Most women know the headline symptoms of perimenopause: hot flashes, night sweats, and periods that start to come and go on their own schedule. What almost no one is told is that those are only a fraction of the story.
Estrogen receptors are found in nearly every tissue in your body, including your joints, skin, heart, blood vessels, brain, bladder, gums, and eyes. Progesterone and testosterone have wide reach too. When these hormones begin to fluctuate, which can start in your late thirties or forties and last anywhere from four to ten years, symptoms can appear in places that seem to have nothing to do with your reproductive system. That is exactly why so many women end up seeing three different specialists before anyone says the word "perimenopause."
Here are the symptoms I most often see women surprised by, and what to do about them.
Estrogen receptors are found in nearly every tissue in your body, including your joints, skin, heart, blood vessels, brain, bladder, gums, and eyes.
Aching Joints and the Frozen Shoulder
Stiff fingers in the morning, aching knees, a sore hip at night, or a shoulder that slowly loses its range of motion until you can barely reach behind your back. Estrogen helps regulate inflammation and supports cartilage, tendons, and muscle. Researchers now use the term "musculoskeletal syndrome of menopause" to describe this cluster, and roughly 70% of women experience musculoskeletal pain during the transition.
Frozen shoulder, or adhesive capsulitis, is most common in women between 40 and 60, and many clinicians and researchers suspect the hormonal shifts of this stage play a role. It deserves prompt evaluation and physical therapy, because early treatment can shorten a condition that otherwise can last a year or more.
A Racing or Fluttering Heart
Many women in perimenopause notice palpitations: a pounding, fluttering, or skipped-beat sensation, sometimes during a hot flash, sometimes at rest, sometimes in the middle of the night. Hormonal fluctuations affect the nervous system signals that regulate heart rate, and these palpitations are often harmless.
But this is one symptom I never want you to assume is "just hormones." Midlife is also when cardiovascular risk begins to climb for women. Palpitations deserve an evaluation, which may include an ECG and blood work to check for anemia and thyroid problems. Chest pain, shortness of breath, or fainting needs emergency care.
Itchy, Crawly, or Suddenly Different Skin
Estrogen supports collagen, skin thickness, and moisture. Research has found that women lose about 30% of their skin collagen in the first five years after menopause, and the decline begins during perimenopause. The result can be new dryness, sensitivity, easy bruising, slower healing, adult acne, and itching. Some women even feel a crawling or tingling sensation on the skin, called formication, which can be unsettling if no one explains it.
Gentle cleansers, rich moisturizers, sun protection, and adequate protein all help. If itching is intense or comes with a rash, see a dermatologist to rule out other causes.
Burning Mouth, Gum Changes, and a Strange Taste
Burning mouth syndrome, a scalding or tingling feeling of the tongue, lips, or roof of the mouth without a visible cause, is far more common in women around and after menopause. Some women also notice a metallic or bitter taste, a dry mouth, or gums that bleed or recede more easily. Your mouth tissues are hormone sensitive too.
Tell your dentist where you are in the menopause transition, and keep up with regular cleanings. Burning mouth deserves an evaluation for other contributors as well, such as nutritional deficiencies, dry mouth, and medication side effects.
Periods That Get Heavier, Not Lighter
Most women expect their periods to taper off quietly. In reality, perimenopause often brings heavier, longer, or more frequent bleeding, sometimes with clots or "flooding" that soaks through protection. This happens because cycles without ovulation can leave estrogen unopposed by progesterone, allowing the uterine lining to build up.
Heavy bleeding is common, but it is not something to simply endure. It can lead to iron deficiency, which drives fatigue, brain fog, shortness of breath, and hair shedding. It also needs evaluation to rule out fibroids, polyps, or changes in the uterine lining. Bleeding between periods, bleeding after sex, or any bleeding after you have gone 12 months without a period should always be checked.
Rage, Anxiety, and the Feeling of Not Being Yourself
Irritability that seems out of proportion, sudden bursts of anger, new anxiety, or a low mood that settles in without explanation are some of the most distressing symptoms women describe to me. Estrogen and progesterone influence serotonin, GABA, and other brain chemicals that regulate mood. Women with a history of premenstrual mood symptoms or postpartum depression may be especially sensitive to these shifts.
Your feelings are real, and they are treatable. Mood symptoms deserve the same serious attention as hot flashes. If you ever have thoughts of harming yourself, reach out for help immediately by calling or texting 988, the Suicide and Crisis Lifeline.
Brain Fog and Lost Words
Walking into a room and forgetting why. Losing a common word mid-sentence. Struggling to concentrate in meetings. Research suggests these changes are common during the transition and tend to improve after it, but they can be frightening, especially for women with a family history of dementia. Poor sleep makes them worse, so protecting your sleep is one of the most effective things you can do for your brain.
