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 lead to restless sleep and frequent wakings throughout the night.
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.”
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 weakened bones, osteoporosis, and muscle weakness.
Dry hair, skin, and eyes
Estrogen drops can lead to a loss of water and collagen, which keep your skin moisturized and plump, and contribute to dryness. The hormone is also responsible for hair growth and fullness, so women often notice hair loss, thinning, and shedding during perimenopause and menopause, 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.
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 type of irregular heartbeat 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 legit heart problems that may require treatment.
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. Topical estrogen cream can usually help relieve this pain 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.
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