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 smartphone app so that it can be easily reviewed and assessed. 

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 the body’s ability to regulate temperature. 

Many women will not notice symptoms of genitourinary syndrome of menopause (GSM) during perimenopause. For some, the symptoms may not become problematic until several years after menopause. As women reach menopause, the decrease in estrogen may cause the surface of the vulva and the vagina to become thin, dry, and less elastic. Vaginal secretions diminish, resulting in less lubrication. This often results in pain with sexual activity, routine pelvic examinations, and even discomfort with wiping after urination or wearing certain clothing. Symptoms such as burning, itching, or irritation of the vulva are common. Loss of estrogen also can make one more susceptible to vaginal infections.  

Managing weight during perimenopause and after menopause is essential. Weight gain around the menopause transition can be prevented by diet and exercise. For women who are already overweight, a weight loss of as little as 3% can provide health improvements, including improved cholesterol levels and a reduced risk of diabetes. Weight loss of 5% to 10% or more has shown significant health benefits, such as further improvement in cholesterol and blood sugar control, improved blood pressure levels, better liver function, improved daily functioning, and less chronic pain. 

Migraines are moderate to severe headaches that involve throbbing or pulsating pain that’s usually aggravated by activity. They’re typically accompanied by sound sensitivity, light sensitivity, or nausea and vomiting. Hormones may play a role in migraine headaches. Some women may notice that headaches tend to occur at certain times in their menstrual cycle. The fluctuation in estrogen levels in perimenopause may cause hormone headaches to increase. Many women will see these headaches stop once menopause is reached; however, some women will continue to have headaches after menopause. 

Women appear to be particularly vulnerable to depression during the perimenopause years and in the years immediately after menopause. Theories exist as to why women have double the rates of depression during this period. One theory is that there is a “window of vulnerability” such that some women are more sensitive to the hormone shifts that occur during perimenopause and puts them at greater risk for depression. In addition, women at greatest risk are those with a history of depressed mood earlier in life. Emotional health during perimenopause requires a balance between self-nurturing and the obligations of work and caring for others. Many women are able to identify and describe sources of tension and symptoms of stress but may still find it difficult to take time for themselves. Recognizing a problem is the first step to finding ways to cope. Although many stressors cannot be altered, coping skills can enable women to meet life’s challenges and create a renewed sense of self-confidence, balance, and harmony.  

Forty to sixty percent of midlife women report cognitive symptoms such as forgetfulness during the menopause transition. These symptoms manifest as brain fog, which reflects difficulty remembering words, names, anecdotes, and numbers; an inability to focus and concentrate; and distractibility. Such symptoms can cause distress and anxiety, often related to an unnecessary concern that these are early signs of dementia. Midlife women should be advised that brain fog during perimenopause is very common, changes in cognitive performance are typically mild and within the limits of normal, and dementia at midlife is very rare.