Signs & symptoms of perimenopause

Woman in perimenopause

Everything you need to know about the signs and symptoms of perimenopause.

Article highlights

  • Perimenopause is the period of time 2-12 years before menopause.
  • Symptoms typically start as women approach their late 30s or early to mid 40s.
  • No single test can confirm perimenopause – instead we look at certain signs and symptoms.
  • So far, 34 symptoms have been identified.
  • The main symptoms of perimenopause are related to changes in your cycle (shorter cycles, heavier, more painful or longer periods), sleep disturbances (difficulty falling or staying asleep), vasomotor symptoms (hot flushes and night sweats), weight gain, increased pre-menstrual mood swings, new allergy symptoms (itchy watery eyes, skin rashes and sneezing) and sore, swollen or lumpy breasts.
  • The main hormonal changes behind the symptoms of perimenopause are high, fluctuating oestrogen and declining progesterone levels.
  • Histamine and insulin resistance are two important factors to consider in perimenopause. 

What is perimenopause?

Perimenopause is a time of hormonal changes, similar to puberty. It is defined as the 2-12 year period or phase leading up to menopause (menopause being the single point in time when periods have ended for 12 months). Typically perimenopause can occur anywhere from the ages 38-50.

Everyone’s perimenopause is different – it lasts for different lengths of time, with different symptoms of differing severity. 

What are the first signs and symptoms?

The best place to start is with Professor Jerilynn Prior’s list of new symptoms that reveal if you are likely to be entering perimenopause. Professor Prior states that a midlife woman – who previously had regular periods – is likely to be in perimenopause if she has three of the following symptoms:

  • New-onset heavy and/or longer flow
  • Shorter (25 days or less) menstrual cycles
  • New sore, swollen or lumpy breasts
  • New mid-sleep waking 
  • Increased menstrual cramps
  • Onset of night sweats, in particular premenstrually
  • New or markedly increased migraine headaches
  • New or increased premenstrual mood swings
  • Weight gain without changes in eating or exercise

It is important to note that these listed above are just a few of the symptoms that you may experience in perimenopause and it is a different experience for each individual. As there is no single test that can define if you are in perimenopause, the above signs and symptoms are the best guide. 

Signs & Symptoms of Perimenopause

WHAT ARE THE MOST COMMON SIGNS AND SYMPTOMS OF PERIMENOPAUSE?

  • Cycle changes: Heavier periods, longer periods, painful periods, shorter cycles, irregular cycles
  • Physical changes: Weight gain, sore breasts, changes in libido, vaginal dryness
  • Sleep changes: More frequent waking, difficulty getting to sleep, insomnia
  • Mood changes: More frequent mood changes, irritability, rage and increased PMS
  • Vasomotor changes: Onset of night sweats, hot flushes
  • New allergy symptoms: Hayfever-type symptoms or the onset of new allergies

WHAT HORMONE CHANGES ARE CAUSING THESE SIGNS AND SYMPTOMS?

To begin it is important to understand the hormone changes that are occurring in perimenopause in order to understand why these symptoms are experienced. 

The time of perimenopause is classified as a time of lowering progesterone and high fluctuating oestrogen

Women can also experience dysregulated hormonal feedback loops such as the hypothalamus- pituitary-adrenal axis. 

Low progesterone is often linked to signs and symptoms such as poor sleep, headaches, migraines, high sweats and heavier periods. High oestrogen is often associated with headaches, allergy symptoms, heavier periods, sore breasts and irritability. 

These hormonal changes typically happen across four separate stages. Read more about the four stages of perimenopause.

Let’s look into each of these groups of symptoms in some detail:

Menstrual cycle changes

It is a normal hallmark of perimenopause to experience menstrual cycle changes such as the initial shortening of your cycle and the onset of more irregular cycles due to the loss of progesterone and fluctuating high oestrogen. But in perimenopause it is also common to experience heavier, longer or more painful periods which can greatly impact day to day quality of life. 

  • Cycle changes are commonly experienced as: 
  • In early perimenopause cycles might shorten towards 21 days
  • Lengthening of bleeding time towards 7 or more days 
  • Heavier periods 
  • Towards the end of perimenopause cycles become longer closer to 45 days
  • Towards menopause cycles lengthen further towards 60 days or longer 

WEIGHT GAIN AND OTHER PHYSICAL SYMPTOMS

One of the most common symptoms of perimenopause is increased weight gain despite no change in exercise or diet routines. The most common type of weight gain in perimenopause is abdominal weight gain (apple shaped). 

