Welcome to Part II in our blog series on perimenopause! If you have landed here but still have a lot of questions about what perimenopause is, how it works, and an overview of common symptoms, check out Part I of our series. 

This blog post will aim to address in greater detail some of the most bothersome and disruptive symptoms associated with perimenopause, also known as the menopausal transition. As a refresher, female-identified individuals and gender queer/non-binary individuals who were assigned female at birth (AFAB) will experience perimenopause as a stage of their reproductive life cycle. Starting as early as age 36, but typically occurring around age 45, these symptoms can last anywhere from 6.5 to 10 years prior to reaching menopause. 

In my clinical practice, I work daily with clients seeking answers and symptom relief from the disruptions they experience during perimenopause. Here are the most common symptoms clients want support in navigating: 

Chronic Fatigue

The most common complaint I hear from my clients, starting in their early 40s, is that they are always exhausted. Though most of them live busy and full lives, they report that fatigue can start to interfere with their ability to enjoy life outside of work and meet responsibilities for caretaking and home management. They start to cut back on hobbies, time with friends, and even when they get time to themselves, they tell me they feel “bogged down” and too tired to experience enjoyment or relaxation. 

As they continue to navigate the disruptions of this chronic fatigue, low energy, and low motivation, I also notice that it intensifies their self-critical thinking patterns. Their inner chatter starts to sound more and more like: “What is wrong with me that I can’t be as productive as I used to be? Why don’t I have the energy to do fun things anymore?” 

Given the role that estrogen plays in managing stress hormones such as cortisol, it makes sense that my clients start to notice a dip in their energy levels. Once estrogen levels fall and cortisol levels rise, sleep can become dysregulated, and insomnia becomes more common. With reduced quality of sleep and less hours sleeping due to sleep latency and sleep disruptions (hello 3 am!), tiredness becomes the new norm. This type of fatigue can be unrelenting, and lead to significant decrease in quality of life, as individuals report feeling additional barriers to engaging with what feels most meaningful to them, beyond the “have to’s” of adulting: work, parenting, house care. 

In fact, perimenopause and postmenopause are associated with elevated risk of developing insomnia. You can read more about insomnia and effective treatment in our Insomnia: A Chronic Problem with Quick Treatment blog post or read about our Insomnia Specialty Clinic. 

Worsening Pain, Headaches, and Migraines

Another common symptom of perimenopause I explore with my clients is their experiences of worsening pain. For some, this means chronic pain issues that were well medicated and managed start to become “unmanageable,” with frequent flare-ups that no longer respond to previous interventions and treatments they’ve relied on. This also can mean that “new aches and pains” start to show up, with backaches, headaches, and achy joints and muscles common complaints. This is in part due to the fluctuations of the hormone progesterone, which works in our bodies to support our pain-tolerance and also reduce our emotional reactivity to physical pain. For example, research on individuals with fibromyalgia found that participants who had the combination of low progesterone and high cortisol (a stress hormone), reported pain levels at greater intensity.

For individuals with a history of migraines, drops in estrogen can trigger migraine episodes, with perimenopause increasing the risk for high-frequency headaches (10+ migraines a month) in middle-aged women (Sims, 2022).   

Common symptoms also include genitourinary pain, also known as Genitourinary Syndrome of Menopause (Tang, 2024). This cluster of symptoms can include vaginal pain, pain with urination, and weakening of the pelvic floor. Pain during vaginal intercourse can also worsen during perimenopause, which can have serious implications, such as reduced pleasure during sex and physical intimacy issues with partners.

While chronic pain is often thought about as a medical problem, research shows it has mental health impacts and that therapy can help reduce chronic pain and help manage its effects. You can read more about chronic pain in our Living Well with Chronic Pain blog post and can also read about our Chronic Pain Specialty Clinic.

Frequent “Brain fog” and Forgetfulness

Fluctuating hormone levels during perimenopause can cause a host of cognitive symptoms, including the dreaded “brain fog,” with memory loss and experiences of forgetfulness. As normal levels of estrogen and progesterone become disrupted during the menopausal transition, neurotransmitters (key “brain messengers” such as serotonin) are imbalanced in this state of hormonal “upheaval” (Sims, 2022). 

Take for example the protective effects of progesterone for your brain health. This hormone supports cognition by producing a “calming, anti-anxiety effect in the brain” and is connected to improved memory and recall (Sims, 2022). As progesterone levels begin to fluctuate and then bottom-out closer to menopause, our ability to stay “sharp and clear-headed” can be radically reduced. So the next time you drive off to work and leave your coffee mug on the roof of your car, just know you can blame your lower levels of progesterone!

