8 Signs You’re in Perimenopause

Carin Luna-Ostaseski still recalls the shock of discovering her periods had become monsoons. Short monsoons, she clarifies—her cycle went from lasting a week to two to three days—but still monsoons. She realized she was going through at least one tampon every hour.

Then, more confusion: Earlier this year, partway through a flight, she became convinced she was having a heart attack—her heart was racing wildly, and she felt scared. It turned out she was actually experiencing a panic attack, triggered by—surprise!—perimenopause, which can lead to symptoms like weird periods, mood swings, and anxiety. “You Google the symptoms, like ‘I’m bleeding too much,’” says Luna-Ostaseski, 47, who lives in San Francisco. “You don’t think, ‘This is perimenopause.’ Our parents’ generation knew about menopause, but I think perimenopause is a new concept for our generation.”

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So what exactly is it? In a nutshell: the conclusion of a woman’s reproductive life, starting anywhere from age 40 to 44, though there can be variances on either side. While it’s still possible to get pregnant during perimenopause, it becomes more difficult; experts caution that you shouldn’t suddenly stop practicing safe sex. The transition lasts until someone officially enters menopause—which is exactly one year after their last period, usually around age 51. During perimenopause, hormones like estrogen and progesterone fluctuate wildly: “What used to be a predictable, EKG-like ebb and flow becomes chaotic,” says Dr. Mary Claire Haver, an ob-gyn who specializes in menopause care (and has developed a large social-media following around it).

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The vast majority of women are “so confused” when they start experiencing symptoms, Haver adds. “They go to their provider, and depending who they see, are told there’s nothing they can do—this is a normal part of life. Or they’re offered a hysterectomy, which is a surgical treatment of a medical issue, not a hormone issue, so they’re being castrated to cure their menopause.” That tracks with Luna-Ostaseski’s experience: She and her friends talk about their symptoms “constantly,” and share helpful services and products with each other. (She even created a website and newsletter called “Hot or Just Me?” to dispense those resources to a wider audience.) They call it “girlfriend medicine” to reflect the way they’ve stepped up to support each other, since doctors often don’t grasp what they’re going through.

Complicating matters: There’s no single, accurate test for perimenopause. To arrive at a diagnosis, Haver does blood work to rule out conditions like hypothyroidism or autoimmune disease, and then narrows things down to perimenopause based on symptoms and through process of elimination. After that, she starts talking about treatment: Many patients benefit from medications like hormone therapy and low-dose birth control pills, in addition to lifestyle changes. “Menopause is inevitable,” Haver says. “But suffering is not. It might mean you need to make some changes in your life, or that pharmacology is going to be helpful—but if you just ignore it, it’s going to get worse.”

With that in mind, we asked experts to describe the symptoms that can indicate you might be experiencing perimenopause.

Irregular periods

Perimenopause is a transitional stage characterized by having an irregular period, says Dr. Christine Greves, an ob-gyn at Orlando Health Women’s Institute. Someone who has always had a 28-day cycle, for example, might find that her periods start to vary by about seven days. “They can be shorter or longer,” she says, or not arrive at all. “Sometimes, you might not release an egg and will skip a period.” Women often report changes in flow, too, noting that their periods become heavier or lighter.

The reason for the change? Unlike men, who make new sperm every day, women are born with all the eggs they’ll ever have. Over time, those eggs “start becoming less sensitive to our hormonal stimulation, and we don’t ovulate as regularly,” says Dr. Mary Farhi, an ob-gyn at Rush University Medical Center. As a result—given that the ovaries are producing fewer hormones—your periods naturally become irregular, she explains.

Hot flashes

About 75% of women experience hot flashes and night sweats during perimenopause, says Dr. Mindy Goldman, chief clinical officer of Midi Health, a virtual care clinic focused on perimenopause and menopause. You might experience intense heat and start sweating or turn bright red, mostly around your head, neck, chest, and upper back. Though scientists don’t understand exactly what causes hot flashes, hormones likely play an important role. Vasomotor symptoms tend to be especially bothersome at night, leading to frequent wake-ups, which is one reason why many perimenopausal women report fatigue.

Read More: How to Deal With Menopause When It’s Hot Outside

They’ve hit Luna-Ostaseski hard: At least once a week, she asks her husband if it’s hot or just her. “He’s wearing a sweater, and I’m stripping off layers of clothes for relief,” she says. She’s found that wearing natural fabrics helps, as does setting her bedroom temperature to 65°F. She avoids alcohol, spicy foods, caffeine, and hot drinks—all of which can trigger flashes—and prioritizes deep breathing, meditation, and stress management. She’s also learned that taking magnesium glycinate before bed is helpful, and she sleeps on cooling sheets and blankets. “I’ve gotten the hot flashes a little more under control,” she says, “but they still come and go.”

