Here’s what to know — and how to find treatment options to help.

Menopause is often referred to as the great ‘change of life,’ but it’s not something that happens overnight, where boom, you no longer have a period. The process of transitioning to menopause, called perimenopause, starts gradually with symptoms appearing years before you have your last menstrual cycle. For some people, the hormone-related symptoms, like irregular periods, mood changes, and hot flashes, may be a dead giveaway, but others may already be in perimenopause and not even realize it.

That’s because perimenopause looks different in every woman. One person might experience prominent hot flashes, while another might not have connected the dots between her sudden bouts of insomnia and perimenopause. Even famous people with access to the best medical care can miss the signs of perimenopause, says Dr. Bruce Dorr, an OB-GYN and senior medical advisor to Biote. For example, Oprah went three years thinking she had a heart condition with no improvements in her symptoms until she went on hormone replacement therapy. Turns out, the culprit was low estrogen.

You may be reading this article right now to get a sense of what’s going on in your body. Or maybe you’re at the age when people start seeing signs of perimenopause and want to get ahead of things. Regardless, it can feel daunting if you’re unsure of what’s to come. Understanding perimenopause symptoms will make you better prepared for this natural biological process.

What happens during perimenopause?

During perimenopause, the ovaries slow down production of estrogen, and don’t release as many eggs, as you slowly lose the ability to get pregnant. These hormonal changes can cause a number of physical and mental health symptoms as your body tries to adjust to this new normal.

Perimenopause symptoms typically happen between the ages of 45 and 55 — though some women may experience it as early as in their mid-30s. The average duration is about 7 years. However, depending on other factors such as smoking and racial background, some women have reported it lasting for up to 14 years. Perimenopause officially ends when when you’ve gone 12 months without a period, which officially signals menopause.

Many of the changes you experience during perimenopause are a result of decreasing estrogen, which along with progesterone rises and falls as you make your way to menopause.

What are the symptoms?

Everyone’s symptoms can be different, but one of the most tell-tale signs you’re entering perimenopause is irregular menstrual cycles. Since your estrogen levels are rising and falling at uneven levels, this results in shorter and longer periods. And while you may also see months where your menstrual cycle is skipped completely, there is still a possibility of getting pregnant during perimenopause. “During perimenopause, women may still have bleeding; however, they may start to have symptoms that are signaling a decrease in estrogen, such as hot flashes, night sweats, and changes in weight, among other symptoms,” says Dr. Jessica Shepherd, an OB-GYN and Flow council member. Here are some other symptoms you can expect.

Hot flashes and night sweats. Most perimenopause symptoms will look similar to the ones women experience during menopause. Dr. Dorr says women often report hot flashes that feel like a sudden warmth coming from the shoulders up. Chills and night sweats that are heavy enough to soak your pajamas and blankets often accompany hot flashes.

Unexplained weight gain. Perimenopause is a time when women start to move from a pear-shaped to an apple-shaped figure. Most women undergoing perimenopause gain about five to ten pounds. This is because estrogen helps regulate metabolic health, so when it slows down, your metabolism does too. The excess calories that are not processed are more likely to be stored as fat in the abdomen area. 

Indirectly, women may experience weight gain during this time because they have little energy to exercise. The fall of estrogen causes a hormone imbalance that ends up affecting the adrenal and thyroid-producing hormones, which regulate energy.

Sexual changes. Fluctuations in sexual behavior are another sign of perimenopause. Estrogen is needed to keep your vagina lubricated. With falling levels, there’s less blood flow to the vagina resulting in vaginal dryness and potentially painful sex. Apart from the pain, perimenopause can zap your sex drive. Reduced estrogen levels may lessen the desire to have sex and make it more difficult to get sexually aroused. The unintended weight gain and trouble sleeping may also dull any desire to have sexual intercourse if people feel especially tired or self-conscious about their body image, says Dr. Dorr.

Brain fog. You may have trouble thinking clearly, concentrating, and memory problems. This is normal, promise. The fuzzy-headed sensation is the result of hormonal changes and the effects of sleep deprivation, another indicator of perimenopause.

Reducing perimenopause symptoms

There’s a lot you can do from a diet and lifestyle perspective to reduce your perimenopause symptoms. These are some places to start:

Get 7 to 8 hours of sleep. Regular sleep can help with the brain fog women experience during perimenopause. Though with night sweats, insomnia, and stress, this is easier said than done. Treating menopause symptoms through hormone therapy or other treatments can help you get a good night’s sleep. Sticking to a regular sleep schedule and not using electronics 30 minutes before bed can improve your chances of sleep.

Reduce your coffee and soda intake. There is research that linked caffeine with worsening vasomotor symptoms. This includes more severe hot flashes and night sweats. Caffeine also stimulates the body and makes it harder to fall asleep, adds Dr. Dorr.

Diet. Eating a fiber-rich diet can boost a healthy metabolism and potentially avoid the weight gain that often occurs during perimenopause. Since bones get weaker during perimenopause, women should consider adding more calcium-rich foods such as dairy products, almonds, and leafy vegetables.

Exercise. Staying in shape is a must when going through perimenopause. Aerobic activities such as a brisk walk around the park, biking, or dancing can boost your cognition and burn body fat. Mixing your routine up with strength training two or three times a week will further help rev up your metabolism along with strengthening bones and muscles to avoid serious injuries from falls. Exercise can also make you tired enough to fall asleep at night.

When to see a doctor

Women should be proactive and start discussions with their healthcare providers in their 40s, even before symptoms begin, Dr. Shepherd says. Doing so could make the perimenopause journey more manageable. “Noticing when the symptoms of perimenopause are beginning should be an important part of the conversation so that it provides solutions as well as comfort during this transition,” she says.

If you’re unsure whether or not your symptoms are related to perimenopause, it doesn’t hurt to get a second opinion from a medical professional. Just make sure it’s someone trained in menopausal care.

About “80 percent of residency programs that are training OB-GYNs don’t have any education in menopause, and for the majority of the 20 percent of programs remaining, that education is only elective,” says Dr. Dorr. He recommends asking your doctor what they know about hormone replacement therapy and finding a new one if that’s something they don’t prescribe. A menopause specialist would do a physical check-up including taking a medical history of your last few menstrual cycles and when your symptoms first began. They may also perform a blood test to measure your hormone levels.

Seeing a doctor for perimenopause is also helpful if you’re not finding relief on your own or the symptoms become so severe they affect your quality of life. Your healthcare provider may recommend systemic estrogen therapy. This hormone treatment — which includes low-dose birth control pills, skin patches, gel, or cream — can help manage the discomfort that comes with night sweats and hot flashes. The vaginal ring and cream have also helped with finding relief against vaginal dryness.

“If your quality of life is suffering, there are different options out there,” adds Dr. Dorr. “If you’re not exercising anymore, if you’re not having sex anymore, or if you’re not sleeping right, those are all signs that you should be seeking professional help now.”