Weight gain in perimenopause is multifaceted. In perimenopause the loss of oestradiol and the increased production of androgens when approaching menopause is linked strongly to the gaining of fat around the abdomen, increased risk of insulin resistance and increased appetite. Therefore all of these aspects together increase the risk for weight gain. 

Of these factors, the most common cause of weight gain in perimenopause is insulin resistance. Insulin is a hormone made in the pancreas that stimulates the cells in the body to take up glucose. Due to long term exposure to high glucose (sugar intake in the diet or stress), the cells no longer respond well to insulin and we have what is known as insulin resistance (chronically elevated levels of insulin). This is important to know as perimenopause and menopause is a time of increased risk of insulin resistance and therefore a time of increased risk of weight gain too. This increased risk during perimenopause is in part due to the drop in the insulin-protective hormones oestrogen and progesterone. 

Other physical changes often experienced are sore breasts due to high fluctuating oestrogen and low progesterone and vaginal dryness due to the eventual lowering of oestrogen.  

Sleep changes

Initial sleep changes in perimenopause are associated with the loss of progesterone. Progesterone is calming for the brain, reduces anxiety and also acts like a sedative, therefore supporting deep and restful sleep. Therefore with the loss or lowering of progesterone new sleep issues may begin to set in. The common sleep problems experienced in perimenopause are inability to fall asleep and frequent night waking. 

Mood changes

Mood changes can vary in perimenopause from:

  • Irritability 
  • Rage 
  • Anger 
  • Increased teariness or sadness
  • Increased PMS
  • Anxiety 
  • Low mood or depression 

Different mood changes occur at different stages of perimenopause. Of course this differs for everyone but here is the common picture:

  • In early perimenopause you are likely to first experience anxiety due to the dropping of progesterone and a rise in cortisol. 
  • In mid perimenopause you may start to experience more anger, rage and irritability due to the fluctuating oestrogen.
  • In later perimenopause you may begin to experience low mood due to the lowering of oestrogen.

Vasomotor signs and symptoms

Hot flashes are one of the most common (and frustrating!) symptoms in perimenopause. Hot flashes are feelings of intense and sudden heat that are not caused by external factors. 

 

What they may feel like:

  • Tingling 
  • Flushed face
  • Sweating
  • Night sweats
  • Palpitations

Simply put, hot flashes or night sweats occur in perimenopause due to the fluctuation of oestrogen and drop in progesterone.

During perimenopause the hypothalamus (the control centre in the brain) becomes more sensitive to temperature changes due to fluctuating oestrogen and serotonin. The more sensitive hypothalamus then attempts to correct any temperature changes in the body with sweating or even shivering (Freedman, 2014; Zhang et al, 2021). 

New allergy symptoms

It is common for women to experience the onset of hayfever-type symptoms or the onset of new allergies in perimenopause. At first you may not associate these symptoms with perimenopause. The culprit here is histamine. 

Histamine is a chemical that regulates physiological functions in the body. It is part of the immune system and in the right amounts is incredibly beneficial for the body. However when histamine is high it can cause a person to suffer from many issues and symptoms, especially in perimenopause.

WHY IS HISTAMINE IMPORTANT?

Symptoms of histamine intolerance can be worse during perimenopause, due to high fluctuating oestrogen. Oestrogen increases histamine levels and in turn histamine increases oestrogen, creating a cycle that brings with it many symptoms. High histamine can worsen perimenopausal symptoms and impact your experience with HRT. 

What are some of the common histamine symptoms you may experience?

  • Itchy skin
  • Runny nose
  • Hives
  • High oestrogen symptoms like PMS 
  • Headaches & Migraines 
  • Digestive disturbance such as loose stools, bloating or cramping
  • Nausea
  • Anxiety 
  • Painful or heavy periods

All of these common symptoms of perimenopause can be supported with testing and working with a FUTURE WOMAN practitioner.

common symptoms experienced by women in perimenopause

0 %
of women experience low mood or depression
0 %
have trouble sleeping
0 %
suffer from increased anxiety or loss of confidence
0 %
experience new PMS or heavy and painful periods

Testing in perimenopause

While there is no test to diagnose perimenopause, testing your hormones can be incredibly beneficial because we can get a more accurate picture of the hormonal changes driving your symptoms. Once we know your unique hormone picture, we can make more targeted diet, lifestyle and supplement recommendations to support you.

And if you’re on or considering HRT, then testing can help us to see whether there are things we need to work on before you start hormone therapy (like your estrogen metabolism) or help to ensure you’re taking the right type and the right dose.

