Estrogen receptors are widely distributed in the brain, including in the regions involved in mood regulation. Mood symptoms may be related to big swings in estrogen levels during perimenopause, but the precise mechanism isn’t known. Some women also experience changes in lifestyle behaviors (such as exercise levels or eating habits), sexuality, and other aspects of their health that have an effect on mood. The presence of stressful life circumstances or events may play a role, as can the presence and severity of menopause symptoms such as hot flashes and sleep changes. 

What is considered a normal menstrual cycle varies greatly from woman to woman. Still, in the years approaching perimenopause, most women will have a pattern that’s fairly consistent, so any changes in their bleeding pattern may be noticeable. To determine whether these changes are of concern, it is important that a woman consults with a healthcare professional. Keep in mind that it can be useful to track the bleeding on a calendar or app so that it can be easily reviewed and assessed. 

Don’t assume that any abnormal bleeding is simply part of normal menopause. Most of the time, that’s true, but abnormal bleeding can also be a sign of another health condition or even cancer. In cases such as cancer, the earlier that symptoms can be identified and diagnosed, the greater likelihood of successful treatment. Other possible causes of abnormal bleeding include fibroids, infections, thyroid dysfunction, and the use of certain medications or herbal products. Heavy or irregular bleeding, even when not related to cancer, can have a negative effect on quality of life.

As women age, the ability to become pregnant (fertility) declines. In fact, before any signs of the menopause transition become apparent, a profound decline in fertility has already occurred. Research has shown that a decline in fertility accelerates after age 35 years. 

Although there are many fertility-enhancing treatments available for midlife women, these options are often expensive, involve some risks, and may not be successful. Additionally, as women age, their pregnancies involve more risks than do those of younger women. These risks include higher rates of spontaneous miscarriage and genetic disorders in babies, as well as increased risks of gestational diabetes, gestational hypertension, stillbirth, and the need for a cesarean delivery. Any woman who is interested in childbearing in her late 30s and beyond is advised to consult with a women’s health specialist to help mitigate and manage these risks. That professional also can help to assess fertility and discuss alternative options for having children if fertility is limited.   

Hot flashes and night sweats, clinically known as vasomotor symptoms, are the most commonly reported symptoms of the menopause transition. One large, diverse US study found that up to 80% of women experience these symptoms at some point during the menopause transition.  

Hot flashes are characterized by a sudden, intense sensation of heat in the upper body—particularly the face, neck, and chest. Each hot flash episode typically lasts between 1 and 5 minutes and may be accompanied by sweating, chills, and anxiety. Some women can feel a rapid heartbeat at the same time. Night sweats are hot flashes that occur during sleep. Chills can also occur, resulting in shivering. These are all disturbances in thermoregulation or regulation of temperature control.  

Hot flashes can range from mild and tolerable to severe and debilitating. Hot flashes that are mild may be experienced as a sensation of heat without sweating. With severe hot flashes, there can be enough sensation of heat and sweating to make a woman have to stop activity. Much like their severity, the duration of hot flashes also may vary. Some women experience hot flashes for a few years, whereas others may have them for decades.

The genitourinary syndrome of menopause (GSM) is defined as a collection of signs and symptoms associated with estrogen deficiency that can involve changes to the lips of the vagina (labia), vaginal opening and vagina, clitoris, bladder, and the short tube through which urine is eliminated from the body (urethra). The syndrome includes genital symptoms of dryness, irritation, and burning; sexual symptoms such as pain with vaginal penetration; and urinary symptoms. These symptoms can range from mildly annoying to debilitating. 

The symptoms of GSM may be more severe in women who undergo menopause as a result of surgical menopause or because of chemotherapy for cancer treatment. They also may be more severe for women who take aromatase inhibitors for prevention or treatment of breast cancer. Unlike vasomotor symptoms, which generally improve over time, GSM often worsens over time without treatment. Fortunately, there are many effective treatment options, including over-the-counter and prescription therapies. 

The dryness and thinning of the vagina that follows the drop in estrogen around menopause is the most common cause of painful sex at midlife and beyond. Less estrogen means less vaginal lubrication and a less stretchable vagina. The vagina also may shorten and become tighter at the opening. In some women, this can lead to a feeling of vaginal tightness during sex along with pain, burning, or soreness. Inflammation and irritation also can develop, leading to greater discomfort and sometimes to the tearing and bleeding of tissue with any penetration of the vagina. The pain can intensify to a point where sexual activity is no longer pleasurable or desirable, or it may not even be possible. 

Estrogen helps protect the health of the bladder and urethra. With menopause, numerous urinary symptoms may develop, including a sensation of burning or pain with urination, increased frequency or urgency of urination, and increased risk of urinary tract infections. 

Women may feel urinary urgency with or without episodes of urine leakage (urinary incontinence) with increased daytime urinary frequency. Along with this, women may awaken two or more times in the night to urinate—a symptom known as nocturia.