The 7 perimenopause signs doctors say women most often miss – and when to see your GP

Does it surprise you that one in three women aged 35 and over aren't sure whether they're perimenopausal? As someone turning 35 later this year, I can't say I'm shocked. Why? Because disrupted sleep, low mood and brain fog aren't just common perimenopausal symptoms: they're also fairly common side effects of parenting young children, stress and, well, trying to juggle work with exercise and some semblance of a social life.

It’s a dilemma Dr Nikki Ramskill, Women’s Health GP and founder of The Female Health Doctor Clinic, regularly encounters.

‘Many women arrive in clinic saying, “I don’t know whether this is perimenopause, stress, ageing, my thyroid or whether I’m simply not coping,”’ she says. ‘Often, they have been experiencing symptoms for months or even years before they make the connection.’

That one in three statistic comes from a new study published in the journal Menopause. Researchers surveyed 7,640 US women aged 35 and older and found that 34% weren't sure which reproductive stage they were in. Uncertainty rose to 42% among women aged 40 to 44 and was more common, not less, among those experiencing severe symptoms.

The biggest source of confusion was working out what their symptoms actually meant. More than half attributed the uncertainty they felt to symptoms that could have several possible causes, while others said they didn’t know enough about perimenopause or had struggled to get clear answers from healthcare professionals. Gaps in knowledge were particularly common among women aged 35 to 39, while difficulties accessing care peaked in women between 40 and 44.

Dr Louise Newson, GP and menopause specialist, says the findings don’t surprise her.

'While awareness of menopause has increased over recent years, many women and healthcare professionals remain confused about perimenopause,’ she says. ‘Healthcare professionals don’t always recognise symptoms as hormonal, and women can undergo unnecessary tests and examinations, plus be prescribed numerous medications, such as antidepressants, because symptoms have been looked at in isolation.

‘At my clinic we routinely see women who have been misdiagnosed or not believed or understood. Symptoms of perimenopause are numerous but they have the same cause – changing hormone levels.’

In simple terms – lots of us know when something feels 'off', but we're just not sure whether it's our hormones or our hectic lives playing havoc.

So, how can you tell the difference – and what does a GP actually look for when identifying perimenopause?

Fatigue, poor sleep and brain fog can be symptoms of perimenopause, but they’re also easily attributed to parenting, stress and burnout

‘Perimenopause is not a neat switch that suddenly turns on,’ says Dr Ramskill, who describes perimenopause instead as a ‘transition during which ovarian hormone production becomes increasingly variable. Symptoms may fluctuate, disappear for several months and then return.’

The range of symptoms is also broad. Beyond the more recognisable hot flushes and night sweats, women may experience changes to their sleep, mood, memory, energy, menstrual cycle and sexual health, alongside physical symptoms such as headaches, palpitations and joint pain.

The problem is that none of these symptoms is unique to perimenopause, nor is there a definitive test that can provide an easy answer, because hormone levels fluctuate significantly throughout perimenopause.

‘[These symptoms] may also be associated with thyroid dysfunction, iron deficiency, pregnancy, medication, depression, anxiety, sleep disorders, metabolic illness or simply overwhelming life circumstances,’ says Dr Ramskill.

‘A good clinician therefore has to recognise the hormonal pattern without assuming that every symptom in a woman over 40 must be caused by menopause.’

1. Mood changes and anxiety

For some women, psychological changes appear before more stereotypical symptoms such as hot flushes or irregular periods.

‘Mood issues are also common, but many people don’t realise that hormones can be the cause or how big an impact they can have,’ says Dr Newson.

These changes can range from irritability, anxiety and mood swings to a loss of confidence or motivation, low mood and intrusive thoughts.

2. Fatigue and low energy

Exhaustion can be particularly easy to attribute to work, parenting, poor sleep or a packed schedule.

Dr Newson says 95% of new patients surveyed at Newson Clinic reported fatigue or low energy. While that figure comes from women already seeking specialist menopause care and therefore doesn’t represent women generally, it illustrates how prominent the symptom can be among those asking for help.

Fatigue is also non-specific, so a GP may consider other possible causes, including anaemia, thyroid dysfunction, vitamin deficiencies, medication and sleep problems.

3. Poor or disrupted sleep

Sleep can become more disrupted during perimenopause. This is sometimes because of night sweats, but not always. Women may notice changes in the quality or consistency of their sleep before their periods become obviously irregular.

This can create a difficult cycle: poor sleep may worsen fatigue, irritability, anxiety and problems concentrating, making it even harder to identify what is driving each symptom.

Changes in mood, concentration and confidence may appear before the better-known signs of perimenopause

4. Brain fog and cognitive changes

Brain fog can include memory lapses, difficulty concentrating and struggling to find the right word, explains Dr Newson. These changes can be particularly worrying, but are easy to dismiss as tiredness or having too much on your plate.

5. Changes to periods or premenstrual symptoms

Periods do not necessarily stop suddenly. They may become more or less frequent, heavier or lighter, longer or more painful. A previously predictable cycle might also begin varying by several days each month.

It's worth noting that you can still have regular periods and be perimenopausal. In fact, says Dr Ramskill, ‘This is one of the most important messages.’

Symptoms may begin while periods still appear regular, particularly in the earlier stages of the transition. Some women experience changes in sleep, mood, temperature regulation, migraines or premenstrual symptoms before they notice an obvious alteration in cycle length.

