Hot flashes, irritability, and vaginal dryness likely come to mind when you think about menopause. But it usually doesn’t start out so cut-and-dry. Perimenopause symptoms can often fly under the radar—think: brain fog, dry eyes, itchy ears, joint problems, and anxiety—because they just don’t scream “hormonal changes!” to most people.
Perimenopause is the transition phase before menopause when your levels of the hormone estrogen start to decline (and for some people, go totally rogue and fluctuate wildly before tapering off)—and it can start four to 10 years prior to your final menstrual cycle. That’s a long time to have to white knuckle through the discomfort. One hurdle that keeps many women from seeking help is that it’s often difficult to know for sure when you’ve entered this era, since perimenopause “doesn’t have a defined definition the way menopause does,” Karen Adams, MD, a professor of obstetrics and gynecology and director of the Program in Menopause and Healthy Aging at Stanford Medicine, tells SELF. Since there’s no test to confirm you’re in perimenopause, Dr. Adams says it’s typically diagnosed solely based on symptoms—and can often be mistaken for a grab bag of other ailments.
The reason symptoms occur at all all comes back to estrogen. Receptors for this hormone are all over your body, including your brain, skin, heart, and bones, and when your ovaries are producing less, it can affect your body in varied ways, Fatima Naqvi, MD, an ob-gyn and interim system medical director of women’s health at Atlantic Health System in Morristown, New Jersey, tells SELF. For that reason, dozens of symptoms are connected to this stage; you might have some or all of them—and they can be mild or severe. “Everybody’s perimenopause and menopause are very individual,” Dr. Adams says.
Below, experts share some common signs of perimenopause that you may not think of or recognize right away—and what to do if they’ve popped up in your life.
1. Brain fog
Whether you can’t think of a word that’s on the tip of your tongue or forgot why you went into the kitchen moments after you arrived, brain fog and forgetfulness are perimenopause symptoms that many women don’t expect, Dr. Adams says. In fact, she’s had patients worry that their brain fog is early-onset dementia. But as many as 60% of women experience cognitive changes during this time, research shows.
The reason? Estrogen affects neurotransmitters in the brain that impact memory, mood, and sleep, so fluctuating levels can result in cognitive changes. Hormonal shifts may also alter how brain cells are produced and connect with other cells and may lower the brain’s main fuel source, glucose. These changes can manifest as forgetfulness, confusion, or difficulty concentrating. If you tend to get hot flashes, your brain fog may also be worse, research suggests, thanks to the way the uncomfortable symptoms disrupt sleep and affect quality of life and mood.
2. Sleep problems
Speaking of sleep: About half of perimenopausal women say they struggle to get a good night’s sleep, according to research. This can look like having trouble falling asleep in the first place or experiencing sleep disturbances throughout the night. For example, you might doze off with no problems but then wake up at 3 a.m. feeling anxious or energetic, Karen Horst, MD, a reproductive psychiatrist and assistant professor of obstetrics and gynecology at the Baylor College of Medicine in Houston, Texas, tells SELF.
Levels of the sleep hormone melatonin start to decline during perimenopause and drop more once a woman is in menopause. Stress, which tends to intensify during perimenopause, can also cause sleep disturbances. Additionally, estrogen fluctuations can affect the part of the brain that regulates temperature, triggering hot flashes and night sweats, which may also lead to restless sleep and frequent awakenings throughout the night.
3. Anxiety and mood changes
Mood shifts, including irritability, frustration, or difficulty dealing with life’s complications, often come up during perimenopause, Dr. Horst says. Estrogen fluctuations can even contribute to mood disorders and other mental health problems. But you might not connect these changes to perimenopause at first. After all, your 40s are a time when you have a lot going on: perhaps a demanding job, numerous financial obligations, raising children, and caring for aging parents. Layer on the political and social issues of today, and it gets complicated, Dr. Adams adds. “Our stress is traffic and deadlines and our kids and climate change and politics and all the things,” she says. “We’re swimming in this cortisol soup all the time.”
4. Joint and muscle pain
If your knee suddenly starts aching after a workout or you get muscle cramps for seemingly no reason, perimenopause could be to blame. More than 70% of perimenopausal women experience musculoskeletal pain, and many others deal with muscle tightness, stiffness, and aches, research shows. “I have patients tell me their feet hurt in the morning; they have to be kind of ginger about their first steps,” Dr. Horst says.
The reason this happens: Estrogen receptors exist in the collagen fibers in your skin and joints, Dr. Adams says. When levels start to decline, it can lead to inflammation and depletion of the fluid that lubricates your joints, causing pain and stiffness. (Experts theorize that this is why “frozen shoulder” tends to be more common during this time.) This can also lead to brittle bones and muscle weakness.
5. Dry hair, skin, and eyes
Estrogen drops can lead to a loss of water and collagen, a protein that gives skin its plumpness and elasticity, leading to allover dryness. The hormone is also responsible for hair growth and fullness, so women often notice hair loss, thinning, and shedding during perimenopause, Dr. Adams says. “Really, everything becomes dry,” she adds. “We have dry eyes, dry mouth, dry skin, dry hair, dry vagina. That’s all estrogen-mediated.”
The eyes are probably the most surprising. Sex hormones (including estrogens and androgens) play a role in producing the thin layer of protective fluid that covers the eye, so hormonal shifts and imbalances can throw things off-kilter. In fact, research shows that the rate of dry eye in women over 50 is nearly double that of men in the same age group.
