Symptoms in Perimenopause and Menopause: A Complete Guide for Women 40+

Perimenopause can feel like your body has suddenly changed the rules without giving you the updated handbook.
One month, you’re sleeping fine, your moods feel predictable, and your cycles are familiar… and then seemingly overnight, everything is upside down.

As a functional medicine physician, women’s health specialist, and someone who has personally experienced perimenopause and now menopause, I want to reassure you:

➡️ You aren’t imagining these changes.
➡️ You aren’t “losing it.”
➡️ You aren’t alone.

The symptoms of perimenopause and menopause are real, they’re common, and they’re directly tied to fluctuations in estrogen, progesterone, testosterone, cortisol, and even your thyroid and blood sugar.

This guide will walk you through the most common symptoms, why they happen, which require medical evaluation, and what you can do to feel better—naturally and effectively.

What Is Perimenopause?

Perimenopause is the hormonal transition before menopause (which is defined as 12 months without a period). For many women, this transition lasts 4–8 years, though some feel changes 10+ years early.

During this time, hormones—especially estrogen and progesterone—stop following their once-predictable rhythm. Instead of rising and falling gently each month, they begin to spike, crash, and fluctuate irregularly, and your symptoms follow their lead.

The result?

A wide variety of symptoms that can range from mildly annoying to truly disruptive- and confusing!

Let’s break down what they are and what they mean.

The Most Common Symptoms in Perimenopause

Below is an overview of symptoms women commonly experience. As you scroll through this list, I want you to notice two things:

You will likely recognize yourself in several of these patterns.
Every symptom has a root cause that can be supported.

Common Symptoms Include:

Irregular or changing periods
Heavier bleeding
Spotting
Shorter cycles
Mood swings
New-onset anxiety
Sleep disturbances
Night sweats
Hot flashes
Brain fog
Belly bloating
Digestive changes
Weight gain (especially around the midsection)
Low libido
Vaginal dryness
Skin changes (itchiness, dryness, breakouts)
Hair thinning
Joint pain
Histamine sensitivity (new allergies)
Heart palpitations
Blood sugar shifts
Snoring or breathing changes during sleep

Below, we’ll go through each of these in detail—what causes them, what’s normal, and when you should seek evaluation.

Why Symptoms Happen: The Hormonal Shifts Behind Them

These symptoms can be a result of one, two, three, or more hormonal fluctuations- so we can’t say they are all simply because of one hormone disruption. But below we cover the most common symptoms associated with each hormone pattern.

Estrogen Fluctuations

Estrogen is often the hormone that affects:

mood
brain function
temperature regulation
joint comfort
metabolism
skin and hair
bleeding patterns
sleep

During perimenopause, estrogen doesn’t slowly decline—it spikes high and then plummets low.

High estrogen days can cause:

irritability
anxiety
breast tenderness
heavy bleeding
bloating

Low estrogen days can cause:

hot flashes
night sweats
joint pain
vaginal dryness
brain fog
insomnia

Check out this blog to learn more about estrogen and peri/menopause: Ultimate Guide: Stages of Perimenopause and What to Expect

Progesterone Decline

Progesterone is your calming, sleep-supporting, anti-anxiety hormone.

During perimenopause, progesterone naturally begins to fall earlier and more consistently than estrogen. You don’t see the spikes that you see with estrogen, but you do see symptoms associated with falling progesterone.

Low progesterone can lead to:

trouble falling asleep
frequent nighttime waking
increased anxiety
shorter cycles
PMS intensification
spotting
new or worsened migraines
night sweats (can be estrogen or progesterone related)

Check out this blog to learn more about declining progesterone in perimenopuase and menopause: Ultimate Guide: Stages of Perimenopause and What to Expect

Testosterone Changes

Yes, women need testosterone too! We may need much smaller amounts but we do need this important hormone and it can shift with aging, not in a predictable way like estrogen and progesterone, but it does have specific symptoms associated with it’s decline so it’s essential to recognize these.

Testosterone helps with:

libido
motivation
muscle maintenance
metabolism
energy
hair growth

Levels often decrease gradually in midlife, contributing to:

low libido
muscle loss
stubborn weight gain
decreased strength
fatigue
hair loss

Check out this blog to learn more about increasing your testosterone naturally: Ultimate Guide: How to Increase Testosterone in Women

Cortisol & Stress Physiology

Midlife is often a perfect storm of stress: career, family, aging parents, and poor sleep.

Cortisol becomes more reactive, which leads to:

blood sugar instability
3 AM wakings
belly fat storage
increased anxiety
energy crashes

Learn more about how cortisol contributes to symptoms in perimenopause and menopause here: What No One Tells You About Cortisol and Estrogen Dominance

Symptom-by-Symptom Breakdown

Below is a deeper dive into the symptoms most women experience. This section can help you recognize your unique patterns that may be happening due to perimenopause or even if you are approaching or have passed menopause (which is actually the day you have gone 1 year without a period). Of course, it’s always best to discuss any symptoms you are having with your healthcare provider as online information should not be considered medical advice unique to you.

Irregular Periods & Cycle Changes

During perimenopause, your cycle may:

come earlier
come later
last longer
arrive with heavier bleeding
include mid-cycle spotting
skip months
shift suddenly

All of these can be normal and there are ways to help smooth out the disruptive nature of these patterns.

Learn more here:

Anxiety, Mood Swings, and Emotional Changes

These hormonal patterns:

estrogen swings
progesterone decline
cortisol reactivity
sleep disruption

…creates a perfect hormonal storm for mood symptoms.

This anxiety is not “in your head.” It is biochemical and hormonally driven.

