When we think of perimenopause, hot flushes often come to mind — but these are rarely the earliest signs, and some women don’t experience them at all.
The transition usually begins more subtly, often in the 40s (though it can start earlier), and it frequently overlaps with one of the busiest chapters of life — sometimes called the “peak hour” of adulthood. It’s a stage where careers are demanding, children may still need support, parents are ageing, and the endless cycle of household tasks and personal admin never seems to stop.
All of this can make it easy to dismiss new symptoms as just “life,” when in fact they may signal hormonal changes.
So, what should we look out for?
Perimenopause is defined by fluctuating hormone levels — particularly estrogen and progesterone — which can trigger a wide range of symptoms. The hallmark sign is a change in menstrual cycle length or flow. Cycles may become shorter, longer, or more irregular, and research from the Stages of Reproductive Aging Workshop (STRAW+10) confirms that menstrual irregularity is the most reliable early marker of perimenopause (Santoro et al., 2016).
For women using a progestin IUD or the progesterone-only pill, these menstrual changes may not be noticeable. In these cases, other symptoms may provide the first clues, such as sleep disturbances, mood shifts, cognitive or concentration difficulties, breast tenderness, changes in libido, musculoskeletal pain, unexplained weight gain, or worsening PMS.
Sleep Disturbance
Difficulty falling asleep or staying asleep is one of the earliest and most common symptoms of perimenopause with 40–56% of perimenopausal women reporting sleep problems, compared with 31% of premenopausal women (Musial et al., 2021).
Estrogen normally helps regulate sleep cycles, while progesterone has a naturally calming effect on the brain. As these hormones begin to fluctuate, women may notice:
- Trouble falling asleep
- Waking more often during the night
- Difficulty getting back to sleep once awake
Higher levels of follicle-stimulating hormone (FSH), which rise as the body transitions toward menopause, are also linked to more frequent night waking (De Zambotti et al., 2015).
The reassuring news is that once hormone levels stabilise after menopause, many women find their sleep improves again. In the meantime, strategies such as good sleep hygiene, regular exercise, relaxation techniques, and professional support can make a significant difference.
Mood Changes
Perimenopause can bring irritability, sudden bursts of anger, low mood, and reduced stress resilience. One reason for this is fluctuating estrogen. Estrogen interacts with key brain chemicals like serotonin and dopamine, which regulate mood, motivation, and emotional balance.
Research shows that women are especially vulnerable to mood disturbances during perimenopause, particularly if they have a history of PMS, postnatal depression, or significant life stress (Musial etc al., 2021).
The good news is that these changes are common, temporary, and manageable. With the right strategies—whether lifestyle adjustments, stress management techniques, or professional support—many women find their mood and resilience improve dramatically.
Cognitive and Concentration Difficulties
“Brain fog” is one of the most common early symptoms of perimenopause. Many women describe feeling unable to retain information, struggling to focus, forgetting simple things, or losing words mid-sentence.
The causes are multifactorial. Fluctuating estrogen is one factor, but poor sleep, heightened stress, and anxiety can also contribute. Estrogen normally supports blood flow to the brain and enhances communication between neurons, so when levels rise and fall unpredictably, mental clarity can suffer.
The reassuring news is that for most women, brain fog is temporary and improves once hormone levels stabilise after menopause (Conde et al., 2021).
Musculoskeletal Pain
Frozen shoulder, tennis elbow, morning stiffness — many women assume these aches are simply ageing. In fact, musculoskeletal pain is one of the most common yet under-recognised symptoms. A meta-analysis found that around 71% of perimenopausal women experience musculoskeletal pain, significantly more than premenopausal women (Lu et al., 2020).
Declining estrogen is a key driver, leading to an increase in inflammation, a decrease in bone mineral density, arthritis, sarcopenia (muscle loss), and slower muscle repair and growth (Wright et al., 2024).
The good news is these symptoms are modifiable. Strength training, mobility work, and low-impact aerobic exercise can reduce pain and preserve joint and bone health. Adequate nutrition and professional support can further improve outcomes.
Weight Gain and Body Composition Changes
Many women notice body composition changes during perimenopause — frustratingly, even if their lifestyle hasn’t changed. Weight may creep up, clothes feel tighter around the middle, and fat tends to redistribute toward the abdomen.
Fluctuating and declining estrogen levels play a key role in how the body stores and metabolises fat. Research shows that perimenopausal women are more likely to accumulate visceral adipose tissue (fat around the internal organs), which is metabolically active and linked to higher risks of insulin resistance, type 2 diabetes, and cardiovascular disease (Kapoor et al., 2017)
Reassuringly, weight gain and visceral fat accumulation are reversable. Lifestyle interventions — particularly resistance training, aerobic exercise, and dietary strategies can reduce visceral fat and preserve lean muscle. Read more about this in our upcoming weight loss in perimenopause and menopause blog.
Other Early Signs
- Breast tenderness and bloating
- Changes in libido
- Increased premenstrual symptoms
What you can do
Recognising the early signs provides the opportunity to take proactive steps — from simple lifestyle adjustments to professional support. At our clinic, we combine comprehensive medical assessments with nutrition, exercise physiology, and health coaching to help you navigate this transition with confidence.
Sources:
- Santoro N. Perimenopause: From Research to Practice. (2016). J Womens Health (Larchmt). Apr;25(4):332-9. doi: 10.1089/jwh.2015.5556. Epub 2015 Dec 10. PMID: 26653408; PMCID: PMC4834516.
- Musial N, Ali Z, Grbevski J, Veerakumar A, Sharma P. (2021). Perimenopause and First-Onset Mood Disorders: A Closer Look. Focus (Am Psychiatr Publ). Jul;19(3):330-337. doi: 10.1176/appi.focus.20200041. Epub 2021 Jul 9. PMID: 34690602; PMCID: PMC8475932.
- De Zambotti M, Colrain IM, Baker FC. (2015). Interaction between reproductive hormones and physiological sleep in women. J Clin Endocrinol Metab.100(4):1426-1433.
- Conde DM, Verdade RC, Valadares ALR, Mella LFB, Pedro AO, Costa-Paiva L. (2021). Menopause and cognitive impairment: A narrative review of current knowledge. World J Psychiatry. Aug 19;11(8):412-428. doi: 10.5498/wjp.v11.i8.412. PMID: 34513605; PMCID: PMC8394691.
- Lu CB, Liu PF, Zhou YS, Meng FC, Qiao TY, Yang XJ, Li XY, Xue Q, Xu H, Liu Y, Han Y, Zhang Y. (2020). Musculoskeletal Pain during the Menopausal Transition: A Systematic Review and Meta-Analysis. Neural Plast. Nov 25;2020:8842110. doi: 10.1155/2020/8842110. PMID: 33299396; PMCID: PMC7710408.
- Wright, V. J., Schwartzman, J. D., Itinoche, R., & Wittstein, J. (2024). The musculoskeletal syndrome of menopause. Climacteric, 27(5), 466–472. https://doi.org/10.1080/13697137.2024.2380363
- Kapoor E, Collazo-Clavell ML, Faubion SS. (2017). Weight Gain in Women at Midlife: A Concise Review of the Pathophysiology and Strategies for Management. Mayo Clin Proc. Oct;92(10):1552-1558. doi: 10.1016/j.mayocp.2017.08.004. PMID: 28982486.
