal women than in any other demographic. As many as 90 percent of BMS suffers are perimenopausal women, though nobody knows exactly why.16
People with BMS are advised to avoid smoking, spicy foods, salty foods, and alcohol. Hormone therapy might help, and some pharmaceutical options show promise.17
When to Talk to Your Doctor about your Perimenopause or Menopause Symptoms
Many women avoid talking to our doctors about symptoms that we find embarrassing. We’re also conditioned to believe that our issues are normal and that discomfort is just part and parcel of having a menstrual cycle, so we suck it up.
If you’re noticing any of these symptoms, especially if they are new or getting worse, it’s worth talking to your doctor and trying to get to the root of them. While they may be “normal,” you don’t simply have to accept them. Hormonal therapies, dietary modifications, or alternative therapies could offer relief. Some of the potential risks associated with hormone therapies are lessened if you start when you’re younger (before the age of 60) or closer to the time of your menopause, so don’t put it off.
When does perimenopause start? How long does it last?
Perimenopause may start with hormone changes as early as your 30s, but for most women, the first noticeable symptom is irregular menstrual periods sometime in their mid- to late-40s. Perimenopause lasts until you go 12 months without menstruating, at which point you are in menopause.
Is there a test for perimenopause?
There is no definitive test to tell you when you are in perimenopause. Perimenopause is determined by looking at the regularity of your menstrual cycle and other symptoms you may be experiencing. Your doctor may also measure your estradiol (estrogen) and follicle-stimulating hormone.
What are the most common symptoms of perimenopause?
Perimenopause is different for every person. Besides irregular periods, you might experience headaches, moodiness, depression, anxiety, sleep problems, difficulty focusing, memory issues, hot flashes, sweating, low libido, or sexual dysfunction. Some women barely notice any symptoms, while others report that their symptoms significantly impact their quality of life.
What are the best supplements for perimenopause?
Some of the more common supplements that may be useful are black cohosh, maca, black seed oil, red clover, ginseng, evening primrose, St. John’s Wort, and wild yam. Always check with your doctor to ensure any supplement is safe for you and will not affect any medications you’re taking.
Lindsay Taylor, Ph.D., is a senior writer and community manager for Primal Nutrition, a certified Primal Health Coach, and the co-author of three keto cookbooks.
As a writer for Mark’s Daily Apple and the leader of the thriving Keto Reset and Primal Endurance communities, Lindsay’s job is to help people learn the whats, whys, and hows of leading a health-focused life. Before joining the Primal team, she earned her master’s and Ph.D. in Social and Personality Psychology from the University of California, Berkeley, where she also worked as a researcher and instructor.
Lindsay lives in Northern California with her husband and two sports-obsessed sons. In her free time, she enjoys ultra running, triathlon, camping, and game nights. Follow along on Instagram @theusefuldish as Lindsay attempts to juggle work, family, and endurance training, all while maintaining a healthy balance and, most of all, having fun in life.