Signs include:

feeling overwhelmed
irritability
racing thoughts
panic attacks
increased sensitivity to stress

Learn more about perimenopause and anxiety here: Top 5 First Signs of Perimenopause Symptoms

Sleep Problems

Sleep is one of the first systems to be disrupted in midlife, and many patterns can contribute to this, in addition to lifestyle and nutrition during perimenopause and menopause.

Causes of poor sleep in perimenopause and beyond include:

cortisol spikes around 2–4 AM
night sweats
blood sugar drops
low progesterone
low estrogen
histamine elevation
stress

Common patterns women report:

falling asleep but waking at 2–4 AM
waking drenched in sweat
waking with anxiety
restless sleep

Check out this post to learn more about perimenopause and sleep: Snoring and Menopause: What is the link|Tips for Good Sleep

Hot Flashes & Night Sweats

Hot flashes and night sweats can be triggered by:

low estrogen
cortisol surges
blood sugar instability
inflammation
stress triggers

Simple lifestyle patterns can reduce severity significantly.

What causes Hot flashes in Perimenopause? And 5 Super Tips for Cooling Off!

Weight Gain & Metabolic Changes

Midlife weight gain is one of the most distressing and frustrating symptoms—and also one of the most misunderstood.

Midlife metabolism shifts are usually driven by:

estrogen shifts affecting fat distribution
progesterone decline affecting insulin sensitivity
cortisol spikes increasing abdominal fat
reduced muscle mass
sleep disruption
lower thermogenesis

The weight gain is not your fault—and there are evidence-based ways to manage it.

To learn more read: 7 Reasons You’re Gaining Weight During Perimenopause (And How to Get Back on Track)

Digestive Issues

Estrogen receptors exist throughout the gut.
When estrogen fluctuates, digestion does too. So bloating, bowel changes, and abdominal pain can be linked to your hormone shifts.

Gut Health Symptoms in Perimenopause can include:

bloating
constipation
diarrhea
IBS flares
increased food sensitivities
histamine intolerance

Here’s more info on gut changes in perimenopause and menopause:

Skin & Hair Changes

This is something I talk about a lot in my functional medicine practice- and here’s the link between skin and hair changes- your hormones are shifting- again, not your fault!

Low estrogen → decreased collagen and moisture
High estrogen → breakouts, oiliness
Histamine sensitivity → itching, redness

Skin and Hair Symptoms include:

itchy skin
dry skin
hair thinning
breakouts
rash flares

Perimenopause and Itchy Skin: 5 Expert Strategies for Relief!

Brain Fog & Cognitive Changes

Brain fog is very common as our hormones shift in perimenopause and menopause.

Brain fog and Cognitive Changes are usually due to:

estrogen fluctuations
sleep disruption
cortisol spikes
blood sugar swings

Women often describe:

losing words
trouble focusing
decreased memory recall
“feeling foggy”

Here’s more info on brain fog: Understanding Brain Fog During Perimenopause: Your Ultimate Guide to Mental Clarity

Histamine & Allergy Changes

Higher histamine levels correlate with estrogen spikes. Women can get worsening allergy symptoms, hives, itchy skin, and more.

This is why women may suddenly experience:

new food reactions
hives
sinus congestion
headaches
sneezing
itchy skin

Perimenopause and Itchy Skin: 5 Expert Strategies for Relief!

When Symptoms Need Medical Evaluation

It is great to stay informed and research your symptoms but definitely seek medical help if:

bleeding every two weeks
bleeding longer than 7–8 days
very heavy bleeding (soaking a pad/tampon hourly)
bleeding after intercourse
bleeding after menopause
severe mood swings
debilitating anxiety
fainting or dizziness with palpitations
new or worsening migraines
significant, rapid weight gain
severe abdominal pain
new breast discharge
persistent night sweats without period changes

As a physician, these are symptoms I evaluate in my practice to rule out thyroid, adrenal, female hormone, or metabolic issues—or rarely, cancerous changes.

How to Manage Perimenopause Symptoms Naturally

Lifestyle Foundations

These are the most impactful daily habits:

Strength training 2–3x/week
Cardio walking (especially interval walking), cycling, hiking, swimming, or interval, gentle jogging
Balanced meals with protein, fiber, and healthy fats
Reducing refined carbs & sugars
Stress-lowering habits (breathwork, meditation, nature time)
Improved sleep hygiene (consistent bedtimes, screens off early, getting 7 to 9 hours of quality sleep)

Here’s more blogs to check out on these topics:

Helpful Supplements

Not every woman needs every supplement, or maybe none at all, but the right ones can be game-changers.

Common evidence-supported options for supplements in perimenopause and beyond include:

Magnesium glycinate
Omega-3s
Vitamin D3 + K2
DIM
Probiotics
Adaptogens (ashwagandha, rhodiola)
Black cohosh
Maca

Internal link placeholders:

Hormone Therapy (HRT)

Not every woman needs hormone therapy either, but for many, it can dramatically improve:

sleep
hot flashes
mood
vaginal dryness
bone density
metabolism
fatigue

Always start low and adjust slowly, and of course, see a qualified healthcare provider trained in hormone replacement therapy!

Quick Guide: How to Use Topical Estrogen, from Estrogen Patches to Creams

Do Bioidentical Hormones Help with Weight Loss? (Doctors Guide)

Explore More Symptom Guides

Below is a curated set of symptom-specific deep dives:

Ready to Take the Next Step?

If you want a simple place to start, you can download my free:

3-Day Perimenopause Meal Plan & Supplement Guide

This guide gives you:

hormone-balancing meal ideas
a simple anti-inflammatory framework
daily supplement suggestions
practical tips to stabilize your energy and mood

It’s the easiest way to begin supporting your hormones today!

Hi, I'm Dr Shelley Meyer

Browse the Blog