‘Women often believe that regular periods rule perimenopause out, but they do not,’ says Dr Ramskill. ‘Even an apparently regular monthly bleed does not tell us that ovulation and hormone production are behaving exactly as they did five or ten years earlier.’

Cycle changes remain a useful part of the picture, but they shouldn’t be treated as the only clue.

‘The question is not simply, “Are your periods irregular?” but, “Are they behaving differently from what is normal for you?”’ she adds.

When it comes to getting changes in your bleeding checked, Dr Newson recommends seeing a healthcare professional if you continue to bleed for more than six months after starting HRT, if you experience heavy, painful or sudden flooding, or if you experience sudden bleeding after going for more than 12 months without a period.

6. Hot flushes and night sweats

‘For years, perimenopause and menopause have been associated with hot flushes and night sweats, but not all women will experience them,’ says Dr Newson.

A hot flush can involve a sudden feeling of heat (sometimes followed by cold) in the face, neck and chest, sometimes accompanied by dizziness or a noticeable heartbeat. Night sweats can soak nightwear or bedding and further disrupt sleep.

7. Sexual, urinary and wider physical symptoms

Perimenopause can also be associated with reduced sexual desire, vaginal dryness or discomfort, and urinary symptoms such as recurrent UTIs.

‘Some women are surprised to learn that symptoms such as dry eyes, heart palpitations, dry skin, muscle and joint pain and headaches can all be perimenopause symptoms,’ says Dr Newson.

Dr Ramskill starts by asking one deceptively simple question: ‘What has changed for you?’

A woman’s baseline is extremely important, she explains. Someone may still have a cycle every 28 days, but perhaps it was previously completely predictable and has recently started varying between 24 and 32 days. Her periods may have become heavier, lighter, longer or more painful. She may have developed new premenstrual anxiety, disrupted sleep or migraines at a particular point in her cycle.

Rather than looking at one symptom in isolation, a GP will place these changes within the wider context. This includes the woman’s age and family history, her usual menstrual pattern, whether symptoms fluctuate or follow her cycle, and any relevant medical conditions, medication, contraception or reproductive treatment. They should also consider whether another condition could explain some or all of the symptoms.

‘Age guides the degree of suspicion but should never be used to dismiss someone,’ she adds. Perimenopause is increasingly likely through the 40s, but early menopause can occur between 40 and 45, and premature ovarian insufficiency can occur below 40. Symptoms in younger women therefore deserve proper assessment rather than the reassurance that they are ‘too young’.

Tracking changes to both your periods and symptoms over several months can help your GP identify patterns

You don’t need to wait until your periods stop. If symptoms are affecting your quality of life, relationships, work or ability to function normally, that is reason enough to make an appointment.

Beforehand, it can help to keep a record of your periods and symptoms for several weeks or months.

‘Don’t just track your periods, as you can still be in perimenopause with regular cycles,’ says Dr Newson. ‘Track any physical and mental health symptoms you have, as they may be linked to fluctuating hormones.’

Note when each symptom began, whether it follows a pattern and how it affects your daily life. Bring details of any medication or contraception you use, along with the questions you most want answered.

Dr Newson also recommends familiarising yourself with the NICE menopause guidelines.‘If you feel the usual 10-minute appointment isn’t going to be long enough to discuss things adequately, ask whether a double appointment is available,’ she says. ‘And if you feel nervous or just want some moral support, it’s perfectly acceptable to ask a friend to come with you.’

There is no single symptom, checklist or blood test that can definitively tell you whether you’re perimenopausal.

What matters is the overall pattern and, crucially, what has changed from your ‘normal’.

Regular periods or a normal hormone result don’t automatically rule perimenopause out, but neither should every new symptom be assumed to be hormonal. If changes are persistent or affecting your quality of life, track what you’re experiencing and speak to your GP.

Alice Barraclough

Nutrition Editor

With a decade in journalism – in print, online and social – at national newspapers and lifestyle magazines, Alice has tackled just about everything when it comes to health and fitness. A former competitive swimmer, sport has shaped her life from a young age, leading her to take on marathons, an Ironman 70.3, and even cycle up Alpe d’Huez. From sweat-testing the latest (and weirdest) fitness fads to living off a diary-free, meat-free, caffeine-free, fun-free diet at an extreme Ayurvedic retreat in Sri Lanka, she’s tried it all – always in pursuit of peak performance and, of course, a great story.

Alice began her career with a five-year stint at The Telegraph, where she wrote for the Telegraph Magazine's ‘Worth leaving the sofa for?’ fitness column and was the face of the Telegraph running newsletter, documenting her journey over 16 weeks training for the London Marathon. She worked as the Special Reports Commissioning Editor and as a Lifestyle Commissioning Editor before stepping into the world of freelance journalism.

As a freelance lifestyle writer, her work appeared in Women’s Health, Elle, Stylist, Grazia, The Independent, Glamour, Marie Claire, Glorious Sport, The Metro, Conde Nast Traveller, Country and Town House, Queen of Retreats and The Wedding Edition. 

In 2022, Alice joined Hearst Magazines as Runner’s World’s Commissioning Editor and now oversees food content as Women’s Health’s Nutrition Editor. With a ‘food first’ ethos, she is here to help you decipher exactly which foods will support your health, and which macro-counting, pasta-replacing, intermittent-fasting, 13-day cleanse is just, well, a scam. A keen baker and host, she firmly believes that no dessert beats a pavlova – especially when topped with summer berries and a generous helping of whipped cream. Delish.

You can keep up with her latest adventures on Instagram at @al_barraclough.