Disruptive Mood & Anxiety Issues

By far the most frequent symptom cluster in the population I work with is the debilitating impact of worsening mood and anxiety symptoms. I hear that their depressive symptoms, even those that had been well-managed with medication and therapy, come roaring back with a vengeance during perimenopause. This is because for individuals with a prior history of depression, risk for severe depressive episodes is higher in perimenopause (Tang, 2024; Behrman & Crockett, 2024).

Clients tell me about their “nameless anxiety” that is with them from the moment they wake up until they finally “crash out” at bedtime. I hear stories of anger, irritability, and at times full-on rage meltdowns that my clients fear means they are “losing it.” Clients tell me they will experience wild mood swings that can leave them in tears in the Costco parking lot. To be fair, as a highly sensitive person I think there is a lot in that environment that can push someone to their limits, BUT I get what they mean when they tell me they become completely overwhelmed by these intense emotional states. Once again, your hormones have a role to play in this!

Estrogen helps to regulate and increase serotonin in your brain, a neurotransmitter that plays a pivotal role in mood and emotional regulation. With lower than usual estrogen in perimenopause, your brain is left with lower than usual serotonin, “which can lead to erratic moods, irritability, restlessness, and anger” (Sims, 2022). 

To make matters worse, as progesterone levels also decrease, you end up spending more time in “fight or flight” (sympathetic arousal). A common experience of getting stuck in sympathetic activation is increased anxiety. This is why when you are passively scrolling social media, your body misinterprets the situation as “dangerous” and works to activate you to a stress reaction in attempts to keep you safe. Your screen shows you cute puppy reels; your body interprets that as a bear chasing you in the woods. The disconnect there is enough to send you into seriously doubting your grip on reality and asking yourself: “What is happening here?” 

Weight Gain & Body Composition Changes

The symptoms clients most discuss in relation to worsening self-esteem are related to weight gain and body composition changes. If you have experienced this during perimenopause, I don’t need to tell you how infuriating this can be. This is the moment when all of the “strategies” that may have been working for you to maintain your weight suddenly stop working. There is no way to use the old formula of “diet and exercise” to fit back into your clothes from last summer. 

These changes are happening in response to lower estrogen and higher cortisol levels. As your weight goes up (for most, an average of 5-8 lbs) during perimenopause, there are also the changes to muscle tone, muscle loss, and increased fat tissue, especially in your abdomen. It’s this particular type of fat storage that increases risk for perimenopausal individuals of heart disease, as visceral fat increases inflammation and affects your metabolism (Tang, 2024; Sims, 2022).

Remember from Part I of this series that we reviewed the 3 types of Estrogen: E1, E2, E3. What can be helpful to keep in mind with weight gain and body composition changes is that not all fat tissue is the same. Past research has found that body fat tissue in the hips and thighs can produce E1 that converts to the more protective E2, which supports heart health in perimenopausal women. That protective fat can help to even offset the risk associated with abdominal fat (Sims, 2022). 

Take a minute to consider what this means for your own relationship with your body following weight gain. It may seem counter to what you hear from medical providers that warn against weight gain and often push for thinness, without proper discernment between fat that can be protective during perimenopause. This is why it is important to do your own research and be prepared to confront biases present in modern medicine, especially with dangerous assumptions about health and thinness. 

This All Sounds Familiar…Now What?

If you have found this blog post in hopes of better understanding your perimenopause symptoms, and now would like to know more about treatment options and ways to manage symptoms, I suggest you read Part III of our perimenopause series. 

At Aviva Psychology Services, we have many providers that work with clients of all ages, genders, and backgrounds to build a healthier sense of self, including tools for managing issues relating to perimenopause. If you would like to learn more about how the psychologists at Aviva could help, we encourage you to reach out to our practice. You can get connected with a psychologist by filling out the Request an Appointment form. 

Sources & Recommended Reading:

1. Karen Tang, MD, MPH (2024) It’s Not Hysteria: Everything You Need to Know About Your Reproductive Health (But Were Never Told) 
   
   
2. Stacy Sims, PhD & Selene Yeager (2022) Next Level: Your Guide to Kicking Ass, Feeling Great, & Crushing Goals Through Menopause and Beyond
   
   
3. Article: Severe Mental Illness and the Perimenopause (2024) S. Behrman & C. Crockett https://www.cambridge.org/core/journals/bjpsych-bulletin/article/severe-mental-illness-and-the-perimenopause/8D072AACBCD3C7888C173B36635C08C3
   
   
4. Maya Dusenberry (2018) Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick