Menopause symptoms that may surprise you: What to watch for during perimenopause

Irregular periods. Night sweats. Mood changes. Trouble sleeping. Brain fog. If you're a woman in your 40s or early 50s, you may experience some - or all - of these symptoms. And there's usually a single culprit: perimenopause. Perimenopause is the period of a woman's life when she begins to transition into menopause.

Menopause and perimenopause are marked by decreasing levels of the hormone estrogen. This hormonal decline can provoke and contribute to a range of symptoms. Some symptoms, like hot flashes, are well known. Women may be less aware that brain fog, dry skin, and increased irritability, can also be attributed to fluctuating hormones.

Perimenopause isn't dangerous, but it can be bothersome and have a negative impact on your day-to-day life. Here's what to know about some lesser-known menopause symptoms, including how to manage them.

Menopause symptoms: Beyond hot flashes

Hot flashes are the most common symptom of menopause. Up to 85% of women get them. But they aren't the only sign that you're going through this change of life.

"Most of my patients in their 40s come to me complaining of symptoms like sleep problems, mood changes, and just not feeling as sharp as they used to," says Dr. Deborah Gomez Kwolek, an assistant professor of medicine at Harvard Medical School and an associate physician at the Menopause Clinic at Brigham and Women's Hospital. "They're surprised when I explain to them that these all may be signs that they are starting perimenopause."

Menopause symptoms that may surprise you

Here's a look at a range of menopause symptoms, as well as some ways to cope with them.

Heavy or irregular periods

Often, the first clue that you are in perimenopause is a change in your periods. You may find that they become either more frequent or less frequent, thanks to estrogen fluctuations. If your periods are spaced further apart, you can expect heavier bleeding. As you get closer to menopause, you'll start to notice more than 60 days between periods. "When that happens, I tell patients that full-blown menopause is a year or two away," says Dr. Kwolek.

Keep in mind that if you are on birth control pills or have a hormonal IUD, you probably won't notice any changes to your period. These treatments help to regulate your menstrual cycle.

Night sweats

If you wake up with your PJs and sheets drenched with perspiration, chances are you're having night sweats. "These are hot flashes that wake you up when you're asleep," says Dr. Kwolek. They can be mild enough that you just feel flushed, or intense enough to cause sweating. Research suggests night sweats are more common in the first few hours after you doze off.

Hormone replacement therapy (described below) is the treatment of choice for night sweats, says Dr. Kwolek. You can also help relieve night sweats by wearing loose-fitting cotton PJs and choosing lightweight bedding. A fan or air conditioner in your bedroom can help, too. Avoid alcohol and caffeine for several hours before bed, as both can also trigger night sweats. The prescription medications paroxetine (Brisdelle) and fezolinetant (Veozah) are FDA-approved to treat severe hot flashes and night sweats caused by menopause.

Vaginal dryness

Estrogen helps to keep your vagina moist and your vaginal tissue thick and flexible. Lower estrogen production causes vaginal dryness, which can make sex uncomfortable and lead to itching and burning.

The most effective treatment for vaginal dryness is estrogen cream. Since it's topical, very little estrogen gets into your bloodstream, explains Dr. Kwolek. This means it's safe for most women, even those with a history of blood clots or breast cancer.

Mood changes

About 40% of women have mood symptoms during perimenopause that are similar to PMS, according to the American College of Obstetricians and Gynecologists. These include:

• irritability
• low energy
• sadness
• difficulty concentrating.

Unlike PMS, these symptoms don't show up on a predictable schedule. "There may seem to be no pattern to them, because hormonal fluctuations during perimenopause are so unpredictable," explains Dr. Kwolek. Sleep problems such as insomnia can make mood changes worse, she adds.

Lifestyle changes such as regular exercise can help, but some women may also benefit from a low-dose antidepressant such as sertraline (Zoloft).

Brain fog

Can't find your keys? Frequently losing your train of thought? Struggling to come up with a word that's on the tip of your tongue? These are all symptoms of brain fog, which is common during perimenopause. About two-thirds of women report memory complaints like forgetfulness during the menopause transition. The good news, reassures Dr. Kwolek, is that most women report these brain fog symptoms get better once they go through menopause.