So if you’re suddenly noticing your hair is more parched than normal, you’re reaching for a thicker moisturizer than you used to, or your mouth or eyes feel like the Sahara (and there are no recent changes in your routine that could be to blame), these could be signs of perimenopause.
6. Itchy ears
All that dryness can also crop up in an even unlikelier place: your ears. “Ear canals are thin and rely on earwax for moisture,” Mindy Goldman, MD, an ob-gyn in San Francisco and chief clinical officer at Midi, a women’s telehealth platform, tells SELF. As that inner-ear skin grows dry with the dearth of estrogen, it can easily become itchy.
What’s more, estrogen fluctuations can alter the pH of the skin in your ear canal, which may activate itching mediators in the skin too, Sameena Rahman, MD, a Chicago-based ob-gyn and menopause specialist, tells SELF. It’s the reason she warns women to avoid sticking any cotton swabs in there—you just risk worsening the irritation. Dr. Goldman says a few drops of mineral or olive oil may help with the dryness, but as with any of the items on this list, itchy ears can indicate it’s time to check in with your ob-gyn. If this shows up alone, it could very well be a precursor to other changes ahead, she adds.
7. Heart palpitations
Estrogen also helps regulate your heart rate and maintain healthy cholesterol levels, so fluctuations in the hormone can cause heart palpitations, even for women without a history of heart problems. “People think they’re having a heart attack or panic attack, and they feel this kind of irregular or racing heartbeat,” Dr. Adams says. This isn’t necessarily something to be concerned about in and of itself, but it’s important to make sure your symptoms aren’t a sign of a bigger issue. Dr. Adams suggests seeing your doctor whenever you have cardiovascular symptoms to rule out any bonafide heart problems that may require treatment.
8. Pain during sex
This one’s probably the most widely recognized symptom on the list, but we’re mentioning it anyway since it’s a biggie. Many women in perimenopause and menopause say they experience pain during sex, which is often due to dryness and other changes in vaginal skin health. “The vagina is very estrogen-sensitive, and when estrogen levels decline, the vagina gets less stretchy and less moist and less flexible,” Dr. Adams says. This can lead to pain, especially around the vaginal opening, during penetration, and in some cases, urinary tract infections (UTIs). Vaginal estrogen (typically applied topically as a cream) can usually help relieve this pain and reduce your infection risk too, if hormone-fueled dryness is to blame, she adds.
How to treat perimenopause symptoms
If you’re in your 40s and noticing some new symptoms or that you don’t feel quite right, Dr. Naqvi urges you to talk to your doctor. However, not all doctors, even ob-gyns, are knowledgeable about menopause. The Menopause Society offers an online tool to help you find a certified menopause practitioner in your area.
Based on your symptoms, your doctor may refer you for additional testing, such as to a rheumatologist to screen for arthritis if you have joint pain, or a cardiologist if you’re having heart palpitations, Dr. Adams says. They may also refer you to a mental health professional for an evaluation if you’re experiencing anxiety or mood changes, Dr. Horst adds.
After ruling out other causes, your doctor may recommend hormone therapy (HT), Dr. Horst says, which comes in different forms such as a patch or pill and essentially helps replace lost estrogen. Many women notice improvements in symptoms like hot flashes or vaginal or skin dryness soon after starting it. However, the exact time that it takes to help can vary depending on the hormone dosage and individual. (And while it may anecdotally help improve some symptoms, there isn’t solid research to show that it’s a guaranteed solution for every potential perimenopause symptom.)
There’s also been some controversy about hormone therapy over the last two decades, stemming from the misinterpreted results of a flawed 2002 study (which included mostly women several years postmenopause, when HT is thought to be less effective). Up until last fall, HT still contained a black box warning calling out risks of conditions like breast cancer, heart attack, and stroke. But that label has since been removed by the FDA based on a body of research conducted since that 2002 study, which has shown that HT is generally safe when started before age 60 or within 10 years of the start of menopause.
That said, women with certain medical conditions like a history of blood clots or stroke should not take HT, so it’s best to chat with your doctor to determine if it’s the right option for you. For those without contraindications, The Menopause Society suggests hormone therapy as a “first-line therapy” for managing hot flashes, vaginal dryness, pain during sex, ovarian insufficiency, and prevention of bone loss.
Beyond hormone therapy, embracing healthy lifestyle habits can also help you manage symptoms. First and foremost, Dr. Horst says to quit smoking. Working regular exercise into your routine is a great way to reduce stress, which can also have a positive effect on some of these symptoms. There are also treatments available to address specific symptoms—like dry eye, itchy ears, or sleep issues—that your doctor can suggest or refer you to a specialist for care.
Even though it can bring a lot of changes, perimenopause is a natural stage and “not something to be feared,” Dr. Adams emphasizes. “It’s something to be aware of, educate yourself about, and then to really use it as an opportunity to prioritize yourself, your own health and your own needs.”
Related:
- Hormone Replacement Therapy Could Help Women Avoid Dementia—If It’s Taken at the Right Time
- 9 Reasons Why You Have Pain After Sex and How to Find Relief
- Perimenopause Raises Your Risk of Stroke—but These Habits Can Help Undo Its Effects
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