Vaginal dryness

Vaginal dryness triggered by hormonal changes is another hallmark symptom of perimenopause. “You can experience dryness in general, or dryness with intercourse,” Greves says. Depending on severity, over-the-counter lubricants can be effective. But she also recommends a more surprising antidote: cooking oil. Coconut oil works particularly well and doesn’t contain any irritants. “It’s in your cabinet, and it’s cheap,” she says. “That is an option to conquer the dryness.” In some cases, Greves adds, vaginal estrogen works best, especially among those experiencing painful intercourse. “Estrogen is like putting lotion in the vagina—it makes it nice and supple,” she says. There are a variety of ways to take it, including creams, gels, and rings; ask your doctor what might work best for you.

Joint pain

More than 70% of women experience musculoskeletal pain during perimenopause—and for 25% of them, it’s debilitating, according to recent research. Changing levels of estrogen, paired with a loss of muscle mass and bone density, can lead to rapid progression of arthritis, frozen shoulder, and other types of joint pain. As the study authors noted, these symptoms can be “silent, devastating, and permanent unless addressed.”

While physical therapy is helpful in some cases, hormone therapy “is actually really, really powerful,” Haver says. Research suggests it can reduce inflammation and pain, while also helping prevent osteoporosis, which weakens bones. Prioritizing good nutrition and resistance training also plays an important role in improving symptoms and preventing falls and frailty.

Weight gain

When Haver entered perimenopause, her biggest complaint was the unexplained belly fat she gained. She had been privileged to not have to worry about her weight for most of her life, she says, and suddenly, without changing her habits, she no longer recognized her own body.

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That’s a familiar experience, experts say. “We know that metabolism slows, and we know that after menopause, there’s an average of about five pounds of weight gain,” Goldman says. “Perimenopause is when people may gradually start noticing an increase in weight.” She coaches them to focus on eating well—protein and whole foods are important—and employing healthy exercise habits. That can help stave off additional weight gain as you progress through menopause, experts agree.

Brain fog

Do you ever feel like there’s a cloud over your head, or that you can’t multitask the way you used to? It could be a lot of things, including perimenopause. Luna-Ostaseski says she occasionally walks into a room and forgets why she’s there—and while driving, she once blanked on why she was headed in a particular direction. “To someone who prides herself on a sharp mind, it’s concerning,” she says. She hasn’t found an effective solution yet, but makes it a point to journal on her foggy days to see if she can identify triggers.

Women frequently tell Goldman they can’t remember a person’s name or summon words as quickly as they’d like. “We know that estrogen withdrawal can clearly have a cognitive impact,” she says. Researchers are currently exploring exactly how estrogen affects the brain, and Goldman notes that many women see cognitive improvements after starting hormone therapy. That’s not, however, always the only factor: If someone isn’t sleeping well because of hot flashes, their fatigue can dampen mental clarity. Plus, “there’s data that says when you’re tired, you don’t exercise as much, and you don’t make healthy food choices,” she adds, which can affect cognitive health. “It’s all tied together.” That’s why treating perimenopause requires thinking holistically.

Mood changes

Perimenopause clues often arrive in the form of mood changes: PMS symptoms sometimes worsen, and you might notice you feel super irritable or angry, or that you’re crying more often. Plus, women who have had postpartum depression could be at increased risk for recurrent depression during perimenopause and menopause. “That’s part of the history I always ask people,” Farhi says. “We can only take so much stress, and once it gets too heavy, it can tip us over. I always tell people that your 40s are the time to fill your tank, because you don’t want to hit menopause with an empty tank.”

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Therapist Jessika Fruchter was “blindsided” when she began experiencing perimenopause symptoms about a year and a half ago. She recalls traveling to a favorite spot by the ocean where she lives in Southern California and bursting into tears. “Because I know myself really well, and also because of my clinical training, I was like, ‘Something’s off here,’” she says. In addition to working to find specialized providers to support her own health, she shifted her practice to focus on serving women in perimenopause. It’s much easier to find a therapist who specializes in perinatal health than it is to find one with menopause expertise, she points out, and she wants to change that. She’s starting to offer menopause training courses for other therapists, as well as support groups for her clients.

To find resources near you, tap into online tools like Psychology Today’s therapist and support group directories, Fruchter suggests. Make it a point to practice self-compassion, too, she urges. “It’s about cultivating that nurturing, calming, caregiver voice inside of us,” she says. “It’s telling yourself that you got this—this is natural, and it’s going to pass—and lowering the bar.”

Shattered sense of identity

Many women feel a sense of grief as they navigate perimenopause. “For some, it’s really about the end of the reproductive years,” Fruchter says. “Others are very attached to their menstrual cycle. And there’s this constant bump up against toxic youth culture and middle-aged invisibility.”

Fruchter suggests reframing perimenopause as stepping into a new—and potentially liberating—chapter of life. She often hears from people who find they don’t have as much of a filter once they hit the years surrounding menopause, finally squashing their people-pleasing tendencies and setting firm boundaries. Some treat it as a literal “pause,” seizing the opportunity to take inventory of their life.

Fruchter—who describes perimenopause as “a second puberty”—stresses that there’s no reason to feel ashamed or to suffer mentally or physically. “There’s so much beauty in this transition if we have the right support,” she says. “Most of the women I know are incredibly resilient and used to white-knuckling through challenges on their own. But just because we can doesn’t mean we should have to.”