In the meantime, you can help minimize brain fog by trying to get enough sleep. Regular exercise also helps. Mindfulness techniques such as deep breathing may also help to relieve stress that can make memory glitches worse.

Trouble concentrating may also be a sign of anxiety or undiagnosed or untreated ADHD. Ask your doctor about these possibilities.

Urinary urgency

If you notice that you need to go to the bathroom more, or even that you're getting more frequent urinary tract infections (UTIs), it's likely not a coincidence. "Low estrogen levels thin your bladder lining, which can lead to urinary frequency and urgency," explains Dr. Kwolek. If it bothers you, talk to your doctor about vaginal estrogen, which can relieve symptoms. The most recent guidelines from the American Urological Association recommend doctors suggest vaginal estrogen therapy to their peri- and postmenopausal patients with recurrent UTIs.

Sleep disturbances

Up to 70% of women report sleep problems as they go through menopause, according to a study published in Menopause. The most frequent complaint is night waking. "Hot flashes can wake you up in the middle of the night, but your sleep can also be disrupted because of low estrogen levels," says Dr. Kwolek. This can make it harder to fall asleep and lead to poorer quality sleep, so you don't feel rested when you wake up. Practicing good sleep hygiene can help. But research suggests some women may also benefit from taking 100 to 200 milligrams (mg) of progesterone at night to improve sleep quality.

Weight gain

Between 60 and 70% of women gain weight during menopause. On average, women gain about 1.5 pounds each year between the ages of 50 and 60. "Some of this weight gain is due to the natural loss of muscle mass that occurs with age," explains Dr. Kwolek. (Muscle tissue burns more calories at rest than fat tissue.) Low estrogen levels also make it more likely that you'll gain weight around your abdomen, as opposed to your thighs and hips.

There's some evidence to suggest that a Mediterranean-style diet - rich in fruits, vegetables, whole grains, beans, and healthy fat such as olive oil - may help to prevent weight gain during menopause. But don't be too hard on yourself if you do gain a few pounds. "If you're eating clean, and you exercise regularly, you're doing your best to lead a healthy lifestyle," says Dr. Kwolek. "Buy yourself some new clothes and embrace your changing body."

Dry skin

"Low estrogen makes you drier all over, including your skin," says Dr. Kwolek. It also makes your skin less able to hold water. As a result, your skin may feel dry and itchy, especially when the air around you is dry, too.

You may have to make some tweaks to your skin care routine. Switch to a mild cleanser instead of soap. Apply moisturizer as soon as you get out of the bath or shower, and throughout the day as needed. Look for moisturizer that contains hydrating ingredients such as hyaluronic acid or glycerin. You should also apply sunscreen whenever you're outdoors. Since your skin is thinner, it's more vulnerable to sun damage.

When to see a doctor

Menopause symptoms are annoying, but unless you go through early menopause, they are rarely dangerous and rarely signal an underlying health problem, says Dr. Kwolek. If they impact your quality of life, though, it's worth talking to your doctor. "We always like to do a thorough examination and bloodwork to check things like thyroid hormone levels, to make sure there's not another underlying health condition going on," she explains.

Menopause and perimenopause themselves do not need to be treated. But to help relieve symptoms, your doctor may recommend one or more of the following:

• hormone replacement therapy (HRT): this is a combination of estrogen and progestin that you can take as a pill, patch, or vaginal ring. It can help with most symptoms of menopause, including hot flashes, night sweats, vaginal dryness, and mood swings. HRT isn't recommended for women with a history of breast cancer, heart disease, or stroke.
• topical vaginal estrogen for vaginal dryness
• low-dose antidepressants to improve sleep and mood
• medications to treat hot flashes.

Remember, also, that you technically haven't gone through menopause until you've gone a full 12 months without a period. "You can still get pregnant during perimenopause," says Dr. Kwolek. If you're sexually active, talk to your doctor about birth control so you don't accidentally get pregnant.