11 Signs You Might Be in Perimenopause

Okay, so you’re over 40. Welcome to midlife. Whether you want to claim that title or not, I get it.

And now you’re starting to wonder:

“Wait… is this perimenopause?”

Maybe your sleep suddenly fell apart.

Maybe your anxiety showed up out of nowhere.

Maybe your periods are acting weird (I know mine are!).

Maybe you walked into a room and forgot why you were there while simultaneously wanting to fight everyone in the room.

Cool cool cool. Also same.

Today I want to walk you through 11 of the most common signs and symptoms of perimenopause, including what tends to happen earlier versus later in the transition. Because despite what many women are told, this is NOT just about hot flashes.

In fact, research documented by Andrea Donsky at Morphus published over 100 possible symptoms associated with perimenopause. Some women get only a few. Some feel like they unlocked the entire symptom list.

We also know about 80% of women develop at least one symptom during the transition. Hot flashes alone affect the vast majority of women at some point.

And before we start, one important thing:

These symptoms can and do overlap.

You can absolutely experience a “late stage” symptom early on, or vice versa. Hormones are not following a perfectly color-coded spreadsheet. They’re more like toddlers with espresso shots.

First, What Counts as “Early” and “Late” Perimenopause?

While I would have picked more options, research technically divides perimenopause into two stages:

Early perimenopause

This is when your cycle starts shifting by about seven days. Personally, I think many women notice changes before that. A lot of women will say:

“I used to be a 28-day girl and now I’m 25 days.”

“I used to be super regular and now things are slightly off.”

That absolutely counts in real life.

Late perimenopause

This is typically defined as going 60 days or more without a period. You can skip two months, get a random period again, then skip three more months. This is where things can start feeling chaotic and even have you questioning if something is wrong or if you’re pregnant!

The reason? Your follicles are really declining now, the brain hormone FSH is screaming at your ovaries, estrogen starts swinging much more dramatically then drops down low while progesterone is often consistently lower because ovulation becomes less reliable.

Which brings us to the symptoms.

Common Early Perimenopause Symptoms

1. Insomnia

By far one of the earliest symptoms I hear about. And yes, the women who warned me in my 30s were right. Around my mid-40s, I started waking up consistently between 3 a.m. and 5 a.m. and thinking:

“What fresh hormonal nonsense is this?”

I hear this constantly from women online, in comments, in clinic conversations, in Reddit threads, everywhere.

A big reason (at first) is progesterone.

Progesterone is one of your calming, soothing hormones. It supports sleep, relaxation, and helps regulate the nervous system. In early perimenopause, ovulation can become less robust, which means progesterone production often declines first.

You may still make progesterone. Just not like you used to.

At the same time, estrogen starts becoming more unpredictable, and both hormones influence:

• deep sleep

• REM sleep

• falling asleep

• staying asleep

So suddenly you’re awake at 4 a.m. contemplating every decision you’ve made since 1997. Couple this with high stress, low melatonin, blood sugar irregularities, your partner’s sleep apnea, waking kids…and there’s you staring at the ceiling again.

2. Mood Changes, Anxiety, Irritability, or Rage

Oh yes. The rage. Two of my colleagues and I were just group texting about how LOUD our husbands are with all their noises. The sniffing, the snorting, the hawking, the yawning, the clearing the throat. This brings on a lot of rage in us!

But, it’s not all rage. I hear women say things like:

• “I’m suddenly anxious.”

• “My depression feels worse.”

• “I’m irritated by literally everything.”

• “I wish somebody would.”

And honestly? I totally get it.

Your ovarian hormones heavily influence neurotransmitters like:

• serotonin

• dopamine

• oxytocin

• GABA

So when estrogen and progesterone start shifting, your brain chemistry feels it too.

Women who already leaned anxious may feel more anxious. Women with depression may notice worsening symptoms. Some women feel emotionally flat. Others feel emotionally explosive.

This is one reason I often describe perimenopause as a second puberty in reverse.

Your body is transitioning out of reproductive years, and your brain is adapting in real time.

3. Period Changes

This can mean:

• heavier periods

• lighter periods

• more clotting

• shorter cycles

• longer cycles

• worse cramps

• irregular timing

Some women suddenly bleed for three days instead of seven. Others feel like their uterus has chosen violence and they’re bleeding forever.

Again, progesterone and estrogen both play a major role here.

Lower progesterone and higher estrogens can contribute to:

• heavier bleeding

• thick clots

• more cramping

• cycle irregularity

Lower estrogens may mean lighter, shorter cycles.

And because hormone signaling between the ovaries and brain is changing, the timing can start shifting too.

4. Brain Fog and Mental Fatigue

This one caught me off guard personally.

I remember sitting at my computer, having a great idea, opening a tab to type it in… and forgetting the idea entirely within seconds.

Not hours later. Seconds.

I just sat there thinking:

“Oh no. I think this is perimenopause.”

Women describe:

• word-finding issues

• forgetting names

• tip-of-the-tongue moments

• feeling mentally overloaded

• struggling with focus

And honestly, sometimes it’s less physical fatigue and more mental exhaustion.

