8 surprising symptoms of perimenopause

Hot flashes, changes in sex drive, and irritability are all common signs of perimenopause, the transitional stage to menopause. But they’re not the only signs. Shifting hormone levels can also contribute to a wide variety of changes in your body and mental state.

Many people overlook less-common perimenopause symptoms, says JoAnn Pinkerton, MD, OBGYN professor and director of the Midlife Health Division at the University of Virginia. This is partly because these symptoms can differ from person to person and they're often mistaken for typical aging.

So, what should you keep an eye out for, beyond hot flashes and mood swings? Here’s what to know.

Additional signs of perimenopause

If any of these sound familiar, you may be in perimenopause:

Your period stops for 3 to 6 months, then starts again

Menopause occurs when you haven’t menstruated for a year. It typically happens in your late 40s or early 50s. Unpredictable periods around this time suggest you’re in perimenopause—that your ovaries have started releasing eggs at irregular intervals. "Another signal is flooding," Dr. Pinkerton says. "You start to become irregular—you may have a spotty period and then go through times of very heavy periods." Though period changes are typical once you’re in perimenopause, you should still let your healthcare provider (HCP) know what’s happening. Sometimes, bleeding abnormalities can indicate a separate health issue.

Sleep changes

You may have trouble falling or staying asleep. Night sweats and mood swings can contribute to this issue.

Breast tenderness intensifies

Hormonal changes can cause your breasts to ache. To note: While breast pain is not a common symptom of breast cancer, if your pain is acute, concentrated in one area, or you feel a change in the tissue, speak with an HCP. Swelling on one side is another reason to reach out.

Migraines worsen

Some people get migraines before or after their periods. During perimenopause, these painful headaches can be more severe and happen more often.

Vaginal tissue changes

Perimenopause can cause the lining of your vagina to thin out, feel dry, and lose elasticity. This could make sex uncomfortable. Changes in your vagina can also lead to tiny tears in the tissue and changes in pH balance in the area, which can increase your risk of vaginal infections.

Urinary tract infection (UTIs) risk increases

This occurs because your urethra—the tube through which you urinate—can become irritated or inflamed. You might find yourself using the restroom more often, as well.

Anxiety increases

If you already have anxiety, your symptoms may increase or you may start to have panic attacks, with symptoms that can include fear disproportionate to the circumstances, difficulty breathing, a racing heartbeat, dizziness, and sweating.

Mental health conditions may become more acute

This is especially true of people with depression, bipolar disorder, or schizophrenia.

What to do about perimenopause symptoms

Without the predictability of regular periods and symptoms, it's important to keep a menstrual calendar, Pinkerton advises. "Note when you have a period and come up with shorthand for a headache, breast tenderness, and heavy flow," she says. This is especially key because the symptoms you experience may not be the same from cycle to cycle. Although you may have heavy flow or an especially painful migraine one month, you may not have the same symptoms with your next period.

Keep in mind, too: Though fluctuating hormones contribute to many perimenopause symptoms, other typical midlife stressors—like family and work problems—can cause or exacerbate health issues, as well.

If quality sleep escapes you or your perimenopause symptoms worsen or become unmanageable—such as having difficulty with your day-to-day activities— discuss solutions with an HCP. Make sure the HCP knows about all of your symptoms so you can receive appropriate treatment. Together, you can talk about ways to become more comfortable, including whether hormone replacement therapy is the right option for you.