Menopause and perimenopause: timing, symptoms and when to get checked

How the transition usually unfolds

For many women, the first sign is a change in the cycle: periods that come closer together, further apart, heavier or lighter than before. Sleep changes, new anxiety or irritability, and night sweats can appear even while cycles are still fairly regular. Over time, skipped periods become more common until they stop altogether.

Because hormones swing up and down during this time, symptoms can be intense one month and quiet the next. That pattern is normal for perimenopause and is one reason a single blood test is not a reliable way to diagnose it.

The total length varies widely. Some women move through it in a couple of years, while others have symptoms for much longer, and hot flashes can continue after periods stop.

Symptoms people do not expect

Hot flashes and night sweats are the best known, but many other changes are linked to the transition. Some are easy to blame on stress or aging, so it helps to know they are common.

• Waking in the early hours and struggling to fall back asleep
• Anxiety, low mood or irritability, sometimes with no prior history
• Heart palpitations, which should still be checked if new
• Joint aches and morning stiffness
• Brain fog and trouble finding words
• Vaginal dryness, painful sex and more frequent urinary tract infections
• Dry eyes, dry skin, thinning hair and adult acne
• Bloating and changes in bowel habits

Hot flashes and night sweats

Hot flashes are thought to come from changes in the brain's temperature control as estrogen falls, which makes the body react to small temperature shifts as if it were overheating. Common triggers include alcohol, spicy food, caffeine, warm rooms and stress. They often last for years rather than months.

Systemic estrogen is the most effective treatment. For women who cannot or prefer not to take estrogen, there are non-hormonal prescription options, and your clinician can review them. Night sweats can also come from infections, some medications, thyroid problems and, rarely, other illnesses, so new drenching sweats with fever or weight loss need evaluation.

Is it menopause, thyroid or something else?

Thyroid disease is common in midlife women and can cause fatigue, weight changes, anxiety, palpitations, sleep problems and changes in periods, which overlap heavily with perimenopause. A TSH blood test is a good first screen. Low iron, depression, sleep apnea and medication side effects can also mimic menopause symptoms. You can have more than one at once, and treating one will not fix the other.

Bleeding: what is normal and what is not

Irregular and sometimes heavier bleeding is common in perimenopause, but very heavy bleeding, bleeding between periods that keeps happening or bleeding after sex should be checked. Once you have reached menopause, any vaginal bleeding is a reason to contact a clinician, because it needs to be investigated.

On hormone therapy, some spotting is common in the first months, especially with continuous regimens. The National Cancer Institute notes that combined therapy increases vaginal bleeding, which sometimes leads to an endometrial biopsy. Do not stop progesterone on your own to see whether bleeding stops; call your clinician instead.

Contraception during perimenopause

Fertility falls during perimenopause but does not disappear until menopause, so pregnancy is still possible while you are having periods, even irregular ones. Hormone therapy for menopause symptoms is not a contraceptive. Keep using birth control until your clinician confirms it is safe to stop, which depends on your age and how long it has been since your last period.

Preparing for a menopause appointment

A few weeks of notes can make your visit far more productive. Track your cycle dates, the timing and number of hot flashes, sleep quality, mood and any bleeding. List medications and supplements, your personal and family history of breast cancer, blood clots, stroke and heart disease, and the symptoms that bother you most. Then ask what each treatment option is likely to help, what it will not help and how you will judge whether it is working.