There are 67 signs you might be entering perimenopause. What should you do about it?

What is perimenopause and why is it important?

Perimenopause refers to the years leading up to menopause, when hormone levels begin to shift and the menstrual cycle becomes irregular. It typically starts anywhere between your late 30s and early 50s, though most experience it in their mid-to-late 40s.

Unlike menopause – defined as 12 months without a period – perimenopause is more like a hormonal prequel. It can last 4 to 8 years, though for some, it lingers even longer. According to the NHS, symptoms may begin gradually and intensify over time.

People usually associate the menopause transition with a decline in oestrogen, but it’s actually progesterone that tends to reduce first, while oestrogen for people in their forties can experience peaks of over 3x that of people in their thirties.

Whilst some people have a seamless transition to menopause, the hormone fluctuations can impact nearly every system in the body.

Is it perimenopause — or something else?

Here’s the kicker: having some of the 67 symptoms doesn’t automatically mean you’re perimenopausal. Many signs – like fatigue, bloating, or low mood – are nonspecific and can be triggered by stress, poor sleep or even diet.

But if you’re noticing clusters of symptoms, especially alongside changes in your menstrual cycle, it could be time to consider the perimenopause lens, particularly if you’re over 40.

Women’s Health specialist Katy Bradbury says, “Many women arrive at my clinic having been told they’re in perimenopause by the doctor based on a standalone FSH or AMH blood test, but the literature suggests that diagnosis should be based on assessment of symptoms.” Frustratingly, though perhaps not surprisingly, the evidence, and our understanding of the physiology of perimenopause only really began to gain traction in the 1990s and some guidelines may benefit from being more inclusive.

The NICE guidelines do state that symptoms alone are enough to begin treatment, especially for those over 45, without needing hormone testing. However, it also states irregular menstrual cycles and vasomotor symptoms (aka hot flushes) as the main identifying symptoms, despite the literature suggesting that these symptoms are often associated with later stages of perimenopause.

The top tell-tale signs to watch for

Endocrinologist and menopause researcher Dr Jerilynn Prior, says that perimenopause can be diagnosed if you develop three of the following nine symptoms, when you haven’t previously experienced them, and differential diagnoses have been ruled out:

1. Changes to your period, such as becoming heavier at the onset, or longer flow
2. Shorter menstrual cycles (less than 26 days)
3. Sore, swollen or lumpy breasts
4. Mid-sleep waking
5. Increased menstrual cramps
6. Onset of night sweats
7. New or increased migraine headaches
8. New or increased PMS mood swings
9. Weight gain without changes in diet

Other signs include dry eyes, vaginal dryness, breast tenderness, joint pain and a sudden drop in libido. Even symptoms you wouldn’t associate with hormones – like electric shock sensations, dizziness or gum problems – can crop up for some.

NHS worker Gemma (43) said “I was expecting hot flashes because that’s what everyone talks about, but nothing prepared me for the premenstrual rage, the loss of confidence and the insatiably itchy ears in the middle of the night”.

Why so many symptoms?

Hormones don’t just regulate reproduction – they have receptors all over the body. As oestrogen begins to fluctuate, it impacts the brain, gut, bones, skin, bladder and more. Meanwhile, progesterone drops (affecting sleep and mood) and testosterone declines (impacting energy, libido and muscle tone).

What’s tricky is that oestrogen doesn’t just gradually decline in perimenopause – it spikes and crashes, sometimes dramatically, and from day to day. It’s this instability that causes the rollercoaster effect of symptoms, and some researchers liken perimenopause to adolescence in reverse, or a second puberty.

What can you actually do about it?

Not everyone needs treatment. If your symptoms are mild and manageable, you may prefer to simply observe. But if they’re affecting your quality of life, there are plenty of options – from lifestyle to medical to complementary.

1. Get your foundations right

Nutrition, movement, rest and stress reduction are your first line of defence.

• Eat a whole-food, blood-sugar-balanced diet
• Prioritise protein and healthy fats to support hormone production
• Get regular movement – especially resistance training to protect bone and muscle
• Prioritise restorative sleep and stress regulation

“This is about replenishing our body battery which has been wearing down over the years with societal expectations, conditioning and being a people-pleasing high achiever, so you can’t bio-hack your way out of a body that’s running on empty,” says Bradbury. “Perimenopause is your body asking you to slow down, refuel, nourish yourself and tune in.”

2. Hormone Replacement Therapy (HRT)

For those who are really struggling, HRT is the most well documented medical treatment for hot flushes, night sweats, vaginal dryness, and mood swings. The British Menopause Society suggests it is safe for most people under 60 or within 10 years of menopause.

Modern HRT usually includes:

• Oestrogen (patches, gel, spray)
• Progesterone (capsules or IUS/coil)
• Testosterone (sometimes used off-label for low libido and energy)

Work with a GP or menopause specialist to tailor your options.

CBT (cognitive behavioural therapy) has also shown benefits for sleep and mood, according to NHS guidance.

3. Complementary approaches

While less researched, many find relief in:

• Herbal remedies like black cohosh, red clover or ashwagandha
• Acupuncture
• Yoga and breathwork
• Mindfulness or somatic therapy

Remember that the menopause wellness industry is big business, and what works for one may not work for another because it depends on your individual underlying imbalances/drivers. This is where personalised integrative healthcare can be extremely helpful.

Is perimenopause a ‘condition’ that needs treating?

Here’s the take home: perimenopause is natural, not pathological. But that doesn’t mean it’s a walk in the park.

On one hand, the drive to normalise menopause helps reduce stigma and empowers people to seek support. On the other, there’s a risk of over-medicalising something that’s not a disease.

The key is choice. You don’t have to suffer. You don’t have to “power through.” And you don’t have to take HRT if it doesn’t feel right. But you deserve access to information, support and dignity through the transition.

So if you’re reading this and wondering if the changes you’re feeling are hormonal, the answer might be yes. And now you know: you’re not alone and you’re not broken. You’re in a transition that deserves care, not dismissal.

Further reading:

Best supplements for perimenopause – to support transition through the menopausal years
What is perimenopause?
What is menopause?
Menopause diet: what to eat

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