You can still go for a walk. You just don’t want to think anymore.

Estrogen plays a huge role in brain function and communication, so when levels become more erratic, your brain notices.

Late Perimenopause Symptoms

Now we move into the phase where estrogen swings become much more dramatic.

This is often where women start saying:

“What is happening to me?”

5. Vaginal and Urinary Symptoms

This category includes:

• vaginal dryness

• pain with sex

• burning

• irritation

• recurrent UTIs

• BV or yeast infections

• pelvic floor changes

• bladder symptoms

• leaking urine

Estrogen helps maintain:

• vaginal tissue health

• lubrication

• elasticity

• microbiome balance

• pelvic floor integrity

When estrogen drops, tissues can become thinner, drier, and more sensitive. Testosterone and DHEA help the whole vaginal area as well and are often a local hormone therapy option.

And yes, this is incredibly common.

6. Hot Flashes and Night Sweats

The classic symptom.

Hot flashes are strongly tied to estrogen fluctuations, which is why they tend to become more common in mid-to-late perimenopause.

Some women get:

• occasional mild warmth

• drenched night sweats

• multiple hot flashes an hour

Triggers can include:

• stress

• alcohol

• poor sleep

• spicy food

• overheating

The good news is there are both hormonal and non-hormonal options for support.

You do not need to suffer through them.

7. Joint Pain and Musculoskeletal Symptoms

This one surprises a lot of women.

Suddenly:

• your hip hurts

• your shoulder freezes

• your Achilles hurts

• your feet ache

• you’re wondering if you have fibromyalgia

• everything feels stiff

Women start wondering if:

• they slept wrong

• need a new mattress

• overtrained

• developed fibromyalgia overnight

Estrogen supports:

• joints

• ligaments

• muscles

• connective tissue

• bones

So when estrogen declines, the entire musculoskeletal system can feel it. This is why Dr. Vonda Wright and her team published the paper on The Musculoskeletal Syndrome of Menopause.

8. Dryness Everywhere

Not just vaginal dryness.

I mean:

• dry eyes

• dry skin

• dry hair

• dry mouth

• dry, itchy ears

Yes. Itchy ears.

I’ve had women say, “Why are my ears suddenly itchy all the time?”

Hormones affect moisture production throughout the body.

And interestingly, higher estrogen swings can also increase histamine in some women, which can contribute to itching and irritation too.

9. GI Symptoms and Gut Changes

This area is finally getting more research attention, and honestly, it’s about time.

Women often notice:

• bloating

• constipation

• reflux

• worsening IBS

• food sensitivities

• SIBO flares

• microbiome changes

Estrogen and progesterone influence:

• gut motility

• the microbiome

• intestinal permeability

• inflammation

• immune signaling

Even oral health can shift during perimenopause.

I’ve had dentists tell me they want to see some perimenopausal women more frequently because hormone changes can affect:

• gums

• dry mouth

• cavities

• burning mouth symptoms

Your hormones impact the entire digestive tract, starting in the mouth.

10. Weight Gain and Body Composition Changes

This one frustrates women endlessly because often they haven’t changed anything.

And yet:

• fat distribution shifts

• the waistline changes

• muscle mass becomes harder to maintain

• inflammation increases

As estrogen declines, insulin resistance tends to increase.

That means the body becomes more likely to store fat centrally around the abdomen, also called visceral adipose tissue.

This type of fat is metabolically active and inflammatory.

And while yes, lifestyle absolutely matters, many women notice their body responds very differently in midlife than it did in their 20s and 30s.

11. The “Everything Else” Category

This is where we put all the symptoms that make women say:

“Surely this cannot be hormones.”

Except sometimes… it is.

Things like:

• phantom smells

• dizziness

• ringing in the ears

• histamine issues

• electric zap sensations

• worsening allergies

• increased sensitivity

One of the wildest symptoms I’ve personally experienced was phantom smells.

I smelled sewer gas repeatedly and became convinced something was wrong with our plumbing.

My husband smelled nothing.

Turns out this can happen during hormonal fluctuations for some women. Other women report smelling cigarettes or burning wires.

Not exactly the candle scents we would’ve chosen, but here we are.

A Quick Reality Check

Not every symptom is automatically perimenopause.

Please still get evaluated appropriately.

If you’re having:

• severe pain

• recurrent infections

• major bleeding

• dizziness

• hearing changes

• digestive symptoms

talk with your healthcare provider.

Perimenopause may absolutely be contributing, but we never want to miss something else important.

The Part Nobody Talks About Enough

There actually can be beautiful things about this phase too.

I see women:

• become more authentic

• create stronger boundaries

• tolerate less nonsense

• speak up more

• finally prioritize themselves

It’s almost like another identity shift, except this time you have decades of life experience behind you. You know yourself better now. And maybe this next chapter is less about becoming who everyone expected you to be… and more about becoming who you actually are.

As the kids say:

New phase. Who this?