Perimenopause symptoms include changes in the menstrual cycle, temperature, sleep, mood and genitourinary symptoms [1]. Periods may become longer or shorter, and bleeding may become heavier or lighter [1]. Perimenopause usually starts in the mid-40s, but may begin as early as the mid-30s or as late as the mid-50s [1]. It runs about four years on average, with an upper end of eight years [1]. Heavy bleeding has causes beyond perimenopause, so it needs its own assessment [2].

What changes in the menstrual cycle?

Irregular periods and heavier or lighter periods are on Cleveland Clinic’s list of perimenopause symptoms [1]. During perimenopause, the menstrual cycle can become longer or shorter than usual, and bleeding can be heavier or lighter than normal [1].

Typical menstrual blood loss is about 2 to 3 tablespoons, while heavy bleeding is more than 5 tablespoons [2]. Other signs include periods lasting longer than seven days, soaking through a pad or tampon every hour for several hours, needing to wear more than one pad at a time, changing pads in the middle of the night, and passing blood clots the size of a quarter or larger several times a day [2].

Heavy menstrual bleeding can be linked to hormone imbalance, polyps, fibroids, adenomyosis, infections, pregnancy complications, bleeding disorders such as von Willebrand disease, liver or kidney disease, cancers and some medications, including blood thinners [2].

Cleveland Clinic’s perimenopause guidance says to contact a provider about bleeding that is very heavy, soaks a pad every 1 to 2 hours, lasts longer than usual, happens between periods, follows sex, or occurs when periods come less than 21 days apart [1].

What can temperature symptoms look like?

Hot flashes and night sweats are listed among perimenopause symptoms [1]. The menopause research refers to these as vasomotor symptoms [4].

The median total duration of frequent vasomotor symptoms was 7.4 years. The median persistence after the final menstrual period was 4.5 years [4].

African American women reported the longest total vasomotor symptom duration in the SWAN analysis, with a median of 10.1 years. The median was 6.5 years for non-Hispanic white women, 8.9 years for Hispanic women, 5.4 years for Chinese women and 4.8 years for Japanese women [4].

For planning, 10.1 years is the middle value reported for the African American women in that analysis [4]. It isn’t a prediction of how long symptoms will last for one person.

What happens to sleep?

Trouble sleeping is on Cleveland Clinic’s list of perimenopause symptoms [1]. Insomnia is also included among symptoms associated with menopause [1].

What changes in mood and thinking?

Mood changes, including irritability and depression, are listed among perimenopause symptoms [1]. The menopause symptom list also includes difficulty concentrating, headaches and a racing heart [1].

What are the genitourinary symptoms?

Vaginal dryness with discomfort during sex, urinary urgency and low libido are listed among perimenopause symptoms [1]. The menopause symptom list also includes vaginal dryness, urinary urgency and changes in libido [1].

Which symptoms need another explanation checked?

Heavy menstrual bleeding can cause tiredness or shortness of breath from blood loss, which may lead to anemia [2]. Iron-deficiency anemia is usually caused by bleeding, and people with heavy periods have increased risk [3].

Symptoms listed for iron-deficiency anemia include fatigue, headaches, irritability, muscle cramps, pale skin, pica, shortness of breath, a sore tongue, spoon-shaped nails and a fast heart rate [3].

Tests used to work up heavy bleeding include pelvic ultrasound, blood tests, transvaginal ultrasound, MRI, a Pap test, cervical culture, endometrial biopsy, sonohysterogram and hysteroscopy [2]. Blood work for iron-deficiency anemia includes ferritin and total iron-binding capacity [3]. Ask which test fits the question your bleeding raises.

Perimenopause is usually identified from symptoms, age, medical history and a physical exam [1]. Follicle-stimulating hormone testing can help, but hormone levels rise and fall erratically during perimenopause [1]. Ask what question the test is meant to answer before treating one result as the whole explanation.

How long can the transition last?

Cleveland Clinic describes perimenopause as running about four years on average, with an upper end of eight years [1]. Its menopause guidance says the menopause transition can begin eight to 10 years before menopause and usually starts in a person’s 40s [1]. These are different time descriptions: the first refers to the average length of perimenopause, while the second describes how early the broader transition can begin before menopause.

Menopause is reached when there has been no menstrual period for 12 months in a row [1]. Menopause occurs at an average age of 52 in the United States [1].

After adjustment for selection at study entry, Black women had earlier natural and surgical menopause than white women by an average of 1.2 years [5]. Write down when symptoms begin and how your periods change.

Symptom tracker by system

System What to note Urgent threshold or action
Cycle Start and end dates, heavier or lighter bleeding, periods closer together or farther apart, bleeding between periods or after sex Soaking at least two pads or tampons per hour for two to three hours in a row calls for prompt professional evaluation [2]
Temperature Hot flashes, night sweats, when they occur, whether they wake you or affect daily tasks No urgent threshold listed here
Sleep Trouble falling asleep, waking during the night, waking with night sweats, fatigue or difficulty concentrating No urgent threshold listed here
Mood Irritability, depression, low mood, difficulty concentrating, headaches or a racing heart No urgent threshold listed here
Genitourinary Vaginal dryness, discomfort during sex, urinary urgency or a change in libido, and when the symptom began No urgent threshold listed here

What to do next

  1. Copy the tracker and record cycle, temperature, sleep, mood and genitourinary symptoms.
  2. Write down whether bleeding lasts longer than seven days, happens between periods, follows sex, or occurs when periods come less than 21 days apart [1][2].
  3. Record the number of pads or tampons used during the heaviest bleeding, whether you change protection during the night, and whether you pass quarter-sized clots [2].
  4. Add fatigue, shortness of breath, headaches, pale skin, a fast heart rate or other listed anemia symptoms to your notes [3].
  5. Open the appointment with: “I have symptoms in these body systems, and I want to know what fits perimenopause and what needs another explanation checked.”
  6. Ask whether your bleeding needs a pelvic ultrasound, transvaginal ultrasound, blood tests or another test from the heavy-bleeding workup [2].
  7. Ask whether blood work should include ferritin and total iron-binding capacity if you have heavy bleeding or symptoms that could fit iron-deficiency anemia [3].
  8. Ask what question a follicle-stimulating hormone test would answer, since hormone levels rise and fall erratically during perimenopause [1].
  9. If you are going through at least two pads or tampons each hour for two to three hours in a row, seek prompt professional evaluation [2].

Related on Ruby: what is perimenopause and heavy periods during perimenopause.

Sources

  1. Cleveland Clinic, Perimenopause. https://my.clevelandclinic.org/health/diseases/21608-perimenopause
  2. Cleveland Clinic, Menorrhagia (heavy menstrual bleeding). https://my.clevelandclinic.org/health/diseases/17734-menorrhagia-heavy-menstrual-bleeding
  3. Cleveland Clinic, Iron-deficiency anemia. https://my.clevelandclinic.org/health/diseases/22824-iron-deficiency-anemia
  4. Avis 2015, Duration of menopausal vasomotor symptoms over the menopause transition, JAMA Internal Medicine, PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC4433164/
  5. Reeves 2022, Systematic exclusion at study commencement masks earlier menopause for Black women in SWAN, Innovation in Aging, PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC9770235/