 

OUR TOP TAKEAWAYS

  • Lowering progesterone and high, fluctuating oestrogen are behind many symptoms of perimenopause.
  • The most common cause of weight gain in perimenopause is insulin resistance. Insulin resistance can also worsen all symptoms of perimenopause. 
  • In perimenopause it is vital to look at the link between histamine and oestrogen as histamine can also worsen all symptoms of perimenopause. 

REFERENCES

Bromberger, J. T., Kravitz, H. M., Chang, Y., Randolph, J. F., Jr, Avis, N. E., Gold, E. B., & Matthews, K. A. (2013). Does risk for anxiety increase during the menopausal transition? Study of women’s health across the nation. Menopause (New York, N.Y.), 20(5), 488–495. https://doi.org/10.1097/GME.0b013e3182730599

Brinton, R. D., Yao, J., Yin, F., Mack, W. J., & Cadenas, E. (2015). Perimenopause as a neurological transition state. Nature reviews. Endocrinology, 11(7), 393–405. https://doi.org/10.1038/nrendo.2015.82

C V, S. B., S, B., & A, S. (2012). Analysis of the degree of insulin resistance in post menopausal women by using skin temperature measurements and fasting insulin and fasting glucose levels: a case control study. Journal of clinical and diagnostic research : JCDR, 6(10), 1644–1647. https://doi.org/10.7860/JCDR/2012/4377.2646

de Kruif, M., Spijker, A. T., & Molendijk, M. L. (2016). Depression during the perimenopause: A meta-analysis. Journal of affective disorders, 206, 174–180. https://doi.org/10.1016/j.jad.2016.07.040

Freeman, E. W., Sammel, M. D., Lin, H., & Nelson, D. B. (2006). Associations of hormones and menopausal status with depressed mood in women with no history of depression. Archives of general psychiatry, 63(4), 375–382. https://doi.org/10.1001/archpsyc.63.4.375

Freedman R. R. (2014). Menopausal hot flashes: mechanisms, endocrinology, treatment. The Journal of steroid biochemistry and molecular biology, 142, 115–120. https://doi.org/10.1016/j.jsbmb.2013.08.010

Hitchcock, C. L., & Prior, J. C. (2012). Oral micronized progesterone for vasomotor symptoms–a placebo-controlled randomized trial in healthy postmenopausal women. Menopause (New York, N.Y.), 19(8), 886–893. https://doi.org/10.1097/gme.0b013e318247f07a

Hoyt, L. T., & Falconi, A. M. (2015). Puberty and perimenopause: reproductive transitions and their implications for women’s health. Social science & medicine (1982), 132, 103–112. https://doi.org/10.1016/j.socscimed.2015.03.031

Jerilynn C. Prior, MD, FRCPC. Clearing confusion about perimenopause. BCMJ, Vol. 47, No. 10, December, 2005, Page(s) 538-542 

Li, R. X., Ma, M., Xiao, X. R., Xu, Y., Chen, X. Y., & Li, B. (2016). Perimenopausal syndrome and mood disorders in perimenopause: prevalence, severity, relationships, and risk factors. Medicine, 95(32), e4466. https://doi.org/10.1097/MD.0000000000004466

Molly C. Carr, The Emergence of the Metabolic Syndrome with Menopause, The Journal of Clinical Endocrinology & Metabolism, Volume 88, Issue 6, 1 June 2003, Pages 2404–2411, https://doi.org/10.1210/jc.2003-030242

Prior J. C. (2018). Progesterone for treatment of symptomatic menopausal women. Climacteric : the journal of the International Menopause Society, 21(4), 358–365. https://doi.org/10.1080/13697137.2018.1472567

Sander, B., & Gordon, J. L. (2021). Premenstrual Mood Symptoms in the Perimenopause. Current psychiatry reports, 23(11), 73. https://doi.org/10.1007/s11920-021-01285-1

Santoro, N., Roeca, C., Peters, B. A., & Neal-Perry, G. (2021). The Menopause Transition: Signs, Symptoms, and Management Options. The Journal of clinical endocrinology and metabolism, 106(1), 1–15. https://doi.org/10.1210/clinem/dgaa764

Whitcroft, S., & Herriot, A. (2011). Insulin resistance and management of the menopause: a clinical hypothesis in practice. Menopause international, 17(1), 24–28. https://doi.org/10.1258/mi.2011.011003

Zhang, Z., DiVittorio, J. R., Joseph, A. M., & Correa, S. M. (2021). The Effects of Estrogens on Neural Circuits That Control Temperature. Endocrinology, 162(8), bqab087. https://doi.org/10.1210/endocr/bqab087

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