Bladder Changes and Recurrent UTIs
The tissues of the vagina, urethra, and bladder depend on estrogen. Changes can start in perimenopause, not just after your final period. Urgency, frequent urination, leaking, recurrent urinary tract infections, vaginal dryness, and painful sex are part of what is called genitourinary syndrome of menopause. Unlike hot flashes, it tends to progress over time without treatment. Low-dose vaginal estrogen is safe and effective for most women and can make a profound difference.
Dry Eyes and Changing Vision
Gritty, burning, or tired eyes, contact lenses that no longer feel comfortable, and vision that blurs and clears with blinking are often linked to hormonal changes in the tear film. If this sounds familiar, our recent article on eye changes in perimenopause walks through what helps.
Sleep That Stops Working
Waking at 3 a.m. and staring at the ceiling, even without night sweats, is one of the most common perimenopause complaints. Progesterone has a calming effect on the brain, and as it declines, many women find it harder to stay asleep. Poor sleep then amplifies nearly every other symptom on this list.
Migraines That Change Character
Women who have had hormonally triggered migraines often find them more frequent or more severe during perimenopause. Others develop headaches for the first time. Any new or changing headache pattern, especially headaches with aura or neurological symptoms, deserves evaluation.
When It Isn't "Just Hormones"
Because perimenopause can touch every system, it can also be blamed for symptoms that have another cause. A thorough clinician will consider thyroid disease, anemia, heart rhythm problems, sleep apnea, depression, autoimmune conditions, and medication side effects. A good evaluation looks for perimenopause and for anything that can mimic it.
What Helps
Track your symptoms. Note what you feel, when it happens, and where you are in your cycle. Patterns help your clinician connect the dots quickly.
Find a menopause-informed provider. You deserve someone who recognizes the full range of symptoms and offers the full range of options.
Know your treatment options. Hormone therapy is the most effective treatment for hot flashes and night sweats and can help with sleep, joint aches, and mood for many women. Low-dose vaginal estrogen treats bladder and vaginal symptoms. There are also effective non-hormonal medications for hot flashes and mood. The right plan depends on your symptoms, your history, and your preferences.
Support your body's foundations. Strength training protects muscle, bones, and joints. Adequate protein supports muscle, skin, and hair. Limiting alcohol often improves sleep, hot flashes, and mood. Stress management is not a luxury in this phase of life; it is part of the treatment.
You Deserve to Be Believed
If you have been dismissed, told you are too young for perimenopause, or handed a separate prescription for every symptom, I want you to hear this clearly: what you are experiencing is real, it has a biological explanation, and it can be treated. Bring this list to your next appointment. Advocate for yourself, and if your provider will not take you seriously, find one who will.
Defy Menopause - Own the Change
Many women tell me: "One day I feel amazing. The next, I can barely get out of bed. Is this normal?"
Yes, it is. And no, you don’t have to suffer through it alone.
Hormonal fluctuations during perimenopause can make you feel like you’ve lost control of your body. But knowledge is powerful. And there are clear, science-backed ways to support your hormones, ease symptoms, and reclaim your energy.
That’s exactly why I created Defy Menopause: Own the Change — a 30-day program designed to give you the tools, knowledge, and support you need to move through these changes with clarity and confidence.
Inside, you’ll find:
Access to Dr. Tracy Verrico at one (1) live, group session
Clear action steps for managing symptoms naturally
Because you deserve more than just "putting up with it."
You deserve to thrive.
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Medical Disclaimer: The information provided in this blog is for general educational and informational purposes only and is not intended as, nor should it be considered, medical advice. This content does not establish a physician-patient relationship and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have read in this newsletter. If you think you may have a medical emergency, call your doctor or emergency services immediately.
References
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Wright VJ, Schwartz L, Wernig F, et al. The musculoskeletal syndrome of menopause. Climacteric. 2024;27(5):466-472.
Brincat M, Moniz CF, Studd JW, et al. Sex hormones and skin collagen content in postmenopausal women. Br Med J (Clin Res Ed). 1983;287(6402):1337-1338.
Teruel A, Patel S. Burning mouth syndrome. BMJ. 2019;365:l1213.
Paramsothy P, Harlow SD, Greendale GA, et al. Bleeding patterns during the menopausal transition in the multi-ethnic Study of Women's Health Across the Nation (SWAN): a prospective cohort study. BJOG. 2014;121(12):1564-1573.
The 2020 Genitourinary Syndrome of Menopause Position Statement of The North American Menopause Society. Menopause. 2020;27(9):976-992.
The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022;29(7):767-794.
The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society. Menopause. 2023;30(6):573-590.
Maki PM, Jaff NG. Brain fog in menopause: a health-care professional's guide for decision-making and counseling on cognition. Climacteric. 2022;